"Is It Realistic?": A Qualitative Study of the Experiences of Elite Women Athletes Considering Parenthood

BACKGROUND AND OBJECTIVE

As the visibility and acceptance of athlete-mothers increase, so does the number of women athletes considering parenthood. Yet, many athletes struggle with the decision to become a parent while competing at the elite level due to the significant changes and uncertainties that have been reported by pregnant and parenting athletes. The experiences of women athletes considering parenthood are under-represented in the vast sport literature but are necessary for developing evidenced-based policies and practices that can support women's equitable participation in high-performance sport contexts. Thus, the purpose of this qualitative study was to describe the experiences of elite women athletes that are considering parenthood.

METHODS

Participants were ten elite North American athletes (29-36 years) who are considering becoming parents in the next 5 years. Each participant self-identified as a woman and competed at the highest level in their respective sport. Data were generated via one-on-one semi-structured interviews that were audio-recorded, transcribed verbatim, and analyzed through a process of content analysis.

RESULTS

The experiences of elite women athletes considering parenthood are represented by five themes: (a) calls for essential mandates and leadership, (b) how do you support yourself?, (c) hesitation of body changes, (d) age inequities, and (e) being proactive about reproductive health. Such findings support an in-depth understanding of gender-specific stressors that limit women's equitable participation in high-performance contexts.

CONCLUSION

This research is grounded in the voices of elite women athletes and identifies actionable steps necessary for research and culture change. Findings provide necessary evidence to inform the development of sport policies to support those athletes that are considering becoming parents.

Assessing the effectiveness of a cadaveric workshop in improving resident physicians' confidence in performing ultrasound-guided joint injections

Our study showed that an educational workshop using a cadaveric specimen is effective in improving resident physicians' confidence in performing ultrasound-guided, as well as landmark-based, joint injections. Participants also reported a strong interest in future cadaveric workshops on ultrasound-guided joint injections and believe such workshops would be a valuable educational resource for other physicians. Implementing cadaver-based ultrasound-guided joint injection workshops similar to the one discussed in this manuscript could be used to supplement training for these procedures in medical education and provide residents with the early experience they need to be able to perform these injections independently in clinic settings.

Exercise-induced deep vein thrombosis in the subclavian vein in an elite female athlete

An adolescent female presented to the emergency room with pain, swelling and a palpable lump in the right axilla following activity on a rowing ergometer. The differential diagnosis at the time of presentation was deep vein thrombosis, mass compression and cellulitis. An ultrasound scan revealed an occlusive thrombus of the right axillary and subclavian veins, basilic vein and proximal cephalic vein. The patient underwent pharmacomechanical thrombolysis followed by catheter-directed thrombolysis. Dynamic venogram testing revealed venous thoracic outlet syndrome (VTOS) and a transaxillary first rib resection was performed to decompress the costoclavicular space. Genetic testing revealed the patient was heterozygous for factor V Leiden. Two rounds of balloon dilatation plasty were performed to relieve recurring symptoms due to scarring and persisting compression, 1 and 3 years post rib resection. After extensive shared decision-making, the patient returned to sport, reporting only intermittent symptoms of post-thrombotic syndrome. This case sheds light on the importance of early diagnosis of VTOS for successful return to sport.

Global Alliance for the Promotion of Physical Activity: the Hamburg Declaration

Non-communicable diseases (NCDs), including coronary heart disease, stroke, hypertension, type 2 diabetes, dementia, depression and cancers, are on the rise worldwide and are often associated with a lack of physical activity (PA). Globally, the levels of PA among individuals are below WHO recommendations. A lack of PA can increase morbidity and mortality, worsen the quality of life and increase the economic burden on individuals and society. In response to this trend, numerous organisations came together under one umbrella in Hamburg, Germany, in April 2021 and signed the 'Hamburg Declaration'. This represented an international commitment to take all necessary actions to increase PA and improve the health of individuals to entire communities. Individuals and organisations are working together as the 'Global Alliance for the Promotion of Physical Activity' to drive long-term individual and population-wide behaviour change by collaborating with all stakeholders in the community: active hospitals, physical activity specialists, community services and healthcare providers, all achieving sustainable health goals for their patients/clients. The 'Hamburg Declaration' calls on national and international policymakers to take concrete action to promote daily PA and exercise at a population level and in healthcare settings.

Outcomes with Endovascular Treatment of Patients with M2 Segment MCA Occlusion in the Late Time Window

BACKGROUND AND PURPOSE

Randomized trials in the late window have demonstrated the efficacy and safety of endovascular thrombectomy in large-vessel occlusions. Patients with M2-segment MCA occlusions were excluded from these trials. We compared outcomes with endovascular thrombectomy in patients with M2-versus-M1 occlusions presenting 6-24 hours after symptom onset.

MATERIALS AND METHODS

Analyses were on pooled data from studies enrolling patients with stroke treated with endovascular thrombectomy 6-24 hours after symptom onset. We compared 90-day functional independence (mRS ≤ 2), mortality, symptomatic intracranial hemorrhage, and successful reperfusion (expanded TICI = 2b-3) between patients with M2 and M1 occlusions. The benefit of successful reperfusion was then assessed among patients with M2 occlusion.

RESULTS

Of 461 patients, 367 (79.6%) had M1 occlusions and 94 (20.4%) had M2 occlusions. Patients with M2 occlusions were older and had lower median baseline NIHSS scores. Patients with M2 occlusion were more likely to achieve 90-day functional independence than those with M1 occlusion (adjusted OR = 2.13; 95% CI, 1.25-3.65). There were no significant differences in the proportion of successful reperfusion (82.9% versus 81.1%) or mortality (11.2% versus 17.2%). Symptomatic intracranial hemorrhage risk was lower in patients with M2-versus-M1 occlusions (4.3% versus 12.2%, P = .03). Successful reperfusion was independently associated with functional independence among patients with M2 occlusions (adjusted OR = 2.84; 95% CI, 1.11-7.29).

CONCLUSIONS

In the late time window, patients with M2 occlusions treated with endovascular thrombectomy achieved better clinical outcomes, similar reperfusion, and lower symptomatic intracranial hemorrhage rates compared with patients with M1 occlusion. These results support the safety and benefit of endovascular thrombectomy in patients with M2 occlusions in the late window.

A Scoping Review of Transgender Policies in the 15 Most Commonly Played UK Professional Sports

INTRODUCTION

There has been much debate recently on the participation of transgender and gender-diverse (TGD) athletes in sport, particularly in relation to fairness, safety and inclusion. The 2021 IOC Framework on Fairness, Inclusion and Non-discrimination acknowledges the central role that eligibility criteria play in ensuring fairness, particularly in the female category, and states that athletes should not be excluded solely on the basis of their TGD identity.

AIMS

To identify policies that address TGD athlete participation in the 15 major United Kingdom (UK) sporting organisations and to summarise the evidence for each of these policies.

METHODS

A scoping review of TGD policies from the 15 major UK sporting organisations.

RESULTS

Eleven of the governing bodies had publicly available TGD policies. Most of the sporting associations drew guidance from the official 2015 IOC Consensus Meeting on Sex Reassignment and Hyperandrogenism, particularly with regard to physiological testosterone levels. Many organisations referenced their policies as a guide for decision making but stated that they ultimately made case-by-case decisions on an athlete's eligibility. Relevant considerations not addressed in most policies included pre- versus post-pubertal athletes, justification for testosterone thresholds, the length of time out of competitive action (if any) for transitioning athletes, the irreversible advantage from male puberty (if any), the responsibility for and frequency of follow up for hormonal testing and the consequences for athletes outside set testosterone limits.

CONCLUSIONS

There is a lack of consensus among the top 15 UK sporting organizations relating to elite sport participation for TGD athletes. It would be useful for sport organizations to work together to develop greater standardization/consensus for TGD athlete policies, taking into consideration fairness, safety and inclusion in each sport.

Longitudinal Doppler Assessments in Late Preterm Fetal Growth Restriction

PURPOSE

 To assess the longitudinal variation of the ratio of umbilical and cerebral artery pulsatility index (UCR) in late preterm fetal growth restriction (FGR).

MATERIALS AND METHODS

 A prospective European multicenter observational study included women with a singleton pregnancy, 32^+ 0-36^+ 6, at risk of FGR (estimated fetal weight [EFW] or abdominal circumference [AC] < 10^th percentile, abnormal arterial Doppler or fall in AC from 20-week scan of > 40 percentile points). The primary outcome was a composite of abnormal condition at birth or major neonatal morbidity. UCR was categorized as normal (< 0.9) or abnormal (≥ 0.9). UCR was assessed by gestational age at measurement interval to delivery, and by individual linear regression coefficient in women with two or more measurements.

RESULTS

 856 women had 2770 measurements; 696 (81 %) had more than one measurement (median 3 (IQR 2-4). At inclusion, 63 (7 %) a UCR ≥ 0.9. These delivered earlier and had a lower birth weight and higher incidence of adverse outcome (30 % vs. 9 %, relative risk 3.2; 95 %CI 2.1-5.0) than women with a normal UCR at inclusion. Repeated measurements after an abnormal UCR at inclusion were abnormal again in 67 % (95 %CI 55-80), but after a normal UCR the chance of finding an abnormal UCR was 6 % (95 %CI 5-7 %). The risk of composite adverse outcome was similar using the first or subsequent UCR values.

CONCLUSION

 An abnormal UCR is likely to be abnormal again at a later measurement, while after a normal UCR the chance of an abnormal UCR is 5-7 % when repeated weekly. Repeated measurements do not predict outcome better than the first measurement, most likely due to the most compromised fetuses being delivered after an abnormal UCR.

Beyond the medals: a cross-sectional study exploring retired elite female athletes' health

Objectives

Little is known about the impact of elite sport participation on long-term athlete health. We aimed to: (1) describe musculoskeletal, mental health, reproductive/endocrine and cardiovascular characteristics in retired elite female athletes and compare to the general population and (2) explore athletes' perceptions of their elite sport participation and its impact on health.

Methods

A 136-item online questionnaire was disseminated to Canadian elite female rowing and rugby athletes >18 years old, >2 years retired from elite competition. Matched general population data were obtained from Statistics Canada when available.

Results

Seventy-four (24% response rate) athletes (average age 45 (±9) years; retired 15 (±9) years) completed the questionnaire (30 rowing, 44 rugby athletes). During their career, 63 athletes (85%) experienced a hip/groin, knee, foot/ankle injury, or low back pain, with 42 (67%) reporting ongoing symptoms. Athletes 35-54 years reported worse knee symptoms and quality of life compared with the general population (symptom: p=0.197; d=1.15 [0.66, 1.63]; quality of life: p=0.312 d=1.03 [0.54, 1.51]) while other hip, knee and foot/ankle outcome scores were similar. Retired athletes had lower odds of anxiety (OR=0.155 [95% CI0.062 to 0.384]), greater lifetime/ever odds of amenorrhea (OR=6.10 [95%CI 2.67 to 13.96]) and gave birth when older (p<0.05). Fifty-nine (79%) recalled witnessing or experiencing at least one form of harassment/abuse during their career. Sixty athletes (81%) rated their current health as above average or excellent and 61 (82%) would compete at the same level again if given the choice.

Conclusion

These novel insights can inform future preventative efforts to promote positive elite sport-related outcomes for current, former and future female athletes.

We're not Superhuman, We're Human: A Qualitative Description of Elite Athletes' Experiences of Return to Sport After Childbirth

BACKGROUND

A growing number of athletes return to elite sport following childbirth. Yet, they face significant barriers to do so safely and successfully. The experiences of elite athletes returning to sport following delivery are necessary to support evidence-informed policy.

OBJECTIVE

The purpose of this qualitative description was to describe the experiences of elite athletes as they returned to sport following childbirth, and to identify actionable steps for research, policy and culture-change to support elite athlete mothers.

METHODS

Eighteen elite athletes, primarily from North America, who had returned to sport following childbirth in the last 5 years were interviewed. Data were generated via one-on-one semi-structured interviews that were audio-recorded, transcribed verbatim, and analyzed through a process of content analysis.

RESULTS

The findings of this study are represented by one overarching theme: Need for More Time, and five main themes: (a) Training "New Bodies" Postpartum, (b) Injuries and Safe Return to Sport, (c) Breastfeeding While Training, (d) Critical Supports for Return to Sport, (e) Navigating Motherhood and Sport. The athletes identified the urgent need to develop best-practice policies and funding to support return to sport, as well as develop evidence-based return-to-sport protocols to support a safe and injury-free return.

CONCLUSION

Athletes shared detailed stories highlighting the challenges, barriers and successes elite athletes experience returning to elite-level sport following childbirth. Participants provided clear recommendations for policy and research to better support the next generation of elite athlete mothers.

119 ENHANCING THE QUALITY OF STROKE CARE IN IRELAND - DEVELOPMENT OF AN IRISH NATIONAL STROKE AUDIT

Background

Population ageing, stroke treatment advances, changing models of care, and between-hospital heterogeneity in stroke outcomes demonstrate the necessity of continual audit of stroke care to support quality improvement at local and national levels, and to enhance patient recovery and wellbeing. This project aims to identify the core minimum datasets for acute and non-acute stroke care, and Patient-Reported Outcome Measures (PROMs), for integration in to the newly-developed Irish National Audit of Stroke (INAS), in addition to identifying resourcing needs and implementation procedures.

Methods

In Phase 1, a minimum dataset for acute stroke care was identified based on a scoping review of international practice and available guidelines. Phase 2 (ongoing) involves identifying datasets for non-acute rehabilitative and follow-up care based on a scoping review of international practice, iterative cycles of qualitative stakeholder engagement, and systematic review of PROMs. In Phase 3, a review of resourcing and data collection procedures used in stroke audits internationally will be used to produce an implementation strategy for data collection, contextualised to the Irish healthcare system.

Results

Twenty-one eligible international stroke registries were identified from the scoping review. Within Phase 1, core clinical and thrombectomy items in the Irish registry were benchmarked against internationally-collected items to identify common items and to generate an inventory of items that other registries collect that Ireland does not. Based on consensus agreement on the most frequently-occurring international items, as reviewed by key stakeholders, a core minimum dataset for audit of acute stroke care was delivered.

Conclusion

These minimum datasets shall act as the “gold standard” for evaluating stroke care in Ireland, by not only incorporating structure, process, and care quality outcome indicators, but also PROMs. The resultant datasets may inform policy and quality improvement initiatives, and shape health service delivery across the trajectory of stroke care, from hyper-acute care, to rehabilitation, and return to the community.

Multimorbidity, low income and unmet need for healthcare: a national study of 41,135 older adults

The aims of this study were: (1) to identify the determinants of unmet need for access to primary care in middle-aged and older adults; and (2) to examine the reasons for unmet need. We used data from the Canadian Longitudinal Study on Aging (CLSA), a nationally representative survey of adults aged 45 to 85 years. Respondents were asked if they ‘needed health care during the last 12 months but did not receive it’. For those who replied ‘Yes’, the survey asked for the reason(s) for not receiving the needed care. Out of 41,135 respondents, 3,468 had unmet need for healthcare in the last 12 months. Among respondents with 0, 1, 2 and ≥3 morbidities, the proportion reporting unmet need was 2.5%, 5.3%, 5.1% and 9.1% respectively. After adjusting for covariates, the odds ratios (ORs) for unmet need for 1, 2 and ≥3 morbidities (compared to no morbidity) were 1.25 (95% CI: 0.87 to 1.78; p = 0.23), 1.57 (95% CI: 1.13 to 2.17; p < 0.05) and 2.03 (95% CI: 1.51 to 2.73; p < 0.05), respectively. For income groups, the ORs for unmet need (compared to >$150,000/year) were 0.94 (95% CI: 0.79 to 1.12) for $100,000-$150,000, 1.02 (95% CI: 0.87 to 1.20;) for $50,000-$100,000, 1.30 (95% CI: 1.09 to 1.55) for $20,000-$50,000, and 1.39 (95% CI: 1.08 to 1.78) for < $20,000. Other statistically significant determinants of unmet need included age (older adults were less likely to have unmet need), sex (females were more likely), having a family physician (less likely) and perceived physical and mental health (poor health more likely to be associated with unmet need). The most common reasons for unmet need were: ‘long wait time’ (52.1%) and ‘doctor did not think it was necessary’ (16.7%). Multimorbidity and low-income are associated with higher odds of unmet need among older adults. This disparity is partly due to not having a regular family physician and long wait time to see a doctor. Reducing these barriers are critical to reducing inequalities in health outcomes.

The 'miracle cure': how do primary care physicians prescribe physical activity with the aim of improving clinical outcomes of chronic disease? A scoping review

Objectives

To identify how primary care physicians (PCPs) prescribe physical activity for patients with chronic disease, and to determine characteristics of physical activity interventions with improved clinical outcomes of chronic disease.

Design

A scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews 2018 was completed.

Data sources

Four bibliographic databases (Medline, EMBASE, SPORTDiscus, CINAHL) and four grey literature/unpublished databases (Proquest, National Institute for Health and Care Excellence, Canadian Health Research Collections, Clinical Trials) were searched from inception to 7 March 2022.

Eligibility criteria for selecting studies

Studies involving PCP-delivered physical activity prescriptions or counselling for participants with a chronic disease or mental health condition, which reported clinical outcomes were included. Opinion papers, news and magazine articles and case reports were excluded, as were studies in which a physical activity intervention was provided for primary prevention of chronic disease, prescribed by healthcare providers or researchers other than PCPs, or for healthy participants without chronic disease.

Results

An initial search identified 4992 records. Fifteen studies met inclusion criteria. Characteristics of physical activity prescriptions that improved clinical outcomes included: personalised advice; brief intervention; behavioural supports (handouts and/or referrals) and physician follow-up. Reported adverse events were rare. Research gaps include optimal timing and length of follow-up, and the long-term and cost-effectiveness of interventions.

Summary/Conclusion

Several characteristics of physical activity counselling by PCPs for patients with chronic disease may improve clinical outcomes, although research gaps remain. Studies exploring the effectiveness of physical activity prescription for individuals with chronic conditions are urgently needed.

Associations between partial foot amputation level, gait parameters, and minimum impairment criteria in para-sport: A research study protocol

Altered biomechanics due to amputation can contribute to substantial limitations, influencing sporting activities. Individuals with lower extremity amputations or congenital lower limb deficiency are encouraged to participate in para-sports. However, to compete in Paralympic sports, the candidate must have an impairment that results in lower extremity loss of function and meets or exceeds the sport's minimum impairment criteria (MIC). This review will focus on the MIC for competitive wheelchair tennis. Limb deficiency is known as one of the MIC used to regulate participation in competitive para-sports since it impacts gait, kinematics, and biomechanics of both the upper and lower body. Notwithstanding, it is questionable whether the MIC concerning limb deficiency is set at the correct level for determining eligibility for participating in Paralympic sports. This study aims to provide an overview of the evidence examining the impact of different partial foot amputation (PFA) levels on gait as a proxy for sporting performance. This scoping review will be based on a 6-step methodological framework and Preferred Reporting Items for Systematic Reviews and Meta-Analysis, extension for scoping reviews (PRISMA-ScR). Studies will be selected from PubMed, Embase, CINAHL, and SPORTDiscus. Two authors will screen the titles/abstracts independently. Selected studies will be scrutinised, and the same authors will extract data. Findings will be relevant to informing the evidence-based development of MIC for lower limb impairment after PFA and may be extrapolated to specific Paralympic sports, including wheelchair tennis. Results will be disseminated through scientific publications and conferences to audiences interested in Paralympic sports.

Are family medicine residents trained to counsel patients on physical activity? The Canadian experience and a call to action

Physical inactivity is a leading risk factor for non-communicable diseases (NCDs) and early mortality. Family physicians have an important role in providing physical activity counselling to patients to help prevent and treat NCDs. Lack of training on physical activity counselling is a barrier in undergraduate medical education, yet little is known regarding physical activity teaching in postgraduate family medicine residency. We assessed the provision, content and future direction of physical activity teaching in Canadian postgraduate family medicine residency programs to address this data gap. Fewer than half of Canadian Family Medicine Residency Programme directors reported providing structured physical activity counselling education to residents. Most directors reported no imminent plans to change the content or amount of teaching. These results reflect significant gaps between the recommendations of WHO, which calls on doctors to prescribe physical activity, and the current curricular content and needs of family medicine residents. Almost all directors agreed that online educational resources developed to assist residents in physical activity prescription would be beneficial. By describing the provision, content and future direction of physical activity training in family medicine, physicians and medical educators can develop competencies and resources to meet this need. When we equip our future physicians with the necessary tools, we can improve patient outcomes and do our part to reduce the global epidemic of physical inactivity and chronic disease.

Health Outcomes after Pregnancy in Elite Athletes: A Systematic Review and Meta-analysis

PURPOSE

This study aimed to evaluate postpartum maternal health and training outcomes of females who were competing or training as elite athletes before or during pregnancy.

METHODS

Online databases were searched up to August 26, 2020. Studies of any design and language were eligible if they contained information on the relevant population (postpartum athletes [any period after pregnancy]), exposure (engaged in the highest level of sport immediately before or during pregnancy), comparators (sedentary/active controls), and outcomes: maternal (breastfeeding initiation and duration, postpartum weight retention or loss, bone mineral density, low back or pelvic girdle pain, incontinence [prevalence or severity of stress, urge or mixed urinary incontinence, fecal incontinence], injury, anemia, diastasis recti, breast pain, depression, anxiety) and training (<6 wk time to resume activity, training volume or intensity, performance level).

RESULTS

Eleven studies (n = 482 females, including 372 elite athletes) were included. We identified "very low" certainty evidence demonstrating a higher rate of return to sport before 6 wk postpartum among elite athletes compared with nonelite athletes (n = 145, odds ratio = 6.93, 95% confidence interval = 2.73-17.63, I2 = 11). "Very low" certainty evidence from three studies (n = 179) indicated 14 elite athletes obtained injuries postpartum (7 stress fractures, 9 "running injuries"). "Very low" certainty evidence from five studies (n = 262) reported that 101 (40.5%) elite athletes experienced improved performance postpartum.

CONCLUSION

Compared with controls, "very low" quality evidence suggests that elite athletes return to physical activity early in the postpartum period and may have an increased risk of injury. Additional high-quality evidence is needed to safely guide return to sport of elite athletes in the postpartum period.

[Cesarean scare niche: Definition, diagnosis, risk factors, prevention, symptoms, adverse effects, and treatments]

OBJECTIVES

To review the definitions, diagnostic methods, risk factors, symptoms, and treatments for caesarean scar niche.

METHODS

Review of the literature, critical reflection, and pragmatic advice.

RESULTS

There is no consensus on the definition of caesarean scar niche. Some suggest an indentation≥2mm of the myometrium of the caesarean scar, but this is present in more than half of women with caesarean history and takes no account of woman's symptoms. The most popular diagnostic method is ultrasound±hysterosonography. Risks factors for niche are multiple Caesareans, Cesarean during labor with too low incision, and retroverted uterus. Symptoms include abnormal gynaecologic bleeding and pelvic pain, and their presence establish the "Caesarean scar syndrome". The risks of pregnancy with niche is poorly studied, but pregnancy is not contraindicated, even if the niche is untreated. The treatment of caesarean scar niche is mainly surgery and conservative. The former should be reserved for symptomatic patients, and those with secondary infertility and fertility treatment failure. Patients with residual myometrium thickness≥2.5mm may benefit from first-line hysteroscopic treatment, whereas a laparoscopic or vaginal approach could be offered in other cases.

CONCLUSIONS

A pragmatic definition of caesarean scar niche as a disease including symptoms is the necessary prerequisite for the management of women. The treatment is mainly surgical, or conservative depending on the desire for subsequent pregnancy.

Improving endovascular access to the target vessel for thrombus aspiration -Use of the wedge device to overcome anatomic hurdles

BACKGROUND AND PURPOSE

Aspiration is a successful technique used in thrombectomy for acute stroke. It is contingent upon the appropriate position of the aspiration catheter, so that it is in contact with the thrombus. However, navigating the craniocervical vasculature is challenging is some patients. The wedge microcatheter (MicroVention®) is designed to reduce the gap between the microcatheter and the SofiaPlus 6F catheter for ease of advancement. The purpose of this study is to describe our initial experience with the wedge microcatheter.

MATERIALS AND METHODS

A retrospective review of 38 consecutive patients in whom the wedge microcatheter was used during thrombectomy was performed to determine whether the wedge microcatheter was successful in delivering the Sofia catheter to the desired location.

RESULTS

We have found this device to be successful in delivering the aspiration catheter to the correct position in 97% (N = 37) of cases. It was used predominantly to pass the origin of branching vessels and also to navigate the tortuous cavernous and petrous segments of the ICA.

CONCLUSION

The wedge microcatheter is a successful tool in delivering the aspiration catheter to the desired vessel for revascularisation.

Elite Athletes and Pregnancy Outcomes: A Systematic Review and Meta-analysis

PURPOSE

The purpose of this systematic review was to evaluate fetal and maternal pregnancy outcomes of elite athletes who had participated in competitive sport immediately before conception.

METHODS

Online databases were searched up to March 24, 2020. Studies of any design and language were eligible if they contained information on the relevant population (pregnant women), exposure (engaged in elite sport immediately before pregnancy), and outcomes (birth weight, low birth weight, macrosomia, preterm birth, fetal heart rate and pulse index, cesarean sections, instrumental deliveries, episiotomies, duration of labor, perineal tears, pregnancy-induced low back pain, pelvic girdle pain, urinary incontinence, miscarriages, prenatal weight gain, inadequate/excess prenatal weight gain, maternal depression or anxiety).

RESULTS

Eleven unique studies (n = 2256 women) were included. We identified "low" certainty evidence demonstrating lower rates of low back pain in elite athletes compared with active/sedentary controls (n = 248; odds ratio, 0.38; 95% confidence interval, 0.20-0.73; I2 = 0%) and "very low" certainty evidence indicating an increased odds of excessive prenatal weight gain in elite athletes versus active/sedentary controls (n = 1763; odds ratio, 2.47; 95% confidence interval, 1.26-4.85; I2 = 0%). Low certainty evidence from two studies (n = 7) indicated three episodes of fetal bradycardia after high-intensity exercise that resolved within 10 min of cessation of activity. No studies reported inadequate gestational weight gain or maternal depression or anxiety. There were no differences between elite athletes and controls for all other outcomes.

CONCLUSIONS

There is "low" certainty of evidence that elite athletes have reduced odds of experiencing pregnancy-related low back pain and "very low"certainty of evidence that elite athletes have increased the odds of excessive weight gain compared with active/sedentary controls. More research is needed to provide strong evidence of how elite competitive sport before pregnancy affects maternal and fetal outcomes.PROSPERO Registration: CRD42020167382.

Zinc Gluconate Induces Potentially Cancer Chemopreventive Activity in Barrett's Esophagus: A Phase 1 Pilot Study

BACKGROUND

Chemopreventive effects of zinc for esophageal cancer have been well documented in animal models. This prospective study explores if a similar, potentially chemopreventive action can be seen in Barrett's esophagus (BE) in humans.

AIMS

To determine if molecular evidence can be obtained potentially indicating zinc's chemopreventive action in Barrett's metaplasia.

METHODS

Patients with a prior BE diagnosis were placed on oral zinc gluconate (14 days of 26.4 mg zinc BID) or a sodium gluconate placebo, prior to their surveillance endoscopy procedure. Biopsies of Barrett's mucosa were then obtained for miRNA and mRNA microarrays, or protein analyses.

RESULTS

Zinc-induced mRNA changes were observed for a large number of transcripts. These included downregulation of transcripts encoding proinflammatory proteins (IL32, IL1β, IL15, IL7R, IL2R, IL15R, IL3R), upregulation of anti-inflammatory mediators (IL1RA), downregulation of transcripts mediating epithelial-to-mesenchymal transition (EMT) (LIF, MYB, LYN, MTA1, SRC, SNAIL1, and TWIST1), and upregulation of transcripts that oppose EMT (BMP7, MTSS1, TRIB3, GRHL1). miRNA arrays showed significant upregulation of seven miRs with tumor suppressor activity (-125b-5P, -132-3P, -548z, -551a, -504, -518, and -34a-5P). Of proteins analyzed by Western blot, increased expression of the pro-apoptotic protein, BAX, and the tight junctional protein, CLAUDIN-7, along with decreased expression of BCL-2 and VEGF-R2 were noteworthy.

CONCLUSIONS

When these mRNA, miRNA, and protein molecular data are considered collectively, a cancer chemopreventive action by zinc in Barrett's metaplasia may be possible for this precancerous esophageal tissue. These results and the extensive prior animal model studies argue for a future prospective clinical trial for this safe, easily-administered, and inexpensive micronutrient, that could determine if a chemopreventive action truly exists.

COVID-19-Myocarditis and Return to Play: Reflections and Recommendations From a Canadian Working Group

The COVID-19–related pandemic has resulted in profound health, financial, and societal impacts. Organized sporting events, from recreational to the Olympic level, have been cancelled to both mitigate the spread of COVID-19 and protect athletes and highly active individuals from potential acute and long-term infection-associated harms. COVID-19 infection has been associated with increased cardiac morbidity and mortality. Myocarditis and late gadolinium enhancement as a result of COVID-19 infection have been confirmed. Correspondingly, myocarditis has been implicated in sudden cardiac death of athletes. A pragmatic approach is required to guide those who care for athletes and highly active persons with COVID-19 infection. Members of the Community and Athletic Cardiovascular Health Network (CATCHNet) and the writing group for the Canadian Cardiovascular Society/Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes recommend that highly active persons with suspected or confirmed COVID-19 infection refrain from exercise for 7 days after resolution of viral symptoms before gradual return to exercise. We do not recommend routine troponin testing, resting 12-lead electrocardiography, echocardiography, or cardiac magnetic resonance imaging before return to play. However, medical assessment including history and physical examination with consideration of resting electrocardiography and troponin can be considered in the athlete manifesting new active cardiac symptoms or a marked reduction in fitness. If concerning abnormalities are encountered at the initial medical assessment, then referral to a cardiologist who cares for athletes is recommended.

Fetal cerebral Doppler changes and outcome in late preterm fetal growth restriction: prospective cohort study

OBJECTIVES

To explore the association between fetal umbilical and middle cerebral artery (MCA) Doppler abnormalities and outcome in late preterm pregnancies at risk of fetal growth restriction.

METHODS

This was a prospective cohort study of singleton pregnancies at risk of fetal growth restriction at 32 + 0 to 36 + 6 weeks of gestation, enrolled in 33 European centers between 2017 and 2018, in which umbilical and fetal MCA Doppler velocimetry was performed. Pregnancies were considered at risk of fetal growth restriction if they had estimated fetal weight and/or abdominal circumference (AC) < 10^th percentile, abnormal arterial Doppler and/or a fall in AC growth velocity of more than 40 percentile points from the 20-week scan. Composite adverse outcome comprised both immediate adverse birth outcome and major neonatal morbidity. Using a range of cut-off values, the association of MCA pulsatility index and umbilicocerebral ratio (UCR) with composite adverse outcome was explored.

RESULTS

The study population comprised 856 women. There were two (0.2%) intrauterine deaths. Median gestational age at delivery was 38 (interquartile range (IQR), 37-39) weeks and birth weight was 2478 (IQR, 2140-2790) g. Compared with infants with normal outcome, those with composite adverse outcome (n = 93; 11%) were delivered at an earlier gestational age (36 vs 38 weeks) and had a lower birth weight (1900 vs 2540 g). The first Doppler observation of MCA pulsatility index < 5^th percentile and UCR Z-score above gestational-age-specific thresholds (1.5 at 32-33 weeks and 1.0 at 34-36 weeks) had the highest relative risks (RR) for composite adverse outcome (RR 2.2 (95% CI, 1.5-3.2) and RR 2.0 (95% CI, 1.4-3.0), respectively). After adjustment for confounders, the association between UCR Z-score and composite adverse outcome remained significant, although gestational age at delivery and birth-weight Z-score had a stronger association.

CONCLUSION

In this prospective multicenter study, signs of cerebral blood flow redistribution were found to be associated with adverse outcome in late preterm singleton pregnancies at risk of fetal growth restriction. Whether cerebral redistribution is a marker describing the severity of fetal growth restriction or an independent risk factor for adverse outcome remains unclear, and whether it is useful for clinical management can be answered only in a randomized trial. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

SAT0332 ANTIBODIES AGAINST CYTOSOLIC 5’-NUCLEOTIDASE 1A IN SPORADIC INCLUSION BODY MYOSITIS: ASSOCIATION WITH CLINICAL AND MRI FEATURES

Background:

Autoantibodies directed against cytosolic 5´-nucleotidase 1A (cN1A) have been identified in sporadic inclusion body myositis (sIBM) and other connective tissue diseases. Anti-cN1A antibodies may support the diagnostic process for sIBM as well as potentially provide clues for disease pathogenesis. Nevertheless, the utility of anti-cN1A autoantibody testing in clinical practice remains unclear and requires validation.

Objectives:

To investigate the association between anti-cN1A antibody status and clinical and MRI features in patients with sIBM.

Methods:

Data for patients fulfilling European Neuromuscular Centre (ENMC) 2011 criteria for sIBM were obtained from a natural history study database. Demographic, clinical, functional assessment, and muscle MRI data in patients with sIBM who had anti-cN1A autoantibody testing were collected and analysed. Comparisons between subgroups with anti-cN1A antibody status were performed with the Mann-Whitney or Fisher’s exact tests, as appropriate.

Results:

Forty-nine patients with sIBM had anti-cN1A autoantibody testing, of whom 17 (34.7%) were positive. Twelve patients had muscle MRI performed (seropositivity=5). Demographics, disease duration at antibody testing and overall disease pattern were closely matched in antibody positive and negative cohorts. Dysphagia was more common in the seropositive subgroup (77% vs 47%, p=0.070). Antibody positive patients were more severely affected with a trend to lower IBM functional rating scale (IBMFRS) scores (22.4±8.4 vs 26.7±6.4, p=0.09) with significantly worse ability to climb stairs (0.9±0.9, 1.7±1.1, p=0.02). On T1-weighted MRI more fatty infiltration was found in seropositive patients (Mercuri score: 3.0±0.8 vs 1.7±0.7, p=0.03). Short tau inversion recovery (STIR) hyperintensity was more conspicuous in seropositive patients (STIR extent score: 2.4±0.6 vs 1.4±0.7, p=0.04).

Conclusion:

There was a trend for more dysphagia and severity of dysphagia in seropositive patients. Differences in upper limb involvement were not seen according to IBMFRS and Medical Research Council (MRC) strength grades. Seropositive patients were more severely affected at the lower limb level, in terms of muscle weakness, physical function, MRI fatty infiltration and muscle inflammation. These results suggest positive antibody status is associated with a worse phenotype. These results have potential implications in clinical trials: whether antibody status influences treatment response should be assessed.

Disclosure of Interests:

Revadee Dejthevaporn: None declared, Sachit Shah: None declared, Stephen Wastling: None declared, John Thornton: None declared, Tarek Yousry: None declared, Jasper M Morrow: None declared, Pedro M Machado Consultant of: PMM: Abbvie, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Speakers bureau: PMM: Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche and UCB

Feasibility of an Electronic Health Tool to Promote Physical Activity in Primary Care: Pilot Cluster Randomized Controlled Trial

Background

Physical inactivity is associated with increased health risks. Primary care providers (PCPs) are well positioned to support increased physical activity (PA) levels through screening and provision of PA prescriptions. However, PCP counseling on PA is not common.

Objective

This study aimed to assess the feasibility of implementing an electronic health (eHealth) tool to support PA counseling by PCPs and estimate intervention effectiveness on patients’ PA levels.

Methods

A pragmatic pilot study was conducted using a stepped wedge cluster randomized trial design. The study was conducted at a single primary care clinic, with 4 pre-existing PCP teams. Adult patients who had a periodic health review (PHR) scheduled during the study period were invited to participate. The eHealth tool involved an electronic survey sent to participants before their PHR via an email or a tablet; data were used to automatically produce tailored resources and a PA prescription in the electronic medical record of participants in the intervention arm. Participants assigned to the control arm received usual care from their PCP. Feasibility was assessed by the proportion of completed surveys and patient-reported acceptability and fidelity measures. The primary effectiveness outcome was patient-reported PA at 4 months post-PHR, measured as metabolic equivalent of task (MET) minutes per week. Secondary outcomes assessed determinants of PA, including self-efficacy and intention to change based on the Health Action Process Approach behavior change theory.

Results

A total of 1028 patients receiving care from 34 PCPs were invited to participate and 530 (51.55%) consented (intervention [n=296] and control [n=234]). Of the participants who completed a process evaluation, almost half (88/178, 49.4%) stated they received a PA prescription, with only 42 receiving the full intervention including tailored resources from their PCP. A cluster-level linear regression analysis yielded a non–statistically significant positive difference in MET-minutes reported per week at follow-up between intervention and control conditions (mean difference 1027; 95% CI −155 to 2209; P=.09). No statistically significant differences were observed for secondary outcomes.

Conclusions

Our results suggest that it is feasible to build an eHealth tool that screens and provides tailored resources for PA in a primary care setting but suboptimal intervention fidelity suggests greater work must be done to address PCP barriers to resource distribution. Participant responses to the primary effectiveness outcome (MET-minutes) were highly variable, reflecting a need for more robust measures of PA in future trials to address limitations in patient-reported data.

Trial Registration

ClinicalTrials.gov NCT03181295; https://clinicaltrials.gov/ct2/show/NCT03181295

Monitoring distributed computing beyond the traditional time-series histogram

In this work we describe a novel approach to monitor the operation of distributed computing services. Current monitoring tools are dominated by the use of time-series histograms showing the evolution of various metrics. These can quickly overwhelm or confuse the viewer due to the large number of similar looking graphs. We propose a supplementary approach through the sonification of real-time data streamed directly from a variety of distributed computing services. The real-time nature of this method allows operations staff to quickly detect problems and identify that a problem is still ongoing, avoiding the case of investigating an issue a-priori when it may already have been resolved. In this paper we present details of the system architecture and provide a recipe for deployment suitable for both site and experiment teams.

Review of external referrals to a regional stroke centre: it is not just about thrombectomy

AIMS

To determine the experience of a regional stroke referral centre of external referrals for endovascular thrombectomy (EVT) in patients with symptoms of acute ischaemic stroke (AIS) and large vessel occlusion (LVO).

MATERIALS AND METHODS

Data were collected prospectively over two 4-month periods (2017-2018) on consecutive external referrals for EVT. Baseline demographics, imaging findings, and key time parameters were recorded. Reasons for not transferring patients and for not performing EVT were recorded. Key time intervals were calculated and compared between the transferred and non-transferred group with and without intracranial occlusion and between the transferred patients who underwent thrombectomy and those who did not.

RESULTS

Two hundred and sixty-two patients were referred. Sixty-one percent (n=159) were accepted and transferred for treatment. Of those transferred, 86% (n=136) had EVT. Fourteen percent (n=23) were unsuitable for EVT on arrival due to no vessel occlusion (48% n=11), poor Alberta Stroke Program Early CT Score (ASPECTS)/established infarct (30%, n=7) haemorrhage (9%, n=2), and clinical recovery (13% n=3). One hundred and three patients (39%) were ineligible for EVT following phone discussion due to absence of intracranial occlusion (59%, n=61), low ASPECTS (22%, n=23), distal occlusion (4%, n=4), low/improving National Institutes of Health Stroke Scale (NIHSS; 10.7%, n=11), and poor modified Rankin Scale (mRS) at baseline (3%, n=3). Patients with LVO but not transferred had longer onset to hospital arrival time compared with those transferred 151.5 versus 91 minutes (p<0.005), with a trend also toward a longer door to CT/CTA 40 minutes versus 30 minutes (p=0.142).

CONCLUSION

These data provide valuable insights into the service provision of a comprehensive stroke network. The present rates of EVT and futile transfers are modest compared to published data. Access to neuroradiology and specialised stroke assessment is crucial to optimise time to treatment.

A Standardized Aspiration-First Approach for Thrombectomy to Increase Speed and Improve Recanalization Rates

BACKGROUND AND PURPOSE

Direct aspiration is a recognized technique for revascularization in large-vessel ischemic strokes. There is ongoing debate regarding its efficacy compared with stent retrievers. Every delay in achieving revascularization and a decrease in reperfusion rates reduces the likelihood of patients achieving functional independence. We propose a standardized setup technique for aspiration-first for all anterior circulation thrombectomy procedures for increasing speed and recanalization rates.

MATERIALS AND METHODS

We analyzed 127 consecutive patients treated by a standardized approach to thrombectomy with an intention to perform aspiration-first compared with 127 consecutive patients treated with a stent retriever-first approach. Key time metrics evaluated included groin to first angiogram, first angiogram to reperfusion, groin to first reperfusion, and length of the procedure. The degree of successful recanalization (TICI 2b-3) and the number of passes were compared between the 2 groups.

RESULTS

In 127 patients who underwent the standardized technique, the median time from groin puncture to first reperfusion was 18 minutes compared with 26 minutes (P < .001). The duration of the procedure was shorter compared with the stent retriever group (26 minutes in the aspiration first group versus 47 minutes, P < .001) and required fewer passes (mean, 2.4 versus 3.1; P < .05). A higher proportion of patients had a TICI score of 2b-3 in the aspiration-first group compared with stent retriever group (96.1% versus 85.8%, P < .005).

CONCLUSIONS

Our study highlights the increasing speed and recanalization rates achieved with fewer passes in a standardized approach to thrombectomy with an intention to attempt aspiration-first. Any attempt to reduce revascularization time and increase successful recanalization should be used.

Delivery or expectant management for prevention of adverse maternal and neonatal outcomes in hypertensive disorders of pregnancy: an individual participant data meta-analysis

OBJECTIVE

Hypertensive disorders affect 3-10% of pregnancies. Delayed delivery carries maternal risks, while early delivery increases fetal risk, so appropriate timing is important. The aim of this study was to compare immediate delivery with expectant management for prevention of adverse maternal and neonatal outcomes in women with hypertensive disease in pregnancy.

METHODS

CENTRAL, PubMed, MEDLINE and ClinicalTrials.gov were searched for randomized controlled trials comparing immediate delivery to expectant management in women presenting with gestational hypertension or pre-eclampsia without severe features from 34 weeks of gestation. The primary neonatal outcome was respiratory distress syndrome (RDS) and the primary maternal outcome was a composite of HELLP syndrome and eclampsia. The PRISMA-IPD guideline was followed and a two-stage meta-analysis approach was used. Relative risks (RR) and numbers needed to treat or harm (NNT/NNH) with 95% CI were calculated to evaluate the effect of the intervention.

RESULTS

Main outcomes were available for 1724 eligible women. Compared with expectant management, immediate delivery reduced the composite risk of HELLP syndrome and eclampsia in all women (0.8% vs 2.8%; RR, 0.33 (95% CI, 0.15-0.73); I2  = 0%; NNT, 51 (95% CI, 31.1-139.3)) as well as in the pre-eclampsia subgroup (1.1% vs 3.5%; RR, 0.39 (95% CI, 0.15-0.98); I2  = 0%). Immediate delivery increased RDS risk (3.4% vs 1.6%; RR, 1.94 (95% CI 1.05-3.6); I2  = 24%; NNH, 58 (95% CI, 31.1-363.1)), but depended upon gestational age. Immediate delivery in the 35th week of gestation increased RDS risk (5.1% vs 0.6%; RR, 5.5 (95% CI, 1.0-29.6); I2  = 0%), but immediate delivery in the 36th week did not (1.5% vs 0.4%; RR, 3.4 (95% CI, 0.4-30.3); I2 not applicable).

CONCLUSION

In women with hypertension in pregnancy, immediate delivery reduces the risk of maternal complications, whilst the effect on the neonate depends on gestational age. Specifically, women with a-priori higher risk of progression to HELLP, such as those already presenting with pre-eclampsia instead of gestational hypertension, were shown to benefit from earlier delivery. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Current evidence for endovascular therapy in stroke and remaining uncertainties

Class 1 level A evidence now supports endovascular thrombectomy as best practice in the management of large vessel occlusion acute ischaemic stroke. However, significant questions pertaining to initial imaging, radiological assessment, patient selection and therapeutic limits remain unanswered. A specific cohort of patients who benefit from endovascular thrombectomy has been established, although current uncertainties regarding selection of those not meeting top-tier evidence criteria may potentially deny certain patients the benefit of intervention. This is of particular relevance in patients presenting in a delayed manner. Whilst superior outcomes are achieved with reduced time to endovascular reperfusion, denying patients intervention based on symptom duration alone may not be appropriate. Advanced understanding of ischaemic stroke pathophysiology supports an individualized approach to patient evaluation, given variance in the rate of ischaemic core progression and the extent of salvageable penumbra. Physiological imaging techniques may therefore be utilized to better inform patient selection for endovascular thrombectomy and evidence suggests that a transition from time-based to tissue-based therapeutic thresholds may be of greater value. Multiple ongoing randomized controlled trials aim to further define the benefit of endovascular thrombectomy and it is hoped that these results will advance, and possibly broaden, patient selection criteria to ensure that maximum benefit from the intervention may be achieved.

Outcomes of endovascular treatment for acute large-vessel ischaemic stroke more than 6 h after symptom onset

BACKGROUND AND OBJECTIVES

Benefit from endovascular thrombectomy (EVT) for large-vessel occlusion (LVO) acute ischaemic stroke (AIS) is well demonstrated. Furthermore, emerging evidence supports efficacy in appropriately selected patients treated beyond current recommendations of 6 h. We evaluated clinical outcomes in patients undergoing late EVT at our institution.

METHODS

Retrospective review of prospectively collected clinical database on 355 patients who underwent EVT for LVO AIS. Data collected consisted of patient demographics, radiological findings and outcome details. Outcomes, including 90-day functional status, recanalization, symptomatic intracranial haemorrhage (sICH) and 90-day mortality, for patients undergoing EVT <6 h, >6 h, and >7.3 h, were compared.

RESULTS

A total of 355 patients underwent EVT for LVO AIS at our institution during the review period, with 74 (21%) patients treated ≥6 h from symptom onset. Successful recanalization was achieved in 285 (80%) patients, with 228 (81%) achieving a mTICI ≥2b in the <6 h group, and 57 (77%) in the >6 h group (P = 0.429). Ninety-day functional independence (mRS 0-2) was achieved in 162 (46%) patients, with 130 (46%) achieving a mRS of 0-2 in the <6 h group, and 32 (43%) in the >6 h group (P = 0.643). No significant differences were found in rates of sICH or 90-day mortality. No significant differences in functional independence, recanalization rates, sICH or mortality were identified in patients treated with EVT >7.3 h compared to <7.3 h.

CONCLUSIONS

In appropriately selected patients, EVT >6 h was associated with comparable outcomes to those treated <6 h. These data support a physiological approach to patient selection.

Is middle cerebral artery Doppler related to neonatal and 2-year infant outcome in early fetal growth restriction?

BACKGROUND

Reduced fetal middle cerebral artery Doppler impedance is associated with hypoxemia in fetal growth restriction. It remains unclear as to whether this finding could be useful in timing delivery, especially in the third trimester. In this regard there is a paucity of evidence from prospective studies.

OBJECTIVES

The aim of this study was to determine whether there is an association between middle cerebral artery Doppler impedance and its ratio with the umbilical artery in relation to neonatal and 2 year infant outcome in early fetal growth restriction (26⁺⁰-31⁺⁶ weeks of gestation). Additionally we sought to explore which ratio is more informative for clinical use.

STUDY DESIGN

This is a secondary analysis from the Trial of Randomized Umbilical and Fetal Flow in Europe, a prospective, multicenter, randomized management study on different antenatal monitoring strategies (ductus venosus Doppler changes and computerized cardiotocography short-term variation) in fetal growth restriction diagnosed between 26⁺⁰ and 31⁺⁶ weeks. We analyzed women with middle cerebral artery Doppler measurement at study entry and within 1 week before delivery and with complete postnatal follow-up (374 of 503). The primary outcome was survival without neurodevelopmental impairment at 2 years corrected for prematurity. Neonatal outcome was defined as survival until first discharge home without severe neonatal morbidity. Z-scores were calculated for middle cerebral artery pulsatility index and both umbilicocerebral and cerebroplacental ratios. Odds ratios of Doppler parameter Z-scores for neonatal and 2 year infant outcome were calculated by multivariable logistic regression analysis adjusted for gestational age and birthweight p50 ratio.

RESULTS

Higher middle cerebral artery pulsatility index at inclusion but not within 1 week before delivery was associated with neonatal survival without severe morbidity (odds ratio, 1.24; 95% confidence interval, 1.02-1.52). Middle cerebral artery pulsatility index Z-score and umbilicocerebral ratio Z-score at inclusion were associated with 2 year survival with normal neurodevelopmental outcome (odds ratio, 1.33; 95% confidence interval, 1.03-1.72, and odds ratio, 0.88; 95% confidence interval, 0.78-0.99, respectively) as were gestation at delivery and birthweight p50 ratio (odds ratio, 1.41; 95% confidence interval, 1.20-1.66, and odds ratio, 1.86; 95% confidence interval, 1.33-2.60, respectively). When comparing cerebroplacental ratio against umbilicocerebral ratio, the incremental range of the cerebroplacental ratio tended toward zero, whereas the umbilicocerebral ratio tended toward infinity as the values became more abnormal.

CONCLUSION

In a monitoring protocol based on ductus venosus and cardiotocography in early fetal growth restriction (26⁺⁰-31⁺⁶ weeks of gestation), the impact of middle cerebral artery Doppler and its ratios on outcome is modest and less marked than birthweight and delivery gestation. It is unlikely that middle cerebral artery Doppler and its ratios are informative in optimizing the timing of delivery in fetal growth restriction before 32 weeks of gestation. The umbilicocerebral ratio allows for a better differentiation in the abnormal range than the cerebroplacental ratio.