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Elmes C, Phillips R. Systematic review evaluating the efficacy of the cerebroplacental ratio (CPR) in saving babies lives. ULTRASOUND (LEEDS, ENGLAND) 2022; 30:184-193. [PMID: 35936964 PMCID: PMC9354181 DOI: 10.1177/1742271x211048213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 08/29/2021] [Indexed: 08/03/2023]
Abstract
Introduction The aim of this systematic review is to critically assess the efficacy of the cerebroplacental ratio performed in the third trimester at predicting adverse perinatal outcomes and reducing stillbirth rates. Method The literature search was performed using CINAHL, EMBASE, EMCARE, MEDLINE and PubMed including systematic reviews, retrospective and prospective studies from inception until July 2020 utilising the PRISMA checklist and flowchart. Data displaying sensitivities, specificity and odds ratios (OR) to include 95% confidence interval (CI) were extracted and synthesised. Findings Initially, 1226 studies were identified, and nine studies met the inclusion criteria. Sample sizes ranged from 491 to 9772 pregnancies. The cerebroplacental ratio had the strongest diagnostic accuracy of all of the independent variables for detecting fetal demise (mean sensitivity and specificity; 79% and 78%). The cerebroplacental ratio, however, did not perform as favourably at predicting operative delivery (mean sensitivity and specificity; 59% and 82%) or anticipating admission to the neonatal intensive care unit (mean sensitivity and specificity; 55% and 74%). Discussion The results from this study showed that the cerebroplacental ratio within third trimester pregnancies has been proven to have moderate to high diagnostic value when detecting adverse perinatal outcomes, in particular fetal demise. Conclusion Cerebroplacental ratio has the potential as a diagnostic tool to reduce adverse perinatal outcomes, in particular fetal demise and help reduce stillbirth rates. The main study limitation involved heterogeneity within the included studies, in particular with a regard to blinding.
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Affiliation(s)
| | - Rita Phillips
- HAS Allied Health Professions, University of the West of England Bristol, Bristol, UK
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2
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Vannevel V, Vogel JP, Pattinson RC, Adanu R, Charantimath U, Goudar SS, Gwako G, Kavi A, Maya E, Osoti A, Pujar Y, Qureshi ZP, Rulisa S, Botha T, Oladapo OT. Antenatal Doppler screening for fetuses at risk of adverse outcomes: a multicountry cohort study of the prevalence of abnormal resistance index in low-risk pregnant women. BMJ Open 2022; 12:e053622. [PMID: 35296477 PMCID: PMC8928296 DOI: 10.1136/bmjopen-2021-053622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Few interventions exist to address the high burden of stillbirths in apparently healthy pregnant women in low- and middle-income countries (LMICs). To establish whether a trial on the impact of routine Doppler screening in a low-risk obstetric population is warranted, we determined the prevalence of abnormal fetal umbilical artery resistance indices among low-risk pregnant women using a low-cost Doppler device in five LMICs. METHODS We conducted a multicentre, prospective cohort study in Ghana, India, Kenya, Rwanda and South Africa. Trained nurses or midwives performed a single, continuous-wave Doppler screening using the Umbiflow device for low-risk pregnant women (according to local guidelines) between 28 and 34 weeks' gestation. We assessed the prevalence of abnormal (raised) resistance index (RI), including absent end diastolic flow (AEDF), and compared pregnancy and health service utilisation outcomes between women with abnormal RI versus those with normal RI. RESULTS Of 7151 women screened, 495 (6.9%) had an abnormal RI, including 14 (0.2%) with AEDF. Caesarean section (40.8% vs 28.1%), labour induction (20.5% vs 9.0%) and low birth weight (<2500 g) (15.0% vs 6.8%) were significantly more frequent among women with abnormal RI compared with women with normal RI. Abnormal RI was associated with lower birth weights across all weight centiles. Stillbirth and perinatal mortality rates were similar between women with normal and abnormal RI. CONCLUSION A single Doppler screening of low-risk pregnant women in LMICs using the Umbiflow device can detect a large number of fetuses at risk of growth restriction and consequent adverse perinatal outcomes. Many perinatal deaths could potentially be averted with appropriate intervention strategies. TRIAL REGISTRATION NUMBER CTRI/2018/07/01486.
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Affiliation(s)
- Valerie Vannevel
- Maternal and Infant Health Care Strategies Unit, SAMRC, Pretoria, South Africa
- Department of Obstetrics and Gynaecology, University of Pretoria, Pretoria, South Africa
- Research Centre for Maternal, Fetal, Newborn & Child Health Care Strategies, University of Pretoria, Pretoria, South Africa
| | - Joshua P Vogel
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Robert C Pattinson
- Maternal and Infant Health Care Strategies Unit, SAMRC, Pretoria, South Africa
- Department of Obstetrics and Gynaecology, University of Pretoria, Pretoria, South Africa
- Research Centre for Maternal, Fetal, Newborn & Child Health Care Strategies, University of Pretoria, Pretoria, South Africa
| | - Richard Adanu
- School of Public Health, University of Ghana, Legon, Ghana
| | - Umesh Charantimath
- Women's and Children's Health Research Unit, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Shivaprasad S Goudar
- Women's and Children's Health Research Unit, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - George Gwako
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - Avinash Kavi
- Women's and Children's Health Research Unit, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Ernest Maya
- School of Public Health, University of Ghana, Legon, Ghana
| | - Alfred Osoti
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - Yeshita Pujar
- Women's and Children's Health Research Unit, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Zahida P Qureshi
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - Stephen Rulisa
- Department of Obstetrics and Gynecology, University Teaching Hospital of Kigali (CHUK), University of Rwanda, Kigali, Rwanda
| | - Tanita Botha
- Department of Statistics, University of Pretoria, Pretoria, South Africa
| | - Olufemi T Oladapo
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Dall'asta A, Ghi T, Mappa I, Maqina P, Frusca T, Rizzo G. Intrapartum Doppler ultrasound: where are we now? Minerva Obstet Gynecol 2021; 73:94-102. [PMID: 33215908 DOI: 10.23736/s2724-606x.20.04698-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Intrapartum hypoxic events most commonly occur in low-risk pregnancies with appropriately grown fetuses. Continuous intrapartum monitoring by means of cardiotocography has not demonstrated a reduction in the frequency of adverse perinatal outcome but has been linked with an increase in the caesarean section rate, particularly among women considered at low risk. Available data from the literature suggests that abnormalities in the uterine artery Doppler and in the ratio between fetal cerebral and umbilical Doppler (i.e. cerebroplacental ratio [CPR]) are associated with conditions of subclinical placental function occurring in fetuses who have failed to achieve their growth potential regardless of their actual size. In this review we summarize the available evidence on the use of intrapartum Doppler ultrasound for the fetal surveillance during labor and the identification of the fetuses at risk of intrapartum distress.
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Affiliation(s)
- Andrea Dall'asta
- Unit of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Parma, Parma, Italy -
- Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, London, UK -
| | - Tullio Ghi
- Unit of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Ilenia Mappa
- Division of Maternal and Fetal Medicine, Cristo Re Hospital, Tor Vergata University, Rome, Italy
| | - Pavjola Maqina
- Division of Maternal and Fetal Medicine, Cristo Re Hospital, Tor Vergata University, Rome, Italy
| | - Tiziana Frusca
- Unit of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Giuseppe Rizzo
- Division of Maternal and Fetal Medicine, Cristo Re Hospital, Tor Vergata University, Rome, Italy
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
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Narendran N, Yusuf K. Fetal Doppler Assessment in Neonatal Care: Analysis of Fetal Doppler Abnormalities and Neonatal Outcomes. Neoreviews 2020; 20:e575-e583. [PMID: 31575779 DOI: 10.1542/neo.20-10-e575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Fetal Doppler ultrasonography provides an effective and noninvasive approach to identify circulatory abnormalities in the maternal-fetal circulation. It is invaluable to assess the hemodynamic status of the fetus under a wide range of physiologic, infectious, and abnormal anatomic conditions. Findings from these studies are often used to make clinical decisions, including whether to proceed with urgent delivery of the fetus. In this review, we focus on key literature describing the main uses of Doppler ultrasonography in neonatal medicine, including how abnormal findings may be implicated in immediate and long-term outcomes. Our review highlights the importance of fetal Doppler examination as an effective intrauterine management strategy, and its full potential is more likely to be realized when considered in context with other available clinical information.
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Affiliation(s)
- Nadia Narendran
- Section of Neonatology, Department of Pediatrics, University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Kamran Yusuf
- Section of Neonatology, Department of Pediatrics, University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada
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Olaya-C M, Vargas W, Martinez RA, Peñaloza IF, Sanchez M, Madariaga I, Aldana S, Bernal JE. Impact of umbilical cord length on fetal circulatory system by Doppler assessment. J Ultrasound 2020; 23:585-592. [PMID: 32654041 DOI: 10.1007/s40477-020-00495-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 06/12/2020] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Numerous studies have revealed the impact of umbilical cord (UC) length on fetal perfusion; abundant data implicate abnormal UC length to neurological delay and subsequent poor prognoses for fetuses and newborns. Indeed, our group previously developed theoretical approximations that contributed to formulas capable of explaining the impact of UC length on cardiac output. METHODS We performed an observational study that measured the pulsatility index and flow velocity in umbilical arteries. A special Doppler measured proximal and distal indexes in both arteries. After birth, medical staff measured complete UC length. We obtained maternal and neonatal outcomes from clinical records. RESULTS Our study enrolled 20 pregnant mothers. We found that flow velocities in the two edges were different: fetal edges exhibited greater velocity in the majority of cases; but, when we compared pressure differentials (ΔP), the pulsatility index was significantly related to umbilical cord length. CONCLUSIONS Fetal perfusion, welfare, and viability are related to UC function as the conveyor of all fetal volemia. Excessive UC length affects cardiac dynamics and increases peripheral vascular resistance. Further studies could validate routine use of the differential proximal and distal measurements proposed in this article, and their implications in in utero fetal heart function. We also hope that early diagnosis or UC alterations could alert neonatologists and obstetricians to clinical conditions of the fetus.
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Affiliation(s)
- Mercedes Olaya-C
- Pathology Department, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogota, Colombia. .,Hospital Universitario San Ignacio, Kra 7 40-62, Bogota, Colombia.
| | - William Vargas
- Forensic Physics Group, Instituto Nacional de Medicina Legal y Ciencias Forenses, Bogota, Colombia
| | - Rodolfo Andres Martinez
- Obstetrics and Gynecology Department, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogota, Colombia.,Hospital Universitario San Ignacio, Kra 7 40-62, Bogota, Colombia
| | - Ivan Felipe Peñaloza
- Pontificia Universidad Javeriana, Bogota, Colombia.,Hospital Universitario San Ignacio, Kra 7 40-62, Bogota, Colombia
| | - Melissa Sanchez
- Pontificia Universidad Javeriana, Bogota, Colombia.,Hospital Universitario San Ignacio, Kra 7 40-62, Bogota, Colombia
| | - Ithzayana Madariaga
- Pontificia Universidad Javeriana, Bogota, Colombia.,Hospital Universitario San Ignacio, Kra 7 40-62, Bogota, Colombia
| | - Sergio Aldana
- Pontificia Universidad Javeriana, Bogota, Colombia.,Hospital Universitario San Ignacio, Kra 7 40-62, Bogota, Colombia
| | - Jaime E Bernal
- Instituto de Genetica Humana, Pontificia Universidad Javeriana, Bogota, Colombia
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Ross JW, Betz A, Paglia MJ, Feng W, Neubert AG, Mackeen AD. Short- and Long-Term Growth as a Function of Abnormal Doppler Flow in Growth-Restricted Fetuses. PRENATAL CARDIOLOGY 2018. [DOI: 10.1515/pcard-2018-0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
OBJECTIVES: To evaluate short- and long-term growth in fetuses with growth restriction (FGR) and elevated umbilical artery Doppler (UAD) systolic/diastolic (S/D) ratios.
METHODS: In this prospective observational study, two UAD waveforms were obtained from each umbilical artery weekly and were classified as normal or abnormal. Fetal growth was assessed every 3 weeks. Short-term growth was calculated from the first visit with elevated ratios until next growth assessment. Results were grouped by number of initial elevated S/D ratios (maximum, 4). Long-term growth was evaluated by change in estimated fetal weight from diagnosis of FGR to birth weight. Fetuses were grouped by average number of elevated S/D ratios and compared to a reference population of growth restricted fetuses with normal testing.
RESULTS: Of 241 fetuses evaluated, 105 demonstrated elevated S/D ratios. Short-term growth was impaired when fetuses had elevated S/D ratios. Long-term growth was affected when the average number of elevated S/D ratios was ≥1 per visit. Progressive 3 or 4 growth delay was noted as the average number of abnormal S/D ratios increased.
CONCLUSIONS: Short- and long-term fetal growth are affected by elevated UAD S/D ratios. Fetuses with more abnormal values initially and those with a higher average of elevated values over pregnancy demonstrate decreased growth.
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Affiliation(s)
- John W. Ross
- Geisinger, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine (1), and Biostatistics Core (2), 100 N. Academy Ave, Danville , Pennsylvania, 17821 USA
| | - Alexandria Betz
- Geisinger, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine (1), and Biostatistics Core (2), 100 N. Academy Ave, Danville , Pennsylvania, 17821 USA
| | - Michael J. Paglia
- Geisinger, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine (1), and Biostatistics Core (2), 100 N. Academy Ave, Danville , Pennsylvania, 17821 USA
| | - Wen Feng
- Department of Obstetrics and Gynecology , Reading Hospital , Sixth Avenue and Spruce Street West Reading, Pennsylvania 19611 USA
| | - A. George Neubert
- Geisinger, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine (1), and Biostatistics Core (2), 100 N. Academy Ave, Danville , Pennsylvania, 17821 USA
| | - A. Dhanya Mackeen
- Geisinger, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine (1), and Biostatistics Core (2), 100 N. Academy Ave, Danville , Pennsylvania, 17821 USA
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Franklin HL, Mirza W, Swanson DL, Newman JE, Goldenberg RL, Muyodi D, Figueroa L, Nathan RO, Swanson JO, Goldsmith N, Kanaiza N, Naqvi F, Pineda IS, López-Gomez W, Hamsumonde D, Bolamba VL, Fogleman EV, Saleem S, Esamai F, Liechty EA, Garces AL, Krebs NF, Michael Hambidge K, Chomba E, Mwenechanya M, Carlo WA, Tshefu A, Lokangaka A, Bose CL, Koso-Thomas M, Miodovnik M, McClure EM. Factors influencing referrals for ultrasound-diagnosed complications during prenatal care in five low and middle income countries. Reprod Health 2018; 15:204. [PMID: 30541560 PMCID: PMC6291965 DOI: 10.1186/s12978-018-0647-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 11/23/2018] [Indexed: 11/16/2022] Open
Abstract
Background Ultrasound during antenatal care (ANC) is proposed as a strategy for increasing hospital deliveries for complicated pregnancies and improving maternal, fetal, and neonatal outcomes. The First Look study was a cluster-randomized trial conducted in the Democratic Republic of Congo, Guatemala, Kenya, Pakistan and Zambia to evaluate the impact of ANC-ultrasound on these outcomes. An additional survey was conducted to identify factors influencing women with complicated pregnancies to attend referrals for additional care. Methods Women who received referral due to ANC ultrasound findings participated in structured interviews to characterize their experiences. Cochran-Mantel-Haenszel statistics were used to examine differences between women who attended the referral and women who did not. Sonographers’ exam findings were compared to referred women’s recall. Results Among 700 referred women, 510 (71%) attended the referral. Among referred women, 97% received a referral card to present at the hospital, 91% were told where to go in the hospital, and 64% were told that the hospital was expecting them. The referred women who were told who to see at the hospital (88% vs 66%), where to go (94% vs 82%), or what should happen, were more likely to attend their referral (68% vs 56%). Barriers to attending referrals were cost, transportation, and distance. Barriers after reaching the hospital were substantial. These included not connecting with an appropriate provider, not knowing where to go, and being told to return later. These barriers at the hospital often led to an unsuccessful referral. Conclusions Our study found that ultrasound screening at ANC alone does not adequately address barriers to referrals. Better communication between the sonographer and the patient increases the likelihood of a completed referral. These types of communication include describing the ultrasound findings, including the reason for the referral, to the mother and staff; providing a referral card; describing where to go in the hospital; and explaining the procedures at the hospital. Thus, there are three levels of communication that need to be addressed to increase completion of appropriate referrals-communication between the sonographer and the woman, the sonographer and the clinic staff, and the sonographer and the hospital. Trial registration NCT01990625.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Antoinette Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Adrien Lokangaka
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Carl L Bose
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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8
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Doppler measurements of both umbilical arteries do not improve predictive value for adverse perinatal outcomes in small-for-gestational age fetuses. Eur J Obstet Gynecol Reprod Biol 2018; 231:169-173. [PMID: 30391865 DOI: 10.1016/j.ejogrb.2018.10.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 10/05/2018] [Accepted: 10/20/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess agreement of Doppler ultrasound measurements of the two umbilical arteries in small-for gestational age (SGA) fetuses, and to compare discriminative ability between the two arteries for adverse perinatal outcome. STUDY DESIGN We analysed a prospective cohort of singleton SGA pregnancies, in which the pulsatility index (PI) of both umbilical arteries was standardly measured by Doppler ultrasound in the free-floating umbilical cord. The outcome of interest was a composite adverse outcome, defined as perinatal death, Apgar score <7 at 5 min, cesarean section for fetal distress, and neonatal intensive care unit admission. RESULTS A total of 531 measurements were performed in 124 patients. Mean absolute difference between PI measured in the two umbilical arteries was 0.14 (95% CI: 0.12 to 0.15), showing good agreement with an ICC of 0.830 (95% CI: 0.801 to 0.854). Perinatal outcomes were available for 101 patients, of which 48 patients (48%) had a composite adverse perinatal outcome. We found no significant differences between AUCs for prediction of an adverse outcome based on lowest, highest and mean PI values in the two umbilical arteries (AUCs = 0.75, 0.74, 0.75 with p = 0.91). As a comparison, the AUC of a PI value obtained in a single, randomly selected umbilical artery was 0.74. CONCLUSION The two umbilical arteries show good agreement in terms of their PI values in the free-floating umbilical cord, and do not differ in terms of their discriminative ability for adverse perinatal outcome in SGA fetuses. We found no evidence of an added value of standard Doppler measurement of both umbilical arteries.
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Widschwendter P, Lato K, Friedl TWP, Janni W, Friebe-Hoffmann U. Foetal Doppler Parameters as a Prognostic Marker Before Induction of Labour. Geburtshilfe Frauenheilkd 2018; 78:859-865. [PMID: 30258245 PMCID: PMC6138469 DOI: 10.1055/a-0659-6873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 06/17/2018] [Accepted: 07/17/2018] [Indexed: 10/28/2022] Open
Abstract
Introduction The value of foetal Doppler ultrasonography before induction of labour for prognostic assessment of the duration of labour and foetal outcome is presented. Patients and Methods Doppler ultrasound of the foetal middle cerebral artery (MCA) and of the umbilical artery (UA) was performed in addition to evaluation of the Bishop score in 49 women around the expected date of confinement (38 + 0 - 42 + 0 weeks of gestation) prior to planned pharmacological induction of labour. These parameters were studied using non-parametric statistical methods for associations with the duration of induction until delivery, the mode of delivery and foetal outcome. Results The resistance index (RI) of the MCA (rs = 0.547, p < 0.001), but not the RI of the UA (rs = - 0.055, p = 0.707) correlated positively with the duration of induction. Moreover, a negative correlation was found between the RI of the UA and the baby's arterial cord pH at birth (rs = - 0.287, p = 0.046). No differences in the RI of MCA or UA were found between babies born vaginally and those delivered by secondary section. Conclusion The present data show that Doppler measurement of the foetal MCA and UA before pharmacological induction of labour at term can be a further parameter for prognostic estimation of the duration and success of induction and of foetal outcome in addition to the established Bishop score.
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Affiliation(s)
| | - Krisztian Lato
- Frauenklinik, Klinikum der Universität Ulm, Ulm, Germany,Correspondence/Korrespondenzadresse Dr. Krisztian Lato Klinikum der Universität UlmFrauenklinik89070 UlmGermany
| | | | - Wolfgang Janni
- Frauenklinik, Klinikum der Universität Ulm, Ulm, Germany
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Goldenberg RL, Nathan RO, Swanson D, Saleem S, Mirza W, Esamai F, Muyodi D, Garces AL, Figueroa L, Chomba E, Chiwala M, Mwenechanya M, Tshefu A, Lokangako A, Bolamba VL, Moore JL, Franklin H, Swanson J, Liechty EA, Bose CL, Krebs NF, Michael Hambidge K, Carlo WA, Kanaiza N, Naqvi F, Pineda IS, López-Gomez W, Hamsumonde D, Harrison MS, Koso-Thomas M, Miodovnik M, Wallace DD, McClure EM. Routine antenatal ultrasound in low- and middle-income countries: first look - a cluster randomised trial. BJOG 2018; 125:1591-1599. [PMID: 29782696 DOI: 10.1111/1471-0528.15287] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Ultrasound is widely regarded as an important adjunct to antenatal care (ANC) to guide practice and reduce perinatal mortality. We assessed the impact of ANC ultrasound use at health centres in resource-limited countries. DESIGN Cluster randomised trial. SETTING Clusters within five countries (Democratic Republic of Congo, Guatemala, Kenya, Pakistan, and Zambia) METHODS: Clusters were randomised to standard ANC or standard care plus two ultrasounds and referral for complications. The study trained providers in intervention clusters to perform basic obstetric ultrasounds. MAIN OUTCOME MEASURES The primary outcome was a composite of maternal mortality, maternal near-miss mortality, stillbirth, and neonatal mortality. RESULTS During the 24-month trial, 28 intervention and 28 control clusters had 24 263 and 23 160 births, respectively; 78% in the intervention clusters received at least one study ultrasound; 60% received two. The prevalence of conditions noted including twins, placenta previa, and abnormal lie was within expected ranges. 9% were referred for an ultrasound-diagnosed condition, and 71% attended the referral. The ANC (RR 1.0 95% CI 1.00, 1.01) and hospital delivery rates for complicated pregnancies (RR 1.03 95% CI 0.89, 1.20) did not differ between intervention and control clusters nor did the composite outcome (RR 1.09 95% CI 0.97, 1.23) or its individual components. CONCLUSIONS Despite availability of ultrasound at ANC in the intervention clusters, neither ANC nor hospital delivery for complicated pregnancies increased. The composite outcome and the individual components were not reduced. TWEETABLE ABSTRACT Antenatal care ultrasound did not improve a composite outcome that included maternal, fetal, and neonatal mortality.
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Affiliation(s)
| | - R O Nathan
- University of Washington, Seattle, WA, USA
| | - D Swanson
- University of Washington, Seattle, WA, USA
| | - S Saleem
- Aga Khan University, Karachi, Pakistan
| | - W Mirza
- Aga Khan University, Karachi, Pakistan
| | | | | | | | | | - E Chomba
- University of Zambia, Lusaka, Zambia
| | - M Chiwala
- University of Zambia, Lusaka, Zambia
| | | | - A Tshefu
- Kinshasa School of Public Health, Kinshasa, DRC
| | - A Lokangako
- Kinshasa School of Public Health, Kinshasa, DRC
| | - V L Bolamba
- Kinshasa School of Public Health, Kinshasa, DRC
| | | | | | - J Swanson
- University of Washington, Seattle, WA, USA
| | | | - C L Bose
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - N F Krebs
- University of Colorado, Denver, CO, USA
| | | | - W A Carlo
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - F Naqvi
- Aga Khan University, Karachi, Pakistan
| | - I S Pineda
- San Carlos University, Guatemala City, Guatemala
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Green CR, Blake JM, Carson GD, Po L, Brown ARH, Friedman CL. Choosing Wisely: SOGC's Top 10 Recommendations. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:716-722. [PMID: 29861082 DOI: 10.1016/j.jogc.2018.04.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 04/05/2018] [Indexed: 11/26/2022]
Affiliation(s)
| | - Jennifer M Blake
- The Society of Obstetricians and Gynaecologists of Canada; Department of Obstetrics and Gynaecology, The University of Ottawa; Department of Obstetrics and Gynaecology, University of Toronto
| | - George D Carson
- Regina General Hospital at Saskatchewan Health Authority; Department of Obstetrics and Gynecology, University of Saskatchewan, SK
| | - Leslie Po
- Department of Obstetrics and Gynaecology, University of Toronto; Department of Obstetrics & Gynaecology, Division of Minimally Invasive Gynaecologic Surgery, Sunnybrook Health Sciences Centre
| | - Adrian R H Brown
- Department of Obstetrics and Gynaecology, University of Toronto; Department of Obstetrics and Gynaecology, North York General Hospital
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Green CR, Blake JM, Carson GD, Po L, Brown ARH, Friedman CL. Choisir avec soin : les 10 principales recommandations de la SOGC. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:e443-e450. [PMID: 29861086 DOI: 10.1016/j.jogc.2018.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 04/05/2018] [Indexed: 11/30/2022]
Affiliation(s)
| | - Jennifer M Blake
- The Society of Obstetricians and Gynaecologists of Canada; Department of Obstetrics and Gynaecology, The University of Ottawa; Department of Obstetrics and Gynaecology, University of Toronto
| | - George D Carson
- Regina General Hospital at Saskatchewan Health Authority; Department of Obstetrics and Gynecology, University of Saskatchewan, SK
| | - Leslie Po
- Department of Obstetrics and Gynaecology, University of Toronto; Department of Obstetrics & Gynaecology, Division of Minimally Invasive Gynaecologic Surgery, Sunnybrook Health Sciences Centre
| | - Adrian R H Brown
- Department of Obstetrics and Gynaecology, University of Toronto; Department of Obstetrics and Gynaecology, North York General Hospital
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13
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Widnes C, Flo K, Wilsgaard T, Kiserud T, Acharya G. Sex differences in umbilical artery Doppler indices: a longitudinal study. Biol Sex Differ 2018; 9:16. [PMID: 29669590 PMCID: PMC5907403 DOI: 10.1186/s13293-018-0174-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 04/02/2018] [Indexed: 11/16/2022] Open
Abstract
Background Sexual dimorphism in placental size and function has been described. Whether this influences the clinically important umbilical artery (UA) waveform remains controversial, although a few cross-sectional studies have shown sex differences in UA pulsatility index (PI). Therefore, we tested whether fetal sex influences the UA Doppler indices during the entire second half of pregnancy and aimed to establish sex-specific reference ranges for UA Doppler indices if needed. Methods Our main objective was to investigate gestational age-associated changes in UA Doppler indices during the second half of pregnancy and compare the values between male and female fetuses. This was a prospective longitudinal study in women with singleton low-risk pregnancies during 19–40 weeks of gestation. UA Doppler indices were serially obtained at a 4-weekly interval from a free loop of the umbilical cord using color-directed pulsed-wave Doppler ultrasonography. Sex-specific reference intervals were calculated for the fetal heart rate (HR), UA PI, resistance index (RI), and systolic/diastolic ratio (S/D) using multilevel modeling. Results Complete data from 294 pregnancies (a total of 1261 observations from 152 male and 142 female fetuses) were available for statistical analysis, and sex-specific reference ranges for the UA Doppler indices and fetal HR were established for the last half of pregnancy. UA Doppler indices were significantly associated with gestational age (P < 0.0001) and fetal HR (P < 0.0001). Female fetuses had 2–8% higher values for UA Doppler indices than male fetuses during gestational weeks 20+0–36+6 (P < 0.05), but not later. Female fetuses had higher HR from gestational week 26+0 until term (P < 0.05). Conclusions We have determined gestational age-dependent sex differences in UA Doppler indices and fetal HR during the second half of pregnancy, and correspondingly established new sex-specific reference ranges intended for refining diagnostics and monitoring individual pregnancies.
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Affiliation(s)
- Christian Widnes
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromso, Norway. .,Department of Obstetrics and Gynecology, University Hospital of North Norway, Sykehusveien 38, PO Box 24, N-9038, Tromso, Norway.
| | - Kari Flo
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromso, Norway.,Department of Obstetrics and Gynecology, University Hospital of North Norway, Sykehusveien 38, PO Box 24, N-9038, Tromso, Norway
| | - Tom Wilsgaard
- Department of Community Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromso, Norway
| | - Torvid Kiserud
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
| | - Ganesh Acharya
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromso, Norway.,Department of Obstetrics and Gynecology, University Hospital of North Norway, Sykehusveien 38, PO Box 24, N-9038, Tromso, Norway.,Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
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14
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Eslamian ZL, Zarean E, Moshfeghi M, Heidari Z. Evaluation of the predictive value of fetal Doppler ultrasound for neonatal outcome from the 36 th week of pregnancy. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2018. [PMID: 29531565 PMCID: PMC5842445 DOI: 10.4103/jrms.jrms_133_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Early prediction of adverse neonatal outcome would be possible by Doppler impedance indices of middle cerebral artery (MCA), umbilical artery (UmA), and descending aortal artery (AO) that result in decrease neonatal morbidity and mortality rate. The aim of the present study was a determination of optimal value for the ratio of MCA to descending aorta blood flow (MCA/AO) impedance indices and its comparison with the ratio of MCA to UmA (MCA/UmA) impedance indices and their relationship with neonatal outcome. Materials and Methods This was a prospective cohort study on 212 pregnant women with gestational age 36 weeks or more, in three hospitals in Tehran, from April 2012 to April 2013. We investigated AO, MCA, and UmA impedance indices Doppler ultrasound every 2 weeks till delivery. The mother was monitored for adverse pregnancy outcome (hypertension [HTN], fetal growth retardation, and other maternal complications) then infant birth weight, cord blood of pH, and Neonatal Intensive Care Unit (NICU) admission during the first 24 h after delivery were assessed. Finally, we investigated relationships between Doppler indices and neonatal outcomes include neonatal body weight (NBW), cord blood of pH, and NICU admission. Results MCA/AO resistance index (RI) and MCA/AO pulsatile index (PI) showed an area under the receiver operating characteristics curve (area under the curve) of 0.905 (95% confidence interval (CI): 0.850, 0.959) and 0.818 (95% CI: 0.679, 0.956), respectively. The cutoff values for pH (≥7.2 vs. <7.2) based on MCA/AO RI and MCA/AO PI indices were 0.951 (sensitivity, 80% and specificity, 86%) and 0.853 (sensitivity, 91% and specificity, 83%), respectively. The cutoff value for NBW (≥2500 vs. <2500 g) based on MCA/UmA PI index was 1.467 (sensitivity, 73% and specificity, 63%). The cutoff value of NICU admission of child based on MCA/AO PI index was 1.114 (sensitivity, 73% and specificity, 54%). Conclusion In the end of third-trimester pregnancies with the assessment of MCA and AO artery Doppler ultrasonography, it is possible to prevent many cases of neonatal acidosis caused by prenatal asphyxia as well as inappropriate interventions which are applied on mother. If MCA/AO PI was <0.85, the fetus needs to be evaluated further because it is at risk for acidosis.
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Affiliation(s)
- Zahra Laleh Eslamian
- Department of Obstetrics and Gynecology, Fetal Medicine Unit, Tehran University of Medical Sciences, Tehran, Iran
| | - Elahe Zarean
- Department of Obstetrics and Gynecology, Fetal Medicine Unit, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Moshfeghi
- Department of Obstetrics and Gynecology, Fetal Medicine Unit, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Heidari
- Department of Biostatistics and Epidemiology, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
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15
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Vollgraff Heidweiller‐Schreurs CA, De Boer MA, Heymans MW, Schoonmade LJ, Bossuyt PMM, Mol BWJ, De Groot CJM, Bax CJ. Prognostic accuracy of cerebroplacental ratio and middle cerebral artery Doppler for adverse perinatal outcome: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:313-322. [PMID: 28708272 PMCID: PMC5873403 DOI: 10.1002/uog.18809] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/30/2017] [Accepted: 07/07/2017] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Doppler ultrasonographic assessment of the cerebroplacental ratio (CPR) and middle cerebral artery (MCA) is widely used as an adjunct to umbilical artery (UA) Doppler to identify fetuses at risk of adverse perinatal outcome. However, reported estimates of its accuracy vary considerably. The aim of this study was to review systematically the prognostic accuracies of CPR and MCA Doppler in predicting adverse perinatal outcome, and to compare these with UA Doppler, in order to identify whether CPR and MCA Doppler evaluation are of added value to UA Doppler. METHODS PubMed, EMBASE, the Cochrane Library and ClinicalTrials.gov were searched, from inception to June 2016, for studies on the prognostic accuracy of UA Doppler compared with CPR and/or MCA Doppler in the prediction of adverse perinatal outcome in women with a singleton pregnancy of any risk profile. Risk of bias and concerns about applicability were assessed using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) tool. Meta-analysis was performed for multiple adverse perinatal outcomes. Using hierarchal summary receiver-operating characteristics meta-regression models, the prognostic accuracy of CPR vs MCA Doppler was compared indirectly, and CPR and MCA Doppler vs UA Doppler compared directly. RESULTS The search identified 4693 articles, of which 128 studies (involving 47 748 women) were included. Risk of bias or suboptimal reporting was detected in 120/128 studies (94%) and substantial heterogeneity was found, which limited subgroup analyses for fetal growth and gestational age. A large variation was observed in reported sensitivities and specificities, and in thresholds used. CPR outperformed UA Doppler in the prediction of composite adverse outcome (as defined in the included studies) (P < 0.001) and emergency delivery for fetal distress (P = 0.003), but was comparable to UA Doppler for the other outcomes. MCA Doppler performed significantly worse than did UA Doppler in the prediction of low Apgar score (P = 0.017) and emergency delivery for fetal distress (P = 0.034). CPR outperformed MCA Doppler in the prediction of composite adverse outcome (P < 0.001) and emergency delivery for fetal distress (P = 0.013). CONCLUSION Calculating the CPR with MCA Doppler can add value to UA Doppler assessment in the prediction of adverse perinatal outcome in women with a singleton pregnancy. However, it is unclear to which subgroup of pregnant women this applies. The effectiveness of the CPR in guiding clinical management needs to be evaluated in clinical trials. © 2017 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
| | - M. A. De Boer
- Department of Obstetrics and GynecologyVU University Medical CenterAmsterdamThe Netherlands
| | - M. W. Heymans
- Department of Epidemiology and BiostatisticsVU University Medical CenterAmsterdamThe Netherlands
| | - L. J. Schoonmade
- Department of Medical LibraryVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - P. M. M. Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical CenterUniversity of AmsterdamAmsterdam, The Netherlands
| | - B. W. J. Mol
- Department of Obstetrics and Gynecology, The Robinson Institute, School of MedicineUniversity of AdelaideAdelaideAustralia
- The South Australian Health and Medical Research InstituteAdelaideAustralia
| | - C. J. M. De Groot
- Department of Obstetrics and GynecologyVU University Medical CenterAmsterdamThe Netherlands
| | - C. J. Bax
- Department of Obstetrics and Gynecology, Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
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16
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Stridsklev S, Salvesen Ø, Salvesen KÅ, Carlsen SM, Vanky E. Uterine Artery Doppler in Pregnancy: Women with PCOS Compared to Healthy Controls. Int J Endocrinol 2018; 2018:2604064. [PMID: 30186323 PMCID: PMC6116456 DOI: 10.1155/2018/2604064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 07/04/2018] [Indexed: 01/26/2023] Open
Abstract
The objective of this study was to investigate possible differences in uterine artery pulsatility index (UtAPI) between pregnant women with PCOS and healthy controls and to explore possible effects of metformin on UtAPI. Material and Methods. The study was conducted in a tertiary center. Forty-eight pregnant women diagnosed with PCOS before pregnancy and 124 healthy pregnant women were included. Women with PCOS were randomly assigned to metformin 2000 mg daily or a placebo. UtAPI was measured five times during 1st and 2nd trimesters of pregnancy in women with PCOS and four times in healthy controls. Results. There was no difference in UtAPI between PCOS women and healthy controls at any point in time (p = 0.34-0.77). In women with PCOS, randomly assigned to metformin 2000 mg or placebo, UtAPI was unaffected by metformin two hours after intake of the first dose of study medication (p = 0.34). All PCOS women, regardless of randomization, had higher UtAPI two hours after intake of study medication and a meal compared to before a meal (p = 0.02). Conclusions. In the first and second trimesters of pregnancy, there was no difference in UtAPI between women with PCOS and healthy controls. Metformin had no immediate effect on the UtAPI. Interestingly, blood flow decreased after a meal, suggesting that time since last meal should be taken into consideration when interpreting the results of UtAPI measurements in pregnancy. This trial is registered with ClinicalTrials.gov (NCT00466622) Metformin in Pregnant PCOS women (PregMet) (NCT00159536).
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Affiliation(s)
- Solhild Stridsklev
- Department of Obstetrics and Gynecology, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Øyvind Salvesen
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kjell Åsmund Salvesen
- Department of Obstetrics and Gynecology, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sven M. Carlsen
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Endocrinology, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Eszter Vanky
- Department of Obstetrics and Gynecology, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
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17
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Li Y, Lorca RA, Su EJ. Molecular and cellular underpinnings of normal and abnormal human placental blood flows. J Mol Endocrinol 2018; 60:R9-R22. [PMID: 29097590 PMCID: PMC5732864 DOI: 10.1530/jme-17-0139] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 11/02/2017] [Indexed: 12/21/2022]
Abstract
Abnormal placental function is well-established as a major cause for poor pregnancy outcome. Placental blood flow within the maternal uteroplacental compartment, the fetoplacental circulation or both is a vital factor in mediating placental function. Impairment in flow in either or both vasculatures is a significant risk factor for adverse pregnancy outcome, potentially impacting maternal well-being, affecting immediate neonatal health and even influencing the long-term health of the infant. Much remains unknown regarding the mechanistic underpinnings of proper placental blood flow. This review highlights the currently recognized molecular and cellular mechanisms in the development of normal uteroplacental and fetoplacental blood flows. Utilizing the entities of preeclampsia and fetal growth restriction as clinical phenotypes that are often evident downstream of abnormal placental blood flow, mechanisms underlying impaired uteroplacental and fetoplacental blood flows are also discussed. Deficiencies in knowledge, which limit the efficacy of clinical care, are also highlighted, underscoring the need for continued research on normal and abnormal placental blood flows.
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Affiliation(s)
- Yingchun Li
- Department of Obstetrics and GynecologyDivision of Reproductive Sciences, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Ramón A Lorca
- Department of Obstetrics and GynecologyDivision of Reproductive Sciences, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Emily J Su
- Department of Obstetrics and GynecologyDivision of Maternal-Fetal Medicine/Division of Reproductive Sciences, University of Colorado School of Medicine, Aurora, Colorado, USA
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18
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Abstract
BACKGROUND The worldwide burden of stillbirths is large, with an estimated 2.6 million babies stillborn in 2015 including 1.3 million dying during labour. The Every Newborn Action Plan set a stillbirth target of ≤12 per 1000 in all countries by 2030. Planning tools will be essential as countries set policy and plan investment to scale up interventions to meet this target. This paper summarises the approach taken for modelling the impact of scaling-up health interventions on stillbirths in the Lives Saved tool (LiST), and potential future refinements. METHODS The specific application to stillbirths of the general method for modelling the impact of interventions in LiST is described. The evidence for the effectiveness of potential interventions to reduce stillbirths are reviewed and the assumptions of the affected fraction of stillbirths who could potentially benefit from these interventions are presented. The current assumptions and their effects on stillbirth reduction are described and potential future improvements discussed. RESULTS High quality evidence are not available for all parameters in the LiST stillbirth model. Cause-specific mortality data is not available for stillbirths, therefore stillbirths are modelled in LiST using an attributable fraction approach by timing of stillbirths (antepartum/ intrapartum). Of 35 potential interventions to reduce stillbirths identified, eight interventions are currently modelled in LiST. These include childbirth care, induction for prolonged pregnancy, multiple micronutrient and balanced energy supplementation, malaria prevention and detection and management of hypertensive disorders of pregnancy, diabetes and syphilis. For three of the interventions, childbirth care, detection and management of hypertensive disorders of pregnancy, and diabetes the estimate of effectiveness is based on expert opinion through a Delphi process. Only for malaria is coverage information available, with coverage estimated using expert opinion for all other interventions. Going forward, potential improvements identified include improving of effectiveness and coverage estimates for included interventions and addition of further interventions. CONCLUSIONS Known effective interventions have the potential to reduce stillbirths and can be modelled using the LiST tool. Data for stillbirths are improving. Going forward the LiST tool should seek, where possible, to incorporate these improving data, and to continually be refined to provide an increasingly reliable tool for policy and programming purposes.
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Kehl S, Dötsch J, Hecher K, Schlembach D, Schmitz D, Stepan H, Gembruch U. Intrauterine Growth Restriction. Guideline of the German Society of Gynecology and Obstetrics (S2k-Level, AWMF Registry No. 015/080, October 2016). Geburtshilfe Frauenheilkd 2017; 77:1157-1173. [PMID: 29375144 PMCID: PMC5784232 DOI: 10.1055/s-0043-118908] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 08/19/2017] [Accepted: 08/25/2017] [Indexed: 12/12/2022] Open
Abstract
AIMS The aim of this official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG) was to provide consensus-based recommendations obtained by evaluating the relevant literature for the diagnostic treatment and management of women with fetal growth restriction. METHODS This S2k guideline represents the structured consensus of a representative panel of experts with a range of different professional backgrounds commissioned by the Guideline Committee of the DGGG. RECOMMENDATIONS Recommendations for diagnostic treatment, management, counselling, prophylaxis and screening are presented.
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Affiliation(s)
- Sven Kehl
- Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Jörg Dötsch
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Köln, Köln, Germany
| | - Kurt Hecher
- Klinik für Geburtshilfe und Pränatalmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Dagmar Schmitz
- Institut für Geschichte, Theorie und Ethik der Medizin, Uniklinik RWTH Aachen, Aachen, Germany
| | - Holger Stepan
- Abteilung für Geburtsmedizin, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Ulrich Gembruch
- Abteilung für Geburtshilfe und Pränatale Medizin, Universitätsklinikum Bonn, Bonn, Germany
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20
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Uquillas KR, Grubbs BH, Prosper AE, Chmait RH, Grant EG, Walker DK. Doppler US in the Evaluation of Fetal Growth and Perinatal Health. Radiographics 2017; 37:1831-1838. [DOI: 10.1148/rg.2017170020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Kristen R. Uquillas
- From the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine (K.R.U., B.H.G., R.H.C.), and Department of Radiology (A.E.P., E.G.G., D.K.W.), Keck School of Medicine, University of Southern California, 2020 Zonal Ave, IRD 203, Los Angeles, CA 90033
| | - Brendan H. Grubbs
- From the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine (K.R.U., B.H.G., R.H.C.), and Department of Radiology (A.E.P., E.G.G., D.K.W.), Keck School of Medicine, University of Southern California, 2020 Zonal Ave, IRD 203, Los Angeles, CA 90033
| | - Ashley E. Prosper
- From the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine (K.R.U., B.H.G., R.H.C.), and Department of Radiology (A.E.P., E.G.G., D.K.W.), Keck School of Medicine, University of Southern California, 2020 Zonal Ave, IRD 203, Los Angeles, CA 90033
| | - Ramen H. Chmait
- From the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine (K.R.U., B.H.G., R.H.C.), and Department of Radiology (A.E.P., E.G.G., D.K.W.), Keck School of Medicine, University of Southern California, 2020 Zonal Ave, IRD 203, Los Angeles, CA 90033
| | - Edward G. Grant
- From the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine (K.R.U., B.H.G., R.H.C.), and Department of Radiology (A.E.P., E.G.G., D.K.W.), Keck School of Medicine, University of Southern California, 2020 Zonal Ave, IRD 203, Los Angeles, CA 90033
| | - Daphne K. Walker
- From the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine (K.R.U., B.H.G., R.H.C.), and Department of Radiology (A.E.P., E.G.G., D.K.W.), Keck School of Medicine, University of Southern California, 2020 Zonal Ave, IRD 203, Los Angeles, CA 90033
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Chauhan SP, Rice MM, Grobman WA, Bailit J, Reddy UM, Wapner RJ, Varner MW, Thorp JM, Leveno KJ, Caritis SN, Prasad M, Tita ATN, Saade G, Sorokin Y, Rouse DJ, Tolosa JE. Neonatal Morbidity of Small- and Large-for-Gestational-Age Neonates Born at Term in Uncomplicated Pregnancies. Obstet Gynecol 2017; 130:511-519. [PMID: 28796674 PMCID: PMC5578445 DOI: 10.1097/aog.0000000000002199] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare morbidity among small-for-gestational-age (SGA; birth weight less than the 10th percentile for gestational age), appropriate-for-gestational-age (AGA; birth weight 10th to 90th percentile; reference group), and large-for-gestational-age (LGA; birth weight greater than the 90th percentile) neonates in apparently uncomplicated pregnancies at term (37 weeks of gestation or greater). METHODS This secondary analysis, derived from an observational obstetric cohort of 115,502 deliveries, included women with apparently uncomplicated pregnancies of nonanomalous singletons who had confirmatory ultrasound dating no later than the second trimester and who delivered between 37 0/7 and 42 6/7 weeks of gestation. We used two different composite neonatal morbidity outcomes: hypoxic composite neonatal morbidity for SGA and traumatic composite neonatal morbidity for LGA neonates. Log Poisson relative risks (RRs) with 95% CIs adjusted for potential confounding factors (nulliparity, body mass index, insurance status, and neonatal sex) were calculated. RESULTS Among the 63,436 women who met our inclusion criteria, SGA occurred in 7.9% (n=4,983) and LGA in 8.3% (n=5,253). Hypoxic composite neonatal morbidity was significantly higher in SGA (1.1%) compared with AGA (0.7%; adjusted RR 1.44, 95% CI 1.07-1.93) but similar between LGA (0.6%) and AGA (adjusted RR 0.84, 95% CI 0.58-1.22). Traumatic composite neonatal morbidity was significantly higher in LGA (1.9%) than AGA (1.0%; adjusted RR 1.88, 95% CI 1.51-2.34) but similar in SGA (1.3%) compared with AGA (adjusted RR 1.28, 95% CI 0.98-1.67). CONCLUSION Among women with uncomplicated pregnancies, hypoxic composite neonatal morbidity is more common with SGA neonates and traumatic-composite neonatal morbidity is more common with LGA neonates.
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Affiliation(s)
- Suneet P Chauhan
- Departments of Obstetrics and Gynecology, University of Texas Health Science Center at Houston, McGovern Medical School-Children's Memorial Hermann Hospital, Houston, Texas, Northwestern University, Chicago, Illinois, MetroHealth Medical Center-Case Western Reserve University, Cleveland, Ohio, Columbia University, New York, New York, the University of Utah Health Sciences Center, Salt Lake City, Utah, the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, the University of Texas Southwestern Medical Center, Dallas, Texas, the University of Pittsburgh, Pittsburgh, Pennsylvania, The Ohio State University, Columbus, Ohio, the University of Alabama at Birmingham, Birmingham, Alabama, the University of Texas Medical Branch, Galveston, Texas, Wayne State University, Detroit, Michigan, Brown University, Providence, Rhode Island, and Oregon Health & Science University, Portland, Oregon; the George Washington University Biostatistics Center, Washington, DC; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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Abstract
BACKGROUND Abnormal blood flow patterns in fetal circulation detected by Doppler ultrasound may indicate poor fetal prognosis. It is also possible that false positive Doppler ultrasound findings could lead to adverse outcomes from unnecessary interventions, including preterm delivery. OBJECTIVES The objective of this review was to assess the effects of Doppler ultrasound used to assess fetal well-being in high-risk pregnancies on obstetric care and fetal outcomes. SEARCH METHODS We updated the search of Cochrane Pregnancy and Childbirth's Trials Register on 31 March 2017 and checked reference lists of retrieved studies. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of Doppler ultrasound for the investigation of umbilical and fetal vessels waveforms in high-risk pregnancies compared with no Doppler ultrasound. Cluster-randomised trials were eligible for inclusion but none were identified. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked. We assessed the quality of evidence using the GRADE approach. MAIN RESULTS Nineteen trials involving 10,667 women were included. Risk of bias in trials was difficult to assess accurately due to incomplete reporting. None of the evidence relating to our main outcomes was graded as high quality. The quality of evidence was downgraded due to missing information on trial methods, imprecision in risk estimates and heterogeneity. Eighteen of these studies compared the use of Doppler ultrasound of the umbilical artery of the unborn baby with no Doppler or with cardiotocography (CTG). One more recent trial compared Doppler examination of other fetal blood vessels (ductus venosus) with computerised CTG.The use of Doppler ultrasound of the umbilical artery in high-risk pregnancy was associated with fewer perinatal deaths (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.52 to 0.98, 16 studies, 10,225 babies, 1.2% versus 1.7 %, number needed to treat (NNT) = 203; 95% CI 103 to 4352, evidence graded moderate). The results for stillbirths were consistent with the overall rate of perinatal deaths, although there was no clear difference between groups for this outcome (RR 0.65, 95% CI 0.41 to 1.04; 15 studies, 9560 babies, evidence graded low). Where Doppler ultrasound was used, there were fewer inductions of labour (average RR 0.89, 95% CI 0.80 to 0.99, 10 studies, 5633 women, random-effects, evidence graded moderate) and fewer caesarean sections (RR 0.90, 95% CI 0.84 to 0.97, 14 studies, 7918 women, evidence graded moderate). There was no comparative long-term follow-up of babies exposed to Doppler ultrasound in pregnancy in women at increased risk of complications.No difference was found in operative vaginal births (RR 0.95, 95% CI 0.80 to 1.14, four studies, 2813 women), nor in Apgar scores less than seven at five minutes (RR 0.92, 95% CI 0.69 to 1.24, seven studies, 6321 babies, evidence graded low). Data for serious neonatal morbidity were not pooled due to high heterogeneity between the three studies that reported it (1098 babies) (evidence graded very low).The use of Doppler to evaluate early and late changes in ductus venosus in early fetal growth restriction was not associated with significant differences in any perinatal death after randomisation. However, there was an improvement in long-term neurological outcome in the cohort of babies in whom the trigger for delivery was either late changes in ductus venosus or abnormalities seen on computerised CTG. AUTHORS' CONCLUSIONS Current evidence suggests that the use of Doppler ultrasound on the umbilical artery in high-risk pregnancies reduces the risk of perinatal deaths and may result in fewer obstetric interventions. The results should be interpreted with caution, as the evidence is not of high quality. Serial monitoring of Doppler changes in ductus venosus may be beneficial, but more studies of high quality with follow-up including neurological development are needed for evidence to be conclusive.
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Affiliation(s)
- Zarko Alfirevic
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Tamara Stampalija
- Institute for Maternal and Child Health, IRCCS Burlo GarofoloUnit of Prenatal DiagnosisTriesteItaly
| | - Therese Dowswell
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Kellie FJ. Vasodilators for treating intrauterine growth restriction. Hippokratia 2017. [DOI: 10.1002/14651858.cd011978.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Frances J Kellie
- The University of Liverpool; Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health; First Floor, Liverpool Women's NHS Foundation Trust Crown Street Liverpool UK L8 7SS
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24
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Care-Related and Maternal Risk Factors Associated with the Antenatal Nondetection of Intrauterine Growth Restriction: A Case-Control Study from Bremen, Germany. BIOMED RESEARCH INTERNATIONAL 2017; 2017:1746146. [PMID: 28473976 PMCID: PMC5394345 DOI: 10.1155/2017/1746146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 03/16/2017] [Indexed: 11/17/2022]
Abstract
Objective. To identify care-related and maternal risk factors for the antenatal nondetection of IUGR. Methods. In this hospital-based case-control study we compared antenatally undetected IUGR neonates (cases) to detected IUGR neonates (controls). Data were collected using newborn documentation sheets and standardized personal interviews with the mothers. We calculated antenatal detection rates and used uni- and multivariable logistic regression models to assess the association of antenatal nondetection of IUGR and maternal and care-related factors. Results. A total of 161 neonates from three hospitals were included in the study. Suboptimal fetal growth was identified antenatally in n = 77 pregnancies while in n = 84 it was not detected antenatally (antenatal detection rate: 47.8%). Severity of IUGR, maternal complications, and a Doppler examination during the course of pregnancy were associated with IUGR detection. We did not find statistically significant differences regarding parental socioeconomic status and maternal migration background. Conclusions. In our study, about half of all pregnancies affected by suboptimal growth remained undetected. Future in-depth studies with larger study populations should further examine factors that could increase antenatal detection rates for IUGR.
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Suspected Fetal Growth Restriction at 37 Weeks: A Comparison of Doppler and Placental Pathology. BIOMED RESEARCH INTERNATIONAL 2017; 2017:3723879. [PMID: 28409154 PMCID: PMC5376925 DOI: 10.1155/2017/3723879] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 03/04/2017] [Accepted: 03/12/2017] [Indexed: 11/17/2022]
Abstract
Objective. Our objective was determining if abnormal Doppler evaluation had a higher prevalence of placental pathology compared to normal Doppler in suspected fetal growth restriction (FGR) of cases delivered at 37 weeks. Study Design. This retrospective cohort study of suspected FGR singletons with antenatal Doppler evaluation delivered at 37 weeks had a primary outcome of the prevalence of placental pathology related to FGR. Significance was defined as p ≤ 0.05. Results. Of 100 pregnancies 46 and 54 were in the abnormal and normal Doppler cohorts, respectively. Placental pathology was more prevalent with any abnormal Doppler, 84.8% versus 55.6%, odds ratio (OR) 4.46, 95% confidence interval (CI): 1.55, 13.22, and p = 0.002. Abnormal middle cerebral artery (MCA) Doppler had a higher prevalence: 96.2% versus 54.8%, OR 20.7, 95% CI: 2.54, 447.1, and p < 0.001. Conclusion. Abnormal Doppler was associated with more placental pathology in comparison to normal Doppler in fetuses with suspected FGR. Abnormal MCA Doppler had the strongest association.
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26
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Devane D, Lalor JG, Daly S, McGuire W, Cuthbert A, Smith V. Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing. Cochrane Database Syst Rev 2017; 1:CD005122. [PMID: 28125772 PMCID: PMC6464914 DOI: 10.1002/14651858.cd005122.pub5] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The admission cardiotocograph (CTG) is a commonly used screening test consisting of a short (usually 20 minutes) recording of the fetal heart rate (FHR) and uterine activity performed on the mother's admission to the labour ward. This is an update of a review published in 2012. OBJECTIVES To compare the effects of admission cardiotocography with intermittent auscultation of the FHR on maternal and infant outcomes for pregnant women without risk factors on their admission to the labour ward. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register to 30 November 2016 and we planned to review the reference list of retrieved papers SELECTION CRITERIA All randomised and quasi-randomised trials comparing admission CTG with intermittent auscultation of the FHR for pregnant women between 37 and 42 completed weeks of pregnancy and considered to be at low risk of intrapartum fetal hypoxia and of developing complications during labour. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial eligibility and quality, and extracted data. Data were checked for accuracy. MAIN RESULTS We included no new trials in this update. We included four trials involving more than 13,000 women which were conducted in the UK and Ireland and included women in labour. Three trials were funded by the hospitals where the trials took place and one trial was funded by the Scottish government. No declarations of interest were made in two trials; the remaining two trials did not mention declarations of interest. Overall, the studies were assessed as low risk of bias. Results reported in the 2012 review remain unchanged.Although not statistically significant using a strict P < 0.05 criterion, data were consistent with women allocated to admission CTG having, on average, a higher probability of an increase in incidence of caesarean section than women allocated to intermittent auscultation (risk ratio (RR) 1.20, 95% confidence interval (CI) 1.00 to 1.44, 4 trials, 11,338 women, I² = 0%, moderate quality evidence). There was no clear difference in the average treatment effect across included trials between women allocated to admission CTG and women allocated to intermittent auscultation in instrumental vaginal birth (RR 1.10, 95% CI 0.95 to 1.27, 4 trials, 11,338 women, I² = 38%, low quality evidence) and perinatal mortality rate (RR 1.01, 95% CI 0.30 to 3.47, 4 trials, 11,339 infants, I² = 0%, moderate quality evidence).Women allocated to admission CTG had, on average, higher rates of continuous electronic fetal monitoring during labour (RR 1.30, 95% CI 1.14 to 1.48, 3 trials, 10,753 women, I² = 79%, low quality evidence) and fetal blood sampling (RR 1.28, 95% CI 1.13 to 1.45, 3 trials, 10,757 women, I² = 0%) than women allocated to intermittent auscultation. There were no differences between groups in other secondary outcome measures including incidence and severity of hypoxic ischaemic encephalopathy (incidence only reported) (RR 1.19, 95% CI 0.37 to 3.90; 2367 infants; 1 trial; very low quality evidence) and incidence of seizures in the neonatal period (RR 0.72, 95% CI 0.32 to 1.61; 8056 infants; 1 trial; low quality evidence). There were no data reported for severe neurodevelopmental disability assessed at greater than, or equal to, 12 months of age. AUTHORS' CONCLUSIONS Contrary to continued use in some clinical areas, we found no evidence of benefit for the use of the admission CTG for low-risk women on admission in labour.Furthermore, the probability is that admission CTG increases the caesarean section rate by approximately 20%. The data lacked power to detect possible important differences in perinatal mortality. However, it is unlikely that any trial, or meta-analysis, will be adequately powered to detect such differences. The findings of this review support recommendations that the admission CTG not be used for women who are low risk on admission in labour. Women should be informed that admission CTG is likely associated with an increase in the incidence of caesarean section without evidence of benefit.Evidence quality ranged from moderate to very low, with downgrading decisions based on imprecision, inconsistency and a lack of blinding for participants and personnel. All four included trials were conducted in developed Western European countries. One additional study is ongoing.The usefulness of the findings of this review for developing countries will depend on FHR monitoring practices. However, an absence of benefit and likely harm associated with admission CTG will have relevance for countries where questions are being asked about the role of the admission CTG.Future studies evaluating the effects of the admission CTG should consider including women admitted with signs of labour and before a formal diagnosis of labour. This would include a cohort of women currently having admission CTGs and not included in current trials.
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Affiliation(s)
- Declan Devane
- National University of Ireland GalwaySchool of Nursing and MidwiferyUniversity RoadGalwayIreland
| | - Joan G Lalor
- Trinity College DublinSchool of Nursing and Midwifery24 D'Olier StreetDublinIreland2
| | - Sean Daly
- Coombe Women & Infants University HospitalDolphin's BarnDublin 8Ireland
| | - William McGuire
- University of YorkCentre for Reviews and DisseminationYorkY010 5DDUK
| | - Anna Cuthbert
- University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Valerie Smith
- Trinity College DublinSchool of Nursing and Midwifery24 D'Olier StreetDublinIreland2
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Dall’Asta A, Brunelli V, Prefumo F, Frusca T, Lees CC. Early onset fetal growth restriction. Matern Health Neonatol Perinatol 2017; 3:2. [PMID: 28116113 PMCID: PMC5241928 DOI: 10.1186/s40748-016-0041-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 12/27/2016] [Indexed: 01/01/2023] Open
Abstract
Fetal growth restriction (FGR) diagnosed before 32 weeks is identified by fetal smallness associated with Doppler abnormalities and is associated with significant perinatal morbidity and mortality and maternal complications. Recent studies have provided new insights into pathophysiology, management options and postnatal outcomes of FGR. In this paper we review the available evidence regarding diagnosis, management and prognosis of fetuses diagnosed with FGR before 32 weeks of gestation.
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Affiliation(s)
- Andrea Dall’Asta
- Centre for Fetal Care, Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS United Kingdom
- Department of Obstetrics & Gynecology, University of Parma, Parma, Italy
| | - Valentina Brunelli
- Department of Obstetrics and Gynaecology, Maternal-Fetal Medicine Unit, University of Brescia, Brescia, Italy
| | - Federico Prefumo
- Department of Obstetrics and Gynaecology, Maternal-Fetal Medicine Unit, University of Brescia, Brescia, Italy
| | - Tiziana Frusca
- Department of Obstetrics & Gynecology, University of Parma, Parma, Italy
| | - Christoph C Lees
- Centre for Fetal Care, Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS United Kingdom
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Department of Development and Regeneration, KU Leuven, Belgium
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28
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Ultrasound prediction of abnormal infant development in hypertensive pregnant women in the second and third trimester. Sci Rep 2017; 7:40429. [PMID: 28091544 PMCID: PMC5238445 DOI: 10.1038/srep40429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 12/02/2016] [Indexed: 11/25/2022] Open
Abstract
The objective was to assess the sensitivities and accuracies of Doppler ultrasound parameters in the second and third trimester of hypertensive pregnancies in determining perinatal outcomes. 1,054 pregnancies were retrospectively categorized into three groups (healthy pregnancies (HP, n = 988), pregnancies of hypertensive women (HypP, n = 30) and high-risk hypertension pregnancies (HRHypP, n = 36), depending on gestational hypertension as well as fetal birth weights and pregnancy outcomes. Systolic/diastolic ratio (S/D), resistance index (RI), pulsatility index (PI) of the bilateral uterine artery, umbilical artery and vein as well as venous flow velocity data were monitored by Doppler ultrasound. At 20–27 and 28–32 gestational weeks, uterine artery PIs and RIs were significantly higher in the HRHypP group than in the HP and HypP patients. At gestational weeks 20–27 and 28–32 left plus right PI data with cut-off values of 2.35 and 1.73 indicated a risk of stillbirth, premature pregnancy termination and a birth weight of less than 2,500 g with sensitivities of 94.4% and 93.1% as well as specificities of 95.2% and 90.1%, respectively.
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29
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Gravett C, Eckert LO, Gravett MG, Dudley DJ, Stringer EM, Mujobu TBM, Lyabis O, Kochhar S, Swamy GK. Non-reassuring fetal status: Case definition & guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine 2016; 34:6084-6092. [PMID: 27461459 PMCID: PMC5139811 DOI: 10.1016/j.vaccine.2016.03.043] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/15/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Courtney Gravett
- Global Alliance to Prevent Prematurity and Stillbirth, Seattle Children's Hospital, Seattle, USA.
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30
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Maitre L, Villanueva CM, Lewis MR, Ibarluzea J, Santa-Marina L, Vrijheid M, Sunyer J, Coen M, Toledano MB. Maternal urinary metabolic signatures of fetal growth and associated clinical and environmental factors in the INMA study. BMC Med 2016; 14:177. [PMID: 27814705 PMCID: PMC5097405 DOI: 10.1186/s12916-016-0706-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/28/2016] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Maternal metabolism during pregnancy is a major determinant of the intra-uterine environment and fetal outcomes. Herein, we characterize the maternal urinary metabolome throughout pregnancy to identify maternal metabolic signatures of fetal growth in two subcohorts and explain potential sources of variation in metabolic profiles based on lifestyle and clinical data. METHODS We used 1H nuclear magnetic resonance (NMR) spectroscopy to characterize maternal urine samples collected in the INMA birth cohort at the first (n = 412 and n = 394, respectively, in Gipuzkoa and Sabadell cohorts) and third trimesters of gestation (n = 417 and 469). Metabolic phenotypes that reflected longitudinal intra- and inter-individual variation were used to predict measures of fetal growth and birth weight. RESULTS A metabolic shift between the first and third trimesters of gestation was characterized by 1H NMR signals arising predominantly from steroid by-products. We identified 10 significant and reproducible metabolic associations in the third trimester with estimated fetal, birth, and placental weight in two independent subcohorts. These included branched-chain amino acids; isoleucine, valine, leucine, alanine and 3 hydroxyisobutyrate (metabolite of valine), which were associated with a significant fetal weight increase at week 34 of up to 2.4 % in Gipuzkoa (P < 0.005) and 1 % in Sabadell (P < 0.05). Other metabolites included pregnancy-related hormone by-products of estrogens and progesterone, and the methyl donor choline. We could explain a total of 48-53 % of the total variance in birth weight of which urine metabolites had an independent predictive power of 12 % adjusting for all other lifestyle/clinical factors. First trimester metabolic phenotypes could not predict reproducibly weight at later stages of development. Physical activity, as well as other modifiable lifestyle/clinical factors, such as coffee consumption, vitamin D intake, and smoking, were identified as potential sources of metabolic variation during pregnancy. CONCLUSIONS Significant reproducible maternal urinary metabolic signatures of fetal growth and birth weight are identified for the first time and linked to modifiable lifestyle factors. This novel approach to prenatal screening, combining multiple risk factors, present a great opportunity to personalize pregnancy management and reduce newborn disease risk in later life.
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Affiliation(s)
- Léa Maitre
- Department of Epidemiology and Biostatistics, Medical Research Council-Public Health England (MRC-PHE) Centre for Environment and Health, School of Public Health, Imperial College London, W2 1PG, London, UK.,Division of Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College London, SW7 2AZ, London, UK
| | - Cristina M Villanueva
- ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), 08003, Barcelona, Spain.,Universitat Pompeu Fabra UPF, 08002, Barcelona, Spain.,CIBER Epidemiología y Salud Pública CIBERESP, 28029, Madrid, Spain.,Municipal Institute of Medical Research IMIM-Hospital del Mar, 08003, Barcelona, Spain
| | - Matthew R Lewis
- MRC-NIHR National Phenome Centre, Department of Surgery and Cancer, Imperial College London, IRDB Building, Du Cane Road, W12 0NN, London, UK
| | - Jesús Ibarluzea
- CIBER Epidemiología y Salud Pública CIBERESP, 28029, Madrid, Spain.,Public Health Division of Gipuzkoa, Basque Government, 20013, San Sebastián, Spain.,Health Research Institute, Biodonostia, 20013, San Sebastián, Spain
| | - Loreto Santa-Marina
- CIBER Epidemiología y Salud Pública CIBERESP, 28029, Madrid, Spain.,Public Health Division of Gipuzkoa, Basque Government, 20013, San Sebastián, Spain.,Health Research Institute, Biodonostia, 20013, San Sebastián, Spain
| | - Martine Vrijheid
- ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), 08003, Barcelona, Spain.,Universitat Pompeu Fabra UPF, 08002, Barcelona, Spain.,CIBER Epidemiología y Salud Pública CIBERESP, 28029, Madrid, Spain.,Municipal Institute of Medical Research IMIM-Hospital del Mar, 08003, Barcelona, Spain
| | - Jordi Sunyer
- ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), 08003, Barcelona, Spain.,Universitat Pompeu Fabra UPF, 08002, Barcelona, Spain.,CIBER Epidemiología y Salud Pública CIBERESP, 28029, Madrid, Spain.,Municipal Institute of Medical Research IMIM-Hospital del Mar, 08003, Barcelona, Spain
| | - Muireann Coen
- Division of Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College London, SW7 2AZ, London, UK.
| | - Mireille B Toledano
- Department of Epidemiology and Biostatistics, Medical Research Council-Public Health England (MRC-PHE) Centre for Environment and Health, School of Public Health, Imperial College London, W2 1PG, London, UK.
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31
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Increasing possibilities – Increasing dilemmas: A qualitative study of Swedish midwives' experiences of ultrasound use in pregnancy. Midwifery 2016; 42:46-53. [DOI: 10.1016/j.midw.2016.09.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 08/26/2016] [Accepted: 09/21/2016] [Indexed: 11/23/2022]
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32
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Andreoli L, Bertsias GK, Agmon-Levin N, Brown S, Cervera R, Costedoat-Chalumeau N, Doria A, Fischer-Betz R, Forger F, Moraes-Fontes MF, Khamashta M, King J, Lojacono A, Marchiori F, Meroni PL, Mosca M, Motta M, Ostensen M, Pamfil C, Raio L, Schneider M, Svenungsson E, Tektonidou M, Yavuz S, Boumpas D, Tincani A. EULAR recommendations for women's health and the management of family planning, assisted reproduction, pregnancy and menopause in patients with systemic lupus erythematosus and/or antiphospholipid syndrome. Ann Rheum Dis 2016; 76:476-485. [PMID: 27457513 PMCID: PMC5446003 DOI: 10.1136/annrheumdis-2016-209770] [Citation(s) in RCA: 465] [Impact Index Per Article: 58.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/13/2016] [Accepted: 06/25/2016] [Indexed: 12/26/2022]
Abstract
Objectives Develop recommendations for women's health issues and family planning in systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS). Methods Systematic review of evidence followed by modified Delphi method to compile questions, elicit expert opinions and reach consensus. Results Family planning should be discussed as early as possible after diagnosis. Most women can have successful pregnancies and measures can be taken to reduce the risks of adverse maternal or fetal outcomes. Risk stratification includes disease activity, autoantibody profile, previous vascular and pregnancy morbidity, hypertension and the use of drugs (emphasis on benefits from hydroxychloroquine and antiplatelets/anticoagulants). Hormonal contraception and menopause replacement therapy can be used in patients with stable/inactive disease and low risk of thrombosis. Fertility preservation with gonadotropin-releasing hormone analogues should be considered prior to the use of alkylating agents. Assisted reproduction techniques can be safely used in patients with stable/inactive disease; patients with positive antiphospholipid antibodies/APS should receive anticoagulation and/or low-dose aspirin. Assessment of disease activity, renal function and serological markers is important for diagnosing disease flares and monitoring for obstetrical adverse outcomes. Fetal monitoring includes Doppler ultrasonography and fetal biometry, particularly in the third trimester, to screen for placental insufficiency and small for gestational age fetuses. Screening for gynaecological malignancies is similar to the general population, with increased vigilance for cervical premalignant lesions if exposed to immunosuppressive drugs. Human papillomavirus immunisation can be used in women with stable/inactive disease. Conclusions Recommendations for women's health issues in SLE and/or APS were developed using an evidence-based approach followed by expert consensus.
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Affiliation(s)
- L Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Unit of Rheumatology and Clinical Immunology, Spedali Civili, Brescia, Italy
| | - G K Bertsias
- Department of Rheumatology, Clinical Immunology and Allergy, University of Crete Medical School, Heraklion, Greece
| | - N Agmon-Levin
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,The Faculty of Medicine, Tel Aviv University, Israel
| | - S Brown
- Royal National Hospital For Rheumatic Diseases, Bath, UK
| | - R Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Catalonia, Spain
| | - N Costedoat-Chalumeau
- AP-HP, Hôpital Cochin, Centre de référence maladies auto-immunes et systémiques rares, Paris, France.,Université Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - A Doria
- Rheumatology Unit, Department of Medicine, University of Padua, Italy
| | - R Fischer-Betz
- Policlinic of Rheumatology, Hiller Research Unit, University Clinic Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - F Forger
- Department of Rheumatology, Immunology and Allergology, University Hospital of Bern, Bern, Switzerland
| | - M F Moraes-Fontes
- Unidade de Doenças Auto-imunes-Serviço Medicina Interna 7.2, Hospital Curry Cabral/Centro Hospitalar Lisboa Central, NEDAI/SPMI, Lisboa, Portugal
| | - M Khamashta
- Lupus Research Unit, The Rayne Institute, St. Thomas Hospital, London, UK.,Department of Rheumatology, Dubai Hospital, Dubai, United Arab Emirates
| | - J King
- EULAR PARE Patient Research Partner, London, UK
| | - A Lojacono
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Unit of Obstetrics and Gynaecology, Spedali Civili, Brescia, Italy
| | - F Marchiori
- EULAR PARE Patient Research Partner, Rome, Italy
| | - P L Meroni
- Department of Clinical Sciences and Community Health, University of Milan, Istituto Auxologico Italiano, Milan, Italy
| | - M Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - M Motta
- Neonatology and Neonatal Intensive Care Unit, Spedali Civili, Brescia, Italy
| | - M Ostensen
- Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - C Pamfil
- Department of Rheumatology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - L Raio
- Department of Obstetrics and Gynaecology, University Hospital of Bern, Inselspital, Switzerland
| | - M Schneider
- Policlinic of Rheumatology, Hiller Research Unit, University Clinic Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - E Svenungsson
- Rheumatology Unit, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - M Tektonidou
- Rheumatology Unit, Joint Academic Rheumatology Programme, 1st Department of Propaedeutic Internal Medicine Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - S Yavuz
- Department of Rheumatology, Istanbul Bilim University, Istanbul Florence Nightingale Hospital, Esentepe-Istanbul, Turkey
| | - D Boumpas
- 4th Department of Internal Medicine, 'Attikon' University Hospital, Medical School, University of Athens, Athens, Greece.,Joint Academic Rheumatology Program, National and Kapodestrian University of Athens, Athens, Greece
| | - A Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Unit of Rheumatology and Clinical Immunology, Spedali Civili, Brescia, Italy
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Sharma D, Shastri S, Sharma P. Intrauterine Growth Restriction: Antenatal and Postnatal Aspects. Clin Med Insights Pediatr 2016; 10:67-83. [PMID: 27441006 PMCID: PMC4946587 DOI: 10.4137/cmped.s40070] [Citation(s) in RCA: 437] [Impact Index Per Article: 54.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 06/07/2016] [Accepted: 06/13/2016] [Indexed: 12/14/2022] Open
Abstract
Intrauterine growth restriction (IUGR), a condition that occurs due to various reasons, is an important cause of fetal and neonatal morbidity and mortality. It has been defined as a rate of fetal growth that is less than normal in light of the growth potential of that specific infant. Usually, IUGR and small for gestational age (SGA) are used interchangeably in literature, even though there exist minute differences between them. SGA has been defined as having birth weight less than two standard deviations below the mean or less than the 10th percentile of a population-specific birth weight for specific gestational age. These infants have many acute neonatal problems that include perinatal asphyxia, hypothermia, hypoglycemia, and polycythemia. The likely long-term complications that are prone to develop when IUGR infants grow up includes growth retardation, major and subtle neurodevelopmental handicaps, and developmental origin of health and disease. In this review, we have covered various antenatal and postnatal aspects of IUGR.
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Affiliation(s)
- Deepak Sharma
- Department of Neonatology, NEOCLINIC, TN Mishra Marg, Everest Vihar, Nirman Nagar, Jaipur, Rajasthan, India
| | - Sweta Shastri
- Department of Pathology, N.K.P Salve Medical College, Nagpur, Maharashtra, India
| | - Pradeep Sharma
- Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Jaipur, Rajasthan, India
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Stock SJ, Bricker L, Norman JE, West HM. Immediate versus deferred delivery of the preterm baby with suspected fetal compromise for improving outcomes. Cochrane Database Syst Rev 2016; 7:CD008968. [PMID: 27404120 PMCID: PMC6457969 DOI: 10.1002/14651858.cd008968.pub3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Immediate delivery of the preterm fetus with suspected compromise may decrease the risk of damage due to intrauterine hypoxia. However, it may also increase the risks of prematurity. OBJECTIVES To assess the effects of immediate versus deferred delivery of preterm babies with suspected fetal compromise on neonatal, maternal and long-term outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2016) and reference lists of retrieved studies. SELECTION CRITERIA Randomised trials comparing a policy of immediate delivery with deferred delivery or expectant management in preterm fetuses with suspected in utero compromise. Quasi-randomised trials and trials employing a cluster-randomised design were eligible for inclusion but none were identified. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS We included one trial of 548 women (588 babies) in the review. Women with pregnancies between 24 and 36 weeks' gestation took part. The study took place in 13 European countries, between 1993 and 2001. The difference in the median randomisation to delivery interval between immediate delivery and deferred delivery was four days (median: 0.9 (inter-quartile range (IQR) 0.4 to 1.3) days for immediate delivery, median: 4.9 (IQR 2.0 to 10.8) days in the delay group).There was no clear difference in the primary outcomes of extended perinatal mortality (risk ratio (RR) 1.17, 95% confidence interval (CI) 0.67 to 2.04, one trial, 587 babies, moderate-quality evidence) or the composite outcome of death or disability at or after two years of age (RR 1.22, 95% CI 0.85 to 1.75, one trial, 573 babies, moderate-quality evidence) with immediate delivery compared to deferred delivery. The results for these outcomes are consistent with both appreciable benefit and harm. More babies in the immediate delivery group were ventilated for more than 24 hours (RR 1.54, 95% CI 1.20 to 1.97, one trial, 576 babies). There were no differences between the immediate delivery and deferred delivery groups in any other infant mortality outcome (stillbirth, neonatal mortality, postneonatal mortality > 28 days to discharge), individual neonatal morbidity or markers of neonatal morbidity (cord pH less than 7.00, Apgar less than seven at five minutes, convulsions, interventricular haemorrhage or germinal matrix haemorrhage, necrotising enterocolitis and periventricular leucomalacia or ventriculomegaly).Some important outcomes were not reported, in particular infant admission to neonatal intensive care or special care facility, and respiratory distress syndrome. We were not able to calculate composite rates of serious neonatal morbidity, even though individual morbidities were reported, due to the risk of double counting infants with more than one morbidity.More children in the immediate delivery group had cerebral palsy at or after two years of age (RR 5.88, 95% CI 1.33 to 26.02, one trial, 507 children). There were, however, no differences in neurodevelopment impairment at or after two years (RR 1.72, 95% CI 0.86 to 3.41, one trial, 507 children), death at or after two years of age (RR 1.04, 95% CI 0.66 to 1.63, one trial, 573 children), or death or disability in childhood (six to 13 years of age) (RR 0.82, 95% CI 0.48 to 1.40, one trial, 302 children). More women in the immediate delivery group had caesarean delivery than in the deferred delivery group (RR 1.15, 95% CI 1.07 to 1.24, one trial, 547 women, high-quality evidence). Data were not available on any other maternal outcomes.There were several methodological weaknesses in the included study, and the level of evidence for the primary outcomes was graded high for caesarean section and moderate for extended perinatal mortality and death or disability at or after two years. The evidence was downgraded because the CIs for these outcomes were wide, and were consistent with both appreciable benefit and harm. Bias may have been introduced by several factors: blinding was not possible due to the nature of the intervention, data for childhood follow-up were incomplete due to attrition, and no adjustment was made in the analysis for the non-independence of babies from multiple pregnancies (39 out of 548 pregnancies). This study only included cases of suspected fetal compromise where there was uncertainty whether immediate delivery was indicated, thus results must be interpreted with caution. AUTHORS' CONCLUSIONS Currently there is insufficient evidence on the benefits and harms of immediate delivery compared with deferred delivery in cases of suspected fetal compromise at preterm gestations to make firm recommendations. There is a lack of trials addressing this question, and limitations of the one included trial means that caution must be used in interpreting and generalising the findings. More research is needed to guide clinical practice.Although the included trial is relatively large, it has insufficient power to detect differences in neonatal mortality. It did not report any maternal outcomes other than mode of delivery, or evaluate maternal satisfaction or economic outcomes. The applicability of the findings is limited by several factors: Women with a wide range of obstetric complications and gestational ages were included, and subgroup analysis is currently limited. Advances in Doppler assessment techniques may diagnose severe compromise more accurately and help make decisions about the timing of delivery. The potential benefits of deferring delivery for longer or shorter periods cannot be presumed.Where there is uncertainty whether or not to deliver a preterm fetus with suspected fetal compromise, there seems to be no benefit to immediate delivery. Deferring delivery until test results worsen or increasing gestation favours delivery may improve the outcomes for mother and baby.There is a need for high-quality randomised controlled trials comparing immediate and deferred delivery where there is suspected fetal compromise at preterm gestations to guide clinical practice. Future trials should report all important outcomes, and should be adequately powered to detect differences in maternal and neonatal morbidity and mortality.
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Affiliation(s)
- Sarah J Stock
- University of Edinburgh Queen's Medical Research CentreMRC Centre for Reproductive HealthEdinburghUKEH16 4TJ
| | | | - Jane E Norman
- University of Edinburgh Queen's Medical Research CentreMRC Centre for Reproductive HealthEdinburghUKEH16 4TJ
| | - Helen M West
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Heazell AEP, Hayes DJL, Whitworth M, Takwoingi Y, Bayliss SE, Davenport C. Diagnostic accuracy of biochemical tests of placental function versus ultrasound assessment of fetal size for stillbirth and small-for-gestational-age infants. Hippokratia 2016. [DOI: 10.1002/14651858.cd012245] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Alexander EP Heazell
- University of Manchester; Maternal and Fetal Health Research Centre; 5th floor (Research), St Mary's Hospital, Oxford Road Manchester UK M13 9WL
| | - Dexter JL Hayes
- University of Manchester; Department of Maternal and Fetal Health; Oxford Road Manchester UK M13 9WL
| | - Melissa Whitworth
- University of Manchester; Maternal and Fetal Health Research Centre; 5th floor (Research), St Mary's Hospital, Oxford Road Manchester UK M13 9WL
| | - Yemisi Takwoingi
- University of Birmingham; Institute of Applied Health Research; Edgbaston Birmingham UK B15 2TT
| | - Susan E Bayliss
- University of Birmingham; Public Health, Epidemiology and Biostatistics; Edgbaston Birmingham UK B15 2TT
| | - Clare Davenport
- University of Birmingham; Public Health, Epidemiology and Biostatistics; Edgbaston Birmingham UK B15 2TT
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Richardson M, Garner P, Donegan S. Cluster Randomised Trials in Cochrane Reviews: Evaluation of Methodological and Reporting Practice. PLoS One 2016; 11:e0151818. [PMID: 26982697 PMCID: PMC4794236 DOI: 10.1371/journal.pone.0151818] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/04/2016] [Indexed: 12/02/2022] Open
Abstract
Objective Systematic reviews can include cluster-randomised controlled trials (C-RCTs), which require different analysis compared with standard individual-randomised controlled trials. However, it is not known whether review authors follow the methodological and reporting guidance when including these trials. The aim of this study was to assess the methodological and reporting practice of Cochrane reviews that included C-RCTs against criteria developed from existing guidance. Methods Criteria were developed, based on methodological literature and personal experience supervising review production and quality. Criteria were grouped into four themes: identifying, reporting, assessing risk of bias, and analysing C-RCTs. The Cochrane Database of Systematic Reviews was searched (2nd December 2013), and the 50 most recent reviews that included C-RCTs were retrieved. Each review was then assessed using the criteria. Results The 50 reviews we identified were published by 26 Cochrane Review Groups between June 2013 and November 2013. For identifying C-RCTs, only 56% identified that C-RCTs were eligible for inclusion in the review in the eligibility criteria. For reporting C-RCTs, only eight (24%) of the 33 reviews reported the method of cluster adjustment for their included C-RCTs. For assessing risk of bias, only one review assessed all five C-RCT-specific risk-of-bias criteria. For analysing C-RCTs, of the 27 reviews that presented unadjusted data, only nine (33%) provided a warning that confidence intervals may be artificially narrow. Of the 34 reviews that reported data from unadjusted C-RCTs, only 13 (38%) excluded the unadjusted results from the meta-analyses. Conclusions The methodological and reporting practices in Cochrane reviews incorporating C-RCTs could be greatly improved, particularly with regard to analyses. Criteria developed as part of the current study could be used by review authors or editors to identify errors and improve the quality of published systematic reviews incorporating C-RCTs.
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Affiliation(s)
- Marty Richardson
- Centre for Evidence Synthesis in Global Health, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- * E-mail:
| | - Paul Garner
- Centre for Evidence Synthesis in Global Health, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Sarah Donegan
- Department of Biostatistics, Block F Waterhouse Building, University of Liverpool, Liverpool, United Kingdom
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Blitz MJ, Rochelson B, Vohra N. Maternal Serum Analytes as Predictors of Fetal Growth Restriction with Different Degrees of Placental Vascular Dysfunction. Clin Lab Med 2016; 36:353-67. [PMID: 27235917 DOI: 10.1016/j.cll.2016.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Abnormal levels of maternal serum analytes have been associated with fetal growth restriction (FGR) and preeclampsia secondary to placental vascular dysfunction. Accurately identifying the FGR fetuses at highest risk for adverse outcomes remains challenging. Placental function can be assessed by Doppler analysis of the maternal and fetal circulation. Although the combination of multiple abnormal maternal serum analytes and abnormal Doppler findings is strongly associated with adverse outcomes, the predictive value remains too low to be used as a screening test in a low-risk population. Stratification of cases based on the severity of Doppler abnormalities may improve predictive models.
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Affiliation(s)
- Matthew J Blitz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hofstra North Shore-LIJ School of Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030, USA.
| | - Burton Rochelson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hofstra North Shore-LIJ School of Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030, USA
| | - Nidhi Vohra
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hofstra North Shore-LIJ School of Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030, USA
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Bardien N, Whitehead CL, Tong S, Ugoni A, McDonald S, Walker SP. Placental Insufficiency in Fetuses That Slow in Growth but Are Born Appropriate for Gestational Age: A Prospective Longitudinal Study. PLoS One 2016; 11:e0142788. [PMID: 26730589 PMCID: PMC4701438 DOI: 10.1371/journal.pone.0142788] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Accepted: 10/27/2015] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To determine whether fetuses that slow in growth but are then born appropriate for gestational age (AGA, birthweight >10th centile) demonstrate ultrasound and clinical evidence of placental insufficiency. METHODS Prospective longitudinal study of 48 pregnancies reaching term and a birthweight >10th centile. We estimated fetal weight by ultrasound at 28 and 36 weeks, and recorded birthweight to determine the relative change in customised weight across two timepoints: 28-36 weeks and 28 weeks-birth. The relative change in weight centiles were correlated with fetoplacental Doppler findings performed at 36 weeks. We also examined whether a decline in growth trajectory in fetuses born AGA was associated with operative deliveries performed for suspected intrapartum compromise. RESULTS The middle cerebral artery pulsatility index (MCA-PI) showed a linear association with fetal growth trajectory. Lower MCA-PI readings (reflecting greater diversion of blood supply to the brain) were significantly associated with a decline in fetal growth, both between 28-36 weeks (p = 0.02), and 28 weeks-birth (p = 0.0002). The MCA-PI at 36 weeks was significantly higher among those with a relative weight centile fall <20%, compared to those with a moderate centile fall of 20-30% (mean MCA-PI 1.94 vs 1.61; p<0.05), or severe centile fall of >30% (mean MCA-PI 1.94 vs 1.56; p<0.01). Of 43 who labored, operative delivery for suspected intrapartum fetal compromise was required in 12 cases; 9/18 (50%) cases where growth slowed, and 3/25 (12%) where growth trajectory was maintained (p = 0.01). CONCLUSIONS Slowing in growth across the third trimester among fetuses subsequently born AGA was associated with ultrasound and clinical features of placental insufficiency. Such fetuses may represent an under-recognised cohort at increased risk of stillbirth.
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Affiliation(s)
- Nadia Bardien
- Department of Perinatal Medicine, Mercy Hospital for Women, Melbourne, Australia
- La Trobe University, Mercy Hospital for Women, Melbourne, Australia
| | - Clare L. Whitehead
- Department of Perinatal Medicine, Mercy Hospital for Women, Melbourne, Australia
- Translational Obstetrics Group, University of Melbourne, Melbourne, Australia
| | - Stephen Tong
- Department of Perinatal Medicine, Mercy Hospital for Women, Melbourne, Australia
- Translational Obstetrics Group, University of Melbourne, Melbourne, Australia
| | - Antony Ugoni
- School of Physiotherapy, University of Melbourne, Melbourne, Victoria, Australia
| | - Susan McDonald
- La Trobe University, Mercy Hospital for Women, Melbourne, Australia
| | - Susan P. Walker
- Department of Perinatal Medicine, Mercy Hospital for Women, Melbourne, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
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Heazell AEP, Whitworth M, Duley L, Thornton JG. Use of biochemical tests of placental function for improving pregnancy outcome. Cochrane Database Syst Rev 2015; 2015:CD011202. [PMID: 26602956 PMCID: PMC8860184 DOI: 10.1002/14651858.cd011202.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The placenta has an essential role in determining the outcome of pregnancy. Consequently, biochemical measurement of placentally-derived factors has been suggested as a means to improve fetal and maternal outcome of pregnancy. OBJECTIVES To assess whether clinicians' knowledge of the results of biochemical tests of placental function is associated with improvement in fetal or maternal outcome of pregnancy. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2015) and reference lists of retrieved studies. SELECTION CRITERIA Randomised, cluster-randomised or quasi-randomised controlled trials assessing the merits of the use of biochemical tests of placental function to improve pregnancy outcome.Studies were eligible if they compared women who had placental function tests and the results were available to their clinicians with women who either did not have the tests, or the tests were done but the results were not available to the clinicians. The placental function tests were any biochemical test of placental function carried out using the woman's maternal biofluid, either alone or in combination with other placental function test/s. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, extracted data and assessed trial quality. Authors of published trials were contacted for further information. MAIN RESULTS Three trials were included, two quasi-randomised controlled trials and one randomised controlled trial. One trial was deemed to be at low risk of bias while the other two were at high risk of bias. Different biochemical analytes were measured - oestrogen was measured in one trial and the other two measured human placental lactogen (hPL). One trial did not contribute outcome data, therefore, the results of this review are based on two trials with 740 participants.There was no evidence of a difference in the incidence of death of a baby (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.36 to 2.13, two trials, 740 participants (very low quality evidence)) or the frequency of a small-for-gestational-age infant (RR 0.44, 95% CI 0.16 to 1.19, one trial, 118 participants (low quality evidence)).In terms of this review's secondary outcomes, there was no evidence of a clear difference between women who had biochemical tests of placental function compared with standard antenatal care for the incidence of stillbirth (RR 0.56, 95% CI 0.16 to 1.88, two trials, 740 participants (very low quality evidence)) or neonatal death (RR 1.62, 95% CI 0.39 to 6.74, two trials, 740 participants, very low quality evidence)) although the directions of any potential effect were in opposing directions. There was no evidence of a difference between groups in elective delivery (RR 0.98, 95% CI 0.84 to 1.14, two trials, 740 participants (low quality evidence)), caesarean section (one trial, RR 0.48, 95% CI 0.15 to 1.52, one trial, 118 participants (low quality evidence)), change in anxiety score (mean difference -2.40, 95% CI -4.78 to -0.02, one trial, 118 participants), admissions to neonatal intensive care (RR 0.32, 95% CI 0.03 to 3.01, one trial, 118 participants), and preterm birth before 37 weeks' gestation (RR 2.90, 95% CI 0.12 to 69.81, one trial, 118 participants). One trial (118 participants) reported that there were no cases of serious neonatal morbidity. Maternal death was not reported.A number of this review's secondary outcomes relating to the baby were not reported in the included studies, namely: umbilical artery pH < 7.0, neonatal intensive care for more than seven days, very preterm birth (< 32 weeks' gestation), need for ventilation, organ failure, fetal abnormality, neurodevelopment in childhood (cerebral palsy, neurodevelopmental delay). Similarly, a number of this review's maternal secondary outcomes were not reported in the included studies (admission to intensive care, high dependency unit admission, hospital admission for > seven days, pre-eclampsia, eclampsia, and women's perception of care). AUTHORS' CONCLUSIONS There is insufficient evidence to support the use of biochemical tests of placental function to reduce perinatal mortality or increase identification of small-for-gestational-age infants. However, we were only able to include data from two studies that measured oestrogens and hPL. The quality of the evidence was low or very low.Two of the trials were performed in the 1970s on women with a variety of antenatal complications and this evidence cannot be generalised to women at low-risk of complications or groups of women with specific pregnancy complications (e.g. fetal growth restriction). Furthermore, outcomes described in the 1970s may not reflect what would be expected at present. For example, neonatal mortality rates have fallen substantially, such that an infant delivered at 28 weeks would have a greater chance of survival were those studies repeated; this may affect the primary outcome of the meta-analysis.With data from just two studies (740 women), this review is underpowered to detect a difference in the incidence of death of a baby or the frequency of a small-for-gestational-age infant as these have a background incidence of approximately 0.75% and 10% of pregnancies respectively. Similarly, this review is underpowered to detect differences between serious and/or rare adverse events such as severe neonatal morbidity. Two of the three included studies were quasi-randomised, with significant risk of bias from group allocation. Additionally, there may be performance bias as in one of the two studies contributing data, participants receiving standard care did not have venepuncture, so clinicians treating participants could identify which arm of the study they were in. Future studies should consider more robust randomisation methods and concealment of group allocation and should be adequately powered to detect differences in rare adverse events.The studies identified in this review examined two different analytes: oestrogens and hPL. There are many other placental products that could be employed as surrogates of placental function, including: placental growth factor (PlGF), human chorionic gonadotrophin (hCG), plasma protein A (PAPP-A), placental protein 13 (PP-13), pregnancy-specific glycoproteins and progesterone metabolites and further studies should be encouraged to investigate these other placental products. Future randomised controlled trials should test analytes identified as having the best predictive reliability for placental dysfunction leading to small-for-gestational-age infants and perinatal mortality.
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Affiliation(s)
- Alexander EP Heazell
- University of ManchesterMaternal and Fetal Health Research Centre5th floor (Research), St Mary's Hospital, Oxford RoadManchesterUKM13 9WL
| | - Melissa Whitworth
- University of ManchesterMaternal and Fetal Health Research Centre5th floor (Research), St Mary's Hospital, Oxford RoadManchesterUKM13 9WL
| | - Lelia Duley
- Nottingham Health Science PartnersNottingham Clinical Trials UnitC Floor, South BlockQueen's Medical CentreNottinghamUKNG7 2UH
| | - Jim G Thornton
- University of NottinghamDivision of Child Health, Obstetrics and Gynaecology, School of MedicineNottingham City Hospital NHS TrustHucknall RoadNottinghamNottinghamshireUKNG5 1PB
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Bond DM, Gordon A, Hyett J, de Vries B, Carberry AE, Morris J. Planned early delivery versus expectant management of the term suspected compromised baby for improving outcomes. Cochrane Database Syst Rev 2015; 2015:CD009433. [PMID: 26599471 PMCID: PMC8935540 DOI: 10.1002/14651858.cd009433.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Fetal compromise in the term pregnancy is suspected when the following clinical indicators are present: intrauterine growth restriction (IUGR), decreased fetal movement (DFM), or when investigations such as cardiotocography (CTG) and ultrasound reveal results inconsistent with standard measurements. Pathological results would necessitate the need for immediate delivery, but the management for 'suspicious' results remains unclear and varies widely across clinical centres. There is clinical uncertainty as to how to best manage women presenting with a suspected term compromised baby in an otherwise healthy pregnancy. OBJECTIVES To assess, using the best available evidence, the effects of immediate delivery versus expectant management of the term suspected compromised baby on neonatal, maternal and long-term outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies. SELECTION CRITERIA Randomised or quasi-randomised controlled trials comparing expectant management versus planned early delivery for women with a suspected compromised fetus from 37 weeks' gestation or more. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors independently extracted data. Data were checked for accuracy. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS Of the 20 reports identified by the search strategy, we included three trials (546 participants: 269 to early delivery and 277 to expectant management), which met our inclusion criteria. Two of the trials compared outcomes in 492 pregnancies with IUGR of the fetus, and one in 54 pregnancies with oligohydramnios. All three trials were of reasonable quality and at low risk of bias. The level of evidence was graded moderate, low or very low, downgrading mostly for imprecision and for some indirectness. Overall, there was no difference in the primary neonatal outcomes of perinatal mortality (no deaths in either group, one trial, 459 women, evidence graded moderate), major neonatal morbidity (risk ratio (RR) 0.15, 95% confidence interval (CI) 0.01 to 2.81, one trial, 459 women, evidence graded low), or neurodevelopmental disability/impairment at two years of age (RR 2.04, 95% CI 0.62 to 6.69,one trial, 459 women, evidence graded low). There was no difference in the risk of necrotising enterocolitis (one trial, 333 infants) or meconium aspiration (one trial, 459 infants), There was also no difference in the reported primary maternal outcomes: maternal mortality (RR 3.07, 95% CI 0.13 to 74.87, one trial, 459 women, evidence graded low), and significant maternal morbidity (RR 0.92, 95% CI 0.38 to 2.22, one trial, 459 women, evidence graded low).The gestational age at birth was on average 10 days earlier in women randomised to early delivery (mean difference (MD) -9.50, 95% CI -10.82 to -8.18, one trial, 459 women) and women in the early delivery group were significantly less likely to have a baby beyond 40 weeks' gestation (RR 0.10, 95% CI 0.01 to 0.67, one trial, 33 women). Significantly more infants in the planned early delivery group were admitted to intermediate care nursery (RR 1.28, 95% CI 1.02 to 1.61, two trials, 491 infants). There was no difference in the risk of respiratory distress syndrome, (one trial, 333 infants), Apgar score less than seven at five minutes (three trials, 546 infants), resuscitation required (one trial, 459 infants), mechanical ventilation (one trial, 337 infants), admission to neonatal intensive care unit (NICU) (RR 0.88, 95% CI 0.35 to 2.23, three trials, 545 infants, evidence graded very low), length of stay in NICU/SCN (one trial, 459 infants), and sepsis (two trials, 366 infants).Babies in the expectant management group were more likely to be < 2.3rd centile for birthweight (RR 0.51, 95% CI 0.36 to 0.73, two trials, 491 infants), however there was no difference in the proportion of babies with birthweight < 10th centile (RR 0.98, 95% CI 0.88 to 1.10). There was no difference in any of the reported maternal secondary outcomes including: caesarean section rates (RR 1.02, 95% CI 0.65 to 1.59, three trials, 546 women, evidence graded low), placental abruption (one trial, 459 women), pre-eclampsia (one trial, 459 women), vaginal birth (three trials 546 women), assisted vaginal birth (three trials 546 women), breastfeeding rates (one trial, 218 women), and number of weeks of breastfeeding after delivery one trial, 124 women). There was an expected increase in induction in the early delivery group (RR 2.05, 95% CI 1.78 to 2.37, one trial, 459 women).No data were reported for the pre-specified secondary neonatal outcomes of the number of days of mechanical ventilation, moderate-severe hypoxic ischaemic encephalopathy or need for therapeutic hypothermia. Likewise, no data were reported for secondary maternal outcomes of postnatal infection, maternal satisfaction or views of care. AUTHORS' CONCLUSIONS A policy for planned early delivery versus expectant management for a suspected compromised fetus at term does not demonstrate any differences in major outcomes of perinatal mortality, significant neonatal or maternal morbidity or neurodevelopmental disability. In women randomised to planned early delivery, the gestational age at birth was on average 10 days earlier, women were less likely to have a baby beyond 40 weeks' gestation, they were more likely to be induced and infants were more likely to be admitted to intermediate care nursery. There was also a significant difference in the proportion of babies with a birthweight centile < 2.3rd, however this did not translate into a reduction in morbidity. The review is informed by only one large trial and two smaller trials assessing fetuses with IUGR or oligohydramnios and therefore cannot be generalised to all term pregnancies with suspected fetal compromise. There are other indications for suspecting compromise in a fetus at or near term such as maternal perception of DFM, and ultrasound and/or CTG abnormalities. Future randomised trials need to assess effectiveness of timing of delivery for these indications.
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Affiliation(s)
- Diana M Bond
- Royal Prince Alfred Hospital; The Kolling Institute of Medicine, University of Sydney at the Royal North Shore HospitalRPA Newborn CareSydneyAustralia
| | - Adrienne Gordon
- Royal Prince Alfred HospitalNeonatologyMissenden RoadCamperdownSydneyNSWAustralia2050
| | - Jon Hyett
- Royal Prince Alfred HospitalDepartment of High Risk Obstetrics, RPA Women and BabiesMissenden RoadCamperdownSydneyAustraliaNSW 2050
| | - Bradley de Vries
- Royal Prince Alfred HospitalDepartment of High Risk Obstetrics, RPA Women and BabiesMissenden RoadCamperdownSydneyAustraliaNSW 2050
| | - Angela E Carberry
- University of SydneySydney School of Public HealthCamperdownSydneyNSWAustralia2050
| | - Jonathan Morris
- University of SydneyThe Kolling Institute of MedicineSt LeonardsNSWAustralia2060
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Åhman A, Persson M, Edvardsson K, Lalos A, Graner S, Small R, Mogren I. Two sides of the same coin--an interview study of Swedish obstetricians' experiences using ultrasound in pregnancy management. BMC Pregnancy Childbirth 2015; 15:304. [PMID: 26589489 PMCID: PMC4654901 DOI: 10.1186/s12884-015-0743-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 11/17/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The extended use of ultrasound that is seen in maternity care in most Western countries has not only affected obstetric care but also impacted on the conception of the fetus in relation to the pregnant woman. This situation has also raised concerns regarding the pregnant woman's reproductive freedom. The purpose of this study was to explore Swedish obstetricians' experiences and views on the role of obstetric ultrasound particularly in relation to clinical management of complicated pregnancy, and in relation to situations where the interests of maternal and fetal health conflict. METHODS A qualitative study design was applied, and data were collected in 2013 through interviews with 11 obstetricians recruited from five different obstetric clinics in Sweden. Data were analysed using qualitative content analysis. RESULTS The theme that emerged in the analysis 'Two sides of the same coin' depicts the view of obstetric ultrasound as a very important tool in obstetric care while it also was experienced as having given rise to new and challenging issues in the management of pregnancy. This theme was built on three categories: I. Ultrasound is essential and also demanding; II. A woman's health interest is prioritised in theory, but not always in practice; and III. Ultrasound is rewarding but may also cause unwarranted anxiety. CONCLUSIONS The widespread use of ultrasound in obstetric care has entailed new challenges for clinicians due to enhanced possibilities to diagnose and treat fetal conditions, which in turn might conflict with the health interests of the pregnant woman. There is a need for further ethical discussions regarding the obstetrician's position in management of situations where maternal and fetal health interests conflict. The continuing advances in the potential of ultrasound to impact on pregnancy management will also increase the need for adequate and appropriate information and counselling. Together with other health care professionals, obstetricians therefore need to develop improved ways of enabling pregnant women and their partners to make informed decisions regarding pregnancy management.
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Affiliation(s)
- Annika Åhman
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden.
| | | | - Kristina Edvardsson
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden. .,Judith Lumley Centre, La Trobe University, Melbourne, Vic, 3000, Australia.
| | - Ann Lalos
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden.
| | - Sophie Graner
- Department of Women's and Children's Health, Karolinska Institutet, Solna, Sweden. .,Department of Medicine, Centre for Pharmacoepidemiology, Karolinska Institutet, Solna, Sweden.
| | - Rhonda Small
- Judith Lumley Centre, La Trobe University, Melbourne, Vic, 3000, Australia.
| | - Ingrid Mogren
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden.
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Edvardsson K, Graner S, Thi LP, Åhman A, Small R, Lalos A, Mogren I. 'Women think pregnancy management means obstetric ultrasound': Vietnamese obstetricians' views on the use of ultrasound during pregnancy. Glob Health Action 2015; 8:28405. [PMID: 26519131 PMCID: PMC4627940 DOI: 10.3402/gha.v8.28405] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 09/06/2015] [Accepted: 09/26/2015] [Indexed: 11/14/2022] Open
Abstract
Objective To explore Vietnamese obstetricians’ experiences and views on the role of obstetric ultrasound in clinical management of complicated pregnancy and in situations where maternal and fetal health interests conflict. Design Seventeen obstetricians in northern Vietnam were interviewed as part of the CROss-Country Ultrasound Study (CROCUS) project in 2013. Data were analysed using qualitative content analysis. Results The participants described ultrasound as a central tool in prenatal care, although they called for increased training and resources to prevent inappropriate management. A prevailing overuse driven by women's request and increased commercialisation was described. Other clinical examinations were seen as being disregarded by women in favour of ultrasound, resulting in missed opportunities for identifying potential pregnancy complications. The use of ultrasound for sex selection purposes raised concern among participants. Visualisation of human features or heartbeat during ultrasound was commonly described as the point where the fetus became regarded as a ‘person’. Women were said to prioritise fetal health interests over their own health, particularly if a woman had difficulties becoming pregnant or had undergone assisted fertilisation. The woman's husband and his family were described as having an important role in decision-making in situations of maternal and fetal health conflicts. Conclusions This study provides insight into issues surrounding ultrasound use in contemporary Vietnam, some of which may be specific to this low-income context. It is clear that ultrasound has become a central tool in prenatal care in Vietnam and that it has also been embraced by women. However, there seems to be a need to balance women's demands for obstetric ultrasound with better recognition of the valuable contribution to be made by the full range of clinical examinations in pregnancy, along with a more strategic allocation of resources, that is, use of obstetric ultrasound based on clinical indications. Better regulation of private obstetric practice also appears to be needed. While the root causes of sex selection need to be addressed at societal level, efforts are also required more immediately to find ways to combat the inappropriate use of ultrasound for the purpose of sex selection.
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Affiliation(s)
- Kristina Edvardsson
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden.,Judith Lumley Centre, La Trobe University, Melbourne, Australia;
| | - Sophie Graner
- Department of Women's and Childrens Health, Karolinska Institute, Stockholm, Sweden.,Department of Medicine, Centre for Pharmacoepidemiology, Karolinska Institute, Stockholm, Sweden
| | - Lan Pham Thi
- Department of Dermatology and Venereology, Hanoi Medical University, Hanoi, Vietnam
| | - Annika Åhman
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
| | - Rhonda Small
- Judith Lumley Centre, La Trobe University, Melbourne, Australia
| | - Ann Lalos
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
| | - Ingrid Mogren
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
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Su EJ. Role of the fetoplacental endothelium in fetal growth restriction with abnormal umbilical artery Doppler velocimetry. Am J Obstet Gynecol 2015; 213:S123-30. [PMID: 26428491 DOI: 10.1016/j.ajog.2015.06.038] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 06/12/2015] [Accepted: 06/16/2015] [Indexed: 01/30/2023]
Abstract
Growth-restricted fetuses with absent or reversed end-diastolic velocities in the umbilical artery are at substantially increased risk for adverse perinatal and long-term outcome, even in comparison to growth-restricted fetuses with preserved end-diastolic velocities. Translational studies show that this Doppler velocimetry correlates with fetoplacental blood flow, with absent or reversed end-diastolic velocities signifying abnormally elevated resistance within the placental vasculature. The fetoplacental vasculature is unique in that it is not subject to autonomic regulation, unlike other vascular beds. Instead, humoral mediators, many of which are synthesized by local endothelial cells, regulate placental vascular resistance. Existing data demonstrate that in growth-restricted pregnancies complicated by absent or reversed umbilical artery end-diastolic velocities, an imbalance in production of these vasoactive substances occurs, favoring vasoconstriction. Morphologically, placentas from these pregnancies also demonstrate impaired angiogenesis, whereby vessels within the terminal villi are sparsely branched, abnormally thin, and elongated. This structural deviation from normal placental angiogenesis restricts blood flow and further contributes to elevated fetoplacental vascular resistance. Although considerable work has been done in the field of fetoplacental vascular development and function, much remains unknown about the mechanisms underlying impaired development and function of the human fetoplacental vasculature, especially in the context of severe fetal growth restriction with absent or reversed umbilical artery end-diastolic velocities. Fetoplacental endothelial cells are key regulators of angiogenesis and vasomotor tone. A thorough understanding of their role in placental vascular biology carries the significant potential of discovering clinically relevant and innovative approaches to prevention and treatment of fetal growth restriction with compromised umbilical artery end-diastolic velocities.
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Abstract
BACKGROUND Cardiotocography (CTG) is a continuous recording of the fetal heart rate obtained via an ultrasound transducer placed on the mother's abdomen. CTG is widely used in pregnancy as a method of assessing fetal well-being, predominantly in pregnancies with increased risk of complications. OBJECTIVES To assess the effectiveness of antenatal CTG (both traditional and computerised assessments) in improving outcomes for mothers and babies during and after pregnancy. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (26 June 2015) and reference lists of retrieved studies. SELECTION CRITERIA Randomised and quasi-randomised trials that compared traditional antenatal CTG with no CTG or CTG results concealed; computerised CTG with no CTG or CTG results concealed; and computerised CTG with traditional CTG. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS Six studies (involving 2105 women) are included. Overall, the included studies were not of high quality, and only two had both adequate randomisation sequence generation and allocation concealment. All studies that were able to be included enrolled only women at increased risk of complications.Comparison of traditional CTG versus no CTG showed no significant difference identified in perinatal mortality (risk ratio (RR) 2.05, 95% confidence interval (CI) 0.95 to 4.42, 2.3% versus 1.1%, four studies, N = 1627, low quality evidence) or potentially preventable deaths (RR 2.46, 95% CI 0.96 to 6.30, four studies, N = 1627), though the meta-analysis was underpowered to assess this outcome. Similarly, there was no significant difference identified in caesarean sections (RR 1.06, 95% CI 0.88 to 1.28, 19.7% versus 18.5%, three trials, N = 1279, low quality evidence). There was also no significant difference identified for secondary outcomes related to Apgar scores less than seven at five minutes (RR 0.83, 95% CI 0.37 to 1.88, one trial, N = 396, very low quality evidence); or admission to neonatal special care units or neonatal intensive care units (RR 1.08, 95% CI 0.84 to 1.39, two trials, N = 883, low quality evidence), nor in the other secondary outcomes that were assessed.There were no eligible studies that compared computerised CTG with no CTG.Comparison of computerised CTG versus traditional CTG showed a significant reduction in perinatal mortality with computerised CTG (RR 0.20, 95% CI 0.04 to 0.88, two studies, 0.9% versus 4.2%, 469 women, moderate quality evidence). However, there was no significant difference identified in potentially preventable deaths (RR 0.23, 95% CI 0.04 to 1.29, two studies, N = 469), though the meta-analysis was underpowered to assess this outcome. There was no significant difference identified in caesarean sections (RR 0.87, 95% CI 0.61 to 1.24, 63% versus 72%, one study, N = 59, low quality evidence), Apgar scores less than seven at five minutes (RR 1.31, 95% CI 0.30 to 5.74, two studies, N = 469, very low quality evidence) or in secondary outcomes. AUTHORS' CONCLUSIONS There is no clear evidence that antenatal CTG improves perinatal outcome, but further studies focusing on the use of computerised CTG in specific populations of women with increased risk of complications are warranted.
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Affiliation(s)
- Rosalie M Grivell
- Flinders University and Flinders Medical CentreDepartment of Obstetrics and GynaecologyBedford ParkSouth AustraliaAustraliaSA 5042
| | - Zarko Alfirevic
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Gillian ML Gyte
- University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Declan Devane
- National University of Ireland GalwaySchool of Nursing and MidwiferyUniversity RoadGalwayIreland
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Edvardsson K, Mogren I, Lalos A, Persson M, Small R. A routine tool with far-reaching influence: Australian midwives' views on the use of ultrasound during pregnancy. BMC Pregnancy Childbirth 2015; 15:195. [PMID: 26311437 PMCID: PMC4551225 DOI: 10.1186/s12884-015-0632-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 08/21/2015] [Indexed: 11/21/2022] Open
Abstract
Background Ultrasound is a tool of increasing importance in maternity care. Midwives have a central position in the care of pregnant women. However, studies regarding their experiences of the use of ultrasound in this context are limited. The purpose of this study was to explore Australian midwives’ experiences and views of the role of obstetric ultrasound particularly in relation to clinical management of complicated pregnancy, and situations where maternal and fetal health interests conflict. Methods A qualitative study was undertaken in Victoria, Australia in 2012, based on six focus group discussions with midwives (n = 37) working in antenatal and intrapartum care, as part of the CROss-Country Ultrasound Study (CROCUS). Data were analysed using qualitative content analysis. Results One overarching theme emerged from the analysis: Obstetric ultrasound – a routine tool with far-reaching influence, and it was built on three categories. First, the category‘Experiencing pros and cons of ultrasound’ highlighted that ultrasound was seen as having many advantages; however, it was also seen as contributing to increased medicalisation of pregnancy, to complex and sometimes uncertain decision-making and to parental anxiety. Second, ‘Viewing ultrasound as a normalised and unquestioned examination’ illuminated how the use of ultrasound has become normalised and unquestioned in health care and in wider society. Midwives were concerned that this impacts negatively on informed consent processes, and at a societal level, to threaten acceptance of human variation and disability. Third, ‘Reflecting on the fetus as a person in relation to the pregnant woman’ described views on that ultrasound has led to increased ‘personification’ of the fetus, and that women often put fetal health interests ahead of their own. Conclusions The results reflect the significant influence ultrasound has had in maternity care and highlights ethical and professional challenges that midwives face in their daily working lives concerning its use. Further discussion about the use of ultrasound is needed, both among health professionals and in the community, in order to protect women’s rights to informed decision-making and autonomy in pregnancy and childbirth and to curb unnecessary medicalisation of pregnancy. Midwives’ experiences and views play an essential role in such discussions.
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Affiliation(s)
- Kristina Edvardsson
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, SE 901 87, Umeå, Sweden. .,Judith Lumley Centre, La Trobe University, 215 Franklin Street, Melbourne, Vic, 3000, Australia.
| | - Ingrid Mogren
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, SE 901 87, Umeå, Sweden.
| | - Ann Lalos
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, SE 901 87, Umeå, Sweden.
| | | | - Rhonda Small
- Judith Lumley Centre, La Trobe University, 215 Franklin Street, Melbourne, Vic, 3000, Australia.
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Welsh A, Henry A. Reproducibility of Doppler evaluation: need to include physiological variation in determination of achievable ICCs. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:128. [PMID: 26134733 DOI: 10.1002/uog.14729] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 11/02/2014] [Indexed: 06/04/2023]
Affiliation(s)
- A Welsh
- Royal Hospital for Women, Department of Maternal-Fetal Medicine Randwick, Sydney, New South Wales, Australia
- University of New South Wales, Division of Women & Children's Health, Randwick, Sydney, New South Wales, Australia
| | - A Henry
- Department of Obstetrics & Gynaecology, St George Hospital, Kogarah, New South Wales, Australia
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Edvardsson K, Small R, Lalos A, Persson M, Mogren I. Ultrasound's 'window on the womb' brings ethical challenges for balancing maternal and fetal health interests: obstetricians' experiences in Australia. BMC Med Ethics 2015; 16:31. [PMID: 25953252 PMCID: PMC4429903 DOI: 10.1186/s12910-015-0023-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 04/24/2015] [Indexed: 11/24/2022] Open
Abstract
Background Obstetric ultrasound has become a significant tool in obstetric practice, however, it has been argued that its increasing use may have adverse implications for women’s reproductive freedom. This study aimed to explore Australian obstetricians’ experiences and views of the use of obstetric ultrasound both in relation to clinical management of complicated pregnancy, and in situations where maternal and fetal health interests conflict. Methods A qualitative study was undertaken as part of the CROss-Country Ultrasound Study (CROCUS). Interviews were held in November 2012 with 14 obstetricians working in obstetric care in Victoria, Australia. Data were analysed using qualitative content analysis. Results One overall theme emerged from the analyses: The ethical challenge of balancing maternal and fetal health interests, built on four categories: First, Encountering maternal altruism’ described how pregnant women’s often ‘altruistic’ position in relation to the health and wellbeing of the fetus could create ethical challenges in obstetric management, particularly with an increasing imbalance between fetal benefits and maternal harms. Second, ‘Facing shifting attitudes due to visualisation and medico-technical advances’ illuminated views that ultrasound and other advances in care have contributed to a shift in what weight to give maternal versus fetal welfare, with increasing attention directed to the fetus. Third, ‘Guiding expectant parents in decision-making’ described the difficult task of facilitating informed decision-making in situations where maternal and fetal health interests were not aligned, or in situations characterised by uncertainty. Fourth, ‘Separating private from professional views’ illuminated divergent views on when the fetus can be regarded as a person. The narratives indicated that the fetus acquired more consideration in decision-making the further the gestation progressed. However, there was universal agreement that obstetricians could never act on fetal grounds without the pregnant woman’s consent. Conclusions This study suggests that medico-technical advances such as ultrasound have set the scene for increasing ethical dilemmas in obstetric practice. The obstetricians interviewed had experienced a shift in previously accepted views about what weight to give maternal versus fetal welfare. As fetal diagnostics and treatment continue to advance, how best to protect pregnant women’s right to autonomy requires careful consideration and further investigation.
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Affiliation(s)
- Kristina Edvardsson
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, SE 901 87, Umeå, Sweden. .,Judith Lumley Centre, La Trobe University, Melbourne, Vic, 3000, Australia.
| | - Rhonda Small
- Judith Lumley Centre, La Trobe University, Melbourne, Vic, 3000, Australia.
| | - Ann Lalos
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, SE 901 87, Umeå, Sweden.
| | | | - Ingrid Mogren
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, SE 901 87, Umeå, Sweden.
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Gomez-Roig MD, Mazarico E, Sabria J, Parra J, Oton L, Vela A. Use of Placental Growth Factor and Uterine Artery Doppler Pulsatility Index in Pregnancies Involving Intrauterine Fetal Growth Restriction or Preeclampsia to Predict Perinatal Outcomes. Gynecol Obstet Invest 2015; 80:99-105. [DOI: 10.1159/000370332] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 12/03/2014] [Indexed: 11/19/2022]
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Abstract
BACKGROUND One of the main aims of routine antenatal care is to identify the 'at risk' fetus in order to apply clinical interventions which could result in reduced perinatal morbidity and mortality. Doppler ultrasound study of umbilical artery waveforms helps to identify the compromised fetus in 'high-risk' pregnancies and, therefore, deserves assessment as a screening test in 'low-risk' pregnancies. OBJECTIVES To assess the effects on obstetric practice and pregnancy outcome of routine fetal and umbilical Doppler ultrasound in unselected and low-risk pregnancies. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group Trials Register (28 February 2015) and reference lists of retrieved studies. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of Doppler ultrasound for the investigation of umbilical and fetal vessels waveforms in unselected pregnancies compared with no Doppler ultrasound. Studies where uterine vessels have been assessed together with fetal and umbilical vessels have been included. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. In addition to standard meta-analysis, the two primary outcomes and five of the secondary outcomes were assessed using GRADE software and methodology. MAIN RESULTS We included five trials that recruited 14,624 women, with data analysed for 14,185 women. All trials had adequate allocation concealment, but none had adequate blinding of participants, staff or outcome assessors. Overall and apart from lack of blinding, the risk of bias for the included trials was considered to be low.Overall, routine fetal and umbilical Doppler ultrasound examination in low-risk or unselected populations did not result in increased antenatal, obstetric and neonatal interventions. There were no group differences noted for the review's primary outcomes of perinatal death and neonatal morbidity. Results for perinatal death were as follows: (average risk ratio (RR) 0.80, 95% confidence interval (CI) 0.35 to 1.83; four studies, 11,183 participants). Only one included trial assessed serious neonatal morbidity and found no evidence of group differences (RR 0.99, 95% CI 0.06 to 15.75; one study, 2016 participants).For the comparison of a single Doppler assessment versus no Doppler, evidence for group differences in perinatal death was detected (RR 0.36, 95% CI 0.13 to 0.99; one study, 3891 participants). However, these results are based on a single trial, and we would recommend caution when interpreting this finding.There was no evidence of group differences for the outcomes of caesarean section, neonatal intensive care admissions or preterm birth less than 37 weeks.When the quality of the evidence for the main comparison of 'All Doppler versus no Doppler' was assessed with GRADE software, the outcomes of perinatal death and serious neonatal morbidity data were graded as of low quality. Evidence for the outcome of stillbirth was graded according to regimen subgroups - with a moderate quality rating for stillbirth (fetal/umbilical vessels only) and a low quality rating for stillbirth (fetal/umbilical vessels + uterine artery vessels). Evidence for admission to neonatal intensive care unit was assessed as of moderate quality, and evidence for the outcomes of caesarean section and preterm birth less than 37 weeks was graded as of high quality.There is no available evidence to assess the effect on substantive long-term outcomes such as childhood neurodevelopment and no data to assess maternal outcomes, particularly maternal satisfaction. AUTHORS' CONCLUSIONS Existing evidence does not provide conclusive evidence that the use of routine umbilical artery Doppler ultrasound, or combination of umbilical and uterine artery Doppler ultrasound in low-risk or unselected populations benefits either mother or baby. Future studies should be designed to address small changes in perinatal outcome, and should focus on potentially preventable deaths.
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Affiliation(s)
- Zarko Alfirevic
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Tamara Stampalija
- Institute for Maternal and Child Health, IRCCS Burlo GarofoloUnit of Prenatal DiagnosisTriesteItaly
| | - Nancy Medley
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Vanlieferinghen S, Anselem O, Le Ray C, Shen Y, Marcellin L, Goffinet F. Prognostic value of umbilical and cerebral Doppler in fetal growth restriction: comparison of dichorionic twins and singletons. PLoS One 2015; 10:e0123067. [PMID: 25875366 PMCID: PMC4395410 DOI: 10.1371/journal.pone.0123067] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 02/17/2015] [Indexed: 11/19/2022] Open
Abstract
Objective To compare the prognostic value of fetal Doppler in dichorionic twins and singletons by measuring the interval between diagnosis of an abnormal Doppler flow and birth in fetuses who are small for gestational age (SGA). Design Comparative retrospective study using a prospectively collected database. Setting A level 3 maternity unit in France. Population Fetuses from singleton and dichorionic pregnancies who are SGA (vascular or unexplained), defined by an abdominal circumference (AC) measurement below the 10th percentile and confirmed by a birth weight below the 10th percentile. Methods Fisher's exact and Chi-2 tests were used to compare frequencies, and the Mann-Whitney-Wilcoxon test was used to compare medians in non-Gaussian distributions. Main outcome measures Both neonatal outcomes and intervals between the first Doppler abnormality and birth were compared in the groups of dichorionic twins and singletons. Results Obstetric and neonatal outcome were similar in the 104 SGA dichorionic twins and 170 SGA singletons. Abnormalities of umbilical artery Doppler, regardless of type, appeared at the same frequency in both groups (52.9%) but were identified earlier in twins (25 versus 28 weeks, p = 0.02). Among fetuses with abnormal Doppler flow, the interval between the finding and birth was significantly longer in the twins than the singletons (44 vs 15 days, p<0.01). Conclusions The prognostic value of an abnormal Doppler finding for the course of a pregnancy may be different in dichorionic twins and singletons. The management of women carrying SGA twins and the information provided to them should take these results into account.
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Affiliation(s)
- Sarah Vanlieferinghen
- Department of Obstetrics and Gynaecology, Cochin Broca Hôtel-Dieu hospital, Assistance Publique-Hôpitaux de Paris, 53 avenue de l’observatoire, 75014 Paris, France
- Universitary Hospital Departement (DHU) Risks in pregnancy, Paris, France
| | - Olivia Anselem
- Department of Obstetrics and Gynaecology, Cochin Broca Hôtel-Dieu hospital, Assistance Publique-Hôpitaux de Paris, 53 avenue de l’observatoire, 75014 Paris, France
- PremUP Foundation for scientific cooperation in connection with pregnancy and prematurity, 53 avenue de l’observatoire, 75014 Paris, France
- Universitary Hospital Departement (DHU) Risks in pregnancy, Paris, France
| | - Camille Le Ray
- Department of Obstetrics and Gynaecology, Cochin Broca Hôtel-Dieu hospital, Assistance Publique-Hôpitaux de Paris, 53 avenue de l’observatoire, 75014 Paris, France
- PremUP Foundation for scientific cooperation in connection with pregnancy and prematurity, 53 avenue de l’observatoire, 75014 Paris, France
- French Institute of Health and Medical Research (INSERM) Unit 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Research Center for Epidemiology and Biostatistics Sorbonne Paris Cité (CRESS), Paris, France
- Universitary Hospital Departement (DHU) Risks in pregnancy, Paris, France
| | - Yao Shen
- Department of Obstetrics and Gynaecology, Cochin Broca Hôtel-Dieu hospital, Assistance Publique-Hôpitaux de Paris, 53 avenue de l’observatoire, 75014 Paris, France
- Universitary Hospital Departement (DHU) Risks in pregnancy, Paris, France
| | - Louis Marcellin
- Department of Obstetrics and Gynaecology, Cochin Broca Hôtel-Dieu hospital, Assistance Publique-Hôpitaux de Paris, 53 avenue de l’observatoire, 75014 Paris, France
- PremUP Foundation for scientific cooperation in connection with pregnancy and prematurity, 53 avenue de l’observatoire, 75014 Paris, France
- Universitary Hospital Departement (DHU) Risks in pregnancy, Paris, France
| | - François Goffinet
- Department of Obstetrics and Gynaecology, Cochin Broca Hôtel-Dieu hospital, Assistance Publique-Hôpitaux de Paris, 53 avenue de l’observatoire, 75014 Paris, France
- PremUP Foundation for scientific cooperation in connection with pregnancy and prematurity, 53 avenue de l’observatoire, 75014 Paris, France
- French Institute of Health and Medical Research (INSERM) Unit 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Research Center for Epidemiology and Biostatistics Sorbonne Paris Cité (CRESS), Paris, France
- Universitary Hospital Departement (DHU) Risks in pregnancy, Paris, France
- * E-mail:
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