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Rizzo G, Pietrolucci ME, Mappa I, Maqina P, Makatsarya A, D'Antonio F. Modeling gestational age centiles for fetal umbilicocerebral ratio by quantile regression analysis: a secondary analysis of a prospective cross-sectional study. J Matern Fetal Neonatal Med 2022; 35:4381-4385. [PMID: 33228405 DOI: 10.1080/14767058.2020.1849123] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE There is a lack of evidence on whether to favor cerebroplacental ratio (CPR) or umbilicocerebral ratio (UCR) when assessing pregnancies at risk of fetal growth restriction. The Recent evidences highlight a significant heterogeneity in the methodology of previously published studies reporting reference ranges for Doppler indices, which may affect the clinical applicability of these charts. The aim of this study was to develop charts of UCR based upon a recently proposed standardized methodology and using quantile regression. METHODS This was a secondary analysis of a prospective cross-sectional study including low-risk singleton pregnancies between 24 and 40 weeks of gestation undergoing Doppler recordings. The UCR centile values were established by quantile regression at different gestational age intervals. Quantile regression analysis was used to build the UCR chart. RESULT 2516 low- risk singleton pregnancies were included in the analysis. UCR decreased with advancing gestational age. The 3rd, 5th 10th, 50th, 90th, 95th, and 97th centiles according to gestational age are provided, as well as equations to allow calculation of any other percentile. CONCLUSIONS We have established gestational age-specific normative centiles reference limits for UCR.
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Affiliation(s)
- Giuseppe Rizzo
- Division of Maternal Fetal Medicine Ospedale Cristo Re Roma, Università di Roma Tor Vergata, Roma, Italy
- Department of Obstetrics and Gynecology Moscow, The First I.M. Sechenov Moscow State Medical University, Moskva, Russia
| | - Maria Elena Pietrolucci
- Division of Maternal Fetal Medicine Ospedale Cristo Re Roma, Università di Roma Tor Vergata, Roma, Italy
| | - Ilenia Mappa
- Division of Maternal Fetal Medicine Ospedale Cristo Re Roma, Università di Roma Tor Vergata, Roma, Italy
| | - Pavjola Maqina
- Division of Maternal Fetal Medicine Ospedale Cristo Re Roma, Università di Roma Tor Vergata, Roma, Italy
| | - Alexander Makatsarya
- Department of Obstetrics and Gynecology Moscow, The First I.M. Sechenov Moscow State Medical University, Moskva, Russia
| | - Francesco D'Antonio
- Department of Obstetrics and Gynecology, University Hospital of Chieti, Roma, Italy
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Middle cerebral artery to uterine artery pulsatility index ratios in pregnancy with fetal growth restriction regarding negative perinatal outcomes. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.7319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background/Aim: Fetal growth restriction (FGR) causes a high risk of perinatal morbidity and mortality, and the timing of the correct delivery time decision remains controversial. Cerebroplacental ratio (CPR), umbilical artery, uterine artery (UA) and middle cerebral artery (MCA) Doppler studies are used to predict adverse perinatal outcomes in FGR. However, since there is insufficient reliability for each separately and together, the search for new methods continues. This retrospective study was conducted to determine the degree of neonatal morbidity in fetuses suspected of having FGR by evaluating the MCA to UA pulsatility index (PI) ratios together with frequently used Doppler examinations.
Methods: This was a retrospective cohort study conducted in a single-center hospital with the approval of the Medical Institutional Ethics Committee. A total of 424 pregnant women admitted to a tertiary hospital and diagnosed with FGR between July 2020 and December 2021 who were informed and approved were included in the study. Gestational age was confirmed by first trimester sonographic measurements of pregnancy. All pregnant women were examined by Doppler USG and umbilical artery, mean UA, fetal MCA, ductus venosus, CPR (MCA/umbilical artery pulsatility index ratio) and cerebrouterine ratio (MCA/UA) PI values were measured. Negative perinatal outcomes were recorded as blood gas level of the newborn at 7.2 and below, Apgar score of 7 and below at the fifth minute, and needing neonatal intensive care (NICU). Adverse perinatal and postnatal outcomes were recorded and compared with Doppler findings. If there were no signs of a negative perinatal outcome, it was considered a positive outcome. If at least one of the symptoms of adverse perinatal outcomes was present, it was considered a negative outcome
Results: Decreased CPR and decreased MCA to UA PI were significantly and positively associated with an increased likelihood of exhibiting negative perinatal outcomes in pregnancies with FGR (P < 0.001, P < 0.001, respectively). The receiver operating characteristic (ROC) curve analysis showed that the optimal cut-off value for MCA to uterine artery PI was 1.41 to predict FGR with 57.37% sensitivity and 62.50% specificity (AUC: 0.629; 95% CI: 0.581–0.675). When the CPR cut-off value was taken as 1.2069, the sensitivity was 42.86% and the specificity 83.93% in predicting negative perinatal outcomes in CPR values below this value (P < 0.001).
Conclusion: CPR is the most successful criterion in distinguishing between positive and negative perinatal outcomes. It has been demonstrated that the MCA to uterine artery PI ratio values after CPR can also be used for this distinction. MCA to UA PI ratio sensitivity was higher than CPR and umbilical artery. This situation shows that MCA to uterine artery PI ratio (alone or when evaluated together with PPV and NPV ratios) is a criterion that can be added to other Doppler examinations in predicting negative perinatal outcomes.
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Casati D, Zavatta A, Cortinovis I, Spada E, Faiola S, Laoreti A, Cetin I, Lanna M. Cerebro-placental and umbilico-cerebral ratios in uncomplicated monochorionic twins: Longitudinal references and comparison with singletons. Prenat Diagn 2022; 42:1111-1119. [PMID: 35801284 DOI: 10.1002/pd.6210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 06/24/2022] [Accepted: 07/03/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Monochorionic twins (MC) are at high risk of adverse outcomes and Doppler investigation of umbilical and cerebral flows is mandatory for their surveillance. The cerebro-placental (CPR) and umbilico-cerebral (UCR) ratios are considered non-invasive measures of fetal adaptation to hypoxemia. We aimed to provide longitudinal references for CPR and UCR from 16 to 37 weeks of gestation that are specific for MC twins, and compare these with singleton charts. METHODS Longitudinal study of a cohort of consecutive uncomplicated MC twin pregnancies monitored at our unit from 2010 to 2018. The estimated centile curves were obtained estimating the median with fractional polynomials by a multilevel model and the external centiles through the residuals. The comparison with singletons references was made through graphic evaluation. RESULTS One-hundred-fifty-two MC pregnancies were included with a median of 10 longitudinal ultrasounds each. References for CPR and UCR in function of gestational age are presented. Compared to singletons, MC twins showed an earlier and greater circulatory redistribution with lower CPR and higher UCR median values. CONCLUSIONS MC twin-specific references for CPR and UCR suitable for serial monitoring are presented. The comparison with singleton references demonstrates substantial differences in the hemodynamic balance that must be considered when interpreting findings in MC twins. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Daniela Casati
- Department of Woman, Mother and Neonate, Buzzi Children's Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Alice Zavatta
- Fetal Therapy Unit 'Umberto Nicolini', Department of Woman, Mother and Neonate, Buzzi Children's Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Ivan Cortinovis
- Laboratory G.A. Maccacaro, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Elena Spada
- Laboratorio della Conoscenza - Carlo Corchia A.P.S, Florence, Italy
| | - Stefano Faiola
- Fetal Therapy Unit 'Umberto Nicolini', Department of Woman, Mother and Neonate, Buzzi Children's Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Arianna Laoreti
- Fetal Therapy Unit 'Umberto Nicolini', Department of Woman, Mother and Neonate, Buzzi Children's Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Irene Cetin
- Fetal Therapy Unit 'Umberto Nicolini', Department of Woman, Mother and Neonate, Buzzi Children's Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Mariano Lanna
- Fetal Therapy Unit 'Umberto Nicolini', Department of Woman, Mother and Neonate, Buzzi Children's Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
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Özalp M, Demir Ö, Özbay G, Akbaş M, Aran T, Osmanağaoğlu MA. The utility of foetal splenic artery Doppler measurement in the diagnosis of late-onset foetal growth restriction. J OBSTET GYNAECOL 2022; 42:1179-1185. [PMID: 35164643 DOI: 10.1080/01443615.2022.2028276] [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: 10/19/2022]
Abstract
We aimed to examine the contribution of splenic artery (SA) Doppler parameters in the detection of foetuses with late-onset foetal growth restriction (LO-FGR) and to evaluate its power in predicting adverse perinatal outcomes. Within the study's scope, 52 cases in the LO-FGR group and 92 cases in the control group were evaluated. The criteria determined in the Delphi procedure by an international consensus were used to define the LO-FGR. Middle cerebral artery (MCA) pulsatility index (PI) and SA PI were significantly lower in the LO-FGR group (p: .002, p<.001, respectively). Likewise, cerebroplacental ratio (CPR) was significantly lower in the LO-FGR group (p<.001). Decreased CPR and decreased SA PI were significantly and positively associated with an increased likelihood of exhibiting adverse obstetric outcome (p<.001, p: .012, respectively). The receiver operating characteristic (ROC) curve analysis showed that the optimal cut-off value for SA PI was 1.41 to predict LO-FGR with 70.7% sensitivity and 61.5% specificity (AUC = 0.684; 95% CI, 0.594-0.774).Impact StatementWhat is already known on this subject? The main clinical difficulty in late-onset foetal growth restriction (LO-FGR) is the detection of the disease.What do the results of this study add? The splenic artery (SA) pulsatility index (PI) may contribute to both diagnostic and the prediction of adverse perinatal outcomes in LO-FGR cases. Our results showed that the SA PI value, as well as cerebroplacental ratio (CPR), can be a useful parameter in predicting negative outcomes.What are the implications of these findings for clinical practice and/or further research? Various degrees of uteroplacental insufficiency in foetuses with LO-FGR may be associated with abnormalities in SA Doppler velocimetry. Splenic artery Doppler velocimetry can be used for the clinical management of LO-FGR.
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Affiliation(s)
- Miraç Özalp
- Department of Perinatology, Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Ömer Demir
- Department of Gynecology and Obstetrics, Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Gülsün Özbay
- Department of Gynecology and Obstetrics, Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Murat Akbaş
- Department of Perinatology, Manisa City Hospital, Manisa, Turkey
| | - Turhan Aran
- Department of Perinatology, Karadeniz Technical University School of Medicine, Trabzon, Turkey
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Wolf H, Stampalija T, Lees CC. Fetal cerebral blood-flow redistribution: analysis of Doppler reference charts and association of different thresholds with adverse perinatal outcome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:705-715. [PMID: 33599336 PMCID: PMC8597586 DOI: 10.1002/uog.23615] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/27/2021] [Accepted: 02/04/2021] [Indexed: 05/27/2023]
Abstract
OBJECTIVES First, to compare published Doppler reference charts of the ratios of flow in the fetal middle cerebral and umbilical arteries (i.e. the cerebroplacental ratio (CPR) and umbilicocerebral ratio (UCR)). Second, to assess the association of thresholds of CPR and UCR based on these charts with short-term composite adverse perinatal outcome in a cohort of pregnancies considered to be at risk of late preterm fetal growth restriction. METHODS Studies presenting reference charts for CPR or UCR were searched for in PubMed. Formulae for plotting the median and the 10th percentile (for CPR) or the 90th percentile (for UCR) against gestational age were extracted from the publication or calculated from the published tables. Data from a prospective European multicenter observational cohort study of singleton pregnancies at risk of fetal growth restriction at 32 + 0 to 36 + 6 weeks' gestation, in which fetal arterial Doppler measurements were collected longitudinally, were used to compare the different charts. Specifically, the association of UCR and CPR thresholds (CPR < 10th percentile or UCR ≥ 90th percentile and multiples of the median (MoM) values) with composite adverse perinatal outcome was analyzed. The association was also compared between chart-based thresholds and absolute thresholds. Composite adverse perinatal outcome comprised both abnormal condition at birth and major neonatal morbidity. RESULTS Ten studies presenting reference charts for CPR or UCR were retrieved. There were large differences between the charts in the 10th and 90th percentile values of CPR and UCR, respectively, while median values were more similar. In the gestational-age range of 28-36 weeks, there was no relationship between UCR or CPR and gestational age. From the prospective observational study, 856 pregnancies at risk of late-onset preterm fetal growth restriction were included in the analysis. The association of abnormal UCR or CPR with composite adverse perinatal outcome was similar for percentile thresholds or MoM values, as calculated from the charts, and for absolute thresholds, both on univariable analysis and after adjustment for gestational age at measurement, estimated fetal weight MoM and pre-eclampsia. The adjusted odds ratio for composite adverse perinatal outcome was 3.3 (95% CI, 1.7-6.4) for an absolute UCR threshold of ≥ 0.9 or an absolute CPR threshold of < 1.11 (corresponding to ≥ 1.75 MoM), and 1.6 (95% CI, 0.9-2.9) for an absolute UCR threshold of ≥ 0.7 to < 0.9 or an absolute CPR threshold of ≥ 1.11 to < 1.43 (corresponding to ≥ 1.25 to < 1.75 MoM). CONCLUSIONS In the gestational-age range of 32 to 36 weeks, adjustment of CPR or UCR for gestational age is not necessary when assessing the risk of adverse outcome in pregnancies at risk of fetal growth restriction. The adoption of absolute CPR or UCR thresholds, independent of reference charts, is feasible and makes clinical assessment simpler than if using percentiles or other gestational-age normalized units. The high variability in percentile threshold values among the commonly used UCR and CPR reference charts hinders reliable diagnosis and clinical management of late preterm fetal growth restriction. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- H. Wolf
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center (Location AMC)University of AmsterdamAmsterdamThe Netherlands
| | - T. Stampalija
- Unit of Fetal Medicine and Prenatal DiagnosisInstitute for Maternal and Child Health, IRCCS Burlo GarofoloTriesteItaly
- Department of Medicine, Surgery and Health SciencesUniversity of TriesteTriesteItaly
| | - C. C. Lees
- Department of Metabolism, Digestion and Reproduction, Imperial College LondonLondonUK
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College NHS TrustLondonUK
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Role of umbilicocerebral and cerebroplacental ratios in prediction of perinatal outcome in FGR pregnancies. Arch Gynecol Obstet 2021; 305:1383-1392. [PMID: 34599678 PMCID: PMC9166852 DOI: 10.1007/s00404-021-06268-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 09/16/2021] [Indexed: 12/02/2022]
Abstract
Purpose Aim of our study was to compare the prognostic value of the Umbilical-to-Cerebral ratio (UCR) directly to the Cerebroplacental ratio (CPR) in the prediction of poor perinatal outcomes in pregnancies complicated by Fetal Growth Restriction (FGR). Methods A retrospective study was carried out on pregnant women with either a small-for-gestational age (SGA) fetus or that were diagnosed with FGR. Doppler measurements of the two subgroups were assessed and the correlation between CPR, UCR and relevant outcome parameters was evaluated by performing linear regression analysis, binary logistic analysis and receiver operator characteristic (ROC) curves. Outcomes of interest were mode of delivery, acidosis, preterm delivery, gestational age at birth as well as birthweight and centiles. Results Boxplots and Scatterplots illustrated the different distribution of CPR and UCR leading to deviant correlational relationships with adverse outcome parameters. In almost all parameters examined, UCR showed a higher independent association with preterm delivery (OR: 5.85, CI 2.23–15.34), APGAR score < 7 (OR: 3.52; CI 1.58–7.85) as well as weight under 10th centile (OR: 2.04; CI 0.97–4.28) in binary logistic regression compared to CPR which was only associated with preterm delivery (OR: 0.38; CI 0.22–0.66) and APGAR score < 7 (OR: 0.27; CI 0.06–1.13). When combined with different ultrasound parameters in order to differentiate between SGA and FGR during pregnancy, odds ratios for UCR were highly significant compared to odds ratios for CPR (OR: 0.065, 0.168–0.901; p = 0.027; OR: 0.810, 0.369–1.781; p = 0.601). ROC curves plotted for CPR and UCR showed almost identical moderate prediction performance. Conclusion Since UCR is a better discriminator of Doppler values in abnormal range it presents a viable option to Doppler parameters and ratios that are used in clinical practice. UCR and CPR showed equal prognostic accuracy conserning sensitivity and specificity for adverse perinatal outcome, while adding UA PI and GA_scan increased prognostic accuracy regarding negative outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s00404-021-06268-4.
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Martínez-Rodríguez M, Luna-García J, López-Briones H, Villalobos-Gómez R, Saldívar-Rodríguez D, Gámez-Varela A, Chávez-González E, Cruz-Martínez R. Brain Doppler abnormalities in fetuses with open spina bifida. J Matern Fetal Neonatal Med 2021; 35:8097-8102. [PMID: 34470130 DOI: 10.1080/14767058.2021.1961728] [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: 10/20/2022]
Abstract
BACKGROUND To describe the brain Doppler changes in fetuses with isolated open spina bifida (OSB). STUDY DESIGN Doppler ultrasound measurements including the umbilical artery (UA) pulsatility index (PI), middle cerebral artery (MCA) PI, and their combination into the cerebroplacental ratio (CPR) and umbilicocerebral ratio (UCR) were performed in a cohort of fetuses with OSB. Included patients were individually matched to a control group without structural anomalies and similar gestational ages. MCA-PI and/or CPR values below the 5th centile were considered abnormal and indicative of cerebral blood redistribution, while UCR and UA-PI above the 95th centile were considered abnormal. RESULTS During the study period, 266 fetuses were recruited, 133 normally grown fetuses with OSB and 133 matched controls. Doppler recordings were successfully obtained in all fetuses at a median gestational age of 30.9 weeks. All cases showed UA-PI within normal ranges, but fetuses with OSB showed significantly higher frequency of cerebral blood redistribution (15.0 vs. 3.0%, p < .01), MCA-PI <5th centile (10.5% vs. 3.0%, p = .01), decreased CPR (9.8% vs. 2.3%, p = .01) and increased UCR (17.2 % vs 7.5 %, p =.02). The rate of cerebral blood redistribution was significantly higher in the OSB group with ventriculomegaly in comparison to those with OSB and normal lateral ventricle diameter (18.6% vs. 3.2%, respectively; p <.05). CONCLUSION A proportion of fetuses with isolated open spina bifida showed cerebral blood redistribution.
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Affiliation(s)
- M Martínez-Rodríguez
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Foundation of Mexico, Qurerétaro, México.,Department of Fetal Surgery, Hospital de Especialidades del Niño y la Mujer "Dr. Felipe Núñez-Lara", Querétaro, México
| | - J Luna-García
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Foundation of Mexico, Qurerétaro, México
| | - H López-Briones
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Foundation of Mexico, Qurerétaro, México
| | - R Villalobos-Gómez
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Foundation of Mexico, Qurerétaro, México
| | - D Saldívar-Rodríguez
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Foundation of Mexico, Qurerétaro, México
| | - A Gámez-Varela
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Foundation of Mexico, Qurerétaro, México
| | - E Chávez-González
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Foundation of Mexico, Qurerétaro, México
| | - R Cruz-Martínez
- Fetal Medicine and Surgery Center, Medicina Fetal México, and Fetal Medicine Foundation of Mexico, Qurerétaro, México.,Department of Fetal Surgery, Hospital de Especialidades del Niño y la Mujer "Dr. Felipe Núñez-Lara", Querétaro, México.,Universidad Autónomadel Estado de Hidalgo (UAEH), Hidalgo, México
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Stefopoulou M, Johnson J, Herling L, Lindgren P, Kiserud T, Acharya G. Fetal Superior Vena Cava Blood Flow and Its Fraction of Cardiac Output: A Longitudinal Ultrasound Study in the Second Half of Pregnancy. Front Pediatr 2021; 9:658502. [PMID: 34295858 PMCID: PMC8289903 DOI: 10.3389/fped.2021.658502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/08/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: In the fetus, a large proportion of the superior vena cava blood flow (QSVC) comes from the brain. To provide the possibility of using this blood flow as a representation of fetal brain circulation, we aimed to determine the fetal QSVC and its fraction of cardiac output during the second half of physiological pregnancies. Materials and Methods: This was a prospective longitudinal study specifically designed for studying fetal hemodynamic development. Healthy women with singleton low-risk pregnancies were included. Ultrasonography was performed at 4-weekly intervals from 20+0 gestational weeks to term. Doppler velocity recordings of the superior vena cava (SVC) and cardiac ventricular outflow tracts were used to obtain the time-averaged maximum velocities (TAMxV). Vessel diameters were measured to calculate their cross-sectional areas (CSA): π(diameter/2)2. Blood flow (Q) was computed as: h *TAMxV*CSA, h being the spatial blood velocity profile, to obtain QSVC and cardiac outputs. The sum of left and right ventricular cardiac outputs constituted the combined cardiac output (CCO). Ultrasound biometry based estimated fetal weight and brain weight were used to normalize the flow. QSVC was also expressed as the fraction (%) of CCO. Gestational age specific percentiles were established for each blood flow parameter using multilevel modeling. Results: Totally, 134 of the 142 included women were eligible for the study with 575 sets of observations. The SVC mean diameter (19-52 mm), mean TAMxV (8.83-16.14 cm/s), and QSVC (15.4-192.0 ml/min) increased significantly during the second half of pregnancy (p < 0.001) while the mean QSVC normalized by estimated fetal weight (49 ml/min/kg) and by estimated brain weight (50 ml/min/100 g) were relatively stable. Similarly, the mean CCO increased (156-1,776 ml/min; p < 0.001) while the normalized CCO (509 ± 13 ml/min/kg) and QSVC as a fraction of CCO (10 ± 0.92%) did not change significantly with gestational age. Conclusion: We provide reference values for fetal QSVC which increases significantly with gestation, and constitutes roughly 10% of the fetal CCO at any time during the second half of pregnancy.
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Affiliation(s)
- Maria Stefopoulou
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention & Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Center for Fetal Medicine Karolinska, University Hospital, Stockholm, Sweden
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway and Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway
| | - Jonas Johnson
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention & Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Center for Fetal Medicine Karolinska, University Hospital, Stockholm, Sweden
| | - Lotta Herling
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention & Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Center for Fetal Medicine Karolinska, University Hospital, Stockholm, Sweden
| | - Peter Lindgren
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention & Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Center for Fetal Medicine Karolinska, University Hospital, Stockholm, Sweden
| | - Torvid Kiserud
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
| | - Ganesh Acharya
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention & Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Center for Fetal Medicine Karolinska, University Hospital, Stockholm, Sweden
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway and Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway
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Winchester ML, McCarther N, Cancino D, Fitzgerald S, Parrish M. Second trimester cerebroplacental ratio versus umbilicocerebral ratio for the prediction of adverse perinatal outcomes. J Matern Fetal Neonatal Med 2021; 35:7929-7935. [PMID: 34151683 DOI: 10.1080/14767058.2021.1938530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION An abnormal third trimester cerebroplacental ratio has been previously associated with adverse perinatal outcome. The less studied inverse of the cerebroplacental ratio, the umbilicocerebral ratio, has been proposed as a better predictor of adverse perinatal outcome. However, little is known about the implication of either an abnormal cerebroplacental ratio or umbilicocerebral ratio in the second trimester. The objective of this study was to evaluate the relationship between an abnormal second trimester cerebroplacental ratio and adverse perinatal outcome and provide comparison to an abnormal second trimester umbilicocerebral ratio. MATERIALS AND METHODS This retrospective cohort study in a single tertiary referral center utilized data from all non-anomalous singleton pregnancies that underwent Doppler assessment of the cerebroplacental ratio between 20 and 28 weeks gestation. The study period was 1 January 2015 to 31 July 2018. Abnormal cerebroplacental ratio was defined as less than the 5th percentile for gestational age. If patients had more than one ultrasound during the study period (i.e. for serial assessment of fetal growth), the lowest value of the cerebroplacental ratio was recorded. The primary outcome was a composite of clinically relevant adverse perinatal outcomes including preterm delivery, small for gestational age, and neonatal intensive care unit admission. Secondary outcomes included urgent delivery for fetal distress (operative vaginal delivery or cesarean section) and hypertensive disorders of pregnancy. An abnormal umbilicocerebral ratio was defined as greater than 95th percentile for gestational age. Areas under the curve were calculated and compared for cerebroplacental ratio and umbilicocerebral ratio. RESULTS 2326 pregnancies met inclusion criteria. Of these, 91 (3.9%) had an abnormal second trimester cerebroplacental ratio. Fetuses with an abnormal second trimester cerebroplacental ratio had a 2.3-fold (95% CI 1.5-3.6, p < .05) increased risk of adverse perinatal outcome after adjusting for potential confounders such as chronic hypertension, pregestational diabetes, and smoking during pregnancy. Significantly increased risks of preterm delivery (OR 2.0, 95% CI 1.1-38, p < .05) and neonatal intensive care unit admission (OR 2.1, 95% CI 1.2-3.6, p < .05) were also seen in a subgroup analysis of abnormal cerebroplacental ratio in appropriate for gestational age infants. 132 (5.7%) fetuses had an abnormal second trimester umbilicocerebral ratio, and these fetuses had a 2.0-fold (95% CI 1.4-3.0, p < .05) increased risk of adverse perinatal outcome. The area under the curve for CPR and UCR for prediction of the primary outcome was 0.6 for both (95% CI 0.57-0.61 and 0.57-0.62, respectively, both p < .05). CONCLUSION An abnormal second trimester cerebroplacental ratio or umbilicocerebral ratio is associated with adverse perinatal outcome. However, the predictive ability of either ratio remains suboptimal.
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Affiliation(s)
- Mae-Lan Winchester
- Department of Obstetrics & Gynecology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Noria McCarther
- University of Kansas School of Medicine, Kansas City, KS, USA
| | - Dominic Cancino
- University of Kansas School of Medicine, Kansas City, KS, USA
| | - Sharon Fitzgerald
- Department of Public Health, University of Kansas Medical Center, Kansas City, KS, USA
| | - Marc Parrish
- Department of Obstetrics & Gynecology, University of Kansas Medical Center, Kansas City, KS, USA
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10
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Leavitt K, Odibo L, Nwosu O, Odibo AO. Comparing the cerebro-placental to umbilico-cerebral Doppler ratios for the prediction of adverse neonatal outcomes in pregnancies complicated by fetal growth restriction. J Matern Fetal Neonatal Med 2021; 35:5904-5908. [PMID: 33820478 DOI: 10.1080/14767058.2021.1901880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The cerebroplacental ratio (CPR) has shown utility as a surrogate marker for fetal growth restriction and can be used to stratify the risk for adverse perinatal outcomes in affected pregnancies. However, recent studies suggest that its inverse, the umbilico-cerebral ratio (UCR), may be a better predictor of such outcomes. The aim of this study was to compare the prognostic accuracy of CPR to that of UCR Doppler in predicting short-term adverse perinatal outcomes in growth-restricted fetuses. METHODS We conducted a secondary analysis using data from a prospective study on women referred for fetal growth ultrasounds between 26 and 36 weeks of gestation and with an EFW < 10th percentile by Hadlock standard. The CPR and UCR were converted into Z-scores adjusted for gestational age at ultrasound. Abnormal CPR was defined as Z-score below the 10th percentile for the gestational age and abnormal UCR as Z-score above the 90th percentile. We calculated sensitivity and specificity of the two Doppler parameters for predicting composite adverse perinatal outcome (APO) defined as the presence of any one of the following: umbilical cord arterial pH <7.10, Apgars at 5 min <7, NICU admission,grade III/IV intraventricular hemorrhage (IVH), neonatal seizure and death. Logistic regression analysis was performed, ROC curves plotted and the area under the ROC curve (AUC) were compared between CPR and UCR. RESULTS Over the study period, there were 197 women meeting inclusion criteria, of which 27 (13.7%) had a composite adverse neonatal outcome. The sensitivity using CPR Z-score for predicting the composite APO was higher thanwas similar to using UCR Z-score (39.3% compared with 37%) for a similar specificity (94.7 versus 94.1), respectively. However, the positive predictive value (PPV) was higher for CPR (55% vs UCR 50%) and the negative predictive values (NPV) were similar. For a fixed false positive rate of 10%, the detection rates for adverse neonatal outcomes were 40% using either CPR or UCR. The AUC for CPR and UCR were 0.70 and 0.68, respectively. CONCLUSION This study did not find any advantage in utilizing the UCR over the CPR.
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Affiliation(s)
- Karla Leavitt
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Linda Odibo
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Oluchi Nwosu
- Tulane University School of Medicine, New Orleans, LA, USA
| | - Anthony O Odibo
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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11
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Jagota D, George H, Walker M, Ravi Chandran A, Milligan N, Shinar S, Whitehead CL, Hobson SR, Serghides L, Parks WT, Baschat AA, Macgowan CK, Sled JG, Kingdom JC, Cahill LS. Sex differences in fetal Doppler parameters during gestation. Biol Sex Differ 2021; 12:26. [PMID: 33691774 PMCID: PMC7944891 DOI: 10.1186/s13293-021-00370-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/01/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Fetal sex is known to affect pregnancy outcomes. In current clinical practice, monitoring of fetal well-being is based on Doppler ultrasound measurements of major placental and fetal vessels. The objective of this study was to investigate the effect of fetal sex on Doppler parameters throughout gestation in healthy pregnancy. METHODS A prospective study was conducted in 240 pregnant women with ultrasound examinations at a 4-weekly interval between 12 and 38 weeks of gestation. Pulsed Doppler spectra were collected for the umbilical arteries (UAs), middle cerebral artery (MCA), descending abdominal aorta (DAo), and ductus venosus (DV). Linear mixed effects models were used to determine if the pulsatility indices (PIs) of these vessels depended on gestational age and fetal sex. RESULTS While there were no differences in the MCA PI and DV PIV over gestation between female and male fetuses, the trajectory of the UA and DAo PIs differed by fetal sex (p = 0.02 and p = 0.01, respectively). CONCLUSIONS Doppler ultrasound parameters were found to be dependent on fetal sex for some vessels and not for others in healthy pregnancies. Further investigations are needed to understand the physiological mechanisms for these sex differences and the relevance for disease processes in pregnancy.
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Affiliation(s)
- Dakshita Jagota
- Department of Chemistry, Memorial University of Newfoundland, 283 Prince Philip Drive, St. John's, NL, A1B 3X7, Canada
| | - Hannah George
- Department of Chemistry, Memorial University of Newfoundland, 283 Prince Philip Drive, St. John's, NL, A1B 3X7, Canada
| | - Melissa Walker
- Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | | | - Natasha Milligan
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Clare L Whitehead
- Pregnancy Research Centre, Department of Obstetrics and Gynaecology, Royal Women's Hospital, Parkville, Australia
| | | | - Lena Serghides
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Immunology and Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - W Tony Parks
- Department of Pathology, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Ahmet A Baschat
- Centre for Fetal Therapy, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Christopher K Macgowan
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - John G Sled
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - John C Kingdom
- Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Lindsay S Cahill
- Department of Chemistry, Memorial University of Newfoundland, 283 Prince Philip Drive, St. John's, NL, A1B 3X7, Canada.
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12
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Stefopoulou M, Herling L, Johnson J, Lindgren P, Kiserud T, Acharya G. Reference ranges of fetal superior vena cava blood flow velocities and pulsatility index in the second half of pregnancy: a longitudinal study. BMC Pregnancy Childbirth 2021; 21:158. [PMID: 33622280 PMCID: PMC7901110 DOI: 10.1186/s12884-021-03635-6] [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: 10/12/2020] [Accepted: 02/09/2021] [Indexed: 11/10/2022] Open
Abstract
Background Fetal superior vena cava (SVC) is essentially the single vessel returning blood from the upper body to the heart. With approximately 80-85% of SVC blood flow representing cerebral venous return, its interrogation may provide clinically relevant information about fetal brain circulation. However, normal reference values for fetal SVC Doppler velocities and pulsatility index are lacking. Our aim was to establish longitudinal reference intervals for blood flow velocities and pulsatility index of the SVC during the second half of pregnancy. Methods This was a prospective study of low-risk singleton pregnancies. Serial Doppler examinations were performed approximately every 4 weeks to obtain fetal SVC blood velocity waveforms during 20–41 weeks. Peak systolic (S) velocity, diastolic (D) velocity, time-averaged maximum velocity (TAMxV), time-averaged intensity-weighted mean velocity (TAMeanV), and end-diastolic velocity during atrial contraction (A-velocity) were measured. Pulsatility index for vein (PIV) was calculated. Results SVC blood flow velocities were successfully recorded in the 134 fetuses yielding 510 sets of observations. The velocities increased significantly with advancing gestation: mean S-velocity increased from 24.0 to 39.8 cm/s, D-velocity from 13.0 to 19.0 cm/s, and A-velocity from 4.8 to 7.1 cm/s. Mean TAMxV increased from 12.7 to 23.1 cm/s, and TAMeanV from 6.9 to 11.2 cm/s. The PIV remained stable at 1.5 throughout the second half of pregnancy. Conclusions Longitudinal reference intervals of SVC blood flow velocities and PIV were established for the second half of pregnancy. The SVC velocities increased with advancing gestation, while the PIV remained stable from 20 weeks to term.
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Affiliation(s)
- Maria Stefopoulou
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Center for Fetal Medicine Karolinska University Hospital, 14186, Stockholm, Sweden.,Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway.,Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway
| | - Lotta Herling
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Center for Fetal Medicine Karolinska University Hospital, 14186, Stockholm, Sweden.,Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway.,Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway
| | - Jonas Johnson
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Center for Fetal Medicine Karolinska University Hospital, 14186, Stockholm, Sweden
| | - Peter Lindgren
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Center for Fetal Medicine Karolinska University Hospital, 14186, Stockholm, Sweden
| | - Torvid Kiserud
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
| | - Ganesh Acharya
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Center for Fetal Medicine Karolinska University Hospital, 14186, Stockholm, Sweden. .,Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway. .,Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway.
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13
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Kalafat E, Ozturk E, Kalaylioglu Z, Akkaya AD, Khalil A. Re: Ratio of umbilical and cerebral artery pulsatility indices in assessment of fetal risk: numerator and denominator matter. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:290-292. [PMID: 32738105 DOI: 10.1002/uog.22139] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/03/2020] [Accepted: 07/03/2020] [Indexed: 06/11/2023]
Affiliation(s)
- E Kalafat
- Department of Statistics, Middle East Technical University, Faculty of Arts and Sciences, Ankara, Turkey
| | - E Ozturk
- Department of Biostatistics, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Z Kalaylioglu
- Department of Statistics, Middle East Technical University, Faculty of Arts and Sciences, Ankara, Turkey
- Department of Mathematical Sciences, RMIT University, Melbourne, Australia
| | - A Dener Akkaya
- Department of Statistics, Middle East Technical University, Faculty of Arts and Sciences, Ankara, Turkey
| | - A Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
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14
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Morales-Roselló J, Loscalzo G, Buongiorno S, Cañada Martínez AJ. Information about fetal sex neither affects CPR nor improves CPR prediction of adverse perinatal outcome at end of pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:293-295. [PMID: 32738106 DOI: 10.1002/uog.22130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/12/2019] [Indexed: 06/11/2023]
Affiliation(s)
- J Morales-Roselló
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- Departmento de Pediatría, Obstetricia y Ginecología, Universidad de Valencia, Valencia, Spain
| | - G Loscalzo
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - S Buongiorno
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - A J Cañada Martínez
- Unidad de Bioestadística, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
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15
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Acharya G, Ebbing C, Karlsen HO, Kiserud T, Rasmussen S. Reply. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:295. [PMID: 32738104 DOI: 10.1002/uog.22131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- G Acharya
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø and Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Science, Intervention & Technology, Karolinska Institutet and Center for Fetal Medicine Karolinska, University Hospital, Stockholm, Sweden
| | - C Ebbing
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
| | - H O Karlsen
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
| | - T Kiserud
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - S Rasmussen
- Department of Clinical Science, University of Bergen, Bergen, Norway
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16
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Kalafat E, Khalil A. Umbilicocerebral ratio: potential implications of inversing the cerebroplacental ratio. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:159-162. [PMID: 31994251 DOI: 10.1002/uog.21985] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 01/15/2020] [Indexed: 06/10/2023]
Affiliation(s)
- E Kalafat
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Department of Statistics, Middle East Technical University, Faculty of Arts and Sciences, Ankara, Turkey
| | - 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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17
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Stefopoulou M, Johnson J, Wilsgaard T, Lindgren P, Herling L, Kiserud T, Acharya G. Volume blood flow-based indices of fetal brain sparing in the second half of pregnancy: A longitudinal study. Acta Obstet Gynecol Scand 2020; 99:1717-1727. [PMID: 32776322 DOI: 10.1111/aogs.13950] [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: 03/23/2020] [Revised: 06/24/2020] [Accepted: 06/30/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Cerebroplacental ratio (CPR) and umbilicocerebral ratio (UCR) are clinically used as a measure of fetal brain sparing. These are calculated as the ratios between the pulsatility indices (PIs) of middle cerebral (MCA) and umbilical (UA) arteries, and are an indirect representation of the balance between cerebral and placental perfusion. Volume blood flow (Q)-based ratios, ie Q-CPR or Q-UCR, would directly reflect the distribution of fetal cardiac output to the placenta and brain. Thus, we aimed to determine the development pattern of Q-CPR and Q-UCR during the second half of pregnancy, construct reference intervals, and evaluate their association with CPR and UCR. MATERIAL AND METHODS In a longitudinal cohort study of low-risk pregnancies, the inner diameter of the fetal superior vena cava (SVC) and umbilical vein (UV) was measured and velocity waveforms were obtained from the MCA, UA, UV and SVC using ultrasound at approximately 4-weekly intervals from 20 to 41 weeks. The CPR was calculated as PIMCA /PIUA and the inverse ratio was the UCR. Cerebral and placental blood flows were estimated as the product of mean velocity and cross-sectional area of the SVC and UV, respectively. Q-CPR was calculated as QSVC /QUV and the inverse as the Q-UCR. Gestational age-specific reference intervals were calculated and associations between variables were tested using multilevel regression modeling. RESULTS Longitudinal reference intervals of Q-CPR and Q-UCR were established based on 471 paired measurements of QSVC and QUV obtained serially from 134 singleton pregnancies. The mean Q-CPR increased from 0.4 to 0.8 during the second half of pregnancy and Q-UCR declined from 2.5 to 1.3, while the CPR and UCR had U-shaped curves but in opposite directions. No significant correlation was found between CPR and Q-CPR (R = 0.10; P = .051), or UCR and Q-UCR (R = 0.09; P = .11), and the agreement between PI-based and Q-based indices of fetal brain sparing was poor. CONCLUSIONS Indices of fetal brain sparing based on placental and cerebral volume blood flow differ from those calculated from UA and MCA PIs. They correlated poorly with conventional CPR and UCR, indicating that they may provide additional/different physiological information. Reference values of Q-CPR and Q-UCR established here can be useful to investigate their clinical value further.
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Affiliation(s)
- Maria Stefopoulou
- Department of Clinical Science, Division of Obstetrics and Gynecology, Intervention & Technology, Karolinska Institutet and Center for Fetal Medicine Karolinska, University Hospital, Stockholm, Sweden.,Department of Clinical Medicine, Faculty of Health Sciences, Women's Health and Perinatology Research Group, UiT-The Arctic University of Norway, Tromsø, Norway.,Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway
| | - Jonas Johnson
- Department of Clinical Science, Division of Obstetrics and Gynecology, Intervention & Technology, Karolinska Institutet and Center for Fetal Medicine Karolinska, University Hospital, Stockholm, Sweden
| | - Tom Wilsgaard
- Department of Community Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
| | - Peter Lindgren
- Department of Clinical Science, Division of Obstetrics and Gynecology, Intervention & Technology, Karolinska Institutet and Center for Fetal Medicine Karolinska, University Hospital, Stockholm, Sweden
| | - Lotta Herling
- Department of Clinical Science, Division of Obstetrics and Gynecology, Intervention & Technology, Karolinska Institutet and Center for Fetal Medicine Karolinska, University Hospital, Stockholm, Sweden.,Department of Clinical Medicine, Faculty of Health Sciences, Women's Health and Perinatology Research Group, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Torvid Kiserud
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Ganesh Acharya
- Department of Clinical Science, Division of Obstetrics and Gynecology, Intervention & Technology, Karolinska Institutet and Center for Fetal Medicine Karolinska, University Hospital, Stockholm, Sweden.,Department of Clinical Medicine, Faculty of Health Sciences, Women's Health and Perinatology Research Group, UiT-The Arctic University of Norway, Tromsø, Norway.,Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway
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