First-trimester maternal serum PAPP-A and free-beta subunit human chorionic gonadotropin concentrations and nuchal translucency are associated with obstetric complications: a population-based screening study (the FASTER Trial)

Association of early-preterm birth with abnormal levels of routinely collected first- and second-trimester biomarkers

OBJECTIVE

The purpose of this study was to examine the relationship between typically measured prenatal screening biomarkers and early-preterm birth in euploid pregnancies.

STUDY DESIGN

The study included 345 early-preterm cases (<30 weeks of gestation) and 1725 control subjects who were drawn from a population-based sample of California pregnancies who had both first- and second-trimester screening results. Logistic regression analyses were used to compare patterns of biomarkers in cases and control subjects and to develop predictive models. Replicability of the biomarker early-preterm relationships that was revealed by the models was evaluated by examination of the frequency and associated adjusted relative risks (RRs) for early-preterm birth and for preterm birth in general (<37 weeks of gestation) in pregnancies with identified abnormal markers compared with pregnancies without these markers in a subsequent independent California cohort of screened pregnancies (n = 76,588).

RESULTS

The final model for early-preterm birth included first-trimester pregnancy-associated plasma protein A in the ≤5th percentile, second-trimester alpha-fetoprotein in the ≥95th percentile, and second-trimester inhibin in the ≥95th percentile (odds ratios, 2.3-3.6). In general, pregnancies in the subsequent cohort with a biomarker pattern that were found to be associated with early-preterm delivery in the first sample were at an increased risk for early-preterm birth and preterm birth in general (<37 weeks of gestation; adjusted RR, 1.6-27.4). Pregnancies with ≥2 biomarker abnormalities were at particularly increased risk (adjusted RR, 3.6-27.4).

CONCLUSION

When considered across cohorts and in combination, abnormalities in routinely collected biomarkers reveal predictable risks for early-preterm birth.

Gestational diabetes mellitus: including serum pregnancy-associated plasma protein-A testing in the clinical management of primiparous women? A case-control study

AIMS

To assess pregnancy-associated plasma protein A (PAPP-A) correlation with GDM and its usefulness in predicting GDM in primiparous women.

METHODS

First trimester data related to 307 pregnant women affected by GDM and 366 control pregnant women were retrieved from a computer data base and integrated with ad hoc data. Clinical data were recorded at delivery. A logistic model was used to analyze the association between first trimester data and subsequent clinical outcomes. We derived a risk score using both classical risk factors for GDM and PAPP-A.

RESULTS

Diabetic and control women were significantly different in terms of age (p<0.001), BMI (p<0.001), weight (p<0.001), family history of diabetes (p<0.001), PAPP-A concentration and PAPP-A corrected multiple of the median (MoM) (p<0.001). The ROC-AUC of the clinical risk score was 0.60 (95%CI 0.56-0.64), the adjusted score including PAPP-A MoM was 0.70 (95%CI 0.66-0.74).

CONCLUSIONS

Low PAPP-A was strongly associated with GDM and lower values were found in diabetic women needing insulin therapy. Adding PAPP-A to first trimester screening could improve the prediction of women at high risk who will develop GDM. Further studies are needed to validate the applicability of our findings in different populations and settings.

First trimester maternal serum pregnancy-associated plasma protein-A is a predictive factor for early preterm delivery in normotensive pregnancies

In this study, we investigated whether the concentrations of pregnancy-associated plasma protein-A (PAPP-A) or free β-hCG (fβhCG) in the first trimester can identify women at increased risk of subsequent preterm delivery in the absence of hypertensive disorders. Preterm and early preterm deliveries are defined as those deliveries before completing 37 and 34 weeks, respectively. A total of 868 women were enrolled into this study. According to the level of the markers, the patients were evaluated in three groups: 1 - maternal serum level ≤ 5 th percentile, 2 - between 5th and 95th percentiles, 3 - ≥ 95 th percentile. In the group of patients with a PAPP-A level ≤ 5 th percentile [≤ 0.35 multiples of the median (MoM)], mean gestational age (GA) at delivery, mean birth weight and the number of the cases with early preterm delivery were significantly lower than the others. Mean level of PAPP-A was significantly lower in cases with early preterm than term deliveries (0.58 ± 0.32 versus 1.09 ± 0.69; p = 0.01). Maternal serum level of fβhCG did not show significant difference between these groups (0.84 ± 0.45 versus 1.17 ± 0.77; p = 0.15). Low levels of maternal serum PAPP-A (≤ 0.35 MoM) (Odds ratio = 7; 95% confidence interval 1.8-27.7; p = 0.0048) significantly predicted early preterm delivery in normotensive pregnancies. Women with low levels of PAPP-A at first trimester have a higher risk of early preterm delivery even in the absence of hypertensive disorders.

IVF culture medium affects human intrauterine growth as early as the second trimester of pregnancy

STUDY QUESTION

When does a difference in human intrauterine growth of singletons conceived after IVF and embryo culture in two different culture media appear?

SUMMARY ANSWER

Differences in fetal development after culture of embryos in one of two IVF media were apparent as early as the second trimester of pregnancy.

WHAT IS KNOWN ALREADY

Abnormal fetal growth patterns are a major risk factor for the development of chronic diseases in adult life. Previously, we have shown that the medium used for culturing embryos during the first few days after fertilization significantly affects the birthweight of the resulting human singletons. The exact onset of this growth difference was unknown.

STUDY DESIGN, SIZE AND DURATION

In this retrospective cohort study, all 294 singleton live births after fresh embryo transfer in the period July 2003 to December 2006 were included. These embryos originated from IVF treatments that were part of a previously described clinical trial. Embryos were allocated to culture in either Vitrolife or Cook commercially available sequential culture media.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We analysed ultrasound examinations at 8 (n = 290), 12 (n = 83) and 20 weeks' (n = 206) gestation and used first-trimester serum markers [pregnancy-associated plasma protein-A (PAPP-A) and free β-hCG]. Differences between study groups were tested by the Student's t-test, χ(2) test or Fisher's exact test, and linear multivariable regression analysis to adjust for possible confounders (for example, parity, gestational age at the time of ultrasound and fetal gender).

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 294 singleton pregnancies (Vitrolife group nVL = 168, Cook group: nC = 126) from 294 couples were included. At 8 weeks' gestation, there was no difference between crown-rump length-based and ovum retrieval-based gestational age (ΔGA) (nVL = 163, nC = 122, adjusted mean difference, -0.04 days, P = 0.84). A total of 83 women underwent first-trimester screening at 12 weeks' gestation (nVL = 45, nC = 38). ΔGA, nuchal translucency (multiples of median, MoM) and PAPP-A (MoM) did not differ between the study groups. Free β-hCG (MoM) ± SEM differed significantly (1.55 ± 0.19 in Vitrolife versus 1.06 ± 0.10 in Cook; P = 0.031, Student's t-test). At 20 weeks' gestation, a more advanced GA, reflecting an increased fetal growth, was seen at ultrasound examination in the Vitrolife group (n = 115) when compared with the Cook group (n = 91). After adjustment for confounding factors, both the difference between GA based on three biparietal diameter dating formulas minus the actual (ovum retrieval based) GA (adjusted mean difference + 1.14 days (P = 0.04), +1.14 days (P = 0.04) and +1.36 days (P = 0.048)), as well as head circumference (HC) and trans-cerebellar diameter (TCD) were significantly higher in the Vitrolife group (HCvl 177.3 mm, HCc 175.9 mm, adjusted mean difference 1.8, P = 0.03; TCDvl 20.5 mm, TCDc 20.2 mm, adjusted mean difference 0.4, P = 0.008).

LIMITATIONS, REASONS FOR CAUTION

A first trimester (12 weeks) fetal screening was not yet offered routinely during the study period, therefore only 28% of women in our study participated in this elective screening programme. Although all sonographers were experienced and specially trained to perform these ultrasound examinations and were unaware of the randomization procedure, we cannot totally rule out possible intra- and inter-observer variability. Despite being indispensable in daily practice, sonographic weight formulas have a limited accuracy.

WIDER IMPLICATIONS OF THE FINDINGS

According to the fetal origins hypothesis, many adult diseases originate in utero owing to adaptations made by the fetus to the environment it encounters. This study indicates that the embryonic environment is already important for fetal development. Therefore, our study emphasizes the need to investigate fetal growth patterns after assisted reproduction technologies and long-term health outcomes of IVF children, especially in relation to the culture medium used during the first few days of preimplantation development.

TRIAL REGISTRATION NUMBER

Not applicable.

The obstetric syndromes: clinical relevance of placental hormones

Preterm delivery, preeclampsia and intrauterine growth restriction are the major diseases of pregnancy. A key role in their pathogenesis is played by the placenta, which is the source of hormones and other important regulatory molecules providing the metabolic and endocrine homeostasis of the fetal-placental unit. Since obstetric syndromes are characterized by important maternal and neonatal morbidity and mortality worldwide, numerous efforts have been made over the years to prevent and treat them. Due to their complex pathogenesis, however, the therapy is poor and not very effective. Therefore, great emphasis is currently given to the prevention of these diseases through the identification of biochemical and biophysical markers, among which placental factors play a crucial role. The increasing knowledge of the role of placental molecules can indeed lead to the development of new therapeutic and diagnostic tools.

Can first-trimester screening program detect women at high risk for gestational diabetes mellitus?

This study was designed to compare first-trimester maternal serum biochemical markers of aneuploidy and fetal nuchal translucency in pregnancies complicated by gestational diabetes mellitus and those of a control group. The study included 60 gestational diabetic and 60 control women who attended the first-trimester combined screening program for Down syndrome between 11 and 14 gestational weeks with complete follow-up data and delivered in our institution. Maternal serum free β-human chorionic gonadotropin, pregnancy-associated plasma protein-A and fetal nuchal translucency were investigated. The combined risks, double test risks and age risks were calculated by PRISCA software version 4.0. Comparison of the results between the two groups yielded no significant differences in serum levels of free β-human chorionic gonadotropin and fetal nuchal translucency. However, women who developed gestational diabetes mellitus had significantly lower pregnancy-associated plasma protein-A. And also, the combined risks and double test risks calculated by PRISCA software were statistically higher in gestational diabetic women than normal pregnant women. These results suggest that differences can be seen between diabetic and healthy pregnant women in first-trimester maternal serum biochemical markers of aneuploidy.

Diagnosis of cleft lip-palate during nuchal translucency screening – case report and review of the literature

Orofacial clefts are the most common group of craniofacial anomalies. The detection rate of cleft lip during the mid-trimester, using two-dimensional (2D) ultrasound screening, has improved over the last three decades. However, the detection rates of defects involving the hard palate or isolated cleft palate have remained poor. Over the last decade, many investigators have studied the use of 3D ultrasound to improve the detection rates of these defects. With the increasing use and acceptance of first-trimester aneuploidy screening in the US, there is growing interest in performing first-trimester fetal anatomy surveys. Reports of first-trimester diagnosis of cleft lip and palate are rare, and this aspect of prenatal sonographic diagnosis remains underexplored. We report a case of unilateral cleft lip and cleft palate diagnosed during a routine first-trimester screening at 12 weeks’ gestation and review the pertinent literature on first-trimester diagnosis of cleft lip/palate.

Natural selection in utero induced by mass layoffs: the hCG evidence

Evolutionary theory, when coupled with research from epidemiology, demography, and population endocrinology, suggests that contracting economies affect the fitness and health of human populations via natural selection in utero. We know, for example, that fetal death increases more among males than females when the economy unexpectedly contracts; that unexpected economic contraction predicts low secondary sex ratios; and that males from low sex ratio birth cohorts live, on average, longer than those from high sex ratio cohorts. We also know that low levels of human chorionic gonadotropin (i.e., hCG) measured in the serum of pregnant women predict fetal death. We do not, however, know whether male survivors of conception cohorts subjected to contracting economies exhibit, as theory predicts, higher hCG than those from other cohorts. We show, in 71 monthly conception cohorts including nearly two million California births, that they do. We thereby add to the literature suggesting that the economy, a phenomenon over which we collectively exercise at least some control, affects population health. Our findings imply that the effect arises via natural selection - a mechanism we largely ignore when attempting to explain, or alter, how collective choice affects our biology.

A test of maternal human chorionic gonadotropin during pregnancy as an adaptive filter of human gestations

The risk of abnormalities and morbidity among live births increases with advanced maternal age. Explanations for this elevated morbidity invoke several maternal mechanisms. The relaxed filter stringency (RFS) hypothesis asserts that mothers, nearing the end of their reproductive lifespan, reduce the stringency of a screen of offspring quality in utero based on life-history traits of parity and interbirth interval (IBI). A separate line of research implicates human chorionic gonadotropin (hCG) during pregnancy as a signal of offspring quality. We test the RFS hypothesis directly by examining whether the difference in gestational hCG across consecutive live births varies positively with the mother's number of previous live births but inversely with her most recent IBI. We applied multivariable regression methods to a unique dataset of gestational hCG for over 500 000 live births from 2002 to 2007. The difference in gestational hCG across mothers' consecutive live births varies positively with both mothers' parity and IBI. These associations remain similar among older mothers (35+ years). Findings support the RFS hypothesis for the parity expectation but not for the IBI expectation. Further evidence for the RFS hypothesis among contemporary human gestations would have to invoke screening mechanisms other than hCG.

First-trimester prediction of preterm birth using ADAM12, PAPP-A, uterine artery Doppler, and maternal characteristics

OBJECTIVE

The objective of this study was to estimate the efficiency of first-trimester a disintegrin and metalloprotease 12 (ADAM12), pregnancy-associated plasma protein A (PAPP-A), uterine artery Doppler, and maternal characteristics in the prediction of preterm birth (PTB).

METHODS

This was a prospective cohort study of patients presenting for first-trimester aneuploidy screening. Maternal serum ADAM12 and PAPP-A levels were measured by immunoassay, and mean uterine artery Doppler pulsatility indices were calculated. The primary outcome was PTB <34 weeks' gestation, and the secondary outcome was PTB <37 weeks' gestation. Logistic regression was used to model the prediction of PTB using ADAM12, PAPP-A, uterine artery Doppler, and maternal characteristics, individually and in combination. Sensitivity, specificity, and area under the receiver-operating characteristic curves were compared between models.

RESULTS

Of 578 patients, 36 (6.2%) delivered <34 weeks, and 78 (13.5%) delivered <37 weeks. For a 20% fixed false positive rate, ADAM12, PAPP-A, and uterine artery Doppler identified 58%, 52%, and 62% of patients with PTB <34 weeks and 42%, 48%, and 50% of patients with PTB <37 weeks, respectively. Combining these first-trimester parameters did not improve the predictive efficiency of the models.

CONCLUSION

First-trimester ADAM12, PAPP-A, and uterine artery Doppler are each modestly predictive of PTB; however, combinations of these parameters do not further improve their screening efficiency.

Diagnostic accuracy of maternal serum macrophage inhibitory cytokine-1 and pregnancy-associated plasma protein-A at 6-10 weeks of gestation to predict miscarriage

OBJECTIVE

To determine whether serum macrophage inhibitory cytokine-1, pregnancy-associated plasma protein-A (PAPP-A), anandamide, or β-human chorionic gonadotropin (hCG) measured in an asymptomatic population in the middle of the first trimester with a viable fetus predicts subsequent miscarriage.

METHODS

We undertook a prospective cohort study at Mercy Hospital for Women between 2004 and 2008. Participants (N=782) were recruited from prenatal clinics, where samples were taken from asymptomatic women at 6 0/7 to 10 6/7 weeks of gestation. We collected samples from only those women for whom we were able to obtain ultrasound evidence of a singleton with fetal cardiac activity. Serum macrophage inhibitory cytokine-1, PAPP-A, anandamide, and β-hCG concentrations were assayed.

RESULTS

Twenty-one (2.7%) miscarried and 761 did not. Among those who miscarried, macrophage inhibitory cytokine-1 and PAPP-A were significantly decreased at 63% (multiples of the median (MOM) 0.63, 25th-75th percentiles 0.33-0.88) and 23% (MOM 0.23, 25th-75th percentiles 0.12-0.48) of levels seen among those with ongoing pregnancies (P<.001 for both comparisons). In contrast, neither serum β-hCG (MOM 0.99, 25th-75th percentiles 0.46-1.86) nor anandamide (MOM 1.07, 25th-75th percentiles 0.87-1.19) was elevated or decreased among those who miscarried compared with those with ongoing pregnancies. At a fixed 10% false-positive rate (90% specificity), a test combining macrophage inhibitory cytokine-1 and PAPP-A yielded 63% sensitivity and a 6.6 positive likelihood ratio in predicting miscarriage.

CONCLUSION

Low serum levels of macrophage inhibitory cytokine-1 and PAPP-A measured from asymptomatic women at 6-10 weeks of gestation with viable pregnancies can predict subsequent miscarriage. These analytes are likely to have an important biological role in early pregnancy and are likely to be useful clinical biomarkers for miscarriage and other early pregnancy complications.

LEVEL OF EVIDENCE

II.

Hormonal evidence supports the theory of selection in utero

OBJECTIVES

Antagonists in the debate over whether the maternal stress response during pregnancy damages or culls fetuses have invoked the theory of selection in utero to support opposing positions. We describe how these opposing arguments arise from the same theory and offer a novel test to discriminate between them. Our test, rooted in reports from population endocrinology that human chorionic gonadotropin (hCG) signals fetal fitness, contributes not only to the debate over the fetal origins of illness, but also to the more basic literature concerned with whether and how natural selection in utero affects contemporary human populations.

METHODS

We linked maternal serum hCG measurements from prenatal screening tests with data from the California Department of Public Health birth registry for the years 2001-2007. We used time series analysis to test the association between the number of live-born male singletons and median hCG concentration among males in monthly gestational cohorts.

RESULTS

Among the 1.56 million gestations in our analysis, we find that median hCG levels among male survivors of monthly conception cohorts rise as the number of male survivors falls.

RESULTS

Elevated median hCG among relatively small male birth cohorts supports the theory of selection in utero and suggests that the maternal stress response culls cohorts in gestation by raising the fitness criterion for survival to birth.

Impact of inherited thrombophilias on first and second trimester maternal serum markers for aneuploidy

OBJECTIVE

To evaluate first and second-trimester maternal serum markers in pregnancies complicated with inherited thrombophilias.

METHODS

A case-control study was conducted in 50 pregnancies complicated with hereditary thrombophilia and 100 control pregnancies.

RESULTS

Each woman with inherited thrombophilia received low molecular weight heparin (LMWH) throughout her pregnancy. Gravidity, parity, number of first-trimester and second-trimester abortions, and rate of adverse pregnancy outcomes (APO) were significantly higher in the thrombophilia group compared to the control group (P < 0.001 for all). Among the thrombophilia group median values of pregnancy associated placental protein-A (PAPP-A) (0.6 vs. 0.9; P < 0.001) and free β-human chorionic gonadotropin (β-hCG) (0.9 vs. 1.1; P = 0.001) in the first trimester; median values of α-fetoprotein (AFP) (0.7 vs. 1.1; P = 0.027), unconjugated estriol 3 (uE3) (0.9 vs. 1.1; P < 0.001), and hCG (0.7 vs. 1.2; P < 0.001) in the second trimester were significantly lower with respect to control pregnancies. Multivariate analysis revealed that low uE3 and hCG levels were independently associated with APO.

CONCLUSION

Pregnant women with hereditary thrombophilias, all of whom were treated with LMWH, had decreased levels of all first and second trimester serum markers. In addition, levels of hCG and uE3 in the second trimester could independently predict placenta-related disorders and adverse outcomes in these patients.

First trimester volumetric measurements: relation with hormone levels and fetal heart rate

PURPOSE

This study aimed to examine two-dimensional ultrasound (2D US) volumetric measurements of 1st trimester structures and their relationship with β-hCG, progesterone, and fetal heart rate (FHR) in 6-10 weeks healthy pregnant women.

METHODS

Using conventional 2D transvaginal ultrasound imaging, the crown rump length (CRL), yolk sac (YS) and gestational sac (GS) were measured in 80 women. Volumetric measurements were done in 32 cases that were selected among 80 women, using a simplified formula for the volume of a prolate ellipsoid: V = 0.523 × length × height × width. The β-hCG and progesterone levels were recorded. The heart rate was determined from M-mode tracings using electronic calipers.

RESULTS

Moderately positive correlation was found between FHR versus CRL, embryo volume and GS volume. FHR increased linearly with CRL value, till CRL became 15 mm, after which it formed a plateau. β-hCG increased linearly till CRL was 15 mm, and then it formed a plateau. Progesterone level was stable till CRL became 20 mm, embryo volume 2 cm(3), after which it increased linearly.

CONCLUSION

Various ranges of relations are observed between FHR, obstetric, and hormonal measurements. The relationship between these parameters might be used for determination of abnormal growth and adverse outcomes in early pregnancy.

First-trimester screening for large-for-gestational-age infants

OBJECTIVES

To examine the relationship between newborn birth weight and first-trimester uterine artery (UtA) pulsatility index (PI), maternal characteristics, serum pregnancy-associated plasma protein-A (PAPP-A), free β-human chorionic gonadotropin (β-hCG) and fetal nuchal translucency (NT) thickness. We also examined the results of screening for large-for-gestational-age (LGA) neonates by an integrated first-trimester approach incorporating these parameters.

METHODS

We evaluated maternal characteristics, fetal NT, PAPP-A, free β-hCG and UtA-PI in 2097 singleton pregnancies at 11 + 0 to 13 + 6 weeks' gestation. Linear models based on quasi Akaike's Information Criterion were used to determine the best predictive model for fetal birth weight. The patient-specific risk of delivering an LGA infant was derived from multiple logistic regression analysis and the performance of screening was determined by receiver-operating characteristics curve analysis.

RESULTS

The best predictive models for fetal birth weight included UtA-PI, PAPP-A, NT, parity, maternal age, smoking status, weight, height and free β-hCG. In pregnancies delivering LGA newborns compared with non-LGA pregnancies, PAPP-A and NT thickness were significantly increased (P = 0.016 and 0.001, respectively) and UtA-PI was significantly decreased (P = 0.011). A combination of maternal factors with PAPP-A, fetal NT and UtA-PI identified 34.4% of LGA newborns for a false-positive rate of 10%.

CONCLUSIONS

This study showed an association between newborn birth weight and maternal factors, and first-trimester PAPP-A, β-hCG, fetal NT and UtA-PI. Together, these factors can be used to identify over a third of pregnancies that will deliver LGA infants.

First trimester maternal serum PIGF, free β-hCG, PAPP-A, PP-13, uterine artery Doppler and maternal history for the prediction of preeclampsia

OBJECTIVE

To evaluate the detection of pregnancy hypertensive disorders by integrating maternal history, serum biomarkers and uterine artery Doppler in the first trimester.

METHODS

We prospectively recruited 2118 women that underwent an 11-13 weeks aneuploidy screening. We gathered information on maternal history, uterine artery Doppler and serum biomarkers (PAPP-A, PlGF, PP-13 and free β-hCG). Models were developed for the prediction of overall preeclampsia (PE), early-onset PE, late-onset PE and gestational hypertension (GH). For each outcome, we performed a multivariate logistic regression starting from the saturated model: adopting a step-down procedure we excluded all factors not statistically significant (p > 0.05). Sensitivity models only for statistically significant parameters were calculated from the ROC curves for fixed false-positive rates (FPR).

RESULTS

Among 2118 women, 46 (2.17%) developed GH and 25 (1.18%) were diagnosed with PE, including 12 (0.57%) early-onset PE and 13 (0.61%) late-onset PE. For a fixed FPR of 10 and 5%, serum PlGF, free β-hCG and chronic hypertension identified respectively 67 and 75% of women who developed early-onset PE. In the model for the prediction of overall PE the combination of the uterine artery Doppler pulsatility index (UtA PI) with PlGF and chronic hypertension reached a sensitivity of 60% for a 20% of FPR.

CONCLUSION

An integration of maternal characteristics and first trimester maternal serum biomarkers (free β-hCG and PlGF) provided a possible screening for early-onset PE. In the overall PE model, UtA PI turned out to be statistically significant but did not improve the detection rate.

Management of abnormal serum markers in the absence of aneuploidy or neural tube defects

OBJECTIVE

Few guidelines address the management of pregnancies complicated by abnormal maternal serum analytes (MSAs) in the absence of aneuploidy or neural tube defects (NTDs). Our objective was to gather preliminary data regarding current opinions and management strategies among perinatologists in the US.

METHODS

This survey of Maternal Fetal Medicine (MFM) physicians and fellows used a secure electronic web-based data capture tool.

RESULTS

A total of 545 potential participants were contacted, and 136 (25%) responded. The majority were experienced academic physicians with robust practices. Nearly all (97.7%) respondents reported a belief in an association between abnormal MSAs and adverse pregnancy outcomes other than aneuploidy or NTDs. Plasma protein A (PAPP-A) and α-fetoprotein (AFP) were most often chosen as markers demonstrating a strong association with adverse outcomes. Most (86.9%) respondents acknowledged that abnormal MSAs influenced their counseling approach, and the majority (80.1%) offered additional ultrasound examinations. Nearly half started at 28 weeks and almost one-third at 32 weeks. Respondents acknowledging a relevant protocol in their hospital or practice were more likely to offer additional antenatal testing (p = 0.01).

CONCLUSIONS

Although most perinatologists were in agreement regarding the association of MSAs with adverse pregnancy outcomes, a lack of consensus exists regarding management strategies.

Low PAPP-A: what are the clinical implications?

Ultrasound and pulsed Doppler can assist in confirming impaired placentation looking at fetal biometry and umbilical artery Dopplers. The authors recommend confirmation of fetal wellbeing at 28–30 weeks with a PAPP‐A level below the first centile.

Evaluation of 7 serum biomarkers and uterine artery Doppler ultrasound for first-trimester prediction of preeclampsia: a systematic review

Preeclampsia (PE) affects 1% to 2% of pregnant women and is a leading cause of maternal and perinatal morbidity and mortality worldwide. The clinical syndrome of PE arises in the second half of pregnancy. However, many underlying factors including defective placentation may already be apparent in the first and early second trimester in many patients. In clinical practice, there is currently no reliable screening method in the first trimester of pregnancy with sufficient accuracy to identify women at high risk to develop PE. Early identification of high-risk pregnancy may facilitate the development of new strategies for antenatal surveillance or prevention and thus improve maternal and perinatal outcome. The aim of this systematic review was to study the literature on the predictive potential of first-trimester serum markers and of uterine artery Doppler velocity waveform assessment (Ut-A Doppler). Literature on the 7 most studied serum markers (ADAM12, fβ-hCG, Inhibin A, Activin A, PP13, PlGF, and PAPP-A) and Ut-A Doppler was primarily selected. In the selected literature, a combination of these markers was analyzed, and where relevant, the value of maternal characteristics was added. Measurements of serum markers and Ut-A Doppler were performed between week 8 + 0 and 14 + 0 GA. Low levels of PP13, PlGF, and PAPP-A and elevated level of Inhibin A have been found to be significantly associated with the development of PE later in pregnancy. The detection rates of single markers, fixed at 10% false-positive rate, in the prediction of early-onset PE were relatively low, and ranged from 22% to 83%. Detection rates for combinations of multiple markers varied between 38% and 100%. Therefore, a combination of multiple markers yields high detection rates and is promising to identify patients at high risk of developing PE. However, large scale prospective studies are required to evaluate the power of this integrated approach in clinical practice.

TARGET AUDIENCE

Obstetricians and Gynecologists, Family physicians Learning Objectives: After completion of this article, the reader should be better able to appraise the recent literature on the development of preeclampsia in the first-trimester, evaluate the predictive value of first-trimester markers and use first-trimester markers, either individually or in combination, to assess the risk of preeclampsia.

First trimester serum levels of 25-hydroxyvitamin D, free β-human chorionic gonadotropin, and pregnancy-associated plasma protein A in Spanish women

BACKGROUND

Vitamin D has been implicated in embryo/placental development and growth; however information in this regard is limited or unavailable.

OBJECTIVE

To assess 25-hydroxyvitamin D (25(OH)D), free β-human chorionic gonadotropin (β-hCG) and pregnancy associated plasma protein A (PAPP-A) status during pregnancy.

METHODS

Serum 25(OH)D, β-hCG, and PAPP-A levels were measured in the first trimester of otherwise healthy Spanish pregnant women (n=488). Rho Spearman coefficients were calculated to determine correlations between analytes.

RESULTS

Median serum 25(OH)D levels for the entire sample was 27.4 ng/ml (interquartile range=12.1). 25(OH)D levels were insufficient (20-29.99 ng/ml) and deficient (<20 ng/ml) in 40.6% and 23.2%, respectively, in relation to ethnics, body mass index values, tobacco use, and season/gestational age at blood sampling. β-hCG and PAPP-A levels significantly correlated (r²=0.47) yet neither of them with 25(OH)D levels. Despite this, the three analytes significantly correlated with gestational age at sampling.

CONCLUSION

First trimester 25(OH)D, β-hCG, and PAPP-A levels increase with gestational age; however, placental peptides do not correlate with vitamin D levels, suggesting a non-placental 25(OH)D production. More research is required in this regard.

Screening for placenta accreta at 11-14 weeks of gestation

OBJECTIVE

We sought to describe the potential value of 11-14 weeks' screening for placenta accreta (PA).

STUDY DESIGN

Patients with a history of lower segment cesarean section were prospectively included between 11-13+6 weeks over a 1.5-year period. The first 258 were offered standard screening whereas the following 105 underwent screening for PA. Women were considered high-risk when the trophoblast overlapped the scar visualized by transvaginal ultrasound and low-risk otherwise.

RESULTS

The group screened for PA did not differ from the nonscreened group for demographic characteristics. In all, 6 of 105 (5.8%) women were considered high-risk. In the nonscreened group, 1 case of PA was discovered during an elective repeat cesarean. In the screened population, 1 case of PA occurred in a high-risk patient allowing a conservative planned management at 35 weeks.

CONCLUSION

At 11-14 weeks, ultrasound may help risk stratification for PA with a specific follow-up. Early recognition of patients at risk might improve the perinatal outcome of PA.

First trimester prediction of small- and large-for-gestation neonates by an integrated model incorporating ultrasound parameters, biochemical indices and maternal characteristics

OBJECTIVE

To identify maternal/pregnancy characteristics, first trimester ultrasound parameters and biochemical indices which are significant independent predictors of small-for-gestational age (SGA) and large-for-gestational age (LGA) neonates.

DESIGN

Retrospective cross-sectional study.

SETTING

Two fetal Medicine Units.

POPULATION

4 702 singleton pregnancies presenting for screening for chromosomal abnormalities by nuchal translucency and maternal serum biochemistry at 11-14 weeks.

METHODS

Reference ranges for birthweight applied to our population were constructed by the Royston and Wright method. Multiple logistic regression was applied to develop first trimester prediction models for SGA and LGA.

MAIN OUTCOME MEASURES

Birth of SGA or LGA neonate.

RESULTS

Maternal height, parity, smoking, assisted conception, delta crown-rump length, delta nuchal translucency, free beta human chorionic gonadotrophin and pregnancy-associated plasma protein-A were significant independent predictors of SGA. Maternal weight and height, smoking, delta crown-rump length and delta nuchal translucency were significant independent predictors of LGA. Models for SGA (AUC=0.7296, CI: 0.69-0.76, p<0.0001) and LGA (AUC=0.6901, CI: 0.65-0.72, p<0.0001) were derived, applicable to routine obstetric population at low risk for these conditions. For 20% screen positive rate the modeling achieves sensitivities of about 55% for SGA and 48% for LGA neonates.

CONCLUSION

Prediction for birthweight deviations is feasible using data available at the routine 11-14 weeks' examination. Delta CRL and delta nuchal translucency were significant independent predictors for both SGA and LGA.

First-trimester prediction of preeclampsia using metabolomic biomarkers: a discovery phase study

OBJECTIVE

We tested the hypothesis that first-trimester metabolic biomarkers offered a unique profile in women with preeclampsia (PE) in the second half of pregnancy, compared with controls.

METHOD

We conducted a nested case-control study within a prospective cohort of pregnant women followed from the first-trimester to delivery. Cases were those who developed PE at any gestational age, and these were compared with a control group without adverse pregnancy outcome, matched for gestational age within 3 days. We analyzed maternal blood obtained at 11-14 weeks' gestation for 40 acylcarnitine species (C2-C18 saturated, unsaturated, and hydroxylated) and 32 amino acids by liquid chromatography tandem mass spectrometry. Logistic regression modeling estimated the association of each metabolite with development of PE.

RESULTS

We compared 41 cases with PE with 41 controls and found four metabolites (hydroxyhexanoylcarnitine, alanine, phenylalanine, and glutamate) that were significantly higher in the cases with PE. The area under the curve (AUC) using these metabolites individually to predict PE varied from 0.77 to 0.80, and when combined, the AUC improved to 0.82 [95% confidence interval (95% CI): 0.80-0.85] for all cases of PE and 0.85 (95% CI: 0.76-0.91) for early onset PE.

CONCLUSION

Our findings suggest a potential role for first-trimester metabolomics in screening for PE.

Placental morphologic features and chorionic surface vasculature at term are highly correlated with 3-dimensional sonographic measurements at 11 to 14 weeks

OBJECTIVES

The purpose of this study was to examine the potential for 3-dimensional sonographic measurement of the early placenta in predicting ultimate placental morphologic features at delivery.

METHODS

In this prospective cohort study, we collected 3-dimensional sonographic volume sets of placentas at 11 to 14 weeks and then collected the placentas after delivery. The sonographic data were manipulated to obtain various novel measurements of early gross placental morphologic features and the umbilical cord insertion location. The placental weight, chorionic plate area, cord location, and mean chorionic vascular density were obtained from the delivered postpartum placentas. Analyses were performed to identify potential early placental characteristics that were correlated with the ultimate placental morphologic features. The placental weight, cord marginality, and mean chorionic vascular density served as the outcome measures of interest.

RESULTS

Measurements of the early placental volume correlated with the delivered placental weight. An irregular early placental shape, as measured by sonography, was significantly inversely correlated with placental weight (P < .05). The placental morphologic index, a measure of a flatter placenta, was inversely correlated with both the placental weight and chorionic plate area, possibly indicating the importance of placental thickness even in the first trimester before villous arborization. In addition, early sonographic measures of the location of the umbilical cord insertion were significantly correlated with the ultimate marginality of the cord insertion as well as the mean chorionic vascular density (P < .05).

CONCLUSIONS

Many important ultimate placental morphologic features are likely predetermined early in pregnancy. Three-dimensional sonography may play an increasing role in the in utero evaluation of the early placenta.

Metabolic profiling uncovers a phenotypic signature of small for gestational age in early pregnancy

Being born small for gestational age (SGA) confers increased risks of perinatal morbidity and mortality and increases the risk of cardiovascular complications and diabetes in later life. Accumulating evidence suggests that the etiology of SGA is usually associated with poor placental vascular development in early pregnancy. We examined metabolomic profiles using ultra performance liquid chromatography-mass spectrometry (UPLC-MS) in three independent studies: (a) venous cord plasma from normal and SGA babies, (b) plasma from a rat model of placental insufficiency and controls, and (c) early pregnancy peripheral plasma samples from women who subsequently delivered a SGA baby and controls. Multivariate analysis by cross-validated Partial Least Squares Discriminant Analysis (PLS-DA) of all 3 studies showed a comprehensive and similar disruption of plasma metabolism. A multivariate predictive model combining 19 metabolites produced by a Genetic Algorithm-based search program gave an Odds Ratio for developing SGA of 44, with an area under the Receiver Operator Characteristic curve of 0.9. Sphingolipids, phospholipids, carnitines, and fatty acids were among this panel of metabolites. The finding of a consistent discriminatory metabolite signature in early pregnancy plasma preceding the onset of SGA offers insight into disease pathogenesis and offers the promise of a robust presymptomatic screening test.

First-trimester screening and its impact on uptake of diagnostic testing

OBJECTIVE

To determine the influence of first-trimester screening (FTS) on a patient's decision regarding prenatal diagnostic testing (PDT) and if the uptake rate of PDT has changed among women with advanced maternal age (AMA) following the January 2007 American College of Obstetricians and Gynecologists statement regarding FTS.

METHODS

A database review was performed for the 2 years before and the 2 years after the January statement. A total of 7424 patient records were evaluated to determine the number of AMA women who obtained PDT, the number of positive and negative FTS results, and how many of those women had PDT. We then surveyed 53 patients and 23 referring physicians to determine what the patient understands about FTS, how patients utilize their FTS results, and how physicians educate their patients about FTS.

RESULTS

We determined that there was a 19.6% decrease in the uptake of PDT since that statement. Prior to their counseling session (2009-2010), 43% of those surveyed were against having PDT. After counseling, only 9% were against PDT. Overall, 91% were either open to or wanted PDT after counseling.

CONCLUSIONS

In addition to FTS results, we found that genetic counseling may be an influential factor in the patient's decision regarding PDT.

Increased nuchal translucency is associated with large for gestational age neonates in singleton pregnancies

OBJECTIVE

To evaluate the correlation between sonographic measurements of nuchal translucency (NT) and neonatal birth weight in non-diabetic population.

METHODS

A retrospective analysis was performed on all singleton term pregnancies delivered at our hospital between 2004 and 2008. Data collected included maternal age, parity, NT measurement, results of glucose challenge test, birth weight, gestational age at delivery, and fetal gender.

RESULTS

The study population comprised of 1649 patients. The mean NT was 1.3 ± 0.5 mm. Male fetuses had a significantly thicker NT (1.3 ± 0.5 vs. 1.2 ± 0.4; P<0.001). NT significantly correlated to birth weight (P=0.002). This correlation was independent of neonatal gender. The median NT in the large for gestational age (LGA) neonates was significantly higher than in the non-LGA neonates (1.4 mm vs. 1.2 mm, P=0.001). Equations for the predicted probability for delivering LGA neonates were derived using either NT alone or in combination with parity. An increase in 0.1 mm in the NT has the odd ratio of 1.042 for delivering an LGA neonate (P=0.02).

CONCLUSIONS

NT correlated with LGA neonates in term non-diabetic patients. This correlation was independent of the neonatal gender. The predictive clinical impact of NT was limited to LGA neonates.

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.

Association between maternal serum cytokine profiles at 7-10 weeks' gestation and birthweight in small for gestational age infants

OBJECTIVE

The purpose of this study was to investigate whether birth of a small-for-gestational-age (SGA) baby (birthweight, <10th percentile) is preceded by altered maternal serum cytokine profiles at early pregnancy, compared with control babies (birthweight, 30-80th percentile).

STUDY DESIGN

A retrospective case-control study of maternal serum collected prospectively across 7-10 weeks of gestation from women attending their first prenatal visit (SGA, 57 cases; control subjects, 71 cases selected retrospectively). Serum concentrations of 27 cytokines were measured in each sample and analyzed by 2-way analysis of variance and nonparametric tests. Logistic regression was used for predictive modeling.

RESULTS

Of 21 detectable cytokines/chemokines, 14 analytes varied significantly (P ≤ .030) among those women who were destined to deliver an SGA baby, when compared with control subjects. Of the cytokines that varied in association with SGA, interferon-γ concentrations increased, and major proinflammatory (interleukin [IL]-2, -7, -12) and antiinflammatory (IL-1 receptor antagonist, -4, -10, -13) cytokine concentrations decreased. Eotaxin and macrophage inflammatory protein-1α were higher; monocyte chemoattractant protein-1 and IL-8 were lower.

CONCLUSION

SGA births may be preceded by altered immune cytokine profiles at 7-10 weeks of gestation.

Prediction of spontaneous preterm delivery from maternal factors, obstetric history and placental perfusion and function at 11-13 weeks

OBJECTIVE

To develop a model for prediction of spontaneous delivery before 34 weeks based on maternal factors, placental perfusion and function at 11-13 weeks' gestation.

METHODS

Two groups of studies: first, screening study of maternal characteristics, serum pregnancy-associated plasma protein-A (PAPP-A), free β-human chorionic gonadotrophin (β-hCG) and uterine artery pulsatility index (PI). Second, case-control studies of maternal serum or plasma concentration of placental growth factor (PlGF), placental protein 13 (PP13), a disintegrin and metalloprotease 12 (ADAM12), inhibin-A and activin-A. Regression analysis was used to develop a model for the prediction of spontaneous early delivery.

RESULTS

Spontaneous early delivery occurred in 365 (1.1%) of the 34 025 pregnancies. A model based on maternal factors could detect 38.2% of the preterm deliveries in women with previous pregnancies at or beyond 16 weeks and 18.4% in those without, at a false positive rate (FPR) of 10%. In the preterm delivery group, compared with unaffected pregnancies there were no significant differences in the markers of placental perfusion or function, except for PAPP-A which was reduced.

CONCLUSIONS

Patient-specific risk of preterm delivery is provided by maternal factors and obstetric history. Placental perfusion and function at 11-13 weeks are not altered in pregnancies resulting in spontaneous early delivery.

Intrauterine growth restriction: new concepts in antenatal surveillance, diagnosis, and management

Intrauterine growth restriction (IUGR) remains one of the main challenges in maternity care. Improvements have to start from a better definition of IUGR, applying the concept of the fetal growth potential. Customized standards for fetal growth and birthweight improve the detection of IUGR by better distinction between physiological and pathological smallness and have led to internationally applicable norms. Such developments have resulted in new insights in the assessment of risk and surveillance during pregnancy. Serial fundal height measurement plotted on customized charts is a useful screening tool, whereas fetal biometry and Doppler flow are the mainstay for investigation and diagnosis of IUGR. Appropriate protocols based on available evidence as well as individualized clinical assessment are essential to ensure good management and timely delivery.

Predicting the risk of pre-eclampsia between 11 and 13 weeks' gestation by combining maternal characteristics and serum analytes, PAPP-A and free β-hCG

OBJECTIVE

To determine if a simplified model for predicting pre-eclampsia (PEC) can be developed by combining first-trimester serum analytes, pregnancy-associated plasma protein A (PAPP-A) and free beta human chorionic gonadotrophin (β-hCG), and maternal characteristics.

METHODS

A retrospective cohort study of patients seen for first-trimester aneuploidy screening from 2003 to 2009. The 5th, 10th, 90th, and 95th percentiles for the analyte multiples of the medians (MoMs) for our population were determined and evaluated for association with PEC. Univariate and backward stepwise logistic regression analyses were performed and the area under the receiver operating characteristic (ROC) curves [area under curve (AUC)] used to determine the best models for predicting PEC.

RESULTS

Among 4020 women meeting the inclusion criteria, outcome data was available for 3716 (93%). There were 293 cases of PEC. The final model identified a history of pre-gestational diabetes [aOR 2.6, 95% confidence interval (CI) 1.7-3.9], chronic hypertension (cHTN) (aOR 2.6, 95% CI 1.7-3.9), maternal body mass index (BMI) > 25 (aOR 2.5, 95% CI 1.9-3.4), African American race (aOR 1.8, 95% CI 1.3-2.6), and PAPP-A MoM < 10th percentile (aOR 1.6, 95% CI 1.1-2.4) to be significant predictors of PEC (AUC = 0.70, 95% CI 0.65-0.72).

CONCLUSION

Low first-trimester PAPP-A levels are associated with the development of PEC; however, the model was only modestly efficient in its predictive ability.

Early fetal growth, PAPP-A and free β-hCG in relation to risk of delivering a small-for-gestational age infant

OBJECTIVES

To examine early fetal growth, pregnancy-associated plasma protein-A (PAPP-A) and free β-human chorionic gonadotropin (β-hCG) in relation to the risk of delivering a small-for-gestational age (SGA) infant.

METHODS

Included in the study were 9450 singleton pregnant women who attended the prenatal screening program at Aarhus University Hospital, Denmark, between January 2005 and December 2007. Maternal serum levels of PAPP-A and free β-hCG were measured between gestational weeks 8 and 13. Two ultrasound examinations were performed, the first at 11-13 weeks and the second at 18-22 weeks, from which gestational age was estimated based on crown-rump length and biparietal diameter, respectively. Early fetal growth was expressed as an index: the ratio between the estimated number of days from the first to the second scan and the actual calendar time elapsed in days. SGA was defined as birth weight < 5(th) centile for gestational age, and the risk of SGA was evaluated according to different cut-offs of the early fetal growth index and the serum markers.

RESULTS

PAPP-A < 0.4 MoM combined with an early fetal growth index < 10(th) centile resulted in an increased risk of SGA (odds ratio (OR), 5.8; 95% CI, 2.7-12.7). Low PAPP-A, low free β-hCG and slow early fetal growth were statistically, independently associated with SGA, and the association between free β-hCG < 0.3 MoM and SGA was as strong as that between PAPP-A < 0.3 MoM and SGA (OR, 3.1 and 3.0, respectively).

CONCLUSION

The combination of slow early fetal growth and low PAPP-A resulted in a nearly six-fold increased risk of delivery of an SGA infant. These findings might improve our chances of early identification of fetuses at increased risk of growth restriction.

Clinical strategies for improving the detection of fetal growth restriction

The single most important condition affecting the viable fetus is intrauterine growth retardation (IUGR). IUGR is a common condition, affecting about 10% to 15% of the general maternity population. Despite its importance and relatively high prevalence, IUGR detection is poor. This article will focus on how to improve on IUGR detection.

The role of serum markers and uterine artery Doppler in identifying at-risk pregnancies

Measures of placental dysfunction, including maternal serum analytes and Doppler studies, have been linked to adverse pregnancy outcomes, although the predictive ability of any single one is poor. Improved knowledge of the multifactorial nature of many of the adverse outcomes of pregnancy has sparked interest in the use of multi-parameter models that combine maternal serum analytes with measures of placental structure and blood flow. The combination of various first-trimester and second-trimester analytes and uterine artery Doppler screening show promise as potential screening tools, but large prospective studies are needed to further define their role in clinical practice.

Placental volume and vascularization flow indices by 3D power Doppler US using VOCAL technique and correlation with IGF-1, free beta-hCG, PAPP-A, and uterine artery Doppler at 11-14 weeks of pregnancy

AIMS

The purpose of this study was to investigate correlations between first trimester placental volume (PV) and blood flow indexes (FIs), bilateral uterine artery pulsatility indexes, notching, and biochemical parameters: pregnancy-associated plasma protein-A (PAPP-A), free beta-human chorionic gonadotropin (f-β-hCG), and insulin-like growth factor-1 (IGF-1) to predict the high-risk pregnancies in the first trimester.

METHODS

We prospectively examined 310 patients at 11-14 weeks of pregnancy using transabdominal 3D gray scale and power Doppler ultrasound for assessing PV, vascularization index, FI, and vascularization FI (VFI). The acquired volumes were analyzed using VOCAL™ imaging software. The results were correlated with biochemical parameters.

RESULTS

We found significant correlations between PV and biochemical parameters, and between placental blood flow studies and other parameters. Finally, PV/crown-rump length so called the placental quotient is also related to both PAPP-A and VFI.

CONCLUSIONS

Placental volumetry, uterine artery Doppler studies, blood flow calculations and biochemical parameters, such as f-β-hCG, PAPP-A, and IGF-1 could be important in the early and rapid diagnosis of high-risk pregnancies. Thus, they may be useful in first trimester prediction of fetal growth restriction presenting with alterations in PV and vascularity.