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Steller JG, Gumina D, Driver C, Peek E, Galan HL, Reeves S, Hobbins JC. Patterns of Brain Sparing in a Fetal Growth Restriction Cohort. J Clin Med 2022; 11:jcm11154480. [PMID: 35956097 PMCID: PMC9369342 DOI: 10.3390/jcm11154480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/18/2022] [Accepted: 07/23/2022] [Indexed: 11/28/2022] Open
Abstract
Objective: Our objective was to compare differences in Doppler blood flow in four fetal intracranial blood vessels in fetuses with late-onset fetal growth restriction (FGR) vs. those with small for gestational age (SGA). Methods: Fetuses with estimated fetal weight (EFW) <10th percentile were divided into SGA (n = 30) and FGR (n = 51) via Delphi criteria and had Doppler waveforms obtained from the middle cerebral artery (MCA), anterior cerebral artery (ACA), posterior cerebral artery (PCA), and vertebral artery (VA). A pulsatility index (PI) <5th centile was considered “abnormal”. Outcomes included birth metrics and neonatal intensive care unit (NICU) admission. Results: There were more abnormal cerebral vessel PIs in the FGR group versus the SGA group (36 vs. 4; p = 0.055). In FGR, ACA + MCA vessel abnormalities outnumbered PCA + VA abnormalities. All 8 fetuses with abnormal VA PIs had at least one other abnormal vessel. Fetuses with abnormal VA PIs had lower BW (1712 vs. 2500 g; p < 0.0001), delivered earlier (35.22 vs. 37.89 wks; p = 0.0052), and had more admissions to the NICU (71.43% vs. 24.44%; p = 0.023). Conclusions: There were more anterior vessels showing vasodilation than posterior vessels, but when the VA was abnormal, the fetuses were more severely affected clinically than those showing normal VA PIs.
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Affiliation(s)
- Jon G. Steller
- Correspondence: ; Tel.: +1-714-456-6810 or +1-559-360-8545
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Rosati P, Buongiorno S, Salvi S, Lanzone A, Familiari A. Reference values for pulsatility index of fetal anterior and posterior cerebral arteries in prolonged pregnancy. JOURNAL OF CLINICAL ULTRASOUND : JCU 2021; 49:199-204. [PMID: 33501682 DOI: 10.1002/jcu.22979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 12/10/2020] [Accepted: 01/13/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To establish consistent normal reference values for fetal anterior cerebral artery (ACA) and posterior cerebral artery (PCA) pulsatility index (PI) in prolonged pregnancy. METHODS This prospective cross-sectional observational study included singleton normal prolonged pregnancies into two study groups according to the gestational age: from 40 + 0 to 40 + 6 and from 41 + 0 to 41 + 6 weeks. The PI was assessed in both anatomical segments of ACA (ACA-S1 and ACA-S2) and of PCA (PCA-S1 and PCA-S2) with color Doppler imaging and pulsed Doppler examination, and reference centiles charts were generated. PI values from the two investigated segments of each vessel were also compared. RESULTS Data were obtained in 771 patients: n = 448 in the 40 + 0 and 40 + 6 weeks group, and n = 323 in the 41 + 0 and 41 + 6 weeks group. A moderate decrease in PI was observed as pregnancy progressed. No differences in PI values were found between the two anatomical segments of ACA and PCA. CONCLUSION This study provides Doppler reference values for the fetal ACA and PCA PI. It also shows that Doppler examination could be performed indifferently in one of the two anatomical segments of these arteries.
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Affiliation(s)
- Paolo Rosati
- Department of "Scienze della Salute della Donna, del Bambino e di Sanità Pubblica" della, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Silvia Buongiorno
- Department of "Scienze della Salute della Donna, del Bambino e di Sanità Pubblica" della, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Silvia Salvi
- Department of "Scienze della Salute della Donna, del Bambino e di Sanità Pubblica" della, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Antonio Lanzone
- Department of "Scienze della Salute della Donna, del Bambino e di Sanità Pubblica" della, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Alessandra Familiari
- Department of "Scienze della Salute della Donna, del Bambino e di Sanità Pubblica" della, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
- Department of Obstetrics and Gynecology, "L. Mangiagalli," Fondazione IRCCS "Ca' Granda" - Ospedale Maggiore Policlinico, Milan, Italy
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Tan Y, Zeng S, Liu Y, Tang H, Zhao B. Doppler evaluation of the posterior cerebral artery in fetuses with transposition of great arteries. J Perinat Med 2020; 48:504-508. [PMID: 32304309 DOI: 10.1515/jpm-2019-0176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 03/29/2020] [Indexed: 11/15/2022]
Abstract
Objective To observe Doppler ultrasound changes in the two segments of the posterior cerebral artery (PCA) in fetuses with transposition of the great arteries (TGA). Methods The peak systolic velocity (PSV), end-diastolic velocity (EDV), pulsatility index (PI), and velocity-time integral (VTI) of the two segments of PCA (the first segment: PCAS1, the second segment: PCAS2) and of the middle cerebral artery (MCA) were compared in TGA fetuses and normal fetuses. The abnormality rate between the PCAS1-PI and MCA-PI was compared in TGA fetuses. Results The PCAS1-PI and MCA-PI were smaller in the TGA fetuses than in the controls (all P < 0.05), but the PCAS2-PI was unchanged (P > 0.05). The MCA-VTI, PCAS1-VTI, and PCAS2-VTI were larger in the TGA fetuses (all P < 0.05). In the TGA fetuses, the abnormality rate of the PCAS1-PI was significantly higher than that of the MCA-PI (P < 0.05). Conclusion In fetuses with TGA, there were hemodynamic differences between the two segments of the posterior cerebral arteries. Moreover, PCAS1 exhibited signs of vasodilatation more obviously than did the MCA in fetuses with TGA.
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Affiliation(s)
- Ya Tan
- Department of Ultrasound, the Second Xiangya Hospital of Central South University, Changsha, P.R. China
| | - Shi Zeng
- Department of Ultrasound, the Second Xiangya Hospital of Central South University, 139 Renmin Road, Changsha, 410011 Hunan, P.R. China
| | - YuShan Liu
- Department of Ultrasound, the Second Xiangya Hospital of Central South University, Changsha, P.R. China
| | - HuaYu Tang
- Department of Ultrasound, the Second Xiangya Hospital of Central South University, Changsha, P.R. China
| | - BaiHua Zhao
- Department of Ultrasound, the Second Xiangya Hospital of Central South University, Changsha, P.R. China
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Robertson N, Okano S, Kumar S. Feto-placental Dopplers are not altered in women with obstructive sleep apnoea symptoms. Aust N Z J Obstet Gynaecol 2020; 60:877-883. [PMID: 32367552 DOI: 10.1111/ajo.13166] [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: 10/09/2019] [Accepted: 03/28/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Snoring, gasping or choking during sleep are common symptoms of sleep-disordered breathing and are associated with multiple adverse maternal and obstetric outcomes. The mechanisms responsible remain unknown; however, placental dysfunction is suspected. AIMS The aim of this study was to investigate feto-placental and fetal cardiac function in women with pregnancies complicated by obstructive sleep apnoea symptoms. MATERIALS AND METHODS This was a prospective observational cohort study at a large tertiary obstetric hospital in Australia. Women were asked to complete a questionnaire relating to the presence and severity of obstructive sleep apnoea symptoms. They also underwent an ultrasound scan where Doppler indices of various feto-placental vessels and fetal cardiac function were measured. Regional cerebral perfusion was also assessed. RESULTS A total of 255 women were included in the final analysis. Of these, 36.1% (92/255) of women reported no obstructive sleep apnoea symptoms; 63.9% (163/255) reported they experienced some form of obstructive sleep apnoea symptoms that included any frequency of snoring or choking/gasping, while 42.0% (107/255) complained of severe obstructive sleep apnoea symptoms (snoring ≥ 3 times a week or choking/gasping). There were no significant differences in feto-placental Dopplers or fetal cardiac function parameters in women with obstructive sleep apnoea symptoms. There were also no differences in regional cerebral blood flow between groups, or any correlation with severity of symptoms. CONCLUSIONS Our data challenge the current perspective that adverse perinatal outcomes in women with obstructive sleep apnoea symptoms are related primarily to placental dysfunction and fetal compromise.
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Affiliation(s)
- Nicole Robertson
- Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia.,Mater Mothers' Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Satomi Okano
- Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia.,Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Sailesh Kumar
- Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia.,Mater Mothers' Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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Sanapo L, Al-Shargabi T, Ahmadzia HK, Schidlow DN, Donofrio MT, Hitchings L, Khoury A, Larry Maxwell G, Baker R, Bulas DI, Gomez LM, du Plessis AJ. Fetal acute cerebral vasoreactivity to maternal hyperoxia in low-risk pregnancies: a cross-sectional study. Prenat Diagn 2020; 40:813-824. [PMID: 32274806 DOI: 10.1002/pd.5694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 02/03/2020] [Accepted: 03/23/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To establish whether fetal cerebral vasoreactivity (CVRO2 ), following maternal hyperoxia, is predicted by fetal cerebral and uteroplacental Doppler pulsatility indices (PI) at baseline, fetal pulmonary vasoreactivity to oxygen (PVRO2 ), gestational age (GA), or sex. METHODS Pulsatility index of middle (MCA), anterior (ACA), posterior cerebral (PCA), umbilical (UA), uterine (UtA), and branch of the pulmonary arteries (PA) were obtained, by ultrasound, before (baseline), during (hyperoxia) and after 15 minutes of maternal administration of 8 L/min of 100% oxygen, through a non-rebreathing face mask, in normal singleton pregnancies within 20 to 38 weeks' gestation. CVRO2 was defined as changes greater than zero in z score of PI of the cerebral arteries from baseline to hyperoxia. Logistic modeling was applied to identify CVRO2 predictors. RESULTS A total of 97 pregnancies were eligible. In the overall population, median z scores of PI of MCA, ACA, and PCA did not differ between study phases. Based on the logistic model, baseline z scores for cerebral PI and GA were the best predictors of CVRO2 . CONCLUSIONS In low-risk pregnancies, fetal CVRO2 to hyperoxia does not occur uniformly but depends on cerebral PI and GA at baseline. These findings may provide useful reference points when oxygen is administered in high-risk pregnancies.
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Affiliation(s)
- Laura Sanapo
- Women's Medicine Collaborative-Division of Research, The Miriam Hospital, Providence, Rhode Island, USA
| | - Tareq Al-Shargabi
- Division of Fetal and Transitional Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Homa K Ahmadzia
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Science, Washington, District of Columbia, USA
| | - David N Schidlow
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary T Donofrio
- Division of Fetal and Transitional Medicine, Children's National Hospital, Washington, District of Columbia, USA.,Division of Cardiology, Children's National Hospital, Washington, District of Columbia, USA
| | - Laura Hitchings
- Division of Fetal and Transitional Medicine, Children's National Hospital, Washington, District of Columbia, USA
| | - Alfred Khoury
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Inova Health System, Falls Church, Virginia, USA
| | - G Larry Maxwell
- Department of Obstetrics and Gynecology, Inova Health System, Falls Church, Virginia, USA
| | - Robin Baker
- Department of Neonatology, Fairfax Neonatal Associates, Inova Children's Hospital, Falls Church, Virginia, USA
| | - Dorothy I Bulas
- Division of Diagnostic Imaging and Radiology, Children's National Hospital, Washington, District of Columbia, USA
| | - Luis M Gomez
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Inova Health System, Falls Church, Virginia, USA
| | - Adre J du Plessis
- Division of Fetal and Transitional Medicine, Children's National Hospital, Washington, District of Columbia, USA
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Ciardulli A, D'Antonio F, Caissutti C, Manzoli L, Flacco ME, Buongiorno S, Saccone G, Rosati P, Lanzone A, Scambia G, Berghella V. Fetal brain hemodynamics in pregnancies at term: correlation with gestational age, birthweight and clinical outcome. J Matern Fetal Neonatal Med 2019; 34:913-919. [PMID: 31288578 DOI: 10.1080/14767058.2019.1622669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION The primary aim of this study was to ascertain the strength of association between cerebral blood flow assessed in anterior (ACA), middle (MCA), and posterior (PCA) cerebral arteries and the following clinical outcomes: small for gestational age (SGA), induction of labor (IOL) for oligohydramnios and caesarean section (CS) for nonreassuring fetal status (NRFS) during labor. MATERIAL AND METHODS Retrospective analysis of prospectively collected data on consecutive singleton pregnancies from 40 0/7 to 41 6/7 week of gestation. UA, ACA, MCA, PCA pulsatility index (PI) were measured from 40 weeks of gestations. Furthermore, the ratios between cerebral blood flow and UA (CPR, ACA/UA and PCA/UA) were calculated and correlated with the observed outcomes. RESULTS Two hundred twenty-four singleton pregnancies were included in the study. Mean PI of either ACA (p = .04), MCA (p = .008), and PCA (p = .003) were lower in the SGA compared to non-SGA group; furthermore, mean PCA PI was significantly lower than MCA PI (p = .04). Furthermore, CPR (p = .016), ACA/UA (p = .02), and PCA/UA (p = .003) were significantly lower in the SGA group compared to controls. UA, ACA, MCA, and PCA PI were higher in women undergoing IOL for oligohydramnios compared to controls. Logistic regression analysis showed that CPR and PCA/UA ratio were independently associated with SGA. SGA, ACA PI, and ACA/UA were independently associated with CS for NRFS. Finally, birthweight centile, were independently associated with IOL oligohydramnios. Despite this, the predictive accuracy of Doppler in detecting any of the explored outcome was only poor to moderate. CONCLUSION Redistribution of cerebral blood flow at term is significantly associated with SGA, IOL for oligohydramnios and CS for NRFS in labor. However, the predictive accuracy of Doppler at term is only poor to moderate, thus advising against its use in clinical practice as a standalone screening test for adverse perinatal outcome in pregnancies at term. Key Message Redistribution of cerebral blood flow at term is significantly associated with SGA, IOL for oligohydramnios and CS for NRFS in labor.
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Affiliation(s)
- Andrea Ciardulli
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco D'Antonio
- Women and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT - the Arctic University of Norway, Tromsø, Norway.,Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway
| | - Claudia Caissutti
- Department of Experimental Clinical and Medical Science, DISM, Clinic of Obstetrics and Gynecology, University of Udine, Udine, Italy
| | - Lamberto Manzoli
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Maria Elena Flacco
- Department of Medicine and Aging Science, University of Chieti, Chieti, Italy
| | - Silvia Buongiorno
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Paolo Rosati
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonio Lanzone
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
| | - Giovanni Scambia
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Rosati P, Buongiorno S, Salvi S, Guariglia L, Lanzone A, Morales-Roselló J. Reproducibility of the fetal cerebral vessels assessment in full and late term pregnancies. J Matern Fetal Neonatal Med 2018; 33:2159-2165. [PMID: 30474451 DOI: 10.1080/14767058.2018.1542681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: Data concerning feasibility of the fetal cerebral Doppler examination in full term and late term pregnancy is lacking. Our purpose was to perform an evaluation of these arteries with power Doppler ultrasound, calculating the percentage of identification and measurement and the intraobserver reproducibility.Methods: This was a cross sectional study evaluating a population of 578 normally grown fetuses divided according to the week of examination. The first group included fetuses examined at week 40 (N = 323) and the second fetuses examined at week 41 (N = 255). The three major branches of the internal carotid artery (anterior, middle and posterior cerebral arteries, ACA, middle cerebral artery (MCA), posterior cerebral arteries (PCA)) and their anastomosis (A1, A2, P1, P2) were examined with power Doppler ultrasonography by three independent ultrasonographers. The proportion of vessel identified and measured was calculated and the reproducibility among the three operators was investigated.Results: The major arteries at the circle of Willis were fully identified/measured in 65/56 and 62/48% of fetuses at 40 and 41 weeks. The MCA obtained the higher percentage of identification and measurement at both periods (> 80 and >70%). The entire set of anastomosis were less frequently identified/measured at both periods (50/< 50% of cases), especially in the A2 segment. The best agreement was obtained in the MCA and the worst in the PCA-P1 segment.Conclusions: At 40 and 41 weeks, the fetal cerebral vessels, especially the MCA, are suitable for power Doppler evaluation, providing an interesting tool to evaluate fetal hemodynamics in full and late term pregnancy.
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Affiliation(s)
- P Rosati
- Department of Woman and Child Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - S Buongiorno
- Department of Woman and Child Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - S Salvi
- Department of Woman and Child Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - L Guariglia
- Department of Woman and Child Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - A Lanzone
- Department of Woman and Child Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - J Morales-Roselló
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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Different vasodilatation characteristics among the main cerebral arteries in fetuses with congenital heart defects. Sci Rep 2018. [PMID: 29540791 PMCID: PMC5852154 DOI: 10.1038/s41598-018-22663-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
To observe Doppler changes in the three main cerebral arteries in fetuses with congenital heart defects (CHDs). The pulsatility index (PI) values of the anterior cerebral artery (ACA), middle cerebral artery (MCA), and posterior cerebral artery (PCA) were prospectively compared in 78 CHD fetuses and 78 normal control fetuses. Correlations between the cerebral artery PIs and the neurodevelopment scores (psychomotor development index [PDI] and mental development index [MDI]) were assessed. The MCA-PI was decreased significantly in fetuses with hypoplastic left heart syndrome (HLHS). The ACA-PI was reduced significantly in fetuses with HLHS, fetuses with left-sided obstructive lesions (LSOLs) and fetuses with transposition of the great arteries. The PCA-PI was significantly smaller in fetuses with HLHS and fetuses with LSOLs. More fetuses presented signs of cerebral vasodilatation of the ACA than the MCA for certain types of CHD (P < 0.05). The ACA-PI was positively correlated with the PDI and MDI scores in fetuses with CHDs (r2 = 0.26, 0.20, P < 0.01). The MCA-PI was only positively correlated with the PDI scores (r2 = 0.15, P < 0.01). The ACA exhibited signs of vasodilatation more frequently and severely than the MCA. The ACA-PI appears to be more sensitive for predicting abnormal neurodevelopmental outcomes than the MCA-PI.
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Morales-Roselló J, Khalil A, Morlando M, Hervás-Marín D, Perales-Marín A. Doppler reference values of the fetal vertebral and middle cerebral arteries, at 19–41 weeks gestation. J Matern Fetal Neonatal Med 2014; 28:338-43. [DOI: 10.3109/14767058.2014.916680] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Morales-Roselló J, Khalil A, Hervás-Marín D, Perales-Marín A. Comment on "Doppler evaluation of the posterior cerebral artery in normally grown and growth restricted fetuses". Prenat Diagn 2014; 34:304. [PMID: 24585530 DOI: 10.1002/pd.4290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Accepted: 11/25/2013] [Indexed: 11/05/2022]
Affiliation(s)
- José Morales-Roselló
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain; Fetal Medicine Unit, St George's Hospital, London, UK
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