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Queirós A, Domingues S, Gomes L, Pereira I, Brito M, Cohen Á, Alves M, Papoila AL, Simões T. First-trimester uterine artery Doppler and hypertensive disorders in twin pregnancies: Use of twin versus singleton references. Int J Gynaecol Obstet 2024. [PMID: 38800867 DOI: 10.1002/ijgo.15706] [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: 01/31/2024] [Revised: 04/13/2024] [Accepted: 05/11/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE To determine the association of first-trimester uterine artery Doppler with hypertensive disorders of pregnancy in twin pregnancies. METHODS This was a retrospective cohort study of twin pregnancies followed at the University Hospital Center of Central Lisbon, Portugal, between January 2010 and December 2022. First-trimester uterine artery pulsatility index (UtA-PI) was determined and compared between twin pregnancies (n = 454) and singleton pregnancies (n = 908), matched to maternal and pregnancy characteristics. Maternal characteristics and mean UtA-PI were analyzed for gestational age, birth weight, gestational hypertension, early- and late-onset pre-eclampsia, HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, and preterm birth. Univariable and multivariable logistic regression models were used. RESULTS The mean first-trimester UtA-PI was significantly lower in dichorionic twins than in singletons (P < 0.001). To study hypertensive disorders of pregnancy in twins, 390 pregnancies were included: 311 (79.7%) dichorionic and 79 (20.3%) monochorionic twins. The observed rates of early- and late-onset pre-eclampsia, gestational hypertension, and HELLP syndrome were 1.0%, 4.4%, 7.4%, and 1.5%, respectively. We achieved a 100% detection rate for early-onset pre-eclampsia using the UtA-PI 90th centile for twins. However, when singleton references were considered, the detection rate decreased to 50%. UtA-PI at or above the 95th centile was associated with increased odds for preterm birth before 32 weeks (adjusted odds ratio 4.1, 95% confidence interval 1.0-16.7, P = 0.043). CONCLUSIONS Unless other major risk factors for hypertensive disorders are present, women with low UtA-PI will probably not benefit from aspirin prophylaxis. Close monitoring of all twin pregnancies for hypertensive disorders is still recommended.
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Affiliation(s)
- Alexandra Queirós
- Fetal Medicine and Surgery Center, University Hospital Center of Central Lisbon, Centro Clínico Académico de Lisboa, Lisbon, Portugal
- Maternal and Fetal Medicine Unit, University Hospital Center of Central Lisbon, Centro Clínico Académico de Lisboa, Lisbon, Portugal
- Nova Medical School, Nova University Lisbon, Lisbon, Portugal
| | - Sofia Domingues
- Obstetrics and Gynecology Unit, Setubal Hospital Center, Setubal, Portugal
| | - Laura Gomes
- Maternal and Fetal Medicine Unit, University Hospital Center of Central Lisbon, Centro Clínico Académico de Lisboa, Lisbon, Portugal
| | - Inês Pereira
- Maternal and Fetal Medicine Unit, University Hospital Center of Central Lisbon, Centro Clínico Académico de Lisboa, Lisbon, Portugal
| | - Marta Brito
- Maternal and Fetal Medicine Unit, University Hospital Center of Central Lisbon, Centro Clínico Académico de Lisboa, Lisbon, Portugal
| | - Álvaro Cohen
- Fetal Medicine and Surgery Center, University Hospital Center of Central Lisbon, Centro Clínico Académico de Lisboa, Lisbon, Portugal
| | - Marta Alves
- Nova Medical School, Nova University Lisbon, Lisbon, Portugal
- Epidemiology and Statistics Unit, University Hospital Center of Central Lisbon, Lisbon, Portugal
- University of Lisbon Center of Statistics and Its Applications, Lisbon, Portugal
| | - Ana Luísa Papoila
- Nova Medical School, Nova University Lisbon, Lisbon, Portugal
- Epidemiology and Statistics Unit, University Hospital Center of Central Lisbon, Lisbon, Portugal
- University of Lisbon Center of Statistics and Its Applications, Lisbon, Portugal
| | - Teresinha Simões
- Maternal and Fetal Medicine Unit, University Hospital Center of Central Lisbon, Centro Clínico Académico de Lisboa, Lisbon, Portugal
- Nova Medical School, Nova University Lisbon, Lisbon, Portugal
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Antunes M, Matias A. Association between first-trimester uterine artery Doppler and crown-rump length with growth discordance: does it make a difference. J Perinat Med 2024; 0:jpm-2024-0145. [PMID: 38753440 DOI: 10.1515/jpm-2024-0145] [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: 03/28/2024] [Accepted: 05/06/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVES The purpose of this study was to investigate the association between first-trimester uterine artery pulsatility index (UtA-PI) and crown-rump length discordance (CRLD) with growth discordance (GD) in twins and analyze the influence of chorionicity in these parameters. METHODS This retrospective analysis integrated data from the twin pregnancy database of Centro Hospitalar São João (2019-2023), including 184 fetuses, with 19 monochorionic and 73 dichorionic gestations. To determine the association between UtA-PI and CRLD with GD, correlation analyses were computed and linear regression models were carried out. Separate analyses were conducted for each type of placentation. Logistic regression analysis was carried out to determine the association of mean UtA-PI and CRLD with severe GD, defined as discordance ≥25 %. RESULTS GD≥25 % was detected in 9.80 % of pregnancies. A statistically significant difference between monochorionic and dichorionic gestations was found in crown-rump length (p=0.009), CRLD (p<0.001) and birth weight (p=0.025), but not in mean UtA-PI (p=0.853) or GD (p=0.556). Mean UtA-PI was significantly higher in discordant than in concordant pairs (p<0.001), but that association was not seen in CRLD (p=0.931). Mean UtA-PI and GD were correlated by the regression line "GD=3.844 × UtA-PI + 6.638", with R2 0.027. CRLD and GD were correlated by the regression line "GD=0.280 × CRLD + 10.79", with R2 0.010. Mean UtA-PI, but not CRLD, was significantly associated with severe GD (odds ratio, 22.753; p=0.002). CONCLUSIONS Mean UtA-PI, but not CRLD, is associated with GD. The prevalence of severe GD increases significantly with increasing mean UtA-PI.
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Affiliation(s)
- Maria Antunes
- Faculty of Medicine, 26705 University of Porto , Porto, Portugal
| | - Alexandra Matias
- Obstetrics and Gynecology, Faculty of Medicine, 26705 University of Porto , Porto, Portugal
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Francisco C, Gamito M, Reddy M, Rolnik DL. Screening for preeclampsia in twin pregnancies. Best Pract Res Clin Obstet Gynaecol 2022; 84:55-65. [PMID: 35450774 DOI: 10.1016/j.bpobgyn.2022.03.008] [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: 01/04/2022] [Accepted: 03/13/2022] [Indexed: 11/02/2022]
Abstract
Twin pregnancies are an important risk factor for preeclampsia, a hypertensive disorder of pregnancy that is associated with a significant risk of maternal and perinatal morbidity. Given the burden of preeclampsia, the identification of women at high risk in early pregnancy is essential to allow for preventive strategies and close monitoring. In singleton pregnancies, the risk factors for preeclampsia are well established, and a combined first-trimester prediction model has been shown to adequately predict preterm disease. Furthermore, intervention with low-dose aspirin at 150 mg/day in those identified as high-risk reduces the rate of preterm preeclampsia by 62%. In contrast, risk factors for preeclampsia in twin pregnancies are less established, the proposed screening models have shown poor performance with high false-positive rates, and the benefit of aspirin for the prevention of preeclampsia is not clearly demonstrated. In this review, we examine the literature assessing prediction and prevention of preeclampsia in twin pregnancies.
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Affiliation(s)
- Carla Francisco
- Department of Obstetrics and Gynaecology, Hospital Beatriz Ângelo, Avenida Carlos, Teixeira 3, 2674-514 Loures, Portugal.
| | - Mariana Gamito
- Department of Obstetrics and Gynaecology, Hospital Beatriz Ângelo, Avenida Carlos, Teixeira 3, 2674-514 Loures, Portugal.
| | - Maya Reddy
- Department of Obstetrics and Gynaecology, Monash University, 246 Clayton Road, Clayton, Melbourne, Victoria, Australia.
| | - Daniel L Rolnik
- Department of Obstetrics and Gynaecology, Monash University, 246 Clayton Road, Clayton, Melbourne, Victoria, Australia.
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Tian Y, Yang X. A Review of Roles of Uterine Artery Doppler in Pregnancy Complications. Front Med (Lausanne) 2022; 9:813343. [PMID: 35308523 PMCID: PMC8927888 DOI: 10.3389/fmed.2022.813343] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/10/2022] [Indexed: 11/22/2022] Open
Abstract
The invasion of trophoblasts into the uterine decidua and decidual vessels is critical for the formation of placenta. The defects of placentation are related to the etiologies of preeclampsia (PE), fetal growth restriction (FGR), and small-for-gestational age (SGA) neonates. It is possible to predict significant vascular events during pregnancy through uterine artery Doppler (UAD). From the implantation stage to the end of pregnancy, detecting changes in uterine and placental blood vessels can provide a favorable diagnostic instrument for pregnancy complications. This review aims to collect literature about the roles of UAD in pregnancy complications. We consider all relevant articles in English from January 1, 1983 to October 30, 2021. Predicting pregnancy complications in advance allows practitioners to carry out timely interventions to avoid or lessen the harm to mothers and neonates. Administering low-dose aspirin daily before 16 weeks of pregnancy can significantly reduce the incidence of pregnancy complications. From early pregnancy to late pregnancy, UAD can combine with other maternal factors, biochemical indicators, and fetal measurement data to identify high-risk population. The identification of high-risk groups can also lessen maternal mortality. Besides, through moderate risk stratification, stringent monitoring for high-risk pregnant women can be implemented, decreasing the incidence of adversities.
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Affiliation(s)
- Yingying Tian
- Department of Obstetrics, The First Hospital of China Medical University, Shenyang, China
| | - Xiuhua Yang
- Department of Obstetrics, The First Hospital of China Medical University, Shenyang, China
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Lu Y, Ding Z, Li W, Mei L, Shen L, Shan H. Prediction of twin pregnancy preeclampsia based on clinical risk factors, early pregnancy serum markers, and uterine artery pulsatility index. Pak J Med Sci 2021; 37:1727-1733. [PMID: 34912386 PMCID: PMC8613048 DOI: 10.12669/pjms.37.7.5041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/26/2021] [Accepted: 09/05/2021] [Indexed: 11/22/2022] Open
Abstract
Objectives: To investigate whether a combination of clinical risk factors, early pregnancy serum markers, and uterine artery pulsatility index (UTPI) can be used to predict twin preeclampsia (PE). Methods: This case control study included women with twin pregnancies who had undergone obstetrics treatments and gave birth at the Huzhou Maternity and Child Health Care Hospital from October 2018 to November 2020. Patients with PE comprised study group, and patients without PE comprised control group based on selection criteria and a 1:1 ratio. Statistical analysis was performed using clinical risk factors, early pregnancy serum markers, and UTPIs, and the area under the receiver operating curve (AUC. Sensitivity, and the specificity of different combinations of these variables were calculated to predict PE in women with twin pregnancy. Results: Logistic regression analysis revealed four independent predictors for the onset of PE during twin pregnancies: first delivery (OR, 7.51; P=0.045), conception method (OR, 7.11; P=0.036), β-HCG level (per SD OR, 2.73; P=0.026), and UTPI (OR, 0.17; P=0.043). First-delivery and IVF pregnancy methods both lead to a 7-fold increase in the PE risk during twin pregnancies. Every one sigma (standard deviation) increase in the β-HCG level led to a 2.73-fold increase in the PE risk. Every UTPI increment by 1.0 reduces the risk of PE by 83%. The prediction efficiencies were based on an AUC of 0.837, a sensitivity of 69%, and a specificity of 92% for the clinical risk factors; an AUC of 0.800, a sensitivity of 81%, and specificity of 78% for the β-HCG level, and an AUC of 0.814, a sensitivity of 88%, and a specificity of 65% for the UTPI. AUC was 0.928, sensitivity 85%, and a specificity 88% after applying the three types of indicators together for prediction. Conclusions: By combining early pregnancy serum markers (β-HCG), and UTPI, the predictive value for PE during twin pregnancy is improved together with its sensitivity and specificity.
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Affiliation(s)
- Yan Lu
- Dr. Yan Lu, Department of Obstetrics and Gynecology, Huzhou Maternity and Child Health Care Hospital, Huzhou 313000, Zhejiang Province, P.R. China
| | - Zhongying Ding
- Dr. Zhongying Ding, Department of Obstetrics and Gynecology, Huzhou Maternity and Child Health Care Hospital, Huzhou 313000, Zhejiang Province, P.R. China
| | - Wenwen Li
- Dr. Wenwen Li, Department of Obstetrics and Gynecology, Huzhou Maternity and Child Health Care Hospital, Huzhou 313000, Zhejiang Province, P.R. China
| | - Lina Mei
- Dr. Lina Mei, Department of Obstetrics and Gynecology, Huzhou Maternity and Child Health Care Hospital, Huzhou 313000, Zhejiang Province, P.R. China
| | - Linglong Shen
- Dr. Linglong Shen, Department of Obstetrics and Gynecology, Huzhou Maternity and Child Health Care Hospital, Huzhou 313000, Zhejiang Province, P.R. China
| | - Huaying Shan
- Dr. Huaying Shan, Department of Obstetrics and Gynecology, Huzhou Maternity and Child Health Care Hospital, Huzhou 313000, Zhejiang Province, P.R. China
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Filipecka-Tyczka D, Pokropek A, Kajdy A, Modzelewski J, Rabijewski M. Uterine Artery Doppler Reference Ranges in a Twin Caucasian Population Followed Longitudinally From 17 to 37 Weeks Gestation Compared to That of Singletons. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:2421-2429. [PMID: 33438788 DOI: 10.1002/jum.15627] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES The primary aim was to measure uterine artery (UtA) indices in twin pregnancies of Polish Caucasian women and compare it with a previously published study by Geipel et al for DC twins (2011). The secondary aim was to find differences in UtA indices in MC, DC twins, and singletons. METHODS A prospective longitudinal evaluation of UtA Doppler indices in 1462 examinations of twins and 5766 examinations of singletons between 17 and 37 gestational age (GA). Pulsatility index (PI) and resistance index (RI) were calculated. RESULTS UtA PI and RI are lower in the twins than singletons but the analyzed mean values throughout gestation are higher than the study presented by Geipel et al. Obtained curves for DC twins and singletons had the same form as Geipel's curves. In MC twins, curves are flatter and characterized by lower differences throughout pregnancy than Geipel's curves for DC twins. They tend to be more similar about 32 weeks of gestations, resulting from different placenta structure in MC than DC twin pregnancies. CONCLUSIONS UtA Doppler indices in twin pregnancies are lower than in singletons. Obtained data have higher values for twins than reference charts proposed by Geipel's for dichorionic twins. We observed some differences between monochorionic and dichorionic twins' curves throughout pregnancy, but they were not significant.
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Affiliation(s)
| | - Artur Pokropek
- Institute of Philosophy and Sociology of the Polish Academy of Sciences, Warsaw, Poland
| | - Anna Kajdy
- Department of Reproductive Health, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Jan Modzelewski
- Department of Reproductive Health, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Michał Rabijewski
- Department of Reproductive Health, Centre of Postgraduate Medical Education, Warsaw, Poland
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Risk Factors for Early and Late Onset Preeclampsia in Reunion Island: Multivariate Analysis of Singleton and Twin Pregnancies. A 20-Year Population-Based Cohort of 2120 Preeclampsia Cases. REPRODUCTIVE MEDICINE 2021. [DOI: 10.3390/reprodmed2030014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: To develop a multivariate model for risk factors specific to early onset preeclampsia (EOP) and late onset preeclampsia (LOP) in our entire population (singleton and twin pregnancies). Material and methods: 20 year-observational population-based historical cohort study (2001–2020). All consecutive births delivered at the Centre Hospitalier Universitaire Hospitalier Sud Reunion’s maternity ward. A standardized validated epidemiological perinatal database was used. Results: During the 20-year period, there were 81,834 pregnancies and 83,497 infants born, 1232 dichorionic and 350 monochorionic twin pregnancies. There were 2120 cases of preeclampsia, of which 2001 were preeclamptic singleton pregnancies and 119 twin pregnancies (incidence 7.5% in twin pregnancies vs. 2.5% singletons, OR 3.0, p < 0.001). Independent risk factors for EOP and LOP in a multivariate model (controlling for the two major confounders: maternal ages—both risks for EOP and LOP, and maternal pre-pregnancy BMI—specific risk factor for LOP) were: history of preeclampsia (adjusted OR (aOR) 11.7 for EOP, 7.8 for LOP, p < 0.0001), chronic hypertension (aOR 7.3 for EOP, 3.9 for LOP, p < 0.0001), history of perinatal death (aOR 2.2 for EOP, p < 0.0001 and 1.48 for LOP, p = 0.007), primipaternity (aOR 3.0 for EOP and 3.6 for LOP, p = 0.001), dizygotic twin pregnancies (aOR 3.7 for EOP, p < 0.0001 and 2.1 for LOP, p = 0.003), monozygotic twin pregnancies (aOR 3.98 for EOP, p = 0.003 and non-significant (NS) for LOP), ovulation induction (aOR 5.6 for EOP, p = 0.004 and NS for LOP), and in vitro fertilization (aOR 2.8 for EOP, p = 0.05 and NS for LOP). Specific to LOP and NS for EOP: renal diseases (aOR for LOP 2.9, p = 0.007) and gestational diabetes mellitus (aOR 1.2, p = 0.04). Conclusions: Maternal ages over 35 years, chronic hypertension, history of preeclampsia, ovulation induction, in vitro fertilizations, history of perinatal deaths and twin pregnancy (in our experience, especially mono zygotic twin pregnancies) are significant risk factors for EOP. New paternity is an independent factor for both EOP and LOP.
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Rizzo G, Mappa I, Bitsadze V, Słodki M, Khizroeva J, Makatsariya A, D'Antonio F. Role of first-trimester umbilical vein blood flow in predicting large-for-gestational age at birth. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:67-72. [PMID: 31343791 DOI: 10.1002/uog.20408] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 07/02/2019] [Accepted: 07/11/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To describe umbilical vein (UV) hemodynamics at 11 + 0 to 13 + 6 weeks of gestation in pregnancies delivering a large-for-gestational-age (LGA) neonate, and to build a multiparametric model, including pregnancy and ultrasound characteristics in the first trimester, that is able to predict LGA at birth. METHODS This was a matched case-control study, of singleton pregnancies that underwent ultrasound examination at 11 + 0 to 13 + 6 weeks for aneuploidy screening, at a single center over a 4-year period. Cases were women who delivered a neonate with birth weight (BW) > 90th centile for gestational age and sex, according to local birth-weight standards, while controls were those who delivered a neonate with BW ranging between the 10th and 90th centiles, matched for maternal and gestational age, at a ratio of 1:3. Each included case underwent Doppler assessment of the uterine arteries and UV, including measurement of its diameter, time-averaged maximum velocity (TAMXV) and UV blood flow (UVBF). UVBF and its components were expressed as Z-scores. Fisher's exact test and Mann-Whitney U-test were used to compare differences in maternal biomarkers and ultrasound characteristics between pregnancies complicated by LGA and controls. Logistic regression and receiver-operating-characteristics (ROC) curve analyses were carried out to identify independent predictors of LGA and to build a multiparametric prediction model integrating different maternal, pregnancy and ultrasound characteristics. Subgroup analysis was also performed, considering women who delivered a neonate with BW > 4000 g. RESULTS In total, 964 pregnancies (241 with LGA at birth and 723 without) were included in the study. In LGA pregnancies compared with controls, UV-TAMXV Z-score (0.8 (interquartile range (IQR), 0.4-1.5) vs 0.0 (IQR, -0.3 to 0.5); P ≤ 0.001) and UVBF Z-score (1.3 (IQR, 0.8-1.9) vs 0.1 (IQR, -0.4 to 0.4); P ≤ 0.001) were higher, while there was no difference in median UV diameter Z-score (P = 0.56). Median uterine artery pulsatility index multiples of the median (MoM; 0.94 (IQR, 0.78-1.12) vs 1.02 (IQR, 0.84-1.19); P = 0.04) was significantly lower in LGA pregnancies. On multivariate logistic regression analysis, maternal body mass index (BMI; adjusted odds ratio (aOR), 1.2 (95% CI, 1.1-1.7); P < 0.001), parity (aOR, 1.4 (95% CI, 1.2-1.6); P < 0.001), pregnancy-associated plasma protein-A (PAPP-A) MoM (aOR, 1.1 (95% CI, 1.0-1.6); P = 0.04) and UVBF Z-score (aOR, 1.6 (95% CI, 1.1-1.9); P < 0.001) were associated independently with LGA. A multiparametric model integrating parity, BMI and PAPP-A MoM provided an area under the ROC curve (AUC) of 0.72 (95% CI, 0.67-0.76) for the prediction of LGA. The addition of UVBF Z-score to this model significantly improved the prediction of LGA provided by maternal and biochemical factors, with an AUC of 0.79 (95% CI, 0.75-0.83; P = 0.03). Similarly, the model incorporating UVBF Z-score predicted BW > 4000 g with an AUC of 0.83 (95% CI, 0.75-0.93). CONCLUSIONS UVBF measured at the time of the 11-14-week scan is associated independently with, and is predictive of, LGA and BW > 4000 g. Adding measurement of UVBF to a multiparametric model that includes maternal (parity and BMI) and biochemical (PAPP-A) parameters improves the diagnostic accuracy of prenatal screening for LGA at birth. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G Rizzo
- Division of Maternal-Fetal Medicine, Università di Roma Tor Vergata, Rome, Italy
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - I Mappa
- Division of Maternal-Fetal Medicine, Università di Roma Tor Vergata, Rome, Italy
| | - V Bitsadze
- Division of Maternal-Fetal Medicine, Università di Roma Tor Vergata, Rome, Italy
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - M Słodki
- Division of Maternal-Fetal Medicine, Università di Roma Tor Vergata, Rome, Italy
- Department of Prenatal Cardiology, Polish Mother's Memorial Hospital Research Institute, Łódź, Poland
| | - J Khizroeva
- Division of Maternal-Fetal Medicine, Università di Roma Tor Vergata, Rome, Italy
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - A Makatsariya
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - F D'Antonio
- Department of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
- Department of Clinical Medicine, Faculty of Health Sciences, The Arctic University of Norway, Tromsø, Norway
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Vikraman SK, Elayedatt RA. Pre-eclampsia screening in the first trimester - preemptive action to prevent the peril. J Matern Fetal Neonatal Med 2020; 35:1808-1816. [PMID: 32434399 DOI: 10.1080/14767058.2020.1767059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Pre-eclampsia complicating 2-5% of pregnancies is an obstetrical syndrome associated with deleterious short-and long-term consequences to the gravid women, the fetus and the neonate. Majority of the obstetrical complications occur in early pre-eclampsia (requiring delivery <34 weeks). The risk factor based approach recommended by the professional organizations for pre-eclampsia screening has shown suboptimal clinical performance. The combined multimarker screening for pre-eclampsia encompassing documentation of maternal medical history, measurement of mean arterial pressure, estimation of the maternal serum levels of placental growth factor, pregnancy associated plasma protein-A, and recording the Uterine artery mean pulsatility index, performed in the first trimester between 11 and 13 + 6 weeks has proven to be an effective screening strategy. The a-priori risk is determined by multivariate analysis of the factors from history, while the other parameters are converted to log 10 transformed multiple of median values. Bayes' theorem is used to calculate the final risk. The above model has shown to detect 77% of preterm pre-eclampsia (<37 weeks), 96% of early preterm pre-eclampsia (<34 weeks), 38% of term pre-eclampsia and 54% of all pre-eclampsia, at a false positive rate of 10%. Uterine artery Doppler is key to pre-eclampsia screening. Currently a risk of >1:100 for pre-eclampsia developing before 37 weeks (preterm pre-eclampsia) is regarded as screen positive. Aspirin at a dose of 150 mg at bedtime given to screen positive subjects is associated with a significant reduction of preterm pre-eclampsia and early pre-eclampsia. The intervention is now supported by a well conducted randomized trial and metanalysis data. Aspirin acts by diminishing stores of constitutive cyclooxygenase enzyme in the non-nucleated platelets without disturbing systemic prostaglandin production. Selective use of aspirin in screen positive women is associated with a very low incidence of adverse maternal, fetal and neonatal side effects. The screening protocol can be applied to twin pregnancies albeit minor differences. Hence, screening for pre-eclampsia in first trimester, which is now endorsed by the federation of international obstetrical and gynecological societies, should be offered universally to all women at 11 to 13 + 6 weeks of gestation, followed by the administration of aspirin and serial maternal-fetal surveillance in the screen positive woman.
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Affiliation(s)
- Seneesh Kumar Vikraman
- Center for Prenatal diagnosis and Fetal therapy, ARMC AEGIS Hospital, Perinthalmana, Kerala, India.,Department of Fetal Medicine, Almas Hospital, Malappuram, Kerala, India
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Chen J, Zhao D, Liu Y, Zhou J, Zou G, Zhang Y, Guo M, Duan T, Van Mieghem T, Sun L. Screening for preeclampsia in low-risk twin pregnancies at early gestation. Acta Obstet Gynecol Scand 2020; 99:1346-1353. [PMID: 32356359 DOI: 10.1111/aogs.13890] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 04/15/2020] [Accepted: 04/22/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Preeclampsia affects about 10% of twin pregnancies and significantly increases the risk of adverse pregnancy outcomes. However, screening models for preeclampsia in twin pregnancies remain elusive. The present study aimed to evaluate the performance of a multi-marker first trimester preeclampsia screening model in low-risk twin pregnancies. MATERIAL AND METHODS Between 2014 and 2017, we prospectively assessed first trimester biomarkers for preeclampsia in a 'low-risk' twin pregnancy cohort at a single center. Multiple logistic regression was used to determine significant predictors for early preeclampsia (occurring prior to 34 weeks) and late preeclampsia (occurring after 34 weeks). The performance of the screening models fitted using the significant predictors was calculated using receiver operating characteristics curves, and internal validation was performed using bootstrapping. RESULTS A total of 769 twin pregnancies were included in the study. Early preeclampsia and late preeclampsia developed in 27 (3.5%) and 59 (7.7%) cases, respectively. Logistic regression analyses showed that maternal age, body mass index, mean artery pressure and placental growth factor were significant predictors for early preeclampsia. Maternal age, body mass index, mean artery pressure and pregnancy-associated plasma protein A were significant for late preeclampsia. Uterine artery pulsatility index was not predictive of either early or late preeclampsia. For the fitted screening model of early and late preeclampsia, the areas under receiver operating characteristics curves were 0.82 (95% confidence interval [CI] 0.76-0.88) and 0.66 (95% CI 0.59-0.73), which were expected to decrease to 0.77 and 0.60, respectively, based on bootstrapping; the positive predictive values were 10.2% and 12.5%; and the estimated detection rates were 40.7% and 22.0%, respectively, at a false-positive rate of 10%. CONCLUSIONS A multi-marker screening model for preeclampsia in low-risk twin pregnancies, using a modified version of Fetal Medicine Foundation predictors in singletons, does not perform well. Uterine artery pulsatility index is of little value in screening for preeclampsia in low-risk twin pregnancies.
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Affiliation(s)
- Jianping Chen
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Depeng Zhao
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Reproductive Medicine, Affiliated Shenzhen Maternity & Child Healthcare Hospital, Southern Medical University, Shenzhen, China
| | - Yang Liu
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China.,Shanghai Putuo District Maternity and Infant Hospital Corporation, Shanghai, China
| | - Jia Zhou
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Gang Zou
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yun Zhang
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ming Guo
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Tao Duan
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Tim Van Mieghem
- Department of Obstetrics and gynecology, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Luming Sun
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
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Benkő Z, Chaveeva P, de Paco Matallana C, Zingler E, Wright A, Wright D, Nicolaides KH. Validation of competing-risks model in screening for pre-eclampsia in twin pregnancy by maternal factors. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:649-654. [PMID: 30887621 DOI: 10.1002/uog.20265] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 03/11/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To examine the predictive performance of the competing-risks model in screening for pre-eclampsia (PE) by maternal demographic characteristics and medical history in twin pregnancy, in a training dataset used for development of the model and a validation dataset. METHODS The data for this study were derived from two prospective non-intervention multicenter screening studies for PE in twin pregnancies at 11 + 0 to 13 + 6 weeks' gestation. The first study of 2219 women, which was reported previously, was used to develop the competing-risks model for prediction of PE and is therefore considered to be the training set. The validation study comprised 2999 women. Patient-specific risks of delivery with PE at < 34 (early), < 37 (preterm) and < 41 + 3 (all) weeks' gestation were calculated using the competing-risks model and the performance of screening for PE in the training and validation datasets was assessed. We examined the predictive performance of the model by, first, its ability to discriminate between the PE and no-PE groups using the area under the receiver-operating characteristics curve (AUC) and, second, calibration, which assesses agreement between the predicted risk and observed incidence of PE. RESULTS The incidence of early PE, preterm PE and all PE in the training and validation datasets was similar (1.8% vs 1.4%, 5.6% vs 5.6% and 7.7% vs 7.2%, respectively) and this was substantially higher than in our previous studies in singleton pregnancies. The training and validation datasets had similar AUCs for early PE (0.670 (95% CI, 0.593-0.747) vs 0.677 (95% CI, 0.594-0.760)), preterm PE (0.666 (95% CI, (0.617-0.715) vs 0.652 (95% CI, 0.609-0.694)) and all PE (0.656 (95% CI, 0.615-0.697) vs 0.644 (95% CI, 0.606-0.682)). Calibration plots of the predictive performance of the competing-risks model demonstrated that, in both the training and validation datasets, the observed incidence of PE was lower than the predicted one and such overestimation of risk was particularly marked for early PE. CONCLUSIONS Discrimination and calibration of the competing-risks model for PE in a validation dataset are consistent with those in the training dataset. However, the model needs to be adjusted to correct the observed overestimation of risk for early PE. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- Z Benkő
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | | | | | - E Zingler
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - A Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - D Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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Sotiriadis A, Hernandez-Andrade E, da Silva Costa F, Ghi T, Glanc P, Khalil A, Martins WP, Odibo AO, Papageorghiou AT, Salomon LJ, Thilaganathan B. ISUOG Practice Guidelines: role of ultrasound in screening for and follow-up of pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:7-22. [PMID: 30320479 DOI: 10.1002/uog.20105] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/15/2018] [Accepted: 07/22/2018] [Indexed: 06/08/2023]
Affiliation(s)
- A Sotiriadis
- Second Department of Obstetrics and Gynecology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - E Hernandez-Andrade
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Hutzel Women Hospital, Wayne State University, Detroit, MI, USA
| | - F da Silva Costa
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil; and Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - T Ghi
- Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - P Glanc
- Department of Radiology, University of Toronto, Toronto, Ontario, Canada
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK; and Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - W P Martins
- SEMEAR Fertilidade, Reproductive Medicine and Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - A O Odibo
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - A T Papageorghiou
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK; and Nuffield Department of Obstetrics and Gynecology, University of Oxford, Women's Center, John Radcliffe Hospital, Oxford, UK
| | - L J Salomon
- Department of Obstetrics and Fetal Medicine, Hopital Necker-Enfants Malades, Assistance Publique-Hopitaux de Paris, Paris Descartes University, Paris, France
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK; and Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Townsend R, Khalil A. Ultrasound surveillance in twin pregnancy: An update for practitioners. ULTRASOUND (LEEDS, ENGLAND) 2018; 26:193-205. [PMID: 30479634 PMCID: PMC6243450 DOI: 10.1177/1742271x18794013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 06/28/2018] [Indexed: 01/31/2023]
Abstract
Ultrasound has revolutionised the management of multiple pregnancies and their complications. Increasing frequency of twin pregnancies mandates familiarity of all clinicians with the relevant pathologies and evidence-based surveillance and management protocols for their care. In this review, we summarise the latest evidence relating to ultrasound surveillance of twin pregnancies including first trimester assessment and screening, growth surveillance and the detection and management of the complications of monochorionic pregnancies including twin-to-twin-transfusion syndrome, selective fetal growth restriction, twin reversed arterial perfusion sequence and conjoined twinning.
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Affiliation(s)
- R Townsend
- Fetal Medicine Unit, St. George's University of London, London, UK
| | - A Khalil
- Fetal Medicine Unit, St. George's University of London, London, UK
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Abstract
In the decades since the introduction of ultrasound into routine obstetric practice, the advantages of ultrasound have moved beyond the simple ability to identify multiple pregnancies antenatally to the possibility of screening them for fetal anomalies, pre-eclampsia, preterm birth, and the complications specific to monochorionic pregnancies. Screening studies have often excluded twins because physiological differences impact on the validity and sensitivity of the screening tests in routine use in singletons, and therefore, the evidence of screening performance in multiple pregnancy lags behind the evidence from singleton pregnancies. In general, most pregnancy complications are more common in twin pregnancy, but screening tests are less accurate or well validated. In this review article we present the current state of the evidence and avenues for future research relating to the use of ultrasound and screening for complications in twin pregnancies, including the monochorionicity-related pathologies, such as twin-twin transfusion syndrome, selective growth restriction, twin anaemia-polycythaemia sequence and twin reversed arterial perfusion sequence.
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Affiliation(s)
| | - Asma Khalil
- Fetal Medicine Unit, St George's University of London, London, UK.
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Francisco C, Wright D, Benkő Z, Syngelaki A, Nicolaides KH. Competing-risks model in screening for pre-eclampsia in twin pregnancy according to maternal factors and biomarkers at 11-13 weeks' gestation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:589-595. [PMID: 28556556 DOI: 10.1002/uog.17531] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 05/18/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To develop a model for screening for pre-eclampsia (PE) in twin pregnancies based on maternal demographic characteristics and medical history and biomarkers at 11-13 weeks' gestation. METHODS This was a screening study in twin pregnancies at 11-13 weeks' gestation. Bayes theorem was used to combine the a-priori risk from maternal factors with various combinations of uterine artery pulsatility index (UtA-PI), mean arterial pressure (MAP), serum pregnancy-associated plasma protein-A (PAPP-A) and placental growth factor (PlGF) multiples of the median (MoM) values. The performance of screening for PE requiring delivery at < 32, < 37 and < 42 weeks' gestation was estimated in 1100 twin pregnancies and 35 948 singleton pregnancies with complete data on UtA-PI, MAP, PlGF and PAPP-A. RESULTS In twin pregnancies that developed PE, the values of MAP and UtA-PI were increased and the values of PlGF and PAPP-A were decreased. The distributions of log10 MoM values of biomarkers with gestational age at delivery were similar to those that were previously reported in singleton pregnancies and it was therefore assumed that the same model could be used for both singleton and twin pregnancies. The performance of screening for PE by maternal factors was improved by the addition of MAP, UtA-PI and PlGF; there was no further improvement with the addition of PAPP-A. In a mixed population of singleton and twin pregnancies, combined screening by maternal factors, MAP, UtA-PI and PlGF and risk cut-off of 1 in 75 for PE at < 37 weeks, the detection rate of PE at < 32, < 37 and < 42 weeks in singleton pregnancies was 91%, 77% and 57%, respectively, at a screen-positive rate (SPR) of 13%; the respective rates for twin pregnancies were 100%, 99% and 97%, at a SPR of 75%. CONCLUSION First-trimester combined screening for PE in singleton pregnancies can be adapted for screening in twins, leading to detection of nearly all affected cases but at a high SPR. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- C Francisco
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - D Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - Z Benkő
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - A Syngelaki
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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Francisco C, Wright D, Benkő Z, Syngelaki A, Nicolaides KH. Competing-risks model in screening for pre-eclampsia in twin pregnancy by maternal characteristics and medical history. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:501-506. [PMID: 28508528 DOI: 10.1002/uog.17529] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 04/30/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE A survival-time regression model for gestational age at delivery with pre-eclampsia (PE) in singleton pregnancy, using maternal demographic characteristics and medical history, was reported previously. The objective of this study was to extend this model to dichorionic (DC) and monochorionic (MC) twin pregnancy. METHODS The study population included 1789 DC and 430 MC twin pregnancies and 93 297 singleton pregnancies. A survival-time model for gestational age at delivery with PE was developed from variables of maternal characteristics and medical history. The risk of PE with delivery < 37 weeks and < 42 weeks in twin pregnancies was determined and compared with that in singleton pregnancies. RESULTS In singleton pregnancies comprising women of Caucasian racial origin, mean weight of 69 kg at 12 weeks' gestation, mean height of 164 cm, nulliparous, with spontaneous conception, no family history of PE and no history of diabetes mellitus, systemic lupus erythematosus or antiphospholipid syndrome, the mean of the Gaussian distribution of gestational age at delivery with PE was 55 weeks. In DC twins with PE, mean gestational age at delivery was shifted to the left by 8.2 (95% CI, 7.2-9.1) weeks and in MC twins it was shifted to the left by 10.0 (95% CI, 8.5-11.4) weeks. The risk of delivery with PE occurring at, or before, a specified gestational age is given by the area under the fitted distribution curve. For a reference population with the above characteristics, the estimated risk of PE < 37 weeks' gestation, assuming no other cause of delivery, was 0.6% for singletons, 9.0% for DC twins and 14.2% for MC twins; the respective values for PE < 42 weeks were 3.6%, 27.0% and 36.5%. CONCLUSIONS A model based on maternal characteristics and medical history has been developed for estimation of patient-specific risks for PE in DC and MC twin pregnancy. Such estimation of the a-priori risk for PE is an essential first step in the use of Bayes' theorem to combine maternal factors with biomarkers for the continuing development of more effective methods of screening for the disease. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- C Francisco
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - D Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - Z Benkő
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - A Syngelaki
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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Francisco C, Wright D, Benkő Z, Syngelaki A, Nicolaides KH. Hidden high rate of pre-eclampsia in twin compared with singleton pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:88-92. [PMID: 28317207 DOI: 10.1002/uog.17470] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/13/2017] [Accepted: 03/15/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To examine the gestational age at delivery in dichorionic (DC) and monochorionic (MC) twin pregnancies, with and without pre-eclampsia (PE), and to determine the relative risk of total and preterm PE compared with that in singleton pregnancies. METHODS This was a screening study for PE in twin pregnancies undergoing first-trimester combined screening for aneuploidy and subsequently delivering two phenotypically normal live or stillborn babies at ≥ 24 weeks' gestation. The distribution of gestational age at delivery in DC and MC twins was determined and compared with that in singleton pregnancies from the same population. The relative risk for total and preterm PE in twins compared with singleton pregnancies was determined. Kaplan-Meier estimates of the cumulative incidence of PE in twin and singleton pregnancies, assuming no other cause for delivery, were determined and hazard ratios for twins relative to singletons were obtained from a Cox proportional hazards regression model. RESULTS The incidence of PE in singletons was 2.3% (2162/93 297), in DC twin pregnancies was 8.1% (145/1789) and in MC twin pregnancies was 6.0% (26/430). Compared with singletons, the relative risk of total PE was 3.5 for DC twins and 2.6 for MC twins. Delivery < 37 weeks' gestation occurred in 5.5% of singletons, 46.5% of DC twins and 91.4% of MC twins. The incidence of preterm PE was 0.6%, 5.5% and 5.8% for singletons, DC twins and MC twins, respectively. Compared with singletons, the relative risk of preterm PE was 8.7 for DC twins and 9.1 for MC twins. In the Cox proportional hazards regression model, the hazard ratios for DC and MC twin pregnancies relative to singleton pregnancies were 14 and 23, respectively. CONCLUSIONS The relative risk of preterm PE in DC and MC twins is similar and substantially higher than in singleton pregnancies. In ongoing twin pregnancies, the high relative risk of PE may merit a higher intensity of monitoring than is routine for singleton pregnancies. © 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)
- C Francisco
- Fetal Medicine Research Institute, Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - D Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - Z Benkő
- Fetal Medicine Research Institute, Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - A Syngelaki
- Fetal Medicine Research Institute, Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - K H Nicolaides
- Fetal Medicine Research Institute, Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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Stagnati V, Pagani G, Fichera A, Prefumo F. Intertwin discrepancy in middle cerebral artery peak systolic velocity and third-trimester fetal growth restriction in monochorionic-diamniotic twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:66-71. [PMID: 26173065 DOI: 10.1002/uog.14944] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 06/30/2015] [Accepted: 07/02/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To assess the role of intertwin discrepancy in middle cerebral artery peak systolic velocity (MCA-PSV) for the prediction of late selective intrauterine growth restriction (sIUGR) at birth and birth weight discrepancy of > 25% (BW-25) in otherwise uncomplicated monochorionic-diamniotic (MCDA) twin pregnancies. METHODS This was a cohort study including all MCDA pregnancies followed in a tertiary fetal medicine unit between 2008 and 2013. Exclusion criteria were referral after first trimester, abnormal karyotype, structural anomalies, twin-to-twin transfusion syndrome, twin anemia-polycythemia sequence and sIUGR detected before 28 weeks. MCA-PSV values of both twins measured in the second trimester (18-24 weeks) and early third trimester (26-32 weeks) were converted in multiples of the median (MoM). sIUGR was defined as birth weight < 5(th) centile. The relationship between MCA-PSV discrepancy, sIUGR and BW-25 was assessed by logistic regression analysis. Receiver-operating characteristics (ROC) curves were used to ascertain the predictive value of MCA-PSV discrepancy for such complications. RESULTS In total, 136 MCDA twin pregnancies were included in the analysis. Thirty (22.1%) were complicated with sIUGR at birth and 12 (8.8%) were complicated with BW-25. Logistic regression analysis identified MCA-PSV discrepancy as an independent predictor for sIUGR. ROC curves identified third-trimester MCA-PSV discrepancy as the best predictor for both sIUGR (area under ROC curve (AUC), 0.73 (95% CI, 0.62-0.85)) and BW-25 (AUC, 0.79 (95% CI, 0.65-0.93)). The optimal cut-off point for MCA-PSV discrepancy was 0.30 MoM (sensitivity, 70% and specificity, 69% for sIUGR; sensitivity, 83% and specificity, 72% for BW-25). CONCLUSION In MCDA twin pregnancies, MCA-PSV discrepancy is associated with both sIUGR at birth and BW discordance. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- V Stagnati
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - G Pagani
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - A Fichera
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - F Prefumo
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
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Leszczyńska K, Preis K, Respondek-Liberska M, Słodki M, Wood D, Weiner S, Gembruch U, Rizzo G, Achiron R, Pruetz JD, Sklansky M, Cuneo B, Arabin B, Blickstein I. Recommendations for Fetal Echocardiography in Twin Pregnancy in 2016. PRENATAL CARDIOLOGY 2016. [DOI: 10.1515/pcard-2016-0001] [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
Progress in the fields of fetal cardiology and fetal surgery have been seen not only in singleton pregnancies but also in multiple pregnancies. Proper interpretation of prenatal echocardiography is critical to clinical decision making, family counseling and perinatal management for obstetricians, maternal fetal medicine specialists, neonatologists and pediatric cardiologists. Fetal echocardiography is one of the most challenging and time-consuming prenatal examinations to perform, especially in multiple gestations. Performing just the basic fetal exam in twin gestations may take an hour or more. Thus, it is not practical to perform this exam in all cases of multiple gestations. Therefore our review and recommendations are related to fetal echocardiography in twin gestation.
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Affiliation(s)
| | - Krzysztof Preis
- 1. Department of Obstetrics, Medical University of Gdansk, Poland
| | - Maria Respondek-Liberska
- 2. Department of Diagnoses and Prevention Fetal Malformations, Medical University of Lodz, Poland
- 3. Department of Prenatal Cardiology, Polish Mother’s Memorial Hospital Research Institute, Lodz, Poland
| | - Maciej Słodki
- 3. Department of Prenatal Cardiology, Polish Mother’s Memorial Hospital Research Institute, Lodz, Poland
- 4. Institute of Health Sciences, The State School of Higher Professional Education in Płock, Poland
| | - Dennis Wood
- 5. Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Stuart Weiner
- 6. Thomas Jefferson University and Hospitals, Philadelphia, Pennsylvania, United States of America
| | - Ulli Gembruch
- 7. Department of Obstetrics and Prenatal Medicine, University Bonn Medical School, Bonn, Germany
| | - Giusseppe Rizzo
- 8. Department of Obstetrics and Gynecology, Università Roma Tor Vergata, Ospedela Fatebenefratelli Isola Tiberina, Rome, Italy
| | - Reuven Achiron
- 9. Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Israel
| | - Jay D Pruetz
- 10. Division of Pediatric Cardiology, Children’s Hospital Los Angeles, Los Angeles, CA, United States of America ; Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Mark Sklansky
- 11. Division of Pediatric Cardiology, Department of Pediatrics, David Geffen School of Medicine, Los Angeles, California, United States of America
| | - Bettina Cuneo
- 12. Department of Pediatric Cardiology, Then Fetal Heart Program, Colorado Fetal Care Center, Colorado Institute for Maternal Fetal Health, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Birgit Arabin
- 13. Center for Mother and Child, Philipps University, Marburg, Germany
| | - Isaac Blickstein
- 14. Department of Obstetrics and Gynecology, Kaplan Medical Center, 76100 Rehovot and the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
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Rizzo G, Aiello E, Pietrolucci ME, Arduini D. Placental volume and uterine artery Doppler evaluation at 11 + 0 to 13 + 6 weeks' gestation in pregnancies conceived with in-vitro fertilization: comparison between autologous and donor oocyte recipients. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:726-31. [PMID: 26053472 DOI: 10.1002/uog.14918] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 05/23/2015] [Accepted: 05/31/2015] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To compare first-trimester uterine artery pulsatility index (UtA-PI) and three-dimensional (3D) placental volume in pregnancies conceived through in-vitro fertilization (IVF) using autologous or donor oocytes and pregnancies conceived naturally, and to relate these measurements to the development of pre-eclampsia (PE). METHODS UtA-PI and placental volume were measured at 11 + 0 to 13 + 6 weeks of gestation in 416 IVF pregnancies (307 with autologous and 109 with donor oocytes) and in 498 spontaneously conceived pregnancies. We recruited nulliparous women with singleton pregnancy. The measured mean UtA-PI and placental volume values were converted to multiples of the expected normal median (MoM), adjusted for gestational age. MoM values of IVF pregnancies were compared with MoM values of the naturally conceived pregnancies and related to PE development. RESULTS Placental volume was significantly reduced in IVF pregnancies (K = 169.3; P < 0.0001) compared with natural pregnancies. No difference was found in UtA-PI MoM between the two groups. Among IVF pregnancies, significantly lower placental volumes were seen in those that received donor oocytes when compared with those with autologous oocytes (z = 3.89; P < 0.001). In IVF pregnancies that developed PE, lower values of placental volume were demonstrated with respect to normotensive pregnancies (donor: U = 6.8; P = 0.009; autologous: U = 5.1; P = 0.023), whereas no difference was found in UtA-PI. Multivariate logistic regression analysis demonstrated that placental volume (odds ratio (OR), 1.97 (95% CI, 1.33-2.27)) and donor oocytes in IVF pregnancy (OR, 2.24 (95% CI, 1.5-2.83)) were independent predictors of PE, whereas autologous oocytes in IVF pregnancy were not found to be significant in the model. CONCLUSIONS First-trimester placental volume, as assessed by 3D ultrasound, is reduced in IVF pregnancies and this reduction is more marked in those involving donor oocyte recipients. The relative decrease in placental volume in IVF pregnancies that developed PE suggests an etiological mechanism different from uterine perfusion in such patients. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G Rizzo
- Department of Obstetrics and Gynecology, Università di Roma 'Tor Vergata', Rome, Italy
| | - E Aiello
- Department of Obstetrics and Gynecology, Università di Roma 'Tor Vergata', Rome, Italy
| | - M E Pietrolucci
- Department of Obstetrics and Gynecology, Università di Roma 'Tor Vergata', Rome, Italy
| | - D Arduini
- Department of Obstetrics and Gynecology, Università di Roma 'Tor Vergata', Rome, Italy
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Matevosyan NR. Predictive accuracy of the first trimester Doppler scan: a meta-study. Wien Med Wochenschr 2015; 165:199-209. [PMID: 26077833 DOI: 10.1007/s10354-015-0358-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 04/29/2015] [Indexed: 12/16/2022]
Abstract
AIM To determine sensitivity and cut-off indices of the uterine artery Doppler (UAD) in prediction of preeclampsia and fetal growth restriction (FGR). METHODS Seventy-six studies published in 1995-2014, present 298,329 prenatal Doppler screenings performed in nullipara in the first and early second trimesters of singleton pregnancies. The sample is stratified into four groups based on the Doppler sensitivity and specificity indices pertaining to the major clinical endpoints of the cohort. RESULTS The FGR diagnostic specificity (r = 0.728) and bilateral notching index (r = 0.803) correlations indicate that the UAD accuracy depends on the placental bed and the screening mode. CONCLUSIONS Predictive sensitivity of the UAD increases after 16 weeks + 3 days (115 days) of gestation. The best predictive parameter of preeclampsia and FGR is the placental side uterine artery resistance index which confers to the highest means when the placenta is on the midline (OR 0.9).
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