Mid-trimester uterine artery Doppler screening as a predictor of adverse pregnancy outcome in high-risk women

Effect of combination of uterine artery doppler and vitamin D level on perinatal outcomes in second trimester pregnant women

OBJECTIVES

To investigate the effect of the combination of uterine artery (UtA) Doppler and vitamin D levels on perinatal outcomes in second trimester pregnants was aimed.

METHODS

UtA Dopplers and vitamin D levels of 226 pregnant women in the second trimester were measured. Patients were followed for adverse pregnancy outcomes. The relationship of this combination with these pregnancy outcomes was evaluated.

RESULTS

Sensitivity and specificity values ​​are respectively; Left UtA-S/D ratio for preeclampsia was 85.29 and 81.77 %, left UtA-RI was 90.62 and 43.30 % for preterm birth, and 76.19 and 66.34 % for the development of fetal distress had the best predictive effect. Vitamin D values ​​had no predictive value for any parameter (p>0.005).

CONCLUSIONS

UtA Doppler has a good predictive value for many adverse pregnancy outcomes. However, in order to correlate these results with second trimester vitamin D levels, more homogeneous and specific groups are needed.

Hemodynamic changes in late advanced pregnant Zaraibi goats during the peripartum period

The objective of the present study was to demonstrate the blood flow velocities, blood flow rate (BFR; bpm) with the accurate ratio of both systolic and diastolic velocities points (S/D) in addition to Doppler indices (resistive and pulsatility index [RI and PI]) in both fetal [fetal heart (FH), fetal abdominal aorta (Ab. A), and umbilical artery (UM.A)] and maternal [Middle uterine artery (MU.A)] sides during the last month of gestation. Ten Zaraibi (Egyptian Nubian) goats weighing 40-50kg and aged from 5-7 years were examined twice per month till reached the last month of pregnancy. Then all females were examined every 5 days starting from day -35 till day -1 before kidding.The pregnant goats were examined by ultrasonic and Doppler indices were recorded with Doppler scanning (7.5 -12 MHz, with colored and spectral graph to form the perfect wave to assess Doppler measurements). The obtained data were analyzed using analysis of variance. Results indicated that on the fetal side; the maximum point of velocity (MSV; cm/sec) in the FH and BFRwere elevated from day -35 till day -10 with a slight decline at days -5 and -1 at the peripartum period (P < 0.05), while FH.PI and S/D ratio declined till day -1(P < 0.05). In addition, the fetal Ab. A, and UM.A PI, RI, and S/D ratio declined from day -35 till day -1 at the peripartum period with a significant increase in the peak systolic velocity (PSV) and BFR(P < 0.05). However, non-significant changes in the end diastolic velocity (EDV) were detected. On the maternal side, the MU.A PI and S/D declined from day -35 till day -1 with an elevation of both PSV and BFRat the same time points (P < 0.05). In conclusion, the Doppler evaluation of fetal and maternal blood flow vessels is important to give complete information that directly affects the health status of the mother and fetus.

Radiotherapy exposure directly damages the uterus and causes pregnancy loss

Female cancer survivors are significantly more likely to experience infertility than the general population. It is well established that chemotherapy and radiotherapy can damage the ovary and compromise fertility, yet the ability of cancer treatments to induce uterine damage, and the underlying mechanisms, have been understudied. Here, we show that in mice total-body γ-irradiation (TBI) induced extensive DNA damage and apoptosis in uterine cells. We then transferred healthy donor embryos into ovariectomized adolescent female mice that were previously exposed to TBI to study the impacts of radiotherapy on the uterus independent from effects to ovarian endocrine function. Following TBI, embryo attachment and implantation were unaffected, but fetal resorption was evident at midgestation in 100% of dams, suggesting failed placental development. Consistent with this hypothesis, TBI impaired the decidual response in mice and primary human endometrial stromal cells. TBI also caused uterine artery endothelial dysfunction, likely preventing adequate blood vessel remodeling in early pregnancy. Notably, when pro-apoptotic protein Puma-deficient (Puma-/-) mice were exposed to TBI, apoptosis within the uterus was prevented, and decidualization, vascular function, and pregnancy were restored, identifying PUMA-mediated apoptosis as a key mechanism. Collectively, these data show that TBI damages the uterus and compromises pregnancy success, suggesting that optimal fertility preservation during radiotherapy may require protection of both the ovaries and uterus. In this regard, inhibition of PUMA may represent a potential fertility preservation strategy.

Contribution of Second Trimester Sonographic Placental Morphology to Uterine Artery Doppler in the Prediction of Placenta-Mediated Pregnancy Complications

Background: Second-trimester uterine artery Doppler is a well-established tool for the prediction of preeclampsia and fetal growth restriction. At delivery, placentas from affected pregnancies may have gross pathologic findings. Some of these features are detectable by ultrasound, but the relative importance of placental morphologic assessment and uterine artery Doppler in mid-pregnancy is presently unclear. Objective: To characterize the association of second-trimester sonographic placental morphology markers with placenta-mediated complications and determine whether these markers are predictive of placental dysfunction independent of uterine artery Doppler. Methods: This was a retrospective cohort study of patients with a singleton pregnancy at high risk of placental complications who underwent a sonographic placental study at mid-gestation (160/7−246/7 weeks’ gestation) in a single tertiary referral center between 2016−2019. The sonographic placental study included assessment of placental dimensions (length, width, and thickness), placental texture appearance, umbilical cord anatomy, and uterine artery Doppler (mean pulsatility index and early diastolic notching). Placental area and volume were calculated based on placental length, width, and thickness. Continuous placental markers were converted to multiples on medians (MoM). The primary outcome was a composite of early-onset preeclampsia and birthweight < 3rd centile. Results: A total of 429 eligible patients were identified during the study period, of whom 45 (10.5%) experienced the primary outcome. The rate of the primary outcome increased progressively with decreasing placental length, width, and area, and increased progressively with increasing mean uterine artery pulsatility index (PI). By contrast, placental thickness followed a U-shaped relationship with the primary outcome. Placental length, width, and area, mean uterine artery PI and bilateral uterine artery notching were all associated with the primary outcome. However, in the adjusted analysis, the association persisted only for placenta area (adjusted odds ratio [aOR] 0.21, 95%-confidence interval [CI] 0.06−0.73) and mean uterine artery PI (aOR 11.71, 95%-CI 3.84−35.72). The area under the ROC curve was highest for mean uterine artery PI (0.80, 95%-CI 0.71−0.89) and was significantly higher than that of placental area (0.67, 95%-CI 0.57−0.76, p = 0.44). A model that included both mean uterine artery PI and placental area did not significantly increase the area under the curve (0.82, 95%-CI 0.74−0.90, p = 0.255), and was associated with a relatively minor increase in specificity for the primary outcome compared with mean uterine artery PI alone (63% [95%-CI 58−68%] vs. 52% [95%-CI 47−57%]). Conclusion: Placental area is independently associated with the risk of placenta-mediated complications yet, when combined with uterine artery Doppler, did not further improve the prediction of such complications compared with uterine artery Doppler alone.

Association of combined second trimester maternal serum Homocysteine and Uterine Artery Doppler to predict adverse pregnancy outcome

Introduction

Disturbances in placentation increase the risk of maternal and fetal complications. Several biochemical and imaging modalities have been studied, but the hunt for a single effective screening test never became a reality as the causes of this complex condition are multifactorial and polygenetic, many of which we are only beginning to discover. Not many studies have been conducted in the developing countries like India and other low resource settings to consider whether it would be worthwhile to combine inexpensive and effective markers together for better prediction of adverse pregnancy outcome.This study primarily aims to investigate the predictability of combined screening with maternal serum homocysteine and second trimester uterine artery Doppler in diagnosis of adverse pregnancy outcome.

Methodology

A prospective cohort study which involved 100 women with singleton gestation, meeting the inclusion criteria, attending the inpatient or outpatient of Obstetrics and Gynaecology in Amrita Institute of Medical Sciences, Kerala, a tertiary care centre in Southern India from July 2016 and September 2018 was conducted. Serum Homocysteine estimation (tHcy) was done between 18 and 28 weeks of gestation with informed consent, and uterine artery (UA) Doppler PI which is a non-invasive routine study was done along with targeted second trimester anomaly scan (18-24 weeks) in Fetal Medicine Department. Cutoff values of tHcy and UA PI were computed at 95th (> / = 9.7 mmol/l) and 90th percentile, respectively as reported by Onalan et al. [9] and Nicholaides et al. [4]. Statistical analysis was performed using IBM SPSS version 20.0 software. Chi-square test and diagnostic measures were also used.

Results

Of the 100 patients, 15% (n = 15) developed hypertensive disorder. 7% (n = 7) had FGR and 7%(n = 7) had spontaneous preterm birth. 6% (n = 6) neonates had an APGAR score < 7 and 8% neonates (n = 8) required immediate NICU admission. Statistically significant association was found when tHcy and UA PI were used together for the prediction of FGR (p = 0.003), preterm birth (p = 0.002) and low APGAR score at birth (p = 0.009) with a specificity of 83.4%. With regard to PIH, both parameters were found to be statistically significant only when used independently (p = 0.001) but not when used in combination (p = 0.17). Both elevated tHcy and abnormal UA PI used in combination predicted adverse pregnancy outcome like FGR but with a low sensitivity of 14.3% and high specificity of 98.9%. However, when used independently these markers predicted FGR with a better sensitivity (tHcy- 28.6% and UA PI- 44.4%).

Conclusion

Findings from this study have been promising with potential clinical implications for the diagnosis and management of high-risk pregnancies. Though the independent role of the two markers in screening various adverse pregnancy outcomes could be proved, their combined use to improve predictivity of more complications warrants further studies on a larger population with appropriate randomisation.

A Review of Roles of Uterine Artery Doppler in Pregnancy Complications

The invasion of trophoblasts into the uterine decidua and decidual vessels is critical for the formation of placenta. The defects of placentation are related to the etiologies of preeclampsia (PE), fetal growth restriction (FGR), and small-for-gestational age (SGA) neonates. It is possible to predict significant vascular events during pregnancy through uterine artery Doppler (UAD). From the implantation stage to the end of pregnancy, detecting changes in uterine and placental blood vessels can provide a favorable diagnostic instrument for pregnancy complications. This review aims to collect literature about the roles of UAD in pregnancy complications. We consider all relevant articles in English from January 1, 1983 to October 30, 2021. Predicting pregnancy complications in advance allows practitioners to carry out timely interventions to avoid or lessen the harm to mothers and neonates. Administering low-dose aspirin daily before 16 weeks of pregnancy can significantly reduce the incidence of pregnancy complications. From early pregnancy to late pregnancy, UAD can combine with other maternal factors, biochemical indicators, and fetal measurement data to identify high-risk population. The identification of high-risk groups can also lessen maternal mortality. Besides, through moderate risk stratification, stringent monitoring for high-risk pregnant women can be implemented, decreasing the incidence of adversities.

Doppler ultrasound measurements of the blood flow velocity in the fetal heart and aorta in Bulgarian White milk goats

The aim of the present study was to determine the parameters characterising the blood flow velocity in the fetal heart and aorta in goats by Doppler ultrasonography. Twenty-four Bulgarian White milk goats, aged 4-6 years, weighing 45-51 kg were used in the study. Doppler ultrasound measurements of the blood flow velocity in fetal heart were done at the end of first, second and third trimesters of pregnancy, and in the fetal aorta - at the end of the second and third trimesters of pregnancy. Ultrasound investigations were carried out by transabdominal approach with linear and convex transducers, with frequency 8.0 MHz. Blood flow parameters that included maximum and minimum systolic velocity, end-diastolic velocity, pulsatility index, resistance index and systolic/diastolic ratio were measured by spectral Doppler ultrasonography. The results showed that the highest maximum systolic velocity in the fetal heart was observed at the end of the first pregnancy trimester. Statistically significantly (p < 0.05) lower values of this parameter were registered in the second and third pregnancy trimesters. A similar tendency was observed for minimum systolic velocity, end-diastolic velocity and systolic/diastolic ratio. The pulsatility index and resistance index had similar values for the three studied periods. Examination of the fetal aorta showed statistically significant differences (p < 0.05) of minimum systolic velocity, end-diastolic velocity, pulsatility and resistance index in the third, compared with the second trimester of pregnancy. The analysis of the results suggested that Doppler ultrasonography can be used to monitor fetal blood flow changes during the various stages of pregnancy.

Placental Glucose Transporters and Response to Bisphenol A in Pregnancies from of Normal and Overweight Mothers

Bisphenol A (BPA) is a synthetic phenol extensively used in the manufacture of polycarbonate plastics and epoxy resins and a component of liquid and food storages. Among health disorders potentially attributed to BPA, the effects on metabolism have been especially studied. BPA represents a hazard in prenatal life because of its presence in tissues and fluids during pregnancy. Our recent study in rats fed with BPA showed a placental increase in glucose type 1 transporter (GLUT-1), suggesting a higher uptake of glucose. However, the role of BPA on GLUT transporters in pregnant women with metabolic dysfunction has not yet been investigated. In this study, placental tissue from 26 overweight (OW) women and 32 age-matched normal weight (NW) pregnant women were examined for expression of GLUT1 and GLUT4. Placental explants from OW and NW mothers were exposed to BPA 1 nM and 1 μM and tested for GLUTs expression. The data showed a different response of placental explants to BPA in GLUT1 expression with an increase in NW mothers and a decrease in OW ones. GLUT4 expression was lower in the explants from OW than NW mothers, while no difference was showed between OW and NW in placental biopsies for any of the transporters.

Uterine blood flow, fetal heart rate, gestational length, and fetal birth weight variability in response to maternal temperament in the goat

This prospective study was designed to investigate the effects of maternal temperament on uterine blood flow, fetal heart rate, gestational length, and fetal birth weight in a goat experimental model. Based on the arena test, behavioral testing related to fear-eliciting stimulus, goats were divided into nervous (n = 13) and calm (n = 11) groups. After mating, the perfusion of maternal uterine arteries (UTAs) and its related Doppler parameters, blood flow volume (BFV), time-averaged mean velocity (TAMEANV), acceleration (Acce), and resistance impedance (S/D), were evaluated biweekly from week two until the end of pregnancy. Fetal heart rate (FHR) was investigated during the pregnancy in addition to the gestation length (GL) and fetal birth weight (FBW). The UTA-BFV and TAMEANV, as well as Acce and S/D, were influenced by maternal temperament (p < .05). The FHR showed no significant changes between experimental animals of different temperaments (p = .81). Both GL and FBW were increased in calm rather than nervous goats (p < .05). These results indicated that the maternal nervous (temperament) have negative impacts on uterine artery Doppler indices, fetal growth, and gestational length in a goat experimental model.

Adverse Maternal and Fetal Outcomes in a Novel Experimental Model of Pregnancy after Recovery from Renal Ischemia-Reperfusion Injury

BACKGROUND

Recent clinical studies report that women with a history of AKI have an increased incidence of maternal and fetal adverse outcomes during pregnancy, despite fully recovering renal function prior to conception. The mechanisms contributing to such adverse outcomes in pregnancy after AKI are not yet understood.

METHODS

To develop a rodent model to investigate fetal and maternal outcomes in female animals with a history of AKI, we used ischemia-reperfusion injury as an experimental model of AKI in female Sprague Dawley rats. The 12-week-old animals underwent warm bilateral ischemia-reperfusion surgery involving clamping of both renal arteries for 45 minutes or sham surgery (control). Rats were allowed to recover for 1 month prior to mating. Recovery from ischemia-reperfusion injury was confirmed by measurements of plasma creatinine and urinary protein excretion. We assessed maternal and fetal outcomes during late pregnancy on gestational day 20.

RESULTS

After recovery from ischemia-reperfusion injury, compared with healthy sham-surgery controls, dams exhibited pregnancy-induced renal insufficiency with increases in plasma creatinine and urea, along with increased urinary protein excretion. Additionally, recovered ischemia-reperfusion dams experienced worse fetal outcomes compared with controls, with intrauterine growth restriction leading to higher rates of fetal demise and smaller pups.

CONCLUSIONS

In this rat model, despite biochemical resolution of ischemia-reperfusion injury, subsequent pregnancy resulted in maternal renal insufficiency and significant impairments in fetal growth. This mirrors findings in recent reports in the clinical population, indicating that this model may be a useful tool to further explore the alterations in kidney function after AKI in women.

End-Stage Kidney Disease and Dialysis in Pregnancy

End-stage kidney disease is associated with low fertility, with rates of conception in women on dialysis estimated at 1/100th of the general population. However, live birth rates are increasing over time in women on hemodialysis, whereas they remain lower and static in women on peritoneal dialysis. Intensification of hemodialysis, targeting a serum blood urea nitrogen <35 mg/dL or 36 hours of dialysis per week in women with no residual kidney function, is associated with improved live birth rates and longer gestational age. Even in intensively dialyzed cohorts, rates of prematurity and need for neonatal intensive care are high, upwards of 50%. Although women on peritoneal dialysis in pregnancy do not appear to be at increased risk of delivering preterm compared with those on hemodialysis, their infants are more likely to be small for gestational age. As such, hemodialysis has emerged as the preferred dialysis modality in pregnancy. Provision of specialized nephrology, obstetric, and neonatal care is necessary to manage these complex pregnancies and family planning counseling should be offered to all women with end-stage kidney disease.

Prognostic role of uterine artery Doppler in early- and late-onset preeclampsia with severe features

OBJECTIVE

To correlate uterine artery Doppler findings with maternal and neonatal outcomes in early- and late-onset preeclampsia with severe features.

METHODOLOGY

Doppler scan was done in both uterine arteries. Maternal and neonatal outcomes in women with abnormal and normal Doppler results were compared.

RESULTS

Abnormal Doppler results were present in 45 women (75%). Thirty-four (56.7%) women had abnormal RI, 19 (31.6%) had abnormal PI, and 36 (60%) had diastolic notch. Of the women who participated in the study, 21.6% developed maternal complications, and the majority belonged to the early-onset severe preeclampsia group. Diastolic notch was twofold more frequent in the early group. RI was abnormal in 63% of the early-onset and 50% of the late-onset group.

CONCLUSION

Pregnancies with early-onset preeclampsia who had abnormal uterine artery Doppler findings were at high risk for both maternal and neonatal complications, whereas those who had late-onset preeclampsia with abnormal Doppler findings only had an increased risk of perinatal complications.

Associations of maternal age at the start of pregnancy with placental function throughout pregnancy: The Generation R Study

OBJECTIVE

To examine the associations of maternal age at the start of pregnancy across the full range with second and third trimester uterine and umbilical artery flow indices, and placental weight.

STUDY DESIGN

In a population-based prospective cohort study among 8271 pregnant women, we measured second and third trimester uterine artery resistance and umbilical artery pulsatility indices and the presence of third trimester uterine artery notching using Doppler ultrasound.

RESULTS

Compared to women aged 25-29.9 years, higher maternal age was associated with a higher third trimester uterine artery resistance index (difference for women 30-34.9 years was 0.10 SD (95% Confidence Interval (CI) 0.02 to 0.17), and for women aged ≥40 years 0.33 SD (95% CI 0.08 to 0.57), overall linear trend 0.02 SD (95% CI 0.01 to 0.03) per year). Compared to women aged 25-29.9 years, women younger than 20 years had an increased risk of third trimester uterine artery notching (Odds Ratio (OR) 1.97 (95% CI 1.30-3.00)). A linear trend was present with a decrease in risk of third trimester uterine artery notching per year increase in maternal age (OR 0.96 (95% CI 0.94 to 0.98)). Maternal age was not consistently associated with umbilical artery pulsatility indices or placental weight.

CONCLUSIONS

Young maternal age is associated with higher risk of third trimester uterine artery notching, whereas advanced maternal age is associated with a higher third trimester uterine artery resistance index, which may predispose to an increased risk of pregnancy complications.

Placental histopathology in sickle cell disease: A descriptive and hypothesis-generating study

INTRODUCTION

Abnormal placental development is a unifying factor amongst many adverse pregnancy outcomes (APOs) in Sickle Cell Disease (SCD). Our aim was to describe placental histopathologic findings in women with SCD and their relationship with APOs, and to explore the association between antenatal sonographic findings and placental pathology.

METHODS

Retrospective single-centre case series of all pregnant women with SCD (January 2000-December 2017), pregnancy beyond 20 weeks' gestation, and available placenta histopathology. APOs included intrauterine fetal death, early neonatal death, preterm birth, small for gestational age, and hypertensive disorders of pregnancy. Review of images for mid-pregnancy ultrasound and one proximal to delivery was completed, blinded to clinical outcomes and histopathology results. Gross and histopathologic findings were reviewed and characterized per published classification.

RESULTS

Of 72 placentas, abnormalities were present in 69%, with Maternal Vascular Malperfusion (MVM) noted in 40%. APOs were encountered in 61% overall and in 79% of those with MVM. Neither SCD genotype nor severe maternal anemia had an influence on histopathologic placental features. Presence of high-resistance uterine artery waveforms at mid-trimester ultrasound was strongly associated with APOs and with abnormal findings on placental histopathology, most notably MVM. MVM was strongly associated with small for gestational age infants, preterm birth, and stillbirth.

DISCUSSION

MVM is the predominant lesion in placentas of women with SCD and is strongly associated with APOs. Mid-trimester ultrasound can identify a subset of women at risk. Future research into advanced imaging modalities to aid in antenatal diagnosis alongside investigations of potentially beneficial therapies is needed.

Doppler Indices and Notching Assessment of Uterine Artery Between the 19th and 22nd Week of Pregnancy in the Prediction of Pregnancy Outcome

BACKGROUND/AIM

The aim of this study was to determine the value of Doppler indices and notching assessment of uterine artery between the 19th and 22nd week of gestation in the prediction of pregnancy outcome such as delivery mode, birth weight, Apgar score, afterbirth pH, fetal presentation, preeclampsia and fetal growth restriction in singleton pregnancy.

PATIENTS AND METHODS

This is a retrospective cohort study of Doppler ultrasound of the uterine arteries at 19-22 week of gestation in 1,472 women with singleton pregnancies.

RESULTS

Patients with bilateral high resistance-index (RI) and pulsatility-index (RI) or with the presence of a notch showed a significantly higher prevalence of small for gestational age (SGA) fetuses and intrauterine growth restriction (IUGR), low Apgar Scores at the 1st and the 5th min, high c-section rate, preterm birth, breech birth, placental insufficiency and placental abruption. The presence of a notch significantly increased the prevalence of severe preeclampsia, HELLP-syndrome and oligohydramnios. Also, patients with a bilateral uterine notching had a higher c-section rate along with higher prevalence of SGA and IUGR at screening time.

CONCLUSION

Uterine artery Doppler waveform analysis as well as the assessment of the presence of a notch in the second trimester can be used as a screening method to identify women who will thereafter develop a severe adverse outcome.

Can increased resistance to uterine artery flow be a risk factor for adverse neurodevelopmental outcomes in childhood? A prospective cohort study

A prospective cohort study was conducted to determine whether an increased uterine artery pulsatility index (UtA-PI) in the second trimester of pregnancy is a risk factor for neurodevelopmental outcomes in children 2-3 years of age. A group of pregnant women with a UtA-PI below the 90th percentile (P90) and a second group with a UtA-PI ≥ P90 in the second trimester were included in this study. The children of these women were evaluated during their second or third year of life using the Bayley III Screening Test. A total of 858 pregnancies with UtA-PI < P90 and 96 pregnancies with UtA-PI ≥ 90 were studied. The differences between the groups related to UtA-PI ≥ 90 were detected in relation to the variables of the Caucasian ethnicity, hypertension, newborn weight and stay in the intensive care unit after birth. However, adjusted neurodevelopmental outcomes did not differ between the groups: OR 0.53 (95% CI 0.27-1.04%). This study failed to demonstrate that the UtA-PI is a risk factor for adverse neurodevelopment in children.Impact statementWhat is already known on this subject? Early interventions in children at high risk for neurodevelopmental deficiency have proved to be beneficial. The complications associated with gestation and delivery negatively influence neurodevelopment. Several studies have shown that some adverse pregnancy outcomes such as preeclampsia, foetal growth restriction and foetal death can be predicted by increased resistance to flow in the uterine artery in the second trimester. However, there are no studies evaluating the association of the uterine artery with neurodevelopmental results.What do the results of this study add? This study concludes that neurodevelopment is influenced by multiple environmental and intrinsic factors and cannot be predicted by only one variable, such as the uterine artery blood flow. The brain has repair mechanisms to attenuate insults that occur during gestation and delivery.What are the implications of these findings for clinical practice and/or further research? This study was unable to demonstrate that blood flow in the uterine artery is a risk factor for neurodevelopment. Different, larger studies should be conducted by combining other factors with the uterine artery in an algorithm to allow the early identification of children at risk for neurodevelopmental impairment.

Role of diffusion MR imaging (DWI) and three-dimensional ultrasound (3DUS) in the assessment of placental insufficiency in the gestational hypertension

Background

DWI is a non-invasive MR modality that is not contrast-based. In the current study, we aimed to evaluate DWI in correlation with 3DUS in the detection of placental insufficiency in high-risk pregnancies complicated with hypertension.

This prospective analysis included 80 pregnancies; 40 hypertensive and 40 controls, gestational age ranged from 22 to 34 weeks. All cases had undergone 3DUS aided by power Doppler scanning and DWI. There is no given contrast. Data were correlated to histopathology.

Results

Doppler US showed a significant relation between RI of the right uterine artery of cases and control (P = 0.014). There was also a positive correlation between the presence of the diastolic notch and RI value. The mean ADC value in the controls was 1.87 ± 0.26 mm2/s, while in hypertensive was 1.36 ± 0.09 mm2/s. In DWI images, there was a significant difference between patients with normal and those with abnormal placental signals (P value = 0.047). Also, there was a significant difference between the measurement of placental volume by MRI and US among cases and controls (P values ≤0.001 and 0.017, respectively).

Conclusion

Diffusion-weighted imaging can detect early subtle findings and signs of placental dysfunction more than detected with 3DUS, so it can add to the diagnostic accuracy of US in imaging of pregnancies at high risk of placental insufficiency.

Uterine Radial Artery Resistance Index Predicts Reproductive Outcome in Women with Recurrent Pregnancy Losses and Thrombophilia

Uterine radial artery resistance index (URa-RI) by Doppler ultrasound may reflect the changes in the uteroplacental circulation and be associated with adverse events in early pregnancy. Recurrent pregnancy losses (RPL) are associated with thrombophilia, and anticoagulation treatment with low molecular weight heparin improves pregnancy outcome in women with RPL and thrombophilia. A retrospective cohort study was conducted in 139 pregnant women with 3 or more RPL and thrombophilia. The relationship between pregnancy outcome and dynamic changes of URa-RI was analyzed in 116 women who delivered a liveborn infant and 23 who miscarried the index pregnancy. Patients were on preconception low molecular weight heparin, low-dose aspirin (81mg per day), and prednisone treatment. URa-RI was measured during periovulation time, at the time of positive pregnancy test, and then repeated every two weeks until 32-week gestation or the time of miscarriage. The URa-RI at 8-week gestation was significantly higher in women who miscarried the index pregnancy than those who delivered alive born infant (0.51±0.08 vs. 0.42±0.03, P<0.001). Receiver operating characteristic curve analysis demonstrated that URa-RI of 8 wk gestation effectively distinguished women who miscarried from those who had a live birth with an area under the curve of 82.6% (95% CI 69.01-97.17). After adjusting for covariates including age, BMI, and number of miscarriages, multiple logistic regression models showed that each 0.1 unit increase of URa-RI of 8 wk gestation was associated with 18.70-point increase in the risk of miscarriage (OR19.70, 95%CI 4.26-91.1, P<0.001), and women with an URa-RI≥0.45 had an OR of 49.48 (95% CI 8.01-307.95; P<0.001) for miscarriage compared to those who had URa-RI<0.45. In women with RPL and inherited thrombophilia, increased URa-RI at 8-week gestation was associated with spontaneous abortion independent of other risk factors while they were on anticoagulation treatment.

Usefulness of uterine artery Doppler velocimetry as a predictor for hypertensive disorders in pregnancy in women with prehypertension before 20 weeks gestation

Hypertensive disorders of pregnancy (HDP) is major complication of maternal-fetal outcomes in obstetric field. Although HDP is mainly defined by high blood pressure, the information about the relationship between prehypertension (preHTN, 120-139mmHg and 80-89mmHg) and HDP development is limited. The objective of this study is to determine the usefulness of preHTN before 20 weeks gestation and uterine artery (UtA) Doppler velocimetry as a predictor of HDP. A total of 2039 singleton pregnant women who had received continuous prenatal care were included in this study. The participants were classified into 2 groups based on the highest blood pressure (BP) under 20 gestational weeks as defined by the Joint National Committee 7: Normotensive (n = 1816) and preHTN pregnant women (n = 223). All preHTN pregnant women were assessed using UtA Doppler velocimetry, and the numbers of preHTN assessments were recorded. The risk of HDP was assessed in the PreHTN groups through patient history and Doppler velocimetry. Compared to normotensive patients, a total of 223 preHTN patients had a higher risk of preeclampsia (OR: 2.3; CI: 1.2-4.3), gestational hypertension (OR: 3.3; CI: 2.0-5.4) and any HDP (OR: 3.0; CI: 2.0-4.5). In the preHTN group, 134 (60.1%) patients had preHTN measured at least twice and 89 (39.9%) patients had preHTN. The results showed that two or more preHTN measurements have high sensitivity for predicting HDP (OR: 1.9; CI: 1.0-3.1; sensitivity: 83.8%; specificity: 47.2%). Additionally, the combination of abnormal UtA Doppler velocimetry results and at least two preHTN measurements showed a high accuracy in predicting HDP (OR: 2.9; CI: 1.1-4.1; sensitivity: 67.6%; specificity: 98.4%). In conclusion, close BP monitoring and recording of every preHTN event are important for pregnant women with preHTN history, and UtA Doppler examination in those women during the 2nd trimester can be a further aid in determining the risk of HDP.

Reference range of gestational uterine artery resistance index in small canine breeds

The objectives of this study were to evaluate the uterine artery blood flow during the second half of normal pregnancy in small breed dogs and to determine the RI reference values of this artery in these bitches. Fifty-two, 1.5-6.5 kg, purebred healthy pregnant bitches were included in this study. Doppler ultrasonographic examinations of the uterus were performed every 10 days from Day 30 of the estrous cycle to parturition. Peak systolic velocity (PSV) and end diastolic velocity (EDV) of the uterine artery were measured while RI [(PSV-EDV)/PSV] was automatically calculated. Values of PSV, EDV and RI were analyzed by repeated measures ANOVA followed by Tukey test using age, body weight, litter size and parity as covariates. Resistance index reference ranges were constructed by regressing this index on gestational age. Equation of the polynomial regression curves was used to calculate the mean, 95th and 5th centiles for each gestational age (GA). A gradual increase of PSV (P < 0.01) and EDV (P < 0.01) and a decrease in RI (P < 0.01) were found throughout the study period. PSV and EDV were influenced by litter size (P < 0.05), while RI was not. None of the Doppler parameters were influenced by age, body weight or parity. A second-degree polynomial described the relationship between RI of uterine artery and GA in the different time points: [RI = 0.993 + 8.4x10-5 x GA2- 0.0117 x GA]. It is concluded that uterine artery blood flow progressively increased throughout normal pregnancy in small breed bitches. In addition, reference ranges of uterine artery RI were 0.64-0.79, 0.57 to 0.75, 0.53 to 0.71 and 0.52 to 0.66 on Days 30, 40, 50 and 60 of gestation, respectively.

Use of placental vascularization indices and uterine artery peak systolic velocity in early detection of pregnancies complicated by gestational diabetes, chronic or gestational hypertension, and preeclampsia at risk

AIM

We aimed to investigate correlations between uterine artery peak systolic velocity (AUtPSV), and placental vascularization in groups of normal blood pressure (NBP) and hypertensive disorders of pregnancy (chronic hypertension (CHT), gestational hypertension (GHT) and preeclampsia (PE)) alone or in combination with gestational diabetes mellitus (GDM), and hypothesized that AUtPSV rises when GDM complicates pregnancy hypertension.

METHODS

Placental 3-dimensional power Doppler indices, such as vascularization index (VI), flow index (FI), and vascularization-flow index (VFI), and uterine artery peak systolic velocity (AUtPSV) were measured in CHT (N=43), CHT+GDM (N=15), GHT (N=57), GHT+GDM (N=23) and PE (N=17) pregnancies, and compared to NBP (N=109). Correlations were analyzed between vascularization indices, AUtPSV, pregestational BMI and adverse pregnancy outcome rates.

RESULTS

In our results VI was higher in CHT (P=0.010), while FI was lower in CHT (P=0.009), GHT and PE (P=0.001) compared to NBP. In case of VFI, significant difference was found between CHT and GHT (P=0.002), and NBP and PE (P=0.001). FI was found prognostic for umbilical pH and neonatal birth weight. Pre-gestational BMI was significantly higher in GHT+GDM compared to GHT, and in CHT+GDM compared to the CHT group. As for AUtPSV, significant difference was found between NBP and CHT (P=0.012), NBP and CHT+GDM (P=0.045), NBP and GHT+GDM (P=0.007), NBP and PE (P=0.032), and GHT and GHT+GDM (P=0.048) groups.

CONCLUSION

Our study revealed that vascularization indices and AUtPSV show significant differences due to gestational pathology, and can be useful in detection of pregnancies at risk.

Maternal Serum Analytes as Predictors of Fetal Growth Restriction with Different Degrees of Placental Vascular Dysfunction

Abnormal levels of maternal serum analytes have been associated with fetal growth restriction (FGR) and preeclampsia secondary to placental vascular dysfunction. Accurately identifying the FGR fetuses at highest risk for adverse outcomes remains challenging. Placental function can be assessed by Doppler analysis of the maternal and fetal circulation. Although the combination of multiple abnormal maternal serum analytes and abnormal Doppler findings is strongly associated with adverse outcomes, the predictive value remains too low to be used as a screening test in a low-risk population. Stratification of cases based on the severity of Doppler abnormalities may improve predictive models.

Predictive accuracy of second-trimester uterine artery Doppler indices for stillbirth: a systematic review and meta-analysis

OBJECTIVE

To assess the predictive accuracy for stillbirth of second-trimester uterine artery Doppler.

METHODS

We searched MEDLINE, EMBASE and The Cochrane Library databases from inception until March 2015 without language restrictions. The included studies were those that assessed the association of abnormal uterine artery Doppler parameters and stillbirth. Two independent reviewers selected the studies, extracted data and assessed quality. Results for studies that were performed in the second trimester were pooled and summary estimates of sensitivity, specificity, likelihood ratios and their 95% confidence intervals were obtained. An overall summary of test accuracy was provided by the diagnostic odds ratio. Subgroup analysis was performed according to whether the study population was high risk or unselected.

RESULTS

Literature searches returned 338 relevant citations with 32 considered in full. Thirteen studies met our search criteria (85 845 women, 508 stillbirths) and were included in the review. Bivariate pooled estimate for sensitivity was 65% (95% CI, 38-85%) and for specificity 82% (95% CI, 72-88%). The positive likelihood ratio was 3.5 (95% CI, 2.3-5.5) and negative likelihood ratio 0.43 (95% CI, 0.22-0.85). The diagnostic odds ratio was 8.3 (95% CI, 3.0-22.4). Heterogeneity was high in the studies of high-risk women.

CONCLUSIONS

Abnormal uterine artery Doppler indices are associated with a three- to four-fold increase in the risk of stillbirth. The heterogeneity was particularly high in the high-risk group rendering it impossible to draw firm conclusions. In view of this, there is a role for individual patient data meta-analysis to define which Doppler parameter and threshold value should be measured.

Is It Possible to Differentiate Chronic Kidney Disease and Preeclampsia by means of New and Old Biomarkers? A Prospective Study

Objective. Chronic kidney disease (CKD) and preeclampsia (PE) may both present with hypertension and proteinuria in pregnancy. Our objective is to test the possibility of distinguishing CKD from PE by means of uteroplacental flows and maternal circulating sFlt-1/PlGF ratio. Design. Prospective analysis. Population. Seventy-six patients (35 CKD, 24 PE, and 17 other hypertensive disorders), with at least one sFlt-1/PlGF and Doppler evaluation after the 20th gestational week. Methods. Maternal sFlt-1-PlGF were determined by immunoassays. Abnormal uterine artery Doppler was defined as resistance index ≥ 0.58. Umbilical Doppler was defined with gestational-age-adjusted Pulsatility Index. Clinical diagnosis was considered as reference. Performance of Doppler study was assessed by sensitivity analysis; sFlt-1/PlGF cut-off values were determined by ROC curves. Results. The lowest sFlt-1/PlGF ratio (8.29) was detected in CKD, the highest in PE (317.32) (P < 0.001). Uteroplacental flows were mostly preserved in CKD patients in contrast to PE (P < 0.001). ROC analysis suggested two cut-points: sFlt-1/PlGF ≥ 32.81 (sensitivity 82.93%; specificity 91.43%) and sFlt-1/PlGF ≥ 78.75 (sensitivity 62.89%, specificity 97.14%). Specificity reached 100% at sFlt-1/PlGF ≥ 142.21 (sensitivity: 48.8%). Early-preterm delivery was associated with higher sFlt-1/PlGF ratio and abnormal uteroplacental flows relative to late-preterm and term deliveries. Conclusions. sFlt-1/PlGF ratio and uteroplacental flows significantly correlated with PE or CKD and preterm delivery.

Uterine Artery Doppler of the Gravid Uterus as a Predictor Identifying At-Risk Pregnancies

Uterine artery Doppler has been a useful aid in the sonographic evaluation of uteroplacental hemodynamics of the gravid uterus. Pulsatility index, resistive index, and systolic/diastolic ratio can be calculated and interpreted in the evaluation of blood flow. The waveform itself can be evaluated for diastolic notching and used to interpret the qualitative appearance of the blood flow. In addition to the hemodynamic characteristics, practitioners have incorporated maternal serum tests to attempt to isolate at-risk candidates. This article summarizes the effectiveness of each methodology, with a primary focus on an at-risk population, since studies of low-risk populations have not demonstrated significant sensitivity for prediction of complications such as pre-eclampsia, placental abruptia, or fetal demise.

Involvement of the Heme Oxygenase System in the Development of Preeclampsia and as a Possible Therapeutic Target

The enzyme heme oxygenase (HO) is an important regulatory molecule present in most nucleated mammalian cells which functions to break down the pro-oxidant molecule heme into three products, carbon monoxide (CO), biliverdin and free iron. The HO system has been associated with many physiologic functions, including vascular tone, regulation of inflammation and apoptosis, angiogenesis and antioxidant capabilities. Deficiencies in HO are associated with several pregnancy disorders, including preeclampsia. With no present cure, this disorder continues to affect 5–7% of all pregnancies worldwide, leading to maternal and fetal morbidity and mortality. Researchers continue to strive for therapeutic potentials and this review will outline the possible use of the HO/CO system as a target treatment/prevention of preeclampsia in the future.

Doppler ultrasonographic assessment of maternal and fetal arteries during normal feline gestation

The aim of this study was to describe Doppler parameters of uterine, umbilical, fetal abdominal aorta, fetal renal and fetal internal carotid arteries, as well as fetal heart rate (FHR), during normal feline gestation. Fifteen, 1-4 years of age, weighing 2.5-3.9kg, domestic short-hair pregnant queens, which were born in our institutional cat colony were included in this study. Color and pulsed-wave Doppler evaluations of uterine arteries were performed every 10 days (Day 0, 10, 20, 30, 40, 50, 60) from mating. Fetal Doppler and M-mode ultrasonography were performed to assess umbilical, fetal abdominal aorta, fetal renal, fetal internal carotid arteries and FHR. Both peak systolic velocity (PSV) and end diastolic velocity (EDV) of uterine artery increased up to parturition (P<0.01), while resistance index (RI) decreased from Day 10 onwards (P<0.01). From Day 40 onwards, RI of umbilical artery diminished, while PSV and EDV augmented (P<0.01). Fetal abdominal aorta (P<0.01), renal (P<0.01) and internal carotid (P<0.01) arteries diminished their RI from Days 40, 60 and 40 onwards, respectively. Both PSV and EDV of these three arteries increased progressively. Fetal heart rate was first registered on Day 20 when it began to increase up to Day 40 and then diminished to the end of gestation (P<0.01). It is concluded that blood flow of uterine, umbilical, fetal abdominal aorta, fetal renal and fetal internal carotid arteries progressively increased during normal feline pregnancy, while FHR rose to mid gestation and then decreased up to parturition.

Second- and third-trimester placental hemodynamics and the risks of pregnancy complications: the Generation R Study

Characteristics of the uterine and umbilical artery blood flow patterns are indirect measures of uteroplacental circulation. We examined whether uterine and umbilical artery resistance indices are influenced by maternal demographic and lifestyle characteristics, track from the second trimester to the third, and are associated with the risk of pregnancy complications. This analysis was embedded among 7,660 pregnant women in the Generation R Study (Rotterdam, the Netherlands, 2001-2005). Placental resistance indices were assessed in the second and third trimesters. Information about pregnancy outcomes was obtained from medical records. Maternal characteristics affected second- and third-trimester placental resistance indices. Correlation coefficients for correlation between the second and third trimesters were 0.50 and 0.32 for uterine artery resistance index and umbilical artery pulsatility index, respectively. Higher placental resistance indices in the second and third trimesters and persistence in the highest tertile of uterine artery resistance index from the second trimester to the third were associated with the risks of preeclampsia, preterm birth, and small size for gestational age at birth (all P's < 0.05). Our study shows that placental resistance indices are influenced by maternal demographic and lifestyle characteristics and track moderately from the second trimester to the third. Increased placental resistance indices in the second and third trimesters are associated with increased risks of adverse pregnancy outcomes.

Physical activity and maternal-fetal circulation measured by Doppler ultrasound

OBJECTIVE

To examine the association of physical activity on maternal-fetal circulation measured by uterine and umbilical artery Doppler flow velocimetry waveforms.

STUDY DESIGN

Participants included 781 pregnant women with Doppler ultrasounds of the uterine and umbilical artery and who self-reported past week physical activity. Linear and generalized estimating equation regression models were used to examine these associations.

RESULT

Moderate-to-vigorous total and recreational activity were associated with higher uterine artery pulsatility index (PI) and an increased risk of uterine artery notching as compared with reporting no total or recreational physical activity, respectively. Moderate-to-vigorous work activity was associated with lower uterine artery PI and a reduced risk of uterine artery notching as compared with no work activity. No associations were identified with the umbilical circulation measured by the resistance index.

CONCLUSION

In this epidemiologic study, recreational and work activity were associated with opposite effects on uterine artery PI and uterine artery notching, although associations were modest in magnitude.

Role of uterine artery Doppler in the management of uterine leiomyoma by arterial embolization

OBJECTIVES

To study Doppler changes in the uterine artery immediately following and 3 months after uterine artery embolization (UAE) and to test the feasibility of using uterine artery Doppler as a predictor of the predominant side of arterial supply to leiomyomas, amount of embolizing material needed and leiomyoma tumor volume at follow-up.

METHODS

The study included 38 patients undergoing UAE for leiomyomas. Uterine artery Doppler was performed transabdominally before, within 6 hours after and 3 months after UAE to determine the peak systolic (PSV) and end-diastolic (EDV) velocities and resistance index (RI). Leiomyoma volume was measured using contrast-enhanced magnetic resonance imaging (MRI) before and 3 months after UAE. The predominant side of arterial supply to the leiomyoma was determined on digital subtraction angiography using the uterine artery diameter and tumor blush after contrast injection. For correlations with leiomyoma volume, the average PSV, EDV and RI of both sides was used, while for prediction of the predominant side of supply and for correlation with the amount of embolizing material needed, separate measurements from each side were used.

RESULTS

Relative to the pre-embolization value, the uterine artery PSV and EDV were significantly reduced (P < 0.05) immediately following UAE, while the RI was significantly elevated (P < 0.05). For prediction of the predominant side of supply, the lowest RI showed the highest accuracy (81.6%). There was no significant correlation between the pre-embolization PSV, EDV or RI and the amount of embolizing material utilized. Immediately post-embolization EDV and RI values were statistically significantly correlated with the 3-month follow-up leiomyoma volume, with RI showing the strongest correlation (P = 0.0400 and 0.0002, rho = 0.34 and - 0.58, respectively). The leiomyoma volume was predicted to have reduced by 38-61% after 3 months if the immediate post-embolization average RI value was between 0.82 and 0.88.

CONCLUSION

Pre-interventional Doppler assessment can be used to predict the predominant side of supply to leiomyomas but not the amount of embolizing material needed. Immediate post-interventional Doppler assessment can predict the leiomyoma volume after UAE.

Prediction of preeclampsia by midtrimester uterine artery Doppler velocimetry in high-risk and low-risk women

OBJECTIVE

To observe the role of uterine artery Doppler flow velocimetry at midtrimester in prediction of preeclampsia.

METHOD

179 women carrying <16 weeks of pregnancy, with singleton fetus and without any fetal anomaly were recruited and were divided in high-risk and low-risk group. Doppler velocimetry of uterine artery was done at 24-26 weeks. Any notch in uterine artery, unilateral or bilateral, or RI > 0.6, was considered abnormal. Women were followed up and development of preeclampsia noted.

RESULT

Sensitivity and specificity of abnormal uterine artery Doppler study for prediction of preeclampsia were 73.33 and 86.48 % in high-risk and 57.14 and 95.83 % in low-risk group, respectively. Relative risk with 95 % confidence interval was 5.427 (2.272-12.958) in high-risk and 13.65 (5.669-32.865) in low-risk women.

CONCLUSION

Doppler velocimetry of uterine artery at 24 weeks can be used as a reliable screening test for prediction of preeclampsia in both high-risk and low-risk women.

Triplex Doppler evaluation of uterine arteries in cyclic and pregnant domestic cats

The aims were to determine resistance index (RI) and pulsatility index (PI) in the uterine arteries of cyclic and pregnant domestic cats comparing the left and right uterine horns, as well as the majority or minority uterine horns, based on fetus number per horn; to determine the presence or absence of an early diastolic notch (EDN) in the uterine artery of pregnant queens. Ten domestic cats were followed during one cycle and one pregnancy until 63rd days after mating. The estrous cycle length was 16 ± 9.57 days. The uterine horn with the highest number of fetuses (majority uterine horn - MUH) presented 2.0 ± 1.0 fetus and the lower (minority uterine horn - miUH) presentes 0.78 ± 0.67 fetus. There were no differences in indexes between uterine arteries during the cycles and pregnancies. The RI and PI of MUH were lower than miUH (P<0.05). Uterine artery of the MUH presented lower indexes than miUH during the acceptance period (P<0.05). On D14 of pregnancy, uterine artery presented reductions in both indexes for the miUH. On D56, the PI was reduced in the miUH. The indexes depended on the week of pregnancy. EDN was present on the uterine arteries of all cats until D35, but disappeared by D49. The blood flow varied according to the category of horn.

Transdermal nitroglycerin in patients with severe pre-eclampsia with placental insufficiency: effect on uterine, umbilical and fetal middle cerebral artery resistance indices

OBJECTIVES

To evaluate the effect of transdermal nitroglycerin on Doppler velocity waveforms of the uterine, umbilical and fetal middle cerebral arteries in patients with severe pre-eclampsia.

METHODS

This was a prospective study of 30 singleton pregnancies (gestational age range: 24-31 weeks) with severe pre-eclampsia and abnormal uterine and umbilical artery Doppler waveforms. We compared maternal blood pressure as well as the resistance index (RI) and the pulsatility index (PI) of the uterine, umbilical and fetal middle cerebral arteries before and after application of a transdermal nitroglycerin patch (average dose 0.4 mg/h) for a period of 3 days. Intra-day comparisons before and after administration of nitroglycerin and a comparison between days 0 (no patch) and 3 after administration of the first dose of nitroglycerin were performed using ANOVA for paired samples.

RESULTS

A significant decrease in the PI and RI of the uterine (25.3 ± 4.9% and 21.2 ± 6.2%, respectively, P < 0.001) and umbilical (23.1 ± 6.9% and 19.7 ± 6.1%, respectively, P < 0.001) arteries was noted when comparing the first day without medication against the third day with the patch. No significant change in the PI and RI of the middle cerebral artery was observed. The mean arterial blood pressure decreased from 119.5 ± 4.5 mmHg to 114.8 ± 4.4 mmHg (P < 0.05).

CONCLUSION

The use of transdermal nitroglycerin in patients with severe pre-eclampsia is associated with a significant reduction in the RI and PI of the uterine and umbilical arteries, as well as of maternal blood pressure. Transdermal nitroglycerin does not affect the RI and PI of the fetal middle cerebral artery.

Uterine artery Doppler and adverse pregnancy outcome in women with extreme levels of fetoplacental proteins used for Down syndrome screening

OBJECTIVE

To evaluate the use of second-trimester uterine artery (UtA) Doppler to predict adverse pregnancy outcome in women with extreme levels of fetoplacental proteins used for Down syndrome screening.

METHODS

At a single institution, women screened for Down syndrome were offered second-trimester UtA Doppler examination if they had one of the following on analysis of maternal serum: pregnancy-associated plasma protein-A ≤ 0.28 multiples of the median (MoM) (1% of screened population), inhibin ≥ 3.0 MoM (2%), human chorionic gonadotropin ≥ 4.0 MoM (2%), alpha-fetoprotein (AFP) ≥ 2.5 MoM (2%), estriol ≤ 0.5 MoM (1%). Abnormal UtA Doppler was defined as bilateral or unilateral notching or mean pulsatility index ≥ 1.45.

RESULTS

Of 240 women studied, 92 (38.3%) had an adverse pregnancy outcome: small for gestational age (either < 10(th) customized centile (SGA(10) ) or < 5(th) customized centile (SGA(5) )), low birth weight (LBW, < 2.5 kg), preterm delivery (< 37 + 0 weeks of gestation), fetal loss (late miscarriage or stillbirth), placental abruption and gestational hypertension. Of 167 women screened with all five hormones, those with two or more extreme levels (n = 18, 10.8%) were significantly at risk of adverse pregnancy outcome compared with those with only one marker (61.1% vs. 35.6%, P = 0.04). UtA Doppler was abnormal in 20% (32 of 159 women screened) and increased the risk of adverse pregnancy outcome (RR 2.5, 65.6% vs. 26.0%, P < 0.001). SGA(10) , SGA(5) and LBW were significantly more common in women with abnormal UtA Doppler (RR 2.98, 56.2% vs. 18.9%, P < 0.001, RR 4.6, 43.7% vs. 9.4%, P < 0.001 and RR 4.4, 31.2% vs. 7.1%, P < 0.001, respectively). Women with normal Doppler examination still had a 26% risk of adverse pregnancy outcome.

CONCLUSIONS

In women with extreme levels of feto-placental proteins used for Down syndrome screening, an abnormal second-trimester UtA Doppler examination confers a high risk of adverse pregnancy outcome and SGA in particular, but a normal examination does not rule out an adverse pregnancy outcome.

Mid-trimester uterine artery Doppler ultrasound as a predictor of adverse obstetric outcome in high-risk pregnancy

OBJECTIVE

The aim of this study was to assess uterine artery Doppler ultrasonography efficiency in prediction of adverse pregnancy outcome in high-risk pregnancies.

MATERIALS AND METHODS

We selected 70 pregnant women who were high risk for development of preeclampsia, abruption, low birth weight (LBW), and preterm delivery during their pregnancy, and Doppler ultrasonography was performed for them in 18-24 gestational weeks for evaluation of uterine artery notching. Absence of diastolic flow in uterine artery waves was defined as notching. The women were divided into two groups: with notching (Group A) and without notching (Group B), then they were compared for complications such as preeclampsia, abruption, LBW, and preterm delivery.

RESULTS

In 70 high-risk pregnant women, 27 women (39.2%) were in Group A and the others were in Group B. The birth weight in Groups A and B was 2,897.5 ± 757.15 and 3,248.39 ± 374.27, respectively. In our study, 15 patients were delivered before 37 gestational weeks (preterm labor). Preeclampsia, abruption, and LBW were significantly higher in the group with positive notching, but preterm delivery did not show any statistical difference between the two groups.

CONCLUSION

According to the results, uterine artery Doppler ultrasonography had high negative predictive value for prediction of preeclampsia, abruption, and LBW. Therefore, absence of uterine artery notching in mid-trimester evaluation of high-risk pregnant women may predict better pregnancy outcome. We recommend Doppler ultrasonography for all high-risk pregnant women in second trimester for prediction of pregnancy outcome.

Spontaneous pregnancy loss mediated by abnormal maternal inflammation in rats is linked to deficient uteroplacental perfusion

Abnormal maternal inflammation during pregnancy is associated with spontaneous pregnancy loss and intrauterine fetal growth restriction. However, the mechanisms responsible for these pregnancy outcomes are not well understood. In this study, we used a rat model to demonstrate that pregnancy loss resulting from aberrant maternal inflammation is closely linked to deficient placental perfusion. Administration of LPS to pregnant Wistar rats on gestational day 14.5, to induce maternal inflammation, caused fetal loss in a dose-dependent manner 3-4 h later, and surviving fetuses were significantly growth restricted. Pregnancy loss was associated with coagulopathy, structural abnormalities in the uteroplacental vasculature, decreased placental blood flow, and placental and fetal hypoxia within 3 h of LPS administration. This impairment in uteroplacental hemodynamics in LPS-treated rats was linked to increased uterine artery resistance and reduced spiral arteriole flow velocity. Pregnancy loss induced by LPS was prevented by maternal administration of the immunoregulatory cytokine IL-10 or by blocking TNF-α activity after treatment with etanercept (Enbrel). These results indicate that alterations in placental perfusion are responsible for fetal morbidities associated with aberrant maternal inflammation and support a rationale for investigating a potential use of immunomodulatory agents in the prevention of spontaneous pregnancy loss.

Uterine and umbilical artery Doppler velocimetry as a predictor for adverse pregnancy outcomes in pregnant women with anemia

AIMS

The aim of this study was to investigate the significance of Doppler ultrasound as a predictor for adverse pregnancy outcomes in Korean women with anemia during the third trimester of pregnancy.

METHODS

A retrospective study comparing women with (n=377) and without (n=3183) anemia was performed. Maternal anemia was defined as hemoglobin concentration <10 g/dL. Umbilical artery Doppler (UmA) and uterine artery Doppler (UtA) velocimetry was performed before delivery.

RESULTS

There were higher rates of small for gestational age, cesareans for fetal distress, and preterm birth among the anemic compared to non-anemic women. When maternal anemia was combined with abnormal Doppler, the odds ratio (OR) of adverse pregnancy outcome was further increased. Both abnormal UtA and UmA to predict adverse pregnancy outcome showed sensitivity, specificity, positive and negative predictive values of 41.2%, 97.4%, 85.9%, and 51.2%, respectively (OR 2.0; 95% confidence interval 1.2-2.3).

CONCLUSIONS

Doppler ultrasound examination could be used as a predictor for adverse pregnancy outcomes in women with anemia during the third trimester.