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Morris RK, Johnstone E, Lees C, Morton V, Smith G. Investigation and Care of a Small-for-Gestational-Age Fetus and a Growth Restricted Fetus (Green-top Guideline No. 31). BJOG 2024; 131:e31-e80. [PMID: 38740546 DOI: 10.1111/1471-0528.17814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Key recommendations
All women should be assessed at booking (by 14 weeks) for risk factors for fetal growth restriction (FGR) to identify those who require increased surveillance using an agreed pathway [Grade GPP]. Findings at the midtrimester anomaly scan should be incorporated into the fetal growth risk assessment and the risk assessment updated throughout pregnancy. [Grade GPP]
Reduce smoking in pregnancy by identifying women who smoke with the assistance of carbon monoxide (CO) testing and ensuring in‐house treatment from a trained tobacco dependence advisor is offered to all pregnant women who smoke, using an opt‐out referral process. [Grade GPP]
Women at risk of pre‐eclampsia and/or placental dysfunction should take aspirin 150 mg once daily at night from 12+0–36+0 weeks of pregnancy to reduce their chance of small‐for‐gestational‐age (SGA) and FGR. [Grade A]
Uterine artery Dopplers should be carried out between 18+0 and 23+6 weeks for women at high risk of fetal growth disorders [Grade B]. In a woman with normal uterine artery Doppler and normal fetal biometry at the midtrimester scan, serial ultrasound scans for fetal biometry can commence at 32 weeks. Women with an abnormal uterine artery Doppler (mean pulsatility index > 95th centile) should commence ultrasound scans at 24+0–28+6 weeks based on individual history. [Grade B]
Women who are at low risk of FGR should have serial measurement of symphysis fundal height (SFH) at each antenatal appointment after 24+0 weeks of pregnancy (no more frequently than every 2 weeks). The first measurement should be carried out by 28+6 weeks. [Grade C]
Women in the moderate risk category are at risk of late onset FGR so require serial ultrasound scan assessment of fetal growth commencing at 32+0 weeks. For the majority of women, a scan interval of four weeks until birth is appropriate. [Grade B]
Maternity providers should ensure that they clearly identify the reference charts to plot SFH, individual biometry and estimated fetal weight (EFW) measurements to calculate centiles. For individual biometry measurements the method used for measurement should be the same as those used in the development of the individual biometry and fetal growth chart [Grade GPP]. For EFW the Hadlock three parameter model should be used. [Grade C]
Maternity providers should ensure that they have guidance that promotes the use of standard planes of acquisition and calliper placement when performing ultrasound scanning for fetal growth assessment. Quality control of images and measurements should be undertaken. [Grade C]
Ultrasound biometry should be carried out every 2 weeks in fetuses identified to be SGA [Grade C]. Umbilical artery Doppler is the primary surveillance tool and should be carried out at the point of diagnosis of SGA and during follow‐up as a minimum every 2 weeks. [Grade B]
In fetuses with an EFW between the 3rd and 10th centile, other features must be present for birth to be recommended prior to 39+0 weeks, either maternal (maternal medical conditions or concerns regarding fetal movements) or fetal compromise (a diagnosis of FGR based on Doppler assessment, fetal growth velocity or a concern on cardiotocography [CTG]) [Grade C]. For fetuses with an EFW or abdominal circumference less than the 10th centile where FGR has been excluded, birth or the initiation of induction of labour should be considered at 39+0 weeks after discussion with the woman and her partner/family/support network. Birth should occur by 39+6 weeks. [Grade B]
Pregnancies with early FGR (prior to 32+0 weeks) should be monitored and managed with input from tertiary level units with the highest level neonatal care. Care should be multidisciplinary by neonatology and obstetricians with fetal medicine expertise, particularly when extremely preterm (before 28 weeks) [Grade GPP]. Fetal biometry in FGR should be repeated every 2 weeks [Grade B]. Assessment of fetal wellbeing can include multiple modalities but must include computerised CTG and/or ductus venous. [Grade B]
In pregnancies with late FGR, birth should be initiated from 37+0 weeks to be completed by 37+6 weeks [Grade A]. Decisions for birth should be based on fetal wellbeing assessments or maternal indication. [Grade GPP]
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Groten T, Lehmann T, Städtler M, Komar M, Winkler JL, Condic M, Strizek B, Seeger S, Jäger Y, Pecks U, Eckmann-Scholz C, Kagan KO, Hoopmann M, von Kaisenberg CS, Hertel B, Tauscher A, Schrey-Petersen S, Friebe-Hoffmann U, Lato K, Hübener C, Delius M, Verlohren S, Sroka D, Schlembach D, de Vries L, Kraft K, Seliger G, Schleußner E. Pentaerythrityl tetranitrate improves the outcome of children born to mothers with compromised uterine perfusion-12-months follow-up and safety data of the double-blind randomized PETN trial. Am J Obstet Gynecol MFM 2024; 6:101332. [PMID: 38460823 DOI: 10.1016/j.ajogmf.2024.101332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/06/2024] [Accepted: 02/27/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND This is a follow-up study to the pentaerythrityl tetranitrate randomized controlled multicenter trial that reports neonatal outcome data of newborns admitted to neonatal intensive care units and outcome data of the offspring at 12 months of age. OBJECTIVE We present data on adverse events reported during the study to document the safety of pentaerythrityl tetranitrate treatment during pregnancy. To further evaluate the effects of pentaerythrityl tetranitrate on neonatal and long-term outcomes, we present follow up data from of 240 children at 12 months of age, including information on height, weight, head circumference, developmental milestones, and the presence of chronic disease and of 144 newborns admitted to the neonatal intensive care unit during the trial. STUDY DESIGN The pentaerythrityl tetranitrate trial was a randomized, double-blind, placebo-controlled study designed to assess the efficacy and safety of the nitric oxide-donor pentaerythrityl tetranitrate in the prevention of fetal growth restriction and perinatal death in pregnancies complicated by abnormal placental perfusion. RESULTS Results at 12 months demonstrated that significantly more children were age appropriately developed without impairments in the pentaerythrityl tetranitrate group (P=.018). In addition, the presence of chronic disease was lower in the pentaerythrityl tetranitrate group (P=.041). Outcome data of the 144 newborns admitted to the neonatal intensive care unit did not reveal differences between the treatment and placebo groups. There were no differences in the number or nature of reported adverse events between the study groups. CONCLUSION The analysis shows that study children born in the pentaerythrityl tetranitrate cohort have a clear advantage compared with the placebo group at the age of 12 months, as evidenced by the increased incidence of normal development without the presence of chronic disease. Although safety has been proven, further follow-up studies are necessary to justify pentaerythrityl tetranitrate treatment during pregnancies complicated by impaired uterine perfusion.
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Affiliation(s)
- Tanja Groten
- Department of Obstetrics, Jena University Hospital (Prof. Groten and Prof. Schleußner), Jena, Germany.
| | - Thomas Lehmann
- Institute of Medical Statistics and Computer Science, Jena University Hospital (Dr Lehmann), Jena, Germany; Center for Clinical Studies, Jena University Hospital (Dr Lehmann and Mrs Städtler), Jena, Germany
| | - Mariann Städtler
- Center for Clinical Studies, Jena University Hospital (Dr Lehmann and Mrs Städtler), Jena, Germany
| | - Matej Komar
- Department of Gynecology and Obstetrics, Technische Universität Dresden (Dr Komar and Dr Winkler), Dresden, Germany
| | - Jennifer Lucia Winkler
- Department of Gynecology and Obstetrics, Technische Universität Dresden (Dr Komar and Dr Winkler), Dresden, Germany
| | - Mateja Condic
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn (Dr Condic and Prof. Strizek), Germany
| | - Brigitte Strizek
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn (Dr Condic and Prof. Strizek), Germany
| | - Sven Seeger
- Department of Gynaecology and Obstetrics, Perinatal Centre, St. Elisabeth and St. Barbara Halle (Drs Seeger and Jäger), Halle (Saale), Germany
| | - Yvonne Jäger
- Department of Gynaecology and Obstetrics, Perinatal Centre, St. Elisabeth and St. Barbara Halle (Drs Seeger and Jäger), Halle (Saale), Germany
| | - Ulrich Pecks
- Department of Obstetrics and Gynaecology and Department of Maternal Health and Midwifery, University Medical Centre Würzburg (Prof. Pecks), Würzburg, Germany
| | - Christel Eckmann-Scholz
- Department of Obstetrics, Christian-Albrechts-University of Kiel (Dr Eckmann-Scholz), Kiel, Germany
| | - Karl Oliver Kagan
- Department of Feto-Maternal Medicine, Women's University Hospital Tübingen (Profs Kagan and Hoopmann), Tübingen, Germany
| | - Markus Hoopmann
- Department of Feto-Maternal Medicine, Women's University Hospital Tübingen (Profs Kagan and Hoopmann), Tübingen, Germany
| | - Constantin S von Kaisenberg
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hannover Medical School (Prof. von Kaisenberg and Dr. Hertel), Hannover, Germany
| | - Bettina Hertel
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hannover Medical School (Prof. von Kaisenberg and Dr. Hertel), Hannover, Germany
| | - Anne Tauscher
- Department of Obstetrics and Gynecology, University of Leipzig (Drs Tauscher and Schrey-Petersen), Leipzig, Germany
| | - Susanne Schrey-Petersen
- Department of Obstetrics and Gynecology, University of Leipzig (Drs Tauscher and Schrey-Petersen), Leipzig, Germany
| | - Ulrike Friebe-Hoffmann
- Department of Gynecology and Obstetrics, Ulm University Hospital (Prof. Friebe-Hoffmann and Dr. Lato), Ulm, Germany
| | - Krisztian Lato
- Department of Gynecology and Obstetrics, Ulm University Hospital (Prof. Friebe-Hoffmann and Dr. Lato), Ulm, Germany
| | - Christoph Hübener
- Department of Obstetrics and Gynecology, Perinatal Center, University Hospital, Campus Grosshadern, LMU Munich (Prof. Hübener and Dr. Delius), Munich, Germany
| | - Maria Delius
- Department of Obstetrics and Gynecology, Perinatal Center, University Hospital, Campus Grosshadern, LMU Munich (Prof. Hübener and Dr. Delius), Munich, Germany
| | - Stefan Verlohren
- Department of Obstetrics, Charité - Universitätsmedizin Berlin (Prof. Verlohren and Dr. Sroka), Berlin, Germany
| | - Dorota Sroka
- Department of Obstetrics, Charité - Universitätsmedizin Berlin (Prof. Verlohren and Dr. Sroka), Berlin, Germany
| | - Dietmar Schlembach
- Vivantes Network of Health GmbH, Clinicum Neukoelln, Clinic for Obstetric Medicine (Dr Schlembach), Berlin, Germany
| | - Laura de Vries
- Department of Obstetrics and Gynecology Städtisches Klinikum Harlaching Munich (Dr de Vries), Germany
| | - Katrina Kraft
- Department of Obstetrics and Gynecology, University Hospital Schleswig-Holstein (Dr Kraft), Lübeck, Germany
| | - Gregor Seliger
- Center for Reproductive Medicine and Andrology, University Medical Center Halle (Saale) (Prof. Seliger), Halle (Saale), Germany
| | - Ekkehard Schleußner
- Department of Obstetrics, Jena University Hospital (Prof. Groten and Prof. Schleußner), Jena, Germany
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Crequit S, Grangé G, Goffinet F, Girault A. Assessing the external validity and clinical relevance of umbilical doppler resistance index references in daily practice. J Gynecol Obstet Hum Reprod 2024; 53:102720. [PMID: 38160906 DOI: 10.1016/j.jogoh.2023.102720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/28/2023] [Accepted: 12/28/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE To assess the external validity and clinical relevance of current references for umbilical artery resistance index (UA RI) in daily practice. METHODS Retrospective cross-sectional single center study including all UA RI measurements between 22 and 40 gestational weeks (GW) from distinct patients between 2014 and 2022. Patients with normal pregnancies and normal neonatal outcomes that had an UA RI measurement between 2014 and 2019 were used to calculate reference ranges. The established reference for the 95th centile was compared to two current references. The clinical relevance of the established reference was tested by comparing neonatal outcomes according to the 95th percentile among the consecutive distinct patients between 2020 and 2022. RESULTS Among the 13342 consecutive distinct patients with a singleton pregnancy that had an UA RI measurement between 22 and 40 GW between 2014 and 2022, 5298 patients were included to establish the reference ranges, and 3634 patients to validate these ranges. For each gestational age, the established references were similar to current references. Using the established references, the proportion of patients presenting an UA RI>95th percentile among the patients with normal pregnancies in the validation population was comparable to the proportion when using the two current references. Among the validation population, 268 patients (7.4 %) (95%CI[6.5-8.2]) presented an UA RI ≥ 95th percentile. Of these 268 patients, 67.9% had a SGA newborn (versus 19.2%, p<0.001) and 59% a preterm birth (versus 13.9%, p<0.001). CONCLUSIONS The reference range obtained from daily practice is clinically relevant and similar to current references.
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Affiliation(s)
- Simon Crequit
- Department of Gynecology and Obstetrics, Montreuil Hospital, Centre Hospitalier Intercommunal de Montreuil Maternity Unit, 56 Boulevard de la Boissière, Montreuil 93100, France.
| | - Gilles Grangé
- Port-Royal Maternity Unit, Department of Obstetrics, FHU PREMA, Cochin Broca Hôtel-Dieu Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris F-75014, France
| | - François Goffinet
- Port-Royal Maternity Unit, Department of Obstetrics, FHU PREMA, Cochin Broca Hôtel-Dieu Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris F-75014, France; INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics, FHU PREMA, Clinical Research Unit of Paris Descartes Necker Cochin, Université de Paris, Paris, France, APHP, Paris, France
| | - Aude Girault
- Port-Royal Maternity Unit, Department of Obstetrics, FHU PREMA, Cochin Broca Hôtel-Dieu Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris F-75014, France; INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics, FHU PREMA, Clinical Research Unit of Paris Descartes Necker Cochin, Université de Paris, Paris, France, APHP, Paris, France
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Bruin CM, Lobmaier SM, Ganzevoort W, Müller A, Wolf H. Comparison of phase rectified signal averaging and short term variation in predicting perinatal outcome in early onset fetal growth restriction. J Perinat Med 2022:jpm-2022-0409. [PMID: 36441559 DOI: 10.1515/jpm-2022-0409] [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: 08/21/2022] [Accepted: 11/04/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare short term variation (STV) and phase rectified signal averaging (PRSA) and their association with fetal outcome in early onset fetal growth restriction (FGR). METHODS Data were used from a retrospective cohort study of women who were admitted for FGR and/or pre-eclampsia and who were delivered by pre-labor Cesarean section or had a fetal death before 32 weeks' gestation. Computerized cardiotocography (cCTG) registrations of the 5 days before delivery or fetal death were used for calculation of STV and PRSA. PRSA was expressed as the average acceleration capacity (AAC) and average deceleration capacity (ADC). FHR decelerations were classified visually as absent, 1-2 per hour or recurrent. Abnormality of STV and of PRSA was either analyzed as a single parameter or in combination with recurrent decelerations. Endpoints were defined as composite adverse condition at birth consisting of fetal death, low Apgar score, low umbilical pH, the need for resuscitation after birth and as major neonatal morbidity or neonatal death. RESULTS Included were 367 pregnancies of which 20 resulted in fetal death. An abnormal cCTG with either recurrent decelerations and/or low STV or recurrent decelerations and/or low PRSA were similarly associated with composite adverse condition at birth (n=99), but neither with major neonatal morbidity. CONCLUSIONS PRSA and STV have similar efficacy for measuring fetal heart rate variation in early onset FGR. An increased risk of a composite adverse condition at birth is indicated by a low value of either parameter and/or the presence of recurrent decelerations.
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Affiliation(s)
- Claartje M Bruin
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center (Location AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Silvia M Lobmaier
- Frauenklinik und Poliklinik, Technische Universität München, Munich, Germany
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center (Location AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Alexander Müller
- Klinik und Poliklinik für Innere Medizin I, Technische Universität München, Munich, Germany
| | - Hans Wolf
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center (Location AMC), University of Amsterdam, Amsterdam, The Netherlands
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Crequit S, Tataru C, Coste E, Diane R, Lefebvre M, Haddad B, Lecarpentier E. Association of fetal heart rate short term variability pattern during term labor with neonatal morbidity and small for gestational age status. Eur J Obstet Gynecol Reprod Biol 2022; 278:77-89. [PMID: 36126423 DOI: 10.1016/j.ejogrb.2022.08.026] [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: 04/03/2022] [Revised: 08/23/2022] [Accepted: 08/27/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the association of fetal heart rate short-term variability (STV) pattern during term labor with both neonatal composite morbidity (cord blood pH ≤ 7.10 and/or neonatal intensive care unit admission and/or Apgar score at 5 min <7) and small for gestational age (SGA) status. STUDY DESIGN Retrospective cohort in a single academic institution between January 2016 and December 2018. A total of 1896 women that delivered a singleton during labor in cephalic presentation after 37 weeks of gestation were included (948 women with SGA neonates and 948 women with appropriate weight for gestational age (AGA) neonates that were matched to women with SGA neonates based on maternal age, parity, induction of labor, gestational diabetes, gestational age at delivery and a history of one cesarean section using propensity score matching). STV was compared at labor onset (cervical dilation ≤ 4 cm), in the first stage of labor (cervical dilation = 6 cm) and in the second stage of labor (cervical dilation = 10 cm). A generalized linear mixed model was used to assess the association between SGA status, neonatal composite morbidity and STV. RESULTS After adjustment for maternal origin, term, gestational diabetes, labor length, SGA status was not associated with any change in STV during labor (mean adjusted STV: -0.20 ms, 95 %CI[-0.58-0.17], p = 0.284 at labor onset, 0.29 ms, 95 %CI[-0.1- 0.68], p = 0.155, in the first stage of labor and 0.36 ms, 95 %CI[-0.02-0.74], p = 0.065 in the second stage of labor). In case of neonatal composite morbidity mean adjusted STV was lower in the first stage of labor (mean adjusted STV: -1.29 ms, 95 %CI[-2.1 - -0.43], p = 0.003) and in the second stage of labor (mean adjusted STV: -1.15 ms, 95 %CI[-1.96 - -0.34], p = 0.005). The results were similar with the addition of delivery mode and meconium-stained amniotic fluid in the model or non-reassuring fetal heart rate and meconium-stained amniotic fluid. CONCLUSIONS This work suggests that STV decrease during term labor is associated with fetal well-being, independently of fetal weight. This suggests that further prospective studies should consider the evaluation of this parameter in the prediction of neonatal compromise.
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Affiliation(s)
- Simon Crequit
- Service de Gynécologie Obstétrique, Centre Hospitalier Intercommunal de Créteil, France; Sorbonne université médecine, 91-105 bd de l'hôpital, 75013, Paris
| | - Consuela Tataru
- Service de Gynécologie Obstétrique, Centre Hospitalier Intercommunal de Créteil, France; Sorbonne université médecine, 91-105 bd de l'hôpital, 75013, Paris
| | - Elise Coste
- Service de Gynécologie Obstétrique, Centre Hospitalier Intercommunal de Créteil, France
| | - Redel Diane
- Service de Gynécologie Obstétrique, Centre Hospitalier Intercommunal de Créteil, France
| | - Marion Lefebvre
- Service de Gynécologie Obstétrique, Centre Hospitalier Intercommunal de Créteil, France
| | - Bassam Haddad
- Service de Gynécologie Obstétrique, Centre Hospitalier Intercommunal de Créteil, France; Faculté de santé, Univ Paris Est Créteil, France; INSERM, IMRB U955 I-BIOT, Créteil 94010, France
| | - Edouard Lecarpentier
- Service de Gynécologie Obstétrique, Centre Hospitalier Intercommunal de Créteil, France; Faculté de santé, Univ Paris Est Créteil, France; INSERM, IMRB U955 I-BIOT, Créteil 94010, France.
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Timing of antenatal steroid administration for imminent preterm birth: results of a prospective observational study in Germany. Arch Gynecol Obstet 2022:10.1007/s00404-022-06724-9. [PMID: 36042053 DOI: 10.1007/s00404-022-06724-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 07/25/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE To evaluate the timing of antenatal steroid administration and associated medical interventions in women with imminent preterm birth. METHODS We performed a prospective observational study at a single tertiary center in Germany from September 2018 to August 2019. We included pregnant women who received antenatal steroids for imminent preterm birth and evaluated the interval from administration to birth. 120 women with antenatal steroid application were included into our analysis. Descriptive statistics were performed to analyze factors influencing the timing of antenatal steroids and to evaluate additional medical interventions which women with imminent preterm birth experience. RESULTS Of the 120 women included into our study, 35.8% gave birth before 34/0 weeks and 64.2% before 37/0 weeks of gestation. Only 25/120 women (20.8%) delivered within the optimal time window of 1-7 days after antenatal steroid application. 5/120 women (4.2%) only received one dose of antenatal steroids before birth and 3/120 (2.5%) gave birth within 8 to 14 days after antenatal steroids. Most women gave birth more than 14 days after steroid application (72.5%, 87/120). Women with preeclampsia (60%), PPROM (31%), and FGR (30%) had the highest rates of delivery within the optimal time window. Women of all timing groups received additional interventions and medications like antibiotics, tocolytics, or anticoagulation. CONCLUSION Our observational data indicate that most pregnant women do not give birth within 7 days after the administration of antenatal steroids. The timing was best for preterm birth due to preeclampsia, PPROM, and FGR. Especially for women with symptoms of preterm labor and bleeding placenta previa, antenatal steroids should be indicated more restrictively to improve neonatal outcome and reduce untimely and unnecessary interventions.
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Catharina Marijnen M, Elisabeth Damhuis S, Smies M, Jehanne Gordijn S, Ganzevoort W. Practice variation in diagnosis, monitoring and management of fetal growth restriction in the Netherlands. Eur J Obstet Gynecol Reprod Biol 2022; 276:191-198. [DOI: 10.1016/j.ejogrb.2022.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 07/18/2022] [Accepted: 07/26/2022] [Indexed: 11/04/2022]
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Altered Transmission of Cardiac Cycles to Ductus Venosus Blood Flow in Fetal Growth Restriction: Why Ductus Venosus Reflects Fetal Circulatory Changes More Precisely. Diagnostics (Basel) 2022; 12:diagnostics12061393. [PMID: 35741203 PMCID: PMC9221754 DOI: 10.3390/diagnostics12061393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/01/2022] [Accepted: 06/01/2022] [Indexed: 02/05/2023] Open
Abstract
We aimed to investigate the relation between the time intervals of the flow velocity waveform of ductus venosus (DV-FVW) and cardiac cycles. We defined Delta A as the difference in the time measurements between DV-FVW and cardiac cycles on the assumption that the second peak of ductus venosus (D-wave) starts simultaneously with the opening of the mitral valve (MV). As well, we defined Delta B as the difference of the time measurements between DV-FVW and cardiac cycles on the assumption that the D-wave starts simultaneously with the closure of the aortic valve (AV). We then compared Delta A and Delta B in the control and fetal growth restriction (FGR) groups. In the control group of healthy fetuses, Delta A was strikingly shorter than Delta B. On the other hand, in all FGR cases, no difference was observed. The acceleration of the D-wave is suggested to be generated by the opening of the MV under normal fetal hemodynamics, whereas it precedes the opening of the MV in FGR. Our results indicate that the time interval of DV analysis might be a more informative parameter than the analysis of cardiac cycles.
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Baschat AA, Galan HL, Lee W, DeVore GR, Mari G, Hobbins J, Vintzileos A, Platt LD, Manning FA. The role of the fetal biophysical profile in the management of fetal growth restriction. Am J Obstet Gynecol 2022; 226:475-486. [PMID: 35369904 DOI: 10.1016/j.ajog.2022.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 11/01/2022]
Abstract
Growth-restricted fetuses are at risk of hypoxemia, acidemia, and stillbirth because of progressive placental dysfunction. Current fetal well-being, neonatal risks following delivery, and the anticipated rate of fetal deterioration are the major management considerations in fetal growth restriction. Surveillance has to quantify the fetal risks accurately to determine the delivery threshold and identify the testing frequency most likely to capture future deterioration and prevent stillbirth. From the second trimester onward, the biophysical profile score correlates over 90% with the current fetal pH, and a normal score predicts a pH >7.25 with a 100% positive predictive value; an abnormal score on the other hand predicts current fetal acidemia with similar certainty. Between 30% and 70% of growth-restricted fetuses with a nonreactive heart rate require biophysical profile scoring to verify fetal well-being, and an abnormal score in 8% to 27% identifies the need for delivery, which is not suspected by Doppler findings. Future fetal well-being is not predicted by the biophysical profile score, which emphasizes the importance of umbilical artery Doppler and amniotic fluid volume to determine surveillance frequency. Studies with integrated surveillance strategies that combine frequent heart rate monitoring with biophysical profile scoring and Doppler report better outcomes and stillbirth rates of between 0% and 4%, compared with those between 8% and 11% with empirically determined surveillance frequency. The variations in clinical behavior and management challenges across gestational age are better addressed when biophysical profile scoring is integrated into the surveillance of fetal growth restriction. This review aims to provide guidance on biophysical profile scoring in the in- and outpatient management of fetal growth restriction.
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Hocquette A, Monier I, Blondel B, Dufourg MN, Heude B, Zeitlin J. Testing the assumptions of customized intrauterine growth charts using national birth studies. Acta Obstet Gynecol Scand 2022; 101:405-416. [PMID: 35224718 DOI: 10.1111/aogs.14335] [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: 09/13/2021] [Revised: 12/06/2021] [Accepted: 01/22/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Customized intrauterine growth charts are widely used for growth monitoring and research. They are based on three assumptions: (1) estimated fetal weight (EFW) has a normal distribution with a constant coefficient of variation at all gestational ages; (2) Hadlock's growth curve accurately describes the relation between EFW and gestational ages; (3) associations between EFW and the fetal and maternal characteristics included in the customization model (fetal sex, pre-pregnancy weight, height, parity) are proportional throughout pregnancy. The aim of this study was to test whether these underlying assumptions are verified. MATERIAL AND METHODS Data came from (1) the French Longitudinal Study of Children (ELFE) cohort, which recruited births after 32 weeks' gestation in 349 maternity hospitals in France in 2011, and (2) the National Perinatal Survey, which included births from all French maternity hospitals in 2016. The study population included, respectively, 6 920 and 8 969 singleton non-malformed term live births with data on customization characteristics and EFW. We computed the coefficient of variation by gestational age and then modeled the association of gestational age, maternal and fetal characteristics with EFW at the second and third trimester ultrasound and with birthweight using linear regression. To assess the proportionality of the impact of maternal and fetal characteristics, we computed the percent change in weight associated with these characteristics at these three time points. RESULTS The coefficient of variation was close to 12% at each gestational age, but EFW was not normally distributed, leading to small but systematic underestimation of fetuses under the 10th percentile. Weights representing the 50th and 10th percentiles based on Hadlock's growth trajectory were lower than observed or predicted weights. Most characteristics more strongly impacted weight at birth than during pregnancy. In the French Longitudinal study of Children (ELFE) cohort, boys were 1.8% (95% confidence interval [CI] 1.3-2.4) heavier than girls in the third trimester, whereas this percentage was 4.6% (95% CI 4.0-5.2) at birth. In the National Perinatal Survey, these percentages were 2.3% (95% CI 1.8-2.8) and 4.3% (95% CI 3.8-4.8). CONCLUSIONS These results from two independent sources revealed discrepancies between routine clinical EFW data used for growth monitoring and the customized growth model's assumptions.
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Affiliation(s)
- Alice Hocquette
- CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Université de Paris, Paris, France
| | - Isabelle Monier
- CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Université de Paris, Paris, France.,Department of Obstetrics and Gynecology, Antoine Béclère Hospital, AP-HP, University Paris Saclay, Clamart, France
| | - Béatrice Blondel
- CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Université de Paris, Paris, France
| | | | - Barbara Heude
- Research Team on the Early Life Origins of Health (EAROH), Center for Research in Epidemiology and Statistics (CRESS), INSERM, Université de Paris, Villejuif, France
| | - Jennifer Zeitlin
- CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Université de Paris, Paris, France
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11
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Suekane T, Tachibana D, Kurihara Y, Yokoi N, Seo N, Kitada K, Tahara M, Hamuro A, Misugi T, Nakano A, Koyama M. Time interval analysis of ductus venosus and cardiac cycles in relation with umbilical artery pH at birth in fetal growth restriction. BMC Pregnancy Childbirth 2021; 21:671. [PMID: 34602049 PMCID: PMC8489040 DOI: 10.1186/s12884-021-04115-7] [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: 02/21/2021] [Accepted: 09/09/2021] [Indexed: 12/27/2022] Open
Abstract
Background The aims of this study were to evaluate the time intervals of flow velocity waveforms (FVW) of ductus venosus (DV) and cardiac cycles, as well as the pulsatility index of DV-FVW (DV-PI), in correlation with umbilical artery (UA) pH at birth in fetal growth restriction (FGR) complicated with placental insufficiency. Methods Data were retrospectively retrieved from pregnancies complicated by FGR. FGR was defined as an estimated fetal weight below − 2.0 S.D. with an elevated UA-PI. Time interval assessments of DV-FVW were as follows: the duration of systolic wave was divided by the duration of diastolic wave and defined as DV-S/D. We also measured the following time intervals of ventricular inflow through tricuspid valve (TV) and mitral valve (MV): (iii), from the second peak of ventricular inflow caused by atrial contraction (A-wave) to the opening of atrio-ventricular valves and: (iv), from the opening of atrio-ventricular valves to the peak of A-wave. (iii)/(iv) was expressed as TV-S/D and MV-S/D, for TV and MV, respectively. The time interval data were transformed into z-scores. Results Thirty-one FGR fetuses were included in this study. Both DV-PI and DV-S/D showed significant correlation with UA-pH (r = − 0.677, p = < 0.001 and r = 0.489, p = 0.005 for DV-PI and z-score of DV-S/D, respectively) and more significances were observed in FGR ≤ 28 + 6 gestational weeks (r = − 0.819, p < 0.001 and r = 0.726, p = 0.005, for DV-PI and z-score of DV-S/D, respectively) than in FGR > 28 + 6 gestational weeks (r = − 0.634, p = 0.007 and r = 0.635, p = 0.020, for DV-PI and z-score of DV-S/D, respectively). On the other hand, TV-S/D and MV-S/D showed no significant correlation with UA-pH, although these z-scores indicated significant decreases compared with normal references. Conclusions Time interval analysis of DV-FVW might be a valuable parameter, as well as DV-PI, for the antenatal prediction of fetal acidemia in the management of FGR fetuses. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04115-7.
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Affiliation(s)
- Tomoki Suekane
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abeno-ku Osaka, Osaka, 545-8585, Japan
| | - Daisuke Tachibana
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abeno-ku Osaka, Osaka, 545-8585, Japan.
| | - Yasushi Kurihara
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abeno-ku Osaka, Osaka, 545-8585, Japan
| | - Natsuko Yokoi
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abeno-ku Osaka, Osaka, 545-8585, Japan
| | - Naomi Seo
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abeno-ku Osaka, Osaka, 545-8585, Japan
| | - Kohei Kitada
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abeno-ku Osaka, Osaka, 545-8585, Japan.,Department of Obstetrics and Gynecology, Osaka City General Hospital, Osaka, Japan
| | - Mie Tahara
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abeno-ku Osaka, Osaka, 545-8585, Japan
| | - Akihiro Hamuro
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abeno-ku Osaka, Osaka, 545-8585, Japan
| | - Takuya Misugi
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abeno-ku Osaka, Osaka, 545-8585, Japan
| | - Akemi Nakano
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abeno-ku Osaka, Osaka, 545-8585, Japan
| | - Masayasu Koyama
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abeno-ku Osaka, Osaka, 545-8585, Japan
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12
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Atallah A, Butin M, Moret S, Claris O, Massoud M, Gaucherand P, Doret-Dion M. Minimum evidence-based care in intrauterine growth-restricted fetuses and neonatal prognosis. Arch Gynecol Obstet 2021; 305:1159-1168. [PMID: 34524504 DOI: 10.1007/s00404-021-06231-3] [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: 07/24/2020] [Accepted: 09/01/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Introduction: There is clear evidence that fetuses with intrauterine growth restriction (IUGR) do not receive the minimum evidence-based care during their antenatal management. OBJECTIVE Considering that optimal management of IUGR may reduce neonatal morbi-mortality in IUGR, the objective of the present study was to evaluate the impact of antenatal management of IUGR according to the recommendations of the French college of gynecologists and obstetricians (CNGOF) on the neonatal prognosis of IUGR fetuses. STUDY DESIGN From a historical cohort of 31,052 children, born at the Femme Mère Enfant hospital (Lyon, France) between January 1, 2011 and December 31, 2017, we selected the population of IUGR fetuses. The minimum evidence-based care (MEC) in the antenatal management of fetuses with IUGR was defined according to the CNGOF recommendations and neonatal prognosis of early and late IUGR fetuses were assessed based on the whether or not they received MEC. The neonatal prognosis was defined according to a composite criterion that included neonatal morbidity and mortality. RESULTS A total of 1020 fetuses with IUGR were studied. The application of MEC showed an improvement in the neonatal prognosis of early-onset IUGR (p = 0.003), and an improvement in the neonatal prognosis of IUGR born before 32 weeks (p = 0.030). Multivariate analysis confirmed the results showing an increase in neonatal morbi-mortality in early-onset IUGR in the absence of MEC with OR 1.79 (95% CI 1.01-3.19). CONCLUSION Diagnosed IUGR with MEC had a better neonatal prognosis when born before 32 weeks. Regardless of the birth term, MEC improved the neonatal prognosis of fetuses with early IUGR. Improvement in the rate of MEC during antenatal management has a significant impact on neonatal prognosis.
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Affiliation(s)
- Anthony Atallah
- Department of Obstetrics and Gynecology, Hospices Civils de Lyon, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel, 69500, Bron, France. .,Health Services and Performance Research (HESPER) EA 7425, University of Lyon, University Claude Bernard Lyon 1, 69008, Lyon, France.
| | - Marine Butin
- Department of Neonatalogy, Hospices Civils de Lyon, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel, 69500, Bron, France.,International Center for Research in Infectiology, INSERM U1111, CNRS UMR5308, University of Lyon 1, Lyon, France
| | - Stéphanie Moret
- Department of Obstetrics and Gynecology, Hospices Civils de Lyon, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel, 69500, Bron, France
| | - Olivier Claris
- Department of Neonatalogy, Hospices Civils de Lyon, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel, 69500, Bron, France.,EA 4129, University of Lyon, University Claude Bernard Lyon 1, 69008, Lyon, France
| | - Mona Massoud
- Department of Obstetrics and Gynecology, Hospices Civils de Lyon, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel, 69500, Bron, France
| | - Pascal Gaucherand
- Department of Obstetrics and Gynecology, Hospices Civils de Lyon, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel, 69500, Bron, France.,Health Services and Performance Research (HESPER) EA 7425, University of Lyon, University Claude Bernard Lyon 1, 69008, Lyon, France
| | - Muriel Doret-Dion
- Department of Obstetrics and Gynecology, Hospices Civils de Lyon, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel, 69500, Bron, France.,Health Services and Performance Research (HESPER) EA 7425, University of Lyon, University Claude Bernard Lyon 1, 69008, Lyon, France
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13
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Bruin C, Damhuis S, Gordijn S, Ganzevoort W. Evaluation and Management of Suspected Fetal Growth Restriction. Obstet Gynecol Clin North Am 2021; 48:371-385. [PMID: 33972072 DOI: 10.1016/j.ogc.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Impaired fetal growth owing to placental insufficiency is a major contributor to adverse perinatal outcomes. No intervention is available that improves outcomes by changing the pathophysiologic process. Monitoring in early-onset fetal growth restriction (FGR) focuses on optimizing the timing of iatrogenic preterm delivery using cardiotocography and Doppler ultrasound. In late-onset FGR, identifying the fetus at risk for immediate hypoxia and who benefits from expedited delivery is challenging. It is likely that studies in the next decade will provide evidence how to best integrate different monitoring variables and other prognosticators in risk models that are aimed to optimize individual treatment strategies.
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Affiliation(s)
- Claartje Bruin
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, University of Amsterdam, Room H4-205, PO Box 22660, Amsterdam 1105 AZ, The Netherlands.
| | - Stefanie Damhuis
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, University of Amsterdam, Room H4-205, PO Box 22660, Amsterdam 1105 AZ, The Netherlands; Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Huispostcode CB20, Hanzeplein 1, Groningen 9700 RB, The Netherlands
| | - Sanne Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Huispostcode CB20, Hanzeplein 1, Groningen 9700 RB, The Netherlands
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, University of Amsterdam, Room H4-205, PO Box 22660, Amsterdam 1105 AZ, The Netherlands
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14
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Hocquette A, Durox M, Wood R, Klungsøyr K, Szamotulska K, Berrut S, Rihs T, Kyprianou T, Sakkeus L, Lecomte A, Zile I, Alexander S, Klimont J, Barros H, Gatt M, Isakova J, Blondel B, Gissler M, Zeitlin J. International versus national growth charts for identifying small and large-for-gestational age newborns: A population-based study in 15 European countries. THE LANCET REGIONAL HEALTH. EUROPE 2021; 8:100167. [PMID: 34557855 PMCID: PMC8454535 DOI: 10.1016/j.lanepe.2021.100167] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND To inform the on-going debate about the use of universal prescriptive versus national intrauterine growth charts, we compared perinatal mortality for small and large-for-gestational-age (SGA/LGA) infants according to international and national charts in Europe. METHODS We classified singleton births from 33 to 42 weeks of gestation in 2010 and 2014 from 15 countries (N = 1,475,457) as SGA (birthweight <10th percentile) and LGA (>90th percentile) using the international Intergrowth-21st newborn standards and national charts based on the customised charts methodology. We computed sex-adjusted odds ratios (aOR) for stillbirth, neonatal and extended perinatal mortality by this classification using multilevel models. FINDINGS SGA and LGA prevalence using national charts were near 10% in all countries, but varied according to international charts with a north to south gradient (3.0% to 10.1% and 24.9% to 8.0%, respectively). Compared with appropriate for gestational age (AGA) infants by both charts, risk of perinatal mortality was increased for SGA by both charts (aOR[95% confidence interval (CI)]=6.1 [5.6-6.7]) and infants reclassified by international charts from SGA to AGA (2.7 [2.3-3.1]), but decreased for those reclassified from AGA to LGA (0.6 [0.4-0.7]). Results were similar for stillbirth and neonatal death. INTERPRETATION Using international instead of national charts in Europe could lead to growth restricted infants being reclassified as having normal growth, while infants with low risks of mortality could be reclassified as having excessive growth. FUNDING InfAct Joint Action, CHAFEA Grant n°801,553 and EU/EFPIA Innovative Medicines Initiative 2 Joint Undertaking ConcePTION grant n°821,520. AH received a PhD grant from EHESP.
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Affiliation(s)
- Alice Hocquette
- Université de Paris, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, F-75004 Paris, France
| | - Mélanie Durox
- Université de Paris, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, F-75004 Paris, France
| | - Rachael Wood
- Public Health Scotland, Edinburgh and University of Edinburgh, Edinburgh, Scotland
| | - Kari Klungsøyr
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Bergen, Norway and Department of Global Public Health and Primary Care, University of Bergen, Norway
| | - Katarzyna Szamotulska
- Institute of Mother and Child, Department of Epidemiology and Biostatistics, Warsaw, Poland
| | - Sylvan Berrut
- Federal Statistical Office FSO, Neuchâtel, Switzerland
| | - Tonia Rihs
- Federal Statistical Office FSO, Neuchâtel, Switzerland
| | | | - Luule Sakkeus
- Estonian Institute for Population Studies, Tallinn University, Tallinn, Estonia
| | - Aline Lecomte
- Department of Population Health, Luxembourg Institute of Health, Luxembourg
| | - Irisa Zile
- The Centre for Disease Prevention and Control of Latvia, Riga, Latvia
| | - Sophie Alexander
- Université Libre de Bruxelles, School of Public Health, Perinatal Epidemiology and Reproductive health Unit, Brussels, Belgium
| | | | - Henrique Barros
- University of Porto Medical School, Department of Public Health, Forensic Sciences and Medical Education, Porto, Portugal
| | - Miriam Gatt
- Directorate for Health Information and Research, National Obstetric Information Systems (NOIS) Register, Tal-Pietà, Malta
| | - Jelena Isakova
- Institute of Hygiene, Health Information Centre, Health Statistics Department, Vilnius, Lithuania
| | - Béatrice Blondel
- Université de Paris, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, F-75004 Paris, France
| | - Mika Gissler
- THL Finnish Institute for Health and Welfare, Information Services Department, Helsinki and Karolinska Institute, Department of Neurobiology, Care Sciences and Society, Stockholm, Sweden
| | - Jennifer Zeitlin
- Université de Paris, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, F-75004 Paris, France
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15
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Poon LC, Magee LA, Verlohren S, Shennan A, von Dadelszen P, Sheiner E, Hadar E, Visser G, Da Silva Costa F, Kapur A, McAuliffe F, Nazareth A, Tahlak M, Kihara AB, Divakar H, McIntyre HD, Berghella V, Yang H, Romero R, Nicolaides KH, Melamed N, Hod M. A literature review and best practice advice for second and third trimester risk stratification, monitoring, and management of pre-eclampsia: Compiled by the Pregnancy and Non-Communicable Diseases Committee of FIGO (the International Federation of Gynecology and Obstetrics). Int J Gynaecol Obstet 2021; 154 Suppl 1:3-31. [PMID: 34327714 PMCID: PMC9290930 DOI: 10.1002/ijgo.13763] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Liona C Poon
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Laura A Magee
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | | | - Andrew Shennan
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Peter von Dadelszen
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Eyal Sheiner
- Department of Obstetrics and Gynecology B, Soroka University Medical Center, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gerard Visser
- Department of Obstetrics, University Medical Center, Utrecht, The Netherlands
| | - Fabricio Da Silva Costa
- Maternal Fetal Medicine Unit, Gold Coast University Hospital and School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Anil Kapur
- World Diabetes Foundation, Bagsvaerd, Denmark
| | - Fionnuala McAuliffe
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Amala Nazareth
- Jumeira Prime Healthcare Group, Emirates Medical Association, Dubai, United Arab Emirates
| | - Muna Tahlak
- Latifa Hospital for Women and Children, Dubai Health Authority, Emirates Medical Association, Mohammed Bin Rashid University for Medica Sciences, Dubai, United Arab Emirates
| | - Anne B Kihara
- African Federation of Obstetricians and Gynaecologists, Khartoum, Sudan
| | | | - H David McIntyre
- University of Queensland Mater Clinical School, Brisbane, Queensland, Australia
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI, USA
| | | | - Nir Melamed
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Moshe Hod
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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16
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Faquini SDLDL, Guerra GVDQL, Galindo MWDS, Gusmão IMBD, Vilela LS, Souza AS. Prognostic factors and perinatal outcomes in early-onset intrauterine growth restriction due to placental insufficiency. J Matern Fetal Neonatal Med 2021; 35:7119-7125. [DOI: 10.1080/14767058.2021.1944092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Silvia de Lourdes Dutra Loreto Faquini
- Department of Fetal Medicine, Instituto de Medicina Integral Prof. Fernando Figueira, Medicina Fetal, Rua dos Coelhos, Recife, Brazil
- Department of Fetal Medicine, Clinical Hospital, Universidade Federal de Pernambuco, Medicina Fetal, Av. Prof. Moraes Rego, 1235 – Cidade Universitária, Recife, Brazil
| | | | | | | | - Lycia Siqueira Vilela
- Department of Medicine, Faculdade Pernambucana de Saúde, Av. Mal. Mascarenhas de Morais, Recife, Brazil
| | - Alex Sandro Souza
- Department of Fetal Medicine, Instituto de Medicina Integral Prof. Fernando Figueira, Medicina Fetal, Rua dos Coelhos, Recife, Brazil
- Department of Maternal Child, Universidade Federal de Pernambuco (UFPE), Recife, Brazil
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17
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Monitoring, Delivery and Outcome in Early Onset Fetal Growth Restriction. REPRODUCTIVE MEDICINE 2021. [DOI: 10.3390/reprodmed2020009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Early fetal growth restriction (FGR) remains a challenging entity associated with an increased risk of perinatal morbidity and mortality as well as maternal complications. Significant variations in clinical practice have historically characterized the management of early FGR fetuses. Nevertheless, insights into diagnosis and management options have more recently emerged. The aim of this review is to summarize the available evidence on monitoring, delivery and outcome in early-onset FGR.
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18
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Valderrama CE, Ketabi N, Marzbanrad F, Rohloff P, Clifford GD. A review of fetal cardiac monitoring, with a focus on low- and middle-income countries. Physiol Meas 2020; 41:11TR01. [PMID: 33105122 PMCID: PMC9216228 DOI: 10.1088/1361-6579/abc4c7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
There is limited evidence regarding the utility of fetal monitoring during pregnancy, particularly during labor and delivery. Developed countries rely on consensus 'best practices' of obstetrics and gynecology professional societies to guide their protocols and policies. Protocols are often driven by the desire to be as safe as possible and avoid litigation, regardless of the cost of downstream treatment. In high-resource settings, there may be a justification for this approach. In low-resource settings, in particular, interventions can be costly and lead to adverse outcomes in subsequent pregnancies. Therefore, it is essential to consider the evidence and cost of different fetal monitoring approaches, particularly in the context of treatment and care in low-to-middle income countries. This article reviews the standard methods used for fetal monitoring, with particular emphasis on fetal cardiac assessment, which is a reliable indicator of fetal well-being. An overview of fetal monitoring practices in low-to-middle income counties, including perinatal care access challenges, is also presented. Finally, an overview of how mobile technology may help reduce barriers to perinatal care access in low-resource settings is provided.
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Affiliation(s)
- Camilo E Valderrama
- Data Intelligence for Health Lab, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Nasim Ketabi
- Department of Biomedical Informatics, Emory University, Atlanta, GA, United States of America
| | - Faezeh Marzbanrad
- Department of Electrical and Computer Systems Engineering, Monash University, Clayton, VIC, Australia
| | - Peter Rohloff
- Wuqu' Kawoq, Maya Health Alliance, Santiago Sacatepéquez, Guatemala
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Gari D Clifford
- Department of Biomedical Informatics, Emory University, Atlanta, GA, United States of America
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, United States of America
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19
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Jouannic JM, Blondiaux E, Senat MV, Friszer S, Adamsbaum C, Rousseau J, Hornoy P, Letourneau A, de Laveaucoupet J, Lecarpentier E, Rosenblatt J, Quibel T, Mollot M, Ancel PY, Alison M, Goffinet F. Prognostic value of diffusion-weighted magnetic resonance imaging of brain in fetal growth restriction: results of prospective multicenter study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:893-900. [PMID: 31765031 DOI: 10.1002/uog.21926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 11/08/2019] [Accepted: 11/15/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To measure prospectively apparent diffusion coefficient (ADC) values between 28 and 32 weeks of gestation in different cerebral territories of fetuses with estimated fetal weight (EFW) ≤ 5th centile, and analyze their association with adverse perinatal outcome. METHODS This was a prospective study involving six tertiary-level perinatal centers. In the period 22 November 2016 to 11 September 2017, we included singleton, small-for-gestational-age (SGA) fetuses with EFW ≤ 5th percentile, between 28 and 32 weeks of gestation, regardless of the umbilical artery Doppler and maternal uterine artery Doppler findings. A fetal magnetic resonance imaging (MRI) examination with diffusion-weighted sequences (DWI) was performed within 14 days following inclusion and before 32 weeks. ADC values were calculated in the frontal and occipital white matter, basal ganglia and cerebellar hemispheres. An ultrasound examination was performed within 1 week prior to the MRI examination. The primary outcome was a composite measure of adverse perinatal outcome, defined as any of the following: perinatal death; admission to neonatal intensive care unit with mechanical ventilation > 48 h; necrotizing enterocolitis; Grade III-IV intraventricular hemorrhage; periventricular leukomalacia. A univariate comparison of median ADC values in all cerebral territories between fetuses with and those without adverse perinatal outcome was performed. The association between ADC values and adverse perinatal outcome was then analyzed using multilevel logistic regression models to adjust for other common prognostic factors for growth-restricted fetuses. RESULTS MRI was performed in 64 patients, of whom five were excluded owing to fetal movement artifacts on DWI and two were excluded for termination of pregnancy with no link to fetal growth restriction (FGR). One intrauterine death occurred secondary to severe FGR. Among the 56 liveborn neonates, delivered at a mean ± SD gestational age of 33.6 ± 3.0 weeks, with a mean birth weight of 1441 ± 566 g, four neonatal deaths occurred. In addition, two neonates required prolonged mechanical ventilation, one of whom also developed necrotizing enterocolitis. Overall, therefore, seven out of 57 (12.3%) cases had an adverse perinatal outcome (95% CI, 3.8-20.8%). The ADC values in the frontal region were significantly lower in the group with adverse perinatal outcome vs those in the group with favorable outcome (mean values of both hemispheres, 1.68 vs 1.78 × 10-3 mm2 /s; P = 0.04). No significant difference in ADC values was observed between the two groups in any other cerebral territory. A cut-off value of 1.70 × 10-3 mm2 /s was associated with a sensitivity of 57% (95% CI, 18-90%), a specificity of 78% (95% CI, 63-88%), a positive predictive value of 27% (95% CI, 8-55%) and a negative predictive value of 93% (95% CI, 80-98%) for the prediction of adverse perinatal outcome. A mean frontal ADC value < 1.70 × 10-3 mm2 /s was not associated significantly with an increased risk of adverse perinatal outcome, either in the univariate analysis (P = 0.07), or when adjusting for gestational age at MRI and fetal sex (odds ratio (OR), 6.06 (95% CI, 0.9-37.1), P = 0.051) or for umbilical artery Doppler (OR, 6.08 (95% CI, 0.89-41.44)). CONCLUSION This first prospective, multicenter, cohort study using DWI in the setting of SGA found lower ADC values in the frontal white-matter territory in fetuses with, compared with those without, adverse perinatal outcome. To determine the prognostic value of these changes, further standardized evaluation of the neurodevelopment of children born with growth restriction is required. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J M Jouannic
- Service de Médecine Foetale, Hôpital Armand Trousseau, Médecine Sorbonne Université, APHP, Paris, France
| | - E Blondiaux
- Service de Radiopédiatrie, Hôpital Armand Trousseau, Médecine Sorbonne Université, APHP, Paris, France
| | - M V Senat
- Service de Gynécologie-Obstétrique, Hôpital Bicêtre, Université Paris Sud, Le Kremlin-Bicêtre, France
| | - S Friszer
- Service de Médecine Foetale, Hôpital Armand Trousseau, Médecine Sorbonne Université, APHP, Paris, France
| | - C Adamsbaum
- Service de Radiopédiatrie, Hôpital Bicêtre, Université Paris Sud, Le Kremlin-Bicêtre, France
| | - J Rousseau
- Obstetrical, Perinatal, and Pediatric Epidemiology Team and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France
- Université Paris Descartes, Paris, France
| | - P Hornoy
- Service de Radiologie, Hôpital Cochin, APHP, Paris, France
| | - A Letourneau
- Service de Gynécologie-Obstétrique, Hôpital Antoine Béclère, Université Paris Sud, APHP, Clamart, France
| | - J de Laveaucoupet
- Service de Radiologie, Hôpital Antoine Béclère, APHP, Clamart, France
| | - E Lecarpentier
- Maternité Port Royal, Hôpital Cochin, APHP, DHU Risques et Grossesse, Université Paris Descartes, Paris, France
| | - J Rosenblatt
- Service de Gynécologie-Obstétrique, Hôpital Robert Debré, APHP, Paris, France
| | - T Quibel
- Service de Gynécologie-Obstétrique, Centre Hospitalier Intercommunal, Poissy, France
| | - M Mollot
- Service de Radiologie, Centre Hospitalier Intercommunal, Poissy, France
| | - P Y Ancel
- Obstetrical, Perinatal, and Pediatric Epidemiology Team and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France
| | - M Alison
- Service de Radiopédiatrie, Hôpital Robert Debré, APHP, Université Paris Diderot, Paris, France
| | - F Goffinet
- Obstetrical, Perinatal, and Pediatric Epidemiology Team and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France
- Maternité Port Royal, Hôpital Cochin, APHP, DHU Risques et Grossesse, Université Paris Descartes, Paris, France
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Saccone G, Tagliaferri S, Grasso A, Ascione R, Esposito G, Esposito FG, Verrazzo P, Gragnano E, Maruotti GM, Campanile M, Zullo F. Antenatal cardiotocography with and without computer analysis in high-risk pregnancy: a randomized clinical trial. Am J Obstet Gynecol MFM 2020; 3:100284. [PMID: 33451612 DOI: 10.1016/j.ajogmf.2020.100284] [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: 10/07/2020] [Revised: 11/18/2020] [Accepted: 11/18/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Cardiotocography or nonstress test is a technical means of recording the fetal heartbeat and uterine contractions for antenatal monitoring. OBJECTIVE This study aimed to evaluate whether antepartum cardiotocography with computer analysis (computerized cardiotocography) increases the incidence of cesarean delivery in women with high-risk pregnancies but without intrauterine growth restriction. STUDY DESIGN This was a parallel group nonblinded randomized clinical trial of singletons with high-risk pregnancies admitted for inpatient monitoring between 24 0/7 and 37 6/7 weeks' gestation. Eligible participants were randomly allocated in a 1:1 ratio to antenatal monitoring with either standard cardiotocography or computerized cardiotocography. Women randomized to the computerized cardiotocography arm received cardiotocographic monitoring with computerized analysis in a central monitoring station. The primary outcome was the incidence of cesarean delivery. RESULTS Overall, 28 women were enrolled in this trial. In addition, 14 women were randomized to the computerized cardiotocography group and 14 women to the control group. No woman was excluded after randomization or lost to follow-up. Cesarean delivery occurred in 9 women (64.3%) in the computerized cardiotocography group and 9 women (64.3%) in the control group (relative risk, 1.00; 95% confidence interval, 0.21-4.69).There was no significant between-group difference in preterm birth, gestational age at delivery, Apgar score, and birthweight. CONCLUSION Among women with high-risk pregnancies, use of computerized cardiotocography for antenatal monitoring did not result in a significant increase in cesarean delivery compared with standard cardiotocography. The results of this single-center randomized trial require confirmation in multicenter studies.
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Affiliation(s)
- Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy.
| | - Salvatore Tagliaferri
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Adele Grasso
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Rossella Ascione
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Giuseppina Esposito
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Francesca G Esposito
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Paolo Verrazzo
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Elisabetta Gragnano
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Giuseppe Maria Maruotti
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Marta Campanile
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Fulvio Zullo
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
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Martins JG, Biggio JR, Abuhamad A, Abuhamad A. Society for Maternal-Fetal Medicine Consult Series #52: Diagnosis and management of fetal growth restriction: (Replaces Clinical Guideline Number 3, April 2012). Am J Obstet Gynecol 2020; 223:B2-B17. [PMID: 32407785 DOI: 10.1016/j.ajog.2020.05.010] [Citation(s) in RCA: 227] [Impact Index Per Article: 56.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Fetal growth restriction can result from a variety of maternal, fetal, and placental conditions. It occurs in up to 10% of pregnancies and is a leading cause of infant morbidity and mortality. This complex obstetrical problem has disparate published diagnostic criteria, relatively low detection rates, and limited preventative and treatment options. The purpose of this Consult is to outline an evidence-based, standardized approach for the prenatal diagnosis and management of fetal growth restriction. The recommendations of the Society for Maternal-Fetal Medicine are as follows: (1) we recommend that fetal growth restriction be defined as an ultrasonographic estimated fetal weight or abdominal circumference below the 10th percentile for gestational age (GRADE 1B); (2) we recommend the use of population-based fetal growth references (such as Hadlock) in determining fetal weight percentiles (GRADE 1B); (3) we recommend against the use of low-molecular-weight heparin for the sole indication of prevention of recurrent fetal growth restriction (GRADE 1B); (4) we recommend against the use of sildenafil or activity restriction for in utero treatment of fetal growth restriction (GRADE 1B); (5) we recommend that a detailed obstetrical ultrasound examination (current procedural terminology code 76811) be performed with early-onset fetal growth restriction (<32 weeks of gestation) (GRADE 1B); (6) we recommend that women be offered fetal diagnostic testing, including chromosomal microarray analysis, when fetal growth restriction is detected and a fetal malformation, polyhydramnios, or both are also present regardless of gestational age (GRADE 1B); (7) we recommend that pregnant women be offered prenatal diagnostic testing with chromosomal microarray analysis when unexplained isolated fetal growth restriction is diagnosed at <32 weeks of gestation (GRADE 1C); (8) we recommend against screening for toxoplasmosis, rubella, or herpes in pregnancies with fetal growth restriction in the absence of other risk factors and recommend polymerase chain reaction for cytomegalovirus in women with unexplained fetal growth restriction who elect diagnostic testing with amniocentesis (GRADE 1C); (9) we recommend that once fetal growth restriction is diagnosed, serial umbilical artery Doppler assessment should be performed to assess for deterioration (GRADE 1C); (10) with decreased end-diastolic velocity (ie, flow ratios greater than the 95th percentile) or in pregnancies with severe fetal growth restriction (estimated fetal weight less than the third percentile), we suggest weekly umbilical artery Doppler evaluation (GRADE 2C); (11) we recommend Doppler assessment up to 2-3 times per week when umbilical artery absent end-diastolic velocity is detected (GRADE 1C); (12) in the setting of reversed end-diastolic velocity, we suggest hospitalization, administration of antenatal corticosteroids, heightened surveillance with cardiotocography at least 1-2 times per day, and consideration of delivery depending on the entire clinical picture and results of additional evaluation of fetal well-being (GRADE 2C); (13) we suggest that Doppler assessment of the ductus venosus, middle cerebral artery, or uterine artery not be used for routine clinical management of early- or late-onset fetal growth restriction (GRADE 2B); (14) we suggest weekly cardiotocography testing after viability for fetal growth restriction without absent/reversed end-diastolic velocity and that the frequency be increased when fetal growth restriction is complicated by absent/reversed end-diastolic velocity or other comorbidities or risk factors (GRADE 2C); (15) we recommend delivery at 37 weeks of gestation in pregnancies with fetal growth restriction and an umbilical artery Doppler waveform with decreased diastolic flow but without absent/reversed end-diastolic velocity or with severe fetal growth restriction with estimated fetal weight less than the third percentile (GRADE 1B); (16) we recommend delivery at 33-34 weeks of gestation for pregnancies with fetal growth restriction and absent end-diastolic velocity (GRADE 1B); (17) we recommend delivery at 30-32 weeks of gestation for pregnancies with fetal growth restriction and reversed end-diastolic velocity (GRADE 1B); (18) we suggest delivery at 38-39 weeks of gestation with fetal growth restriction when the estimated fetal weight is between the 3rd and 10th percentile and the umbilical artery Doppler is normal (GRADE 2C); (19) we suggest that for pregnancies with fetal growth restriction complicated by absent/reversed end-diastolic velocity, cesarean delivery should be considered based on the entire clinical scenario (GRADE 2C); (20) we recommend the use of antenatal corticosteroids if delivery is anticipated before 33 6/7 weeks of gestation or for pregnancies between 34 0/7 and 36 6/7 weeks of gestation in women without contraindications who are at risk of preterm delivery within 7 days and who have not received a prior course of antenatal corticosteroids (GRADE 1A); and (21) we recommend intrapartum magnesium sulfate for fetal and neonatal neuroprotection for women with pregnancies that are <32 weeks of gestation (GRADE 1A).
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Affiliation(s)
| | | | | | - Alfred Abuhamad
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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Quezada MS, Rodríguez-Calvo J, Villalaín C, Gómez-Arriaga PI, Galindo A, Herraiz I. sFlt-1/PlGF ratio and timing of delivery in early-onset fetal growth restriction with antegrade umbilical artery flow. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:549-556. [PMID: 31840879 DOI: 10.1002/uog.21949] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 10/23/2019] [Accepted: 12/04/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To analyze the value of the soluble fms-like tyrosine kinase-1/placental growth factor (sFlt-1/PlGF) ratio in predicting the time to delivery in early-onset fetal growth restriction (FGR) with preserved antegrade umbilical artery (UA) flow at diagnosis. METHODS This was a prospective observational single-center cohort study of pregnancies with early-onset (< 32 + 0 weeks) FGR and antegrade UA flow, in which maternal serum sFlt-1/PlGF ratio was determined at diagnosis. FGR was defined as estimated fetal weight < 3rd centile or < 10th centile with UA pulsatility index > 95th centile, fetal middle cerebral artery pulsatility index < 5th centile or cerebroplacental ratio < 5th centile. The previously described sFlt-1/PlGF ratio cut-off value of 85 for facilitating the diagnosis of pre-eclampsia was assessed in the prediction of the need to deliver in < 1 week and ≥ 4 weeks. RESULTS In total, 120 cases were included. There were 116 (96.7%) liveborn neonates and 108 (90.0%) perinatal survivors. Median (interquartile range (IQR)) gestational age at diagnosis of early-onset FGR was 27.1 (25.7-29.4) weeks. Median (IQR) sFlt-1/PlGF ratio at diagnosis was 196 (84-474). Ninety (75.0%) cases had a sFlt-1/PlGF ratio ≥ 85. Among pregnancies with a liveborn neonate, median (IQR) interval to delivery in the groups with sFlt-1/PlGF ratio < 85 and ≥ 85 was 41 (22-54) days and 11 (4-20) days, respectively (P < 0.01). The probability of having to deliver within 1 week after diagnosis was 0% and 35.6% in those with sFlt-1/PlGF ratio < 85 and ≥ 85, respectively (P = 0.03), and the probability of delaying delivery for ≥ 4 weeks was 72.4% and 19.5%, respectively (P < 0.01). CONCLUSION sFlt-1/PlGF ratio < 85 at diagnosis of early-onset FGR with antegrade UA flow identifies a group of pregnancies in which the need to deliver within 1 week is very low and the interval to delivery is expected to be prolonged for ≥ 4 weeks in > 70% of cases. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M S Quezada
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain
| | - J Rodríguez-Calvo
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain
| | - C Villalaín
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain
| | - P I Gómez-Arriaga
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain
| | - A Galindo
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain
| | - I Herraiz
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain
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Wolf H, Gordijn SJ, Onland W, Vliegenthart RJS, Ganzevoort JW. Computerized fetal heart rate analysis in early preterm fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:51-60. [PMID: 31605504 DOI: 10.1002/uog.21887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 09/09/2019] [Accepted: 09/20/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To assess the value of computerized cardiotocography (cCTG) with calculation of fetal heart rate (FHR) short-term variability (STV) in early preterm fetal growth restriction (FGR) for prevention of fetal death and neonatal asphyxia, neonatal morbidity, and 2-year neurodevelopmental impairment. METHODS This was a retrospective cohort study of all women who were admitted to the Amsterdam University Medical Center-AMC between 2003 and 2015 due to FGR and/or pre-eclampsia, and who were delivered by prelabor Cesarean section, or had a fetal death, before 32 weeks' gestation. STV of all available cCTG registrations during the 5 days preceding fetal death or delivery was calculated retrospectively, and FHR decelerations were classified visually as absent, 1-2/h or recurrent (> 2/h). Adverse outcome endpoints were defined as fetal death, neonatal asphyxia at birth (including fetal death), neonatal death, major neonatal morbidity and 2-year neurodevelopmental outcome. A simulation analysis was performed to assess the incidence of adverse outcome using two thresholds for cCTG: (1) highly abnormal (STV < 2.6 ms before 29 weeks and < 3.0 ms thereafter, and/or recurrent FHR decelerations); and (2) moderately abnormal (STV < 3.5 ms before 29 weeks and < 4.0 ms thereafter, and/or recurrent FHR decelerations). Three management strategies were assessed using a strict schedule for the frequency of cCTG recordings: (1) cCTG without use of fetal arterial Doppler; (2) cCTG with additional fetal arterial Doppler after 29 weeks; and (3) cCTG with additional fetal arterial Doppler after 27 weeks. RESULTS Included were 367 pregnancies (3295 cCTG recordings), of which 20 resulted in fetal death and 347 were delivered by Cesarean section before the onset of labor. Cesarean delivery was indicated by fetal condition in 94% of cases and by maternal condition in 6%. Median gestational age at delivery was 30 (interquartile range (IQR), 28-31) weeks and median birth weight was 900 (IQR, 740-1090) g. Six cases of fetal death were not anticipated by standard practice using visual assessment of CTG. A last highly abnormal cCTG was associated with fetal death and with neonatal asphyxia (including fetal death; n = 99), but not with major neonatal morbidity and 2-year neurodevelopmental outcome. Moderately abnormal cCTG had no significant association with any endpoint. Simulation analysis showed that a strategy that combined cCTG results with umbilicocerebral ratio or umbilical absent or reversed end-diastolic flow could detect all fetal deaths. CONCLUSIONS Computerized CTG in combination with fetal arterial Doppler, with a strict protocol for the frequency of recordings, is likely to be more effective than visual CTG assessment for preventing fetal death in early preterm FGR. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- H Wolf
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center (Location AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - S J Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - W Onland
- Department of Neonatology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - R J S Vliegenthart
- Department of Neonatology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - J W Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center (Location AMC), University of Amsterdam, Amsterdam, The Netherlands
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Stampalija T, Arabin B, Wolf H, Bilardo C, Lees C. An abnormal cerebroplacental ratio (CPR) is predictive of early childhood delayed neurodevelopment in the setting of fetal growth restriction. Am J Obstet Gynecol 2020; 222:391-392. [PMID: 31870732 DOI: 10.1016/j.ajog.2019.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 12/09/2019] [Indexed: 10/25/2022]
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Monteith C, Dicker P, Foran A. Reply. Am J Obstet Gynecol 2020; 222:392-393. [PMID: 31870733 DOI: 10.1016/j.ajog.2019.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 12/06/2019] [Indexed: 10/25/2022]
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Fratelli N, Amighetti S, Bhide A, Fichera A, Khalil A, Papageorghiou AT, Prefumo F, Thilaganathan B. Ductus venosus Doppler waveform pattern in fetuses with early growth restriction. Acta Obstet Gynecol Scand 2019; 99:608-614. [PMID: 31784981 DOI: 10.1111/aogs.13782] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 11/12/2019] [Accepted: 11/25/2019] [Indexed: 12/28/2022]
Abstract
INTRODUCTION We aimed to assess if maximum velocities of the ductus venosus flow velocity waveform are associated with adverse outcomes in early-onset fetal growth restriction. MATERIAL AND METHODS Retrospective cohort study from two tertiary referral units, including singleton fetuses with estimated birthweight or fetal abdominal circumference ≤10th centile and absent or reversed end-diastolic velocity in the umbilical artery delivered between 26+0 and 34+0 weeks of gestation. Pulsatility index for veins, and maximum velocities of S-, D-, v- and a-waves, were measured in the ductus venosus within 24 hours of birth. Logistic regression was used to describe the relation between severe neonatal morbidity or neonatal death and clinical independent predictors. RESULTS The study population included 132 early-onset fetal growth restriction fetuses. Newborns with neonatal morbidity or neonatal death had significantly lower values of v/D maximum velocity ratio multiples of the median (0.86 vs 095; P = 0.006) within 24 hours of birth. The v/D ratio remained a significant predictor of neonatal death or severe neonatal morbidity after adjusting for gestational age and birthweight (adjusted odds ratio 0.065, 95% confidence interval 0.004-0.957). CONCLUSIONS Assessment of ductus venosus v/D maximum velocity ratio might help to identify fetal growth restriction fetuses at increased risk for neonatal death or severe neonatal morbidity. Confirmation in prospective studies is necessary.
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Affiliation(s)
- Nicola Fratelli
- Department of Obstetrics and Gynecology, ASST Spedali Civili di Brescia and University of Brescia, Brescia, Italy
| | - Serena Amighetti
- Department of Obstetrics and Gynecology, ASST Spedali Civili di Brescia and University of Brescia, Brescia, Italy
| | - Amar Bhide
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust and Molecular & Clinical Sciences Research Institute, St George's University, London, UK
| | - Anna Fichera
- Department of Obstetrics and Gynecology, ASST Spedali Civili di Brescia and University of Brescia, Brescia, Italy
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust and Molecular & Clinical Sciences Research Institute, St George's University, London, UK
| | - Aris T Papageorghiou
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust and Molecular & Clinical Sciences Research Institute, St George's University, London, UK
| | - Federico Prefumo
- Department of Obstetrics and Gynecology, ASST Spedali Civili di Brescia and University of Brescia, Brescia, Italy
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust and Molecular & Clinical Sciences Research Institute, St George's University, London, UK
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Mazarico E, Molinet-Coll C, Martinez-Portilla RJ, Figueras F. Heparin therapy in placental insufficiency: Systematic review and meta-analysis. Acta Obstet Gynecol Scand 2019; 99:167-174. [PMID: 31519033 DOI: 10.1111/aogs.13730] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/19/2019] [Accepted: 09/06/2019] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The objective of this study was to establish whether heparin improves the neonatal outcome of fetuses with suspected placental insufficiency. MATERIAL AND METHODS Before data extraction, the project was registered in the PROSPERO International Prospective Register of Systematic Reviews (registration number: CRD42019117627). A systematic search was performed to identify relevant studies, using PubMed, SCOPUS, ISI Web of Knowledge, and PROSPERO database for meta-analysis. Suspected placental insufficiency was defined as either an estimated fetal weight or abdominal circumference below the 10th centile or when at least 2 of the following criteria were met: (1) abnormal biochemical markers, (2) sonographic evidence of abnormal placental morphology, or (3) abnormal uterine artery Doppler. Heparin in any commercial presentation was defined as the intervention. Mean difference (MD) by random effects model was used. Heterogeneity between studies was assessed using Cochran's Q, H, and I2 statistics. RESULTS From 1159 assessed studies, two were retained for analysis. The results showed a significantly higher birthweight (MD 365; 95% CI 236 to 494; P < 0.001) and a significant increase of gestational age at birth by 1 week in those women treated with heparin (MD 0.806; 95% CI 0.354 to 1.258; P < 0.001). However, there were no significant differences in Apgar scores, neonatal admission, neonatal mortality, or composite neonatal morbidity. CONCLUSIONS In women with very high suspicion of placental insufficiency, heparin may increase fetal growth and prolong pregnancy. There is no evidence for a beneficial effect of heparin in reducing neonatal adverse outcomes.
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Affiliation(s)
- Edurne Mazarico
- Fetal i+D Fetal Medicine Research Center, BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Cristina Molinet-Coll
- Fetal i+D Fetal Medicine Research Center, BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Raigam Jafet Martinez-Portilla
- Fetal i+D Fetal Medicine Research Center, BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Fetal Medicine and Therapy Research Center Mexico on behalf of the Iberoamerican Research Network in Translational, Molecular and Maternal-Fetal Medicine, Mexico City, Mexico
| | - Francesc Figueras
- Fetal i+D Fetal Medicine Research Center, BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Center for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain
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Kalafat E, Ozturk E, Sivanathan J, Thilaganathan B, Khalil A. Longitudinal change in cerebroplacental ratio in small-for-gestational-age fetuses and risk of stillbirth. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:492-499. [PMID: 30549126 DOI: 10.1002/uog.20193] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 11/29/2018] [Accepted: 12/07/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To investigate whether assessment of longitudinal change in Doppler variables in small-for-gestational-age (SGA) fetuses improves the prediction of those at risk of stillbirth. METHODS This was a longitudinal study of two cohorts of singleton pregnancies, which included SGA and appropriate-for-gestational-age (AGA) fetuses, respectively. The inclusion criteria for the SGA cohort were singleton pregnancy at ≥ 20 weeks' gestation, classified as SGA (estimated fetal weight < 10th centile). The AGA cohort consisted of singleton pregnancies deemed at high risk of being SGA, which were followed up longitudinally but remained AGA. Fetal middle cerebral artery (MCA) pulsatility index (PI) and umbilical artery (UA)-PI were measured longitudinally and cerebroplacental ratio (CPR) was calculated, and values were converted to multiples of the median. The last two measurements prior to delivery were included in the analysis. Longitudinal models for Doppler variables were developed using linear-mixed models and their accuracy in the prediction of stillbirth was tested using generalized linear models. A Bayesian framework was employed to compare the accuracy of longitudinal and standard (last-scan measurement) models. RESULTS In total, 1549 AGA and 941 SGA pregnancies were included in the analysis. There were 30 (3.2%) and no stillbirth cases in the SGA and AGA groups, respectively. Change in MCA-PI, UA-PI and CPR with advancing gestation was significantly different between liveborn AGA and SGA fetuses, with a less pronounced difference with advancing gestation. Using the last measurement, the best models for the prediction of stillbirth in SGA pregnancies were those based on CPR (accuracy, 75.0%; 95% CI, 72.6-77.2%) and UA-PI (accuracy, 71.0%; 95% CI, 68.6-73.4%). The posterior probability of the standard CPR model having a higher accuracy compared with the UA-PI model was 97.2% (magnitude of change (MC), 3.9%; 95% credible interval (CrI), 0.5-7.3%). The accuracies of the standard, compared with the longitudinal, models for UA-PI (71.0% vs 72.8%), MCA-PI (64.6% vs 63.8%) and CPR (75.0% vs 74.9%) in the prediction of stillbirth were not significantly different. The posterior probabilities for improvement in accuracy using longitudinal, compared with standard, assessment were 50.1% (MC, < 0.1%; 95% CrI, -3.3 to 3.3%), 35.2% (MC, -0.1%; 95% CrI, -4.5 to 2.8%) and 82.2% (MC, 1.9%; 95% CrI, -1.5 to 5.3%) for CPR, MCA-PI and UA-PI models, respectively. Therefore, change in Doppler parameters did not improve the accuracy of the prediction of stillbirth, compared with that of the last-scan measurement. CONCLUSION Longitudinal assessment of Doppler parameters was not useful in improving the detection of stillbirth in SGA pregnancies, as compared with a single-point assessment. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- E Kalafat
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Department of Statistics, Faculty of Arts and Sciences, Middle East Technical University, Ankara, Turkey
| | - E Ozturk
- Department of Biostatistics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - J Sivanathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Aiken CE, Tarry-Adkins JL, Spiroski AM, Nuzzo AM, Ashmore TJ, Rolfo A, Sutherland MJ, Camm EJ, Giussani DA, Ozanne SE. Chronic gestational hypoxia accelerates ovarian aging and lowers ovarian reserve in next-generation adult rats. FASEB J 2019; 33:7758-7766. [PMID: 30888848 PMCID: PMC6529349 DOI: 10.1096/fj.201802772r] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Chronic fetal hypoxia is a common complication observed in human pregnancy, impacting pregnancies across global contexts. Exposure to chronic intrauterine hypoxia has major short- and long-term consequences for offspring health. However, the impact of chronic gestational hypoxia on female reproductive system development is unknown. We aimed to understand the impact of exposure to chronic fetal hypoxia on the developing female reproductive system. Wistar rat dams underwent normoxia (21%) or hypoxia (13%) during pregnancy. Postnatally, all female offspring were maintained in normoxic conditions into early adulthood. Female rats exposed to chronic gestational hypoxia (13%) during their intrauterine development had decreased ovarian primordial follicular reserve compared to controls (P < 0.05). Adult females who had been exposed to chronic fetal hypoxia had significantly reduced somatic ovarian telomere length (P < 0.05) and reduced ovarian protein expression of KU70, a critical component of the DNA-activated protein kinase repair complex (P < 0.01). Gene expression of NADPH oxidase 2-mediated oxidative stress markers was increased (P < 0.05). Exposure to chronic hypoxia during fetal development leads to accelerated aging of the somatic ovary and decreased ovarian reserve in adulthood. Ovarian aging is highly sensitive to gestational hypoxia, with implications for future fertility in next-generation offspring of high-risk pregnancies.-Aiken, C. E., Tarry-Adkins, J. L., Spiroski, A.-M., Nuzzo, A. M., Ashmore, T. J., Rolfo, A., Sutherland, M. J., Camm, E. J., Giussani, D. A., Ozanne, S. E. Chronic gestational hypoxia accelerates ovarian aging and lowers ovarian reserve in next-generation adult rats.
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Affiliation(s)
- Catherine E. Aiken
- University of Cambridge Metabolic Research Laboratories and Medical Research Council (MRC) Metabolic Diseases Unit, Wellcome Trust–MRC Institute of Metabolic Science, Addenbrooke’s Treatment Centre, Addenbrooke’s Hospital, Cambridge, United Kingdom;,Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, United Kingdom;,Correspondence: University of Cambridge, Hills Rd, Cambridge CB2 0QQ, United Kingdom. E-mail:
| | - Jane L. Tarry-Adkins
- University of Cambridge Metabolic Research Laboratories and Medical Research Council (MRC) Metabolic Diseases Unit, Wellcome Trust–MRC Institute of Metabolic Science, Addenbrooke’s Treatment Centre, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Ana-Mishel Spiroski
- Department of Physiology, Development, and Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Anna M. Nuzzo
- Dipartimento di Scienze Chirurgiche, Universita degli Studi di Torino, Turin, Italy
| | - Thomas J. Ashmore
- University of Cambridge Metabolic Research Laboratories and Medical Research Council (MRC) Metabolic Diseases Unit, Wellcome Trust–MRC Institute of Metabolic Science, Addenbrooke’s Treatment Centre, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Alessandro Rolfo
- Dipartimento di Scienze Chirurgiche, Universita degli Studi di Torino, Turin, Italy
| | - Megan J. Sutherland
- Department of Physiology, Development, and Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Emily J. Camm
- Department of Physiology, Development, and Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Dino A. Giussani
- Department of Physiology, Development, and Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Susan E. Ozanne
- University of Cambridge Metabolic Research Laboratories and Medical Research Council (MRC) Metabolic Diseases Unit, Wellcome Trust–MRC Institute of Metabolic Science, Addenbrooke’s Treatment Centre, Addenbrooke’s Hospital, Cambridge, United Kingdom
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Monari F, Parazzini F, Cetin I, Ballarini M, Facchinetti F. Iatrogenic late preterm birth: when is it recommended? A Delphi survey promoted by the Italian Society of Perinatal Medicine. Eur J Obstet Gynecol Reprod Biol 2019; 240:23-28. [PMID: 31212221 DOI: 10.1016/j.ejogrb.2019.05.042] [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] [Received: 04/28/2019] [Accepted: 05/30/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The rate of iatrogenic Late Preterm (LP) Birth varies in different settings. This is due to the lack of strong evidence/guidelines on the management of the different maternal, fetal and placental complications affecting pregnancy in the LP window. Steroid prophylaxis is also under discussion. AIM To build recommendations about the management of main medical complications (pregestational diabetes, placenta previa, preeclampsia, cholestasis, p-PROM, intrauterine growth restriction -IUGR-) occurring in the LP period to reduce clinical heterogeneity. METHODS A group of Italian Perinatal experts were identified by Scientific Societies. A Delphi consensus methodology was used to reach agreement on different clinical sceneries. Two rounds of consultation by using a purpose built on-line survey and a third open panel discussion were performed. RESULTS The panel of 50 experts reached agreement for the vast majority of clinical sceneries (Placenta Previa, Preeclampsia, Diabetes, Cholestasis). Overall, there was agreement to be conservative at 34 weeks and in favor of delivery at 36 weeks. The management of p-PROM and mostly of IUGR were characterized by a minor degree of consensus. Corticosteroids were found necessary at the 34th week and unnecessary at the 36th week. CONCLUSIONS Besides providing some guidance on clinical indications for LP iatrogenic delivery, these results represent a stimulus for designing future trials investigating the grey areas in this field.
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Affiliation(s)
- F Monari
- Obstetrics Unit, Mother Infant Department, University Hospital Policlinico of Modena, Via del Pozzo 71, 41124. Modena, Italy
| | - F Parazzini
- Dipartimento della Donna, del Neonato e del Bambino, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 12, 20122, Milan, Italy
| | - I Cetin
- Unit of Obstetrics and Gynecology, Buzzi Children's Hospital, Department of Clinical and Biological Sciences, University of Milan, Milan, Italy
| | - M Ballarini
- Obstetrics Unit, Mother Infant Department, University Hospital Policlinico of Modena, Via del Pozzo 71, 41124. Modena, Italy
| | - F Facchinetti
- Obstetrics Unit, Mother Infant Department, University Hospital Policlinico of Modena, Via del Pozzo 71, 41124. Modena, Italy
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Contag S, Patel P, Payton S, Crimmins S, Goetzinger KR. Renal artery Doppler compared with the cerebral placental ratio to identify fetuses at risk for adverse neonatal outcome. J Matern Fetal Neonatal Med 2019; 34:532-540. [PMID: 31060397 DOI: 10.1080/14767058.2019.1610735] [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: 12/31/2022]
Abstract
Background: Current clinical practice incorporates an umbilical artery resistance index or a ratio of the middle cerebral artery (MCA PI) to the umbilical artery pulsatility index (UA PI) known as the cerebral placental ratio (CPR) to assess wellbeing in the small for gestational age fetus. Previous reports using the renal artery Doppler indices have not been consistent in regards to their design and clinical use. Our objective is to develop reference values for renal artery Doppler indices and validate their use compared with the UA PI or CPR to identify fetuses that will develop a composite neonatal outcome.Methods: We performed 9700 ultrasounds among 2852 women at 20-40 weeks of gestation at the University of Maryland between 1 June 2016 and 1 December 2016. Nomograms were first developed using one randomly selected scan from each of a subgroup of 860 women without any comorbidities. The nomograms were validated among a cohort of 550 women who subsequently delivered at the University of Maryland Medical Center. We compared the area under the receiver operating characteristic curve (AUROC) between the CPR and UA PI, and the renal artery Doppler parameters (renal artery pulsatility index (RA PI), systolic diastolic ratio (RA SDR), and peak systolic velocity (RA PSV)). The primary outcome was the development any one of the composite neonatal outcome components (death, intensive care unit admission, ventilator for more than 6 h, hypoxic ischemic encephalopathy or necrotizing enterocolitis) or admission to the neonatal intensive care unit (NICU) for any indication.Results: The renal artery Doppler indices did not improve identification of fetuses that would subsequently develop one of the components of the composite neonatal outcome (AUROC for CPR 0.54, 95% CI (0.49-0.59), versus the UA PI: 0.59 (0.54-0.64) p = .07, the RA PI: 0.51 (0.48-0.55) p = .41, RA SDR 0.54 (0.49-0.58) p = .99, or RA PSV 0.51 (0.47-0.55) p = .37). There was no difference when comparing AUROC to detect NICU admission (AUROC for CPR 0.53, 95% CI (0.49-0.58), versus the UA PI: 0.57 (0.52-0.62) p = .14, the RA PI: 0.50 (0.47-0.54) p = .44, RA SDR: 0.54 (0.50-0.59) p = .62 or RAPSV: 0.51 (0.47-0.55) p = .54).Conclusion: The renal artery indices do not improve detection of fetuses at risk for adverse neonatal outcomes compared with the CPR or the UA PI.
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Affiliation(s)
- Stephen Contag
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology and Women's Health, University of Minnesota, Minneapolis, MN, USA
| | - Pooja Patel
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Stephanie Payton
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sarah Crimmins
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Katherine R Goetzinger
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Ross MG. Threshold of metabolic acidosis associated with newborn cerebral palsy: medical legal implications. Am J Obstet Gynecol 2019; 220:348-353. [PMID: 30529344 DOI: 10.1016/j.ajog.2018.11.1107] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 10/30/2018] [Accepted: 11/30/2018] [Indexed: 12/15/2022]
Abstract
Obstetricians and gynecologists belong to 1 of the medical specialties with the highest rate of litigation claims. Among birth injury cases, those cases with cerebral palsy outcomes account for litigation settlements or judgments often in the millions of dollars. In cases of potential perinatal asphyxia, a threshold level of metabolic acidosis (base deficit ≥12 mmol/L) is necessary to attribute neonatal encephalopathy to an intrapartum hypoxic event. With increasing duration or severity of a hypoxic stress resulting in metabolic acidosis, newborn infant umbilical artery base deficit increases. It may be alleged that, as base deficit levels increase beyond 12 mmol/L, there is an increased likelihood and severity of cerebral palsy. As a corollary, it may be claimed that an earlier delivery (by minutes) would reduce the base deficit and prevent or reduce the severity of cerebral palsy. This issue is of relevance to obstetricians as defendants, because retrospective "expert" analysis of cases may suggest that optimal management decisions would have resulted in an earlier delivery. In addressing the association of metabolic acidosis and cerebral palsy, base deficit should be measured as the extracellular component (base deficitextracellular fluid) rather than the commonly used base deficitblood. Studies suggest that, beyond the base deficit threshold of 12 mmol/L, the incidence and severity of cerebral palsy does not significantly increase (until ≥20 mmol/L), although the risk of neonatal death rises markedly. Thus, among most infants with hypoxia-associated neonatal encephalopathy, the occurrence of cerebral palsy is unlikely to be impacted by delivery time variation of few minutes, and this argument should not serve as the basis for medical legal claims.
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Affiliation(s)
- Michael G Ross
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Department of Obstetrics and Gynecology, Geffen School of Medicine at UCLA, Los Angeles, CA.
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Herraiz I, Quezada MS, Rodriguez-Calvo J, Gómez-Montes E, Villalaín C, Galindo A. Longitudinal change of sFlt-1/PlGF ratio in singleton pregnancy with early-onset fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:631-638. [PMID: 28876491 DOI: 10.1002/uog.18894] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 08/10/2017] [Accepted: 08/25/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To describe the evolution of soluble fms-like tyrosine kinase-1 to placental growth factor (sFlt-1/PlGF) ratio in the last 5 weeks prior to delivery in singleton pregnancy complicated by early-onset fetal growth restriction (FGR), with or without pre-eclampsia (PE). METHODS This was a prospective observational cohort study of early-onset FGR cases that underwent serial assessment of maternal serum sFlt-1/PlGF ratio from diagnosis to delivery. Measurements were made at weekly intervals and within the last 48 h before birth. Absolute values and percentage increase between time intervals were computed, and previously described cut-off values of 38 (suspicion of PE), 85 (aids diagnosis of PE) and 655 (high risk for imminent delivery) were used for analysis of the sFlt-1/PlGF ratio. We compared findings between cases with early-onset FGR only (n = 37) and those that additionally developed PE (n = 36). RESULTS Overall perinatal survival was 63/73 (86.3%). A sFlt-1/PlGF ratio above 38 was observed 4 weeks before delivery in most FGR-only and FGR with PE cases (73% and 100%, respectively), but absolute values of sFlt-1/PlGF were significantly higher in FGR cases with PE. Extremely elevated values of the ratio (≥ 655) within the last 48 h before delivery were found in 65% of cases of FGR with PE, but in only 8% of isolated FGR cases (P < 0.001). CONCLUSION Elevated sFlt-1/PlGF was observed in most early-onset FGR pregnancies from 4 weeks before delivery, and values were even higher if there was concurrent PE. However, serial measurements of the ratio were of limited value, being useful only to anticipate the need for imminent delivery in cases of FGR with PE when sFlt-1/PlGF values ≥ 655 were reached. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- I Herraiz
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain
| | - M S Quezada
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain
| | - J Rodriguez-Calvo
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain
| | - E Gómez-Montes
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain
| | - C Villalaín
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain
| | - A Galindo
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain
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Abstract
Fetal growth restriction (FGR) continues to be a leading cause of preventable stillbirth and poor neurodevelopmental outcomes in offspring, and furthermore is strongly associated with the obstetrical complications of iatrogenic preterm birth and pre-eclampsia. The terms small for gestational age (SGA) and FGR have, for too long, been considered equivalent and therefore used interchangeably. However, the delivery of improved clinical outcomes requires that clinicians effectively distinguish fetuses that are pathologically growth-restricted from those that are constitutively small. A greater understanding of the multifactorial pathogenesis of both early- and late-onset FGR, especially the role of underlying placental pathologies, may offer insight into targeted treatment strategies that preserve placental function. The new maternal blood biomarker placenta growth factor offers much potential in this context. This review highlights new approaches to effective screening for FGR based on a comprehensive review of: etiology, diagnosis, antenatal surveillance and management. Recent advances in novel imaging methods provide the basis for stepwise multi-parametric testing that may deliver cost-effective screening within existing antenatal care systems.
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Planning management and delivery of the growth-restricted fetus. Best Pract Res Clin Obstet Gynaecol 2018; 49:53-65. [PMID: 29606482 DOI: 10.1016/j.bpobgyn.2018.02.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 02/23/2018] [Accepted: 02/23/2018] [Indexed: 11/22/2022]
Abstract
A uniform approach to management of fetal growth restriction (FGR) improves outcome, prevents stillbirth, and allows appropriately timed delivery. An estimated fetal weight below the tenth percentile with coexisting abnormal umbilical artery (UA), middle cerebral artery (MCA), or cerebroplacental ratio Doppler index best identifies the small fetus requiring surveillance. Placental perfusion defects are more common earlier in gestation; accordingly, early-onset (≤32 weeks of gestation) and late-onset (>32 weeks) FGR differ in clinical phenotype. In early-onset FGR, progression of UA Doppler abnormality determines clinical acceleration, while abnormal ductus venosus (DV) Doppler precedes deterioration of biophysical variables and stillbirth. Accordingly, late DV Doppler changes, abnormal biophysical variables, or an abnormal cCTG require delivery. In late-onset FGR, MCA Doppler abnormalities precede deterioration and stillbirth. However, from 34 to 38 weeks, randomized evidence on optimal delivery timing is lacking. From 38 weeks onward, the balance of neonatal versus fetal risks favors delivery.
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Caradeux J, Martinez-Portilla RJ, Basuki TR, Kiserud T, Figueras F. Risk of fetal death in growth-restricted fetuses with umbilical and/or ductus venosus absent or reversed end-diastolic velocities before 34 weeks of gestation: a systematic review and meta-analysis. Am J Obstet Gynecol 2018; 218:S774-S782.e21. [PMID: 29233550 DOI: 10.1016/j.ajog.2017.11.566] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/31/2017] [Accepted: 11/08/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of the study was to establish the risk of fetal death in early-onset growth-restricted fetuses with absent or reversed end-diastolic velocities in the umbilical artery or ductus venosus. DATA SOURCES A systematic search was performed to identify relevant studies published in English, Spanish, French, Italian, or German using the databases PubMed, ISI Web of Science, and SCOPUS, without publication time restrictions. STUDY ELIGIBILITY CRITERIA The study criteria included observational cohort studies and randomized controlled trials of early-onset growth-restricted fetuses (diagnosed before 34 weeks of gestation), with information on the rate of fetal death occurring before 34 weeks of gestation and absent or reversed end-diastolic velocities in the umbilical artery and/or ductus venosus. STUDY APPRAISAL AND SYNTHESIS METHODS For quality assessment, 2 reviewers independently assessed the risk of bias using the Newcastle-Ottawa Scale for observational studies and the Cochrane Collaboration's tool for randomized trials. For the meta-analysis, odds ratio for both fixed and random-effects models (weighting by inverse of variance) were used. Heterogeneity between studies was assessed using tau2, χ2 (Cochrane Q), and I2 statistics. Publication bias was assessed by a funnel plot for meta-analyses and quantified by the Egger method. RESULTS A total of 31 studies were included in this meta-analysis. The odds ratios for fetal death (random-effects models) were 3.59 (95% confidence interval, 2.3-5.6), 7.27 (95% confidence interval, 4.6-11.4), and 11.6 (95% confidence interval, 6.3-19.7) for growth-restricted fetuses with umbilical artery absent end-diastolic velocities, umbilical artery reversed end-diastolic velocities, and ductus venosus absent or reversed end-diastolic velocities, respectively. There was no substantial heterogeneity among studies for any of the analyses. CONCLUSION Early-onset growth-restricted fetuses with either umbilical artery or ductus venosus absent or reserved end-diastolic velocities are at a substantially increased risk for fetal death.
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Affiliation(s)
- J Caradeux
- Fetal i+D Fetal Medicine Research Center, BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, University of Barcelona, Barcelona, Spain; Fetal Medicine Unit, Clínica Dávila, Santiago, Chile
| | - R J Martinez-Portilla
- Fetal i+D Fetal Medicine Research Center, BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, University of Barcelona, Barcelona, Spain; Fetal Medicine Unit, Clínica Hospital Sinaí, Xalapa Veracruz, México
| | - T R Basuki
- Fetal i+D Fetal Medicine Research Center, BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, University of Barcelona, Barcelona, Spain
| | - T Kiserud
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway; Research Group for Pregnancy, Fetal Development, and Birth, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - F Figueras
- Fetal i+D Fetal Medicine Research Center, BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, University of Barcelona, Barcelona, Spain; Center for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain.
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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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38
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Bilardo CM, Hecher K, Visser GHA, Papageorghiou AT, Marlow N, Thilaganathan B, Van Wassenaer-Leemhuis A, Todros T, Marsal K, Frusca T, Arabin B, Brezinka C, Derks JB, Diemert A, Duvekot JJ, Ferrazzi E, Ganzevoort W, Martinelli P, Ostermayer E, Schlembach D, Valensise H, Thornton J, Wolf H, Lees C. Severe fetal growth restriction at 26-32 weeks: key messages from the TRUFFLE study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:285-290. [PMID: 28938063 DOI: 10.1002/uog.18815] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Indexed: 06/07/2023]
Affiliation(s)
- C M Bilardo
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - G H A Visser
- University Medical Center, Division of Woman and Baby, Utrecht, The Netherlands
| | - A T Papageorghiou
- St George's, University of London and St George's University Hospitals NHS Foundation Trust, Molecular and Clinical Sciences Research Institute, London, UK
| | - N Marlow
- Department of Academic Neonatology, UCL Institute for Women's Health, London, UK
| | - B Thilaganathan
- St George's, University of London and St George's University Hospitals NHS Foundation Trust, Molecular and Clinical Sciences Research Institute, London, UK
| | - A Van Wassenaer-Leemhuis
- Department of Neonatology, Emma Children's Hospital Academic Medical Centre, Amsterdam, The Netherlands
| | - T Todros
- Department of Obstetrics & Gynecology, University of Turin, Turin, Italy
| | - K Marsal
- Department of Obstetrics and Gynecology, Lund University, University Hospital, Lund, Sweden
| | - T Frusca
- Maternal-Fetal Medicine Unit, University of Parma, Parma, Italy
| | - B Arabin
- Department of Perinatology, Isala Clinics, Zwolle, The Netherlands
- Center for Mother and Child of the Philipps University, Marburg, Germany
| | - C Brezinka
- Department of Obstetrics and Gynecology, Medical University Innsbruck, Innsbruck, Austria
| | - J B Derks
- Perinatal Center, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - A Diemert
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J J Duvekot
- Division of Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC, Rotterdam, The Netherlands
| | - E Ferrazzi
- Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - W Ganzevoort
- Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam, The Netherlands
| | - P Martinelli
- Department of Gynecology and Obstetrics, University Federico II of Naples, Naples, Italy
| | - E Ostermayer
- Section of Perinatal Medicine, Department of Obstetrics and Gynecology, Technical University, Munich, Germany
| | - D Schlembach
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - H Valensise
- Department of Biomedicine, Tor Vergata University, Policlinico Casilino, Rome, Italy
| | - J Thornton
- Department of Obstetrics and Gynaecology, City Hospital, Nottingham, UK
| | - H Wolf
- Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam, The Netherlands
| | - C Lees
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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