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Ramirez Zegarra R, Ghi T, Lees C. Does the use of angiogenic biomarkers for the management of preeclampsia and fetal growth restriction improve outcomes?: Challenging the current status quo. Eur J Obstet Gynecol Reprod Biol 2024; 300:268-277. [PMID: 39053087 DOI: 10.1016/j.ejogrb.2024.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Accepted: 07/21/2024] [Indexed: 07/27/2024]
Abstract
Monitoring and timing of delivery in preterm preeclampsia and fetal growth restriction is one of the biggest challenges in Obstetrics. Finding the optimal time of delivery of these fetuses usually involves a trade-off between the severity of the disease and prematurity. So far, most clinical guidelines recommend the use of a combination between clinical, laboratory and ultrasound markers to guide the time of delivery. Angiogenic biomarkers, especially placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1), have gained significant attention in recent years for their potential role in the prediction and diagnosis of placenta-related disorders including preeclampsia and fetal growth restriction. Another potential clinical application of the angiogenic biomarkers is for the differential diagnosis of patients with chronic kidney disease, as this condition shares similar clinical features with preeclampsia. Consequently, angiogenic biomarkers have been advocated as tools for monitoring and deciding the optimal time of the delivery of fetuses affected by placental dysfunction. In this clinical opinion, we critically review the available literature on PlGF and sFlt-1 for the surveillance and time of the delivery in fetuses affected by preterm preeclampsia and fetal growth restriction. Moreover, we explore the use of angiogenic biomarkers for the differentiation between chronic kidney disease and superimposed preeclampsia.
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Affiliation(s)
- Ruben Ramirez Zegarra
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Tullio Ghi
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Christoph Lees
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom; Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium
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2
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Marijnen MC, Kamphof HD, Damhuis SE, Smies M, Leemhuis AG, Wolf H, Gordijn SJ, Ganzevoort W. Doppler ultrasound of umbilical and middle cerebral artery in third trimester small-for-gestational age fetuses to decide on timing of delivery for suspected fetal growth restriction: A cohort with nested RCT (DRIGITAT). BJOG 2024; 131:1042-1053. [PMID: 38498267 DOI: 10.1111/1471-0528.17770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/09/2024] [Accepted: 01/10/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVE To assess the association of the umbilicocerebral ratio (UCR) with adverse perinatal outcome in late preterm small-for-gestational age (SGA) fetuses and to investigate the effect on perinatal outcomes of immediate delivery. DESIGN Multicentre cohort study with nested randomised controlled trial (RCT). SETTING Nineteen secondary and tertiary care centres. POPULATION Singleton SGA pregnancies (estimated fetal weight [EFW] or fetal abdominal circumference [FAC] <10th centile) from 32 to 36+6 weeks. METHODS Women were classified: (1) RCT-eligible: abnormal UCR twice consecutive and EFW below the 3rd centile at/or below 35 weeks or below the 10th centile at 36 weeks; (2) abnormal UCR once or intermittent; (3) never abnormal UCR. Consenting RCT-eligible patients were randomised for immediate delivery from 34 weeks or expectant management until 37 weeks. MAIN OUTCOME MEASURES A composite adverse perinatal outcome (CAPO), defined as perinatal death, birth asphyxia or major neonatal morbidity. RESULTS The cohort consisted of 690 women. The study was halted prematurely for low RCT-inclusion rates (n = 40). In the RCT-eligible group, gestational age at delivery, birthweight and birthweight multiple of the median (MoM) (0.66, 95% confidence interval [CI] 0.59-0.72) were significantly lower and the CAPO (n = 50, 44%, p < 0.05) was more frequent. Among patients randomised for immediate delivery there was a near-significant lower birthweight (p = 0.05) and higher CAPO (p = 0.07). EFW MoM, pre-eclampsia, gestational hypertension and Doppler classification were independently associated with the CAPO (area under the curve 0.71, 95% CI 0.67-0.76). CONCLUSIONS Perinatal risk was effectively identified by low EFW MoM and UCR. Early delivery of SGA fetuses with an abnormal UCR at 34-36 weeks should only be performed in the context of clinical trials.
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Affiliation(s)
- Mauritia C Marijnen
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Hester D Kamphof
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Stefanie E Damhuis
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Maddy Smies
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Aleid G Leemhuis
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Hans Wolf
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Sanne J Gordijn
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
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Nieto-Tous M, Novillo-Del Álamo B, Martínez-Varea A, Satorres-Pérez E, Morales-Roselló J. Comparison of a Two (32/38 Weeks) versus One (36 Weeks) Ultrasound Protocol for the Detection of Decreased Fetal Growth and Adverse Perinatal Outcome. J Pers Med 2024; 14:709. [PMID: 39063963 PMCID: PMC11278302 DOI: 10.3390/jpm14070709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 06/22/2024] [Accepted: 06/27/2024] [Indexed: 07/28/2024] Open
Abstract
Third-trimester ultrasound has low sensitivity to small for gestational age (SGA) and adverse perinatal outcomes (APOs). The objective of this study was to compare, in terms of cost-effectiveness, two routine third-trimester surveillance protocols for the detection of SGA and evaluate the added value of a Doppler study for the prediction of APO. This was a retrospective observational study of low-risk pregnancies that were followed by a two growth scans protocol (P2) at 32 and 38 weeks or by a single growth scan at 36 weeks (P1). Ultrasound scans included an estimated fetal weight (EFW) in all cases and a Doppler evaluation in most cases. A total of 1011 pregnancies were collected, 528 with the P2 protocol and 483 with the P1 protocol. While the two models presented no differences for the detection of SGA in terms of sensitivity (47.89% vs. 50% p = 0.85) or specificity (94.97 vs. 95.86% p = 0.63), routine performance of two growth scans (P2) led to a 35% cost increase. The accuracy of EFW for the detection of SGA showed a noteworthy improvement when reducing the interval to labor, and the only parameter with predictive capacity of APO was the cerebroplacental ratio at 38 weeks. In low-risk pregnancies, the higher costs of a two-scan growth surveillance protocol at the third trimester are not justified by an increase in diagnostic effectivity.
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Affiliation(s)
- Mar Nieto-Tous
- Departamento de Obstetricia y Ginecología, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (B.N.-D.Á.); (A.M.-V.); (E.S.-P.); (J.M.-R.)
| | - Blanca Novillo-Del Álamo
- Departamento de Obstetricia y Ginecología, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (B.N.-D.Á.); (A.M.-V.); (E.S.-P.); (J.M.-R.)
| | - Alicia Martínez-Varea
- Departamento de Obstetricia y Ginecología, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (B.N.-D.Á.); (A.M.-V.); (E.S.-P.); (J.M.-R.)
- Departmen of Medicine, CEU Cardenal Herrera University, 12006 Castellón de la Plana, Spain
- Faculty of Health Sciences, Universidad Internacional de Valencia, 46002 Valencia, Spain
| | - Elena Satorres-Pérez
- Departamento de Obstetricia y Ginecología, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (B.N.-D.Á.); (A.M.-V.); (E.S.-P.); (J.M.-R.)
| | - José Morales-Roselló
- Departamento de Obstetricia y Ginecología, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (B.N.-D.Á.); (A.M.-V.); (E.S.-P.); (J.M.-R.)
- Instituto de Investigación Sanitaria La Fe de Valencia, Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain
- Departamento de Pediatría, Obstetricia y Ginecología, Facultad de Medicina, Universitat de València, 46010 Valencia, Spain
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La Verde M, Torella M, Mainini G, Mollo A, Guida M, Passaro M, Dominoni M, Gardella B, Cicinelli E, DE Franciscis P. Late-onset fetal growth restriction management: a national survey. Minerva Obstet Gynecol 2024; 76:244-249. [PMID: 36345906 DOI: 10.23736/s2724-606x.22.05217-4] [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: 06/16/2023]
Abstract
BACKGROUND Fetal growth restriction (FGR) is an obstetric condition that increases the risk of adverse neonatal outcomes. FGR antenatal care aims to decrease fetal morbidity and mortality through optimal fetal monitoring. However, no univocal strategies for late-onset FGR outpatient management are available, and this survey investigated gynaecologists' attitudes concerning outpatient frequency tests. METHODS We mailed a survey to 429 Italian gynaecologists. The primary purpose was the ambulatory care of late-onset FGR without doppler alterations evaluation. The queries estimated the self-reported medical practice regarding cardiotocography (CTG) and obstetric ultrasound exams before hospitalization. Statistical analysis was performed with Stata 14.1 (Stata corp., College Station, TX, USA) for symmetrically distributed continuous variables, and the mean differences were analyzed using the t-test. Where appropriate, the proportions between the groups were evaluated using Fisher's exact or χ2 test. All P value <0.05 were considered statistically significant. RESULTS 128 responses (29.8%) from the 429 SCCAL members were available for the survey. 39.9% of respondents had a late FGR standardized protocol. Regarding non-severe FGR with normal fetal doppler, 70.8% suggested a fetal doppler study after one week (92/128), 13.8% (18/128) and 6.9% (9/128) proposed the exam, respectively, two and three times for a week. 0.8% (1/128) of respondents had a daily doppler exam, 7.7% (10/128) did not answer, and 3.1% (4/128) repeated the ultrasound exam to time for a week. The antenatal CTG was offered: 70.8% (92/128) of gynaecologists recommended one weekly CTG, whereas 13.8% (18/128) suggested two. 6.9% (9/128) recommended three weekly tests and 0.8% a daily test. 7.7% (10/128) of gynaecologists did not respond. At least, we investigated the gynaecologist's recommendations for outpatient EFW evaluation: 59.4% (76/128) repeated EFW after two weeks, 31.3% (40/128) after one week. 3.9% (4/128) and 3.1 (4/128) recommended EFW after three weeks and twice a week. CONCLUSIONS Gynaecologists recommend unnecessary cardiotocography and ultrasound Doppler exams for non-severe late-onset FGR with normal doppler. However, additional studies and comprehensive surveys are needed to support a standardized protocol and assess the feto-maternal outcomes impact.
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Affiliation(s)
- Marco La Verde
- Unit of Obstetrics and Gynecology, Department of Woman, Child and General and Specialized Surgery, Luigi Vanvitelli University of Campania, Naples, Italy
| | - Marco Torella
- Unit of Obstetrics and Gynecology, Department of Woman, Child and General and Specialized Surgery, Luigi Vanvitelli University of Campania, Naples, Italy
| | | | - Antonio Mollo
- Unit of Surgery and Dentistry, Department of Medicine, Schola Medica Salernitana, University of Salerno, Baronissi, Salerno, Italy
| | - Maurizio Guida
- School of Medicine, Unit of Gynecology and Obstetrics, Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy
| | | | - Mattia Dominoni
- Department of Obstetrics and Gynecology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy -
| | - Barbara Gardella
- Department of Obstetrics and Gynecology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
| | - Ettore Cicinelli
- Department of Biomedical Sciences and Human Oncology, University of Bari, Bari, Italy
| | - Pasquale DE Franciscis
- Unit of Obstetrics and Gynecology, Department of Woman, Child and General and Specialized Surgery, Luigi Vanvitelli University of Campania, Naples, Italy
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Mylrea-Foley B, Napolitano R, Gordijn S, Wolf H, Stampalija T, Lees CC. All fetal growth restriction definitions fall short. Am J Obstet Gynecol MFM 2024; 6:101194. [PMID: 37863198 DOI: 10.1016/j.ajogmf.2023.101194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/09/2023] [Indexed: 10/22/2023]
Affiliation(s)
- Bronacha Mylrea-Foley
- Institute of Developmental and Reproductive Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom; Department of Fetal Medicine, Queen Charlotte's and Chelsea Hospital, Imperial College NHS Trust, London, United Kingdom
| | - Raffaele Napolitano
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom; Fetal Medicine Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - Sanne Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hans Wolf
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center (Location AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy; Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Christoph C Lees
- Institute of Developmental and Reproductive Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom; Centre for Fetal Care, Department of Fetal Medicine, Queen Charlotte's and Chelsea Hospital, Imperial College NHS Trust, Du Cane Road, London W120HS, United Kingdom.
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Rajiv P, Cade T, Dean J, Jones GD, Brennecke SP. Maternal serum soluble fms-like tyrosine kinase-1-to-placental growth factor ratio distinguishes growth-restricted from non-growth-restricted small-for-gestational-age fetuses. AJOG GLOBAL REPORTS 2024; 4:100302. [PMID: 38318268 PMCID: PMC10839529 DOI: 10.1016/j.xagr.2023.100302] [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] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Fetal growth restriction secondary to chronic placental insufficiency is a major cause of perinatal morbidity and mortality. A significant proportion of fetuses with fetal growth restriction are small for gestational age, defined as a birthweight of ≤10th percentile. However, not all small-for-gestational-age fetuses are growth restricted. Some are constitutionally small and otherwise healthy. It is important to distinguish between small-for-gestational-age fetuses with and without fetal growth restriction to ensure appropriate interventions in small-for-gestational-age fetuses with fetal growth restriction and to minimize unnecessary interventions in healthy small-for-gestational-age fetuses. The maternal serum ratio of soluble fms-like tyrosine kinase-1 and placental growth factor is an indicator of placental insufficiency in the latter half of pregnancy. As such, the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio may be a clinically useful tool to distinguish between small-for-gestational-age fetuses with and without fetal growth restriction. OBJECTIVE This study aimed to determine whether the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio can distinguish between small-for-gestational-age fetuses with and without fetal growth restriction with a birthweight of ≤10th percentile. STUDY DESIGN A retrospective audit of 233 singleton pregnancies delivering an infant with a birthweight of ≤10th percentile corrected for gestational age with an antenatal maternal serum soluble fms-like tyrosine kinase-1-to-placental growth factor result was performed. Fetal growth restriction was defined as a birthweight of ≤10th percentile with an umbilical artery pulsatility index of >95th percentile, fetal middle cerebral artery pulsatility index of <5th percentile, amniotic fluid index of <6 cm, and/or cerebroplacental ratio of <1st percentile. The soluble fms-like tyrosine kinase-1-to-placental growth factor ratios before delivery between fetuses with and without fetal growth restriction (121 [fetal growth restriction] vs 112 [no fetal growth restriction]) were compared. The Student t test and Fisher exact test were used to compare cases and controls. The Mann-Whitney U test, linear regression analysis, and Spearman correlation coefficient (Rho) were used to examine associations between the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio and fetal outcomes to determine whether the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio served as a prognostic marker of fetal growth restriction severity. RESULTS The mean soluble fms-like tyrosine kinase-1-to-placental growth factor ratio was increased in fetal growth restriction cases compared with non-fetal growth restriction controls (234.3±25.0 vs 67.4±7.7, respectively; P<.0001). When controlling for preeclampsia, which is associated with placental insufficiency, fetal growth restriction cases still demonstrated an independent increase in the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio (effect size, 0.865; 95% confidence interval, 0.509-1.220; P<.001). The soluble fms-like tyrosine kinase-1-to-placental growth factor ratio was negatively correlated with birthweight percentiles in pregnancies delivering an infant with a birthweight of ≤10th percentile (r=-0.3565; P<.0001). This association was maintained for fetuses with fetal growth restriction (r=-0.2309; P<.05), whereas fetuses without fetal growth restriction had no significant correlation between the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio and neonatal birthweight percentiles. CONCLUSION The soluble fms-like tyrosine kinase-1-to-placental growth factor ratio was significantly higher in small-for-gestational-age fetuses with fetal growth restriction than small-for-gestational-age fetuses without fetal growth restriction, independent of preeclampsia. Furthermore, the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio was negatively correlated with fetal growth restriction birthweight percentiles, suggesting that it may be a clinical measure of fetal growth restriction severity. Therefore, the ratio may usefully delineate fetal growth restriction from constitutionally small but otherwise healthy fetuses antenatally, allowing for timely interventions in small-for-gestational-age cases with fetal growth restriction and unnecessary interventions to be minimized in small-for-gestational-age cases without fetal growth restriction.
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Affiliation(s)
- Prithi Rajiv
- Department of Maternal-Fetal Medicine, Pregnancy Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia (Drs Rajiv, Cade, Dean, Davis Jones, and Brennecke)
| | - Thomas Cade
- Department of Maternal-Fetal Medicine, Pregnancy Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia (Drs Rajiv, Cade, Dean, Davis Jones, and Brennecke)
| | - Jennifer Dean
- Department of Maternal-Fetal Medicine, Pregnancy Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia (Drs Rajiv, Cade, Dean, Davis Jones, and Brennecke)
| | - Gabriel Davis Jones
- Department of Maternal-Fetal Medicine, Pregnancy Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia (Drs Rajiv, Cade, Dean, Davis Jones, and Brennecke)
| | - Shaun P. Brennecke
- Department of Maternal-Fetal Medicine, Pregnancy Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia (Drs Rajiv, Cade, Dean, Davis Jones, and Brennecke)
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Melbourne, Australia (Dr Brennecke)
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La Verde M, Savoia F, Riemma G, Schiattarella A, Conte A, Hidar S, Torella M, Colacurci N, De Franciscis P, Morlando M. Fetal aortic isthmus Doppler assessment to predict the adverse perinatal outcomes associated with fetal growth restriction: systematic review and meta-analysis. Arch Gynecol Obstet 2024; 309:79-92. [PMID: 37072584 PMCID: PMC10769912 DOI: 10.1007/s00404-023-06963-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/01/2023] [Indexed: 04/20/2023]
Abstract
PURPOSE Fetal growth restriction (FGR) management and delivery planning is based on a multimodal approach. This meta-analysis aimed to evaluate the prognostic accuracies of the aortic isthmus Doppler to predict adverse perinatal outcomes in singleton pregnancies with FGR. METHODS PubMed, EMBASE, the Cochrane Library, ClinicalTrials.gov and Google scholar were searched from inception to May 2021, for studies on the prognostic accuracy of anterograde aortic isthmus flow compared with retrograde aortic isthmus flow in singleton pregnancy with FGR. The meta-analysis was registered on PROSPERO and was assessed according to PRISMA and Newcastle-Ottawa Scale. DerSimonian and Laird's random-effect model was used for relative risks, Freeman-Tukey Double Arcsine for pooled estimates and exact method to stabilize variances and CIs. Heterogeneity was quantified using I2 statistics. RESULTS A total of 2933 articles were identified through the electronic search, of which 6 studies (involving 240 women) were included. The quality evaluation of studies revealed an overall acceptable score for study group selection and comparability and substantial heterogeneity. The risk of perinatal death was significantly greater in fetuses with retrograde Aortic Isthmus blood flow, with a RR of 5.17 (p value 0.00001). Similarly, the stillbirth rate was found to have a RR of 5.39 (p value 0.00001). Respiratory distress syndrome had a RR of 2.64 (p value = 0.03) in the group of fetuses with retrograde Aortic Isthmus blood flow. CONCLUSION Aortic Isthmus Doppler study may add information for FGR management. However, additional clinical trial are required to assess its applicability in clinical practice.
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Affiliation(s)
- M La Verde
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", Largo Madonna delle Grazie 1, 80138, Naples, Italy.
| | - F Savoia
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", Largo Madonna delle Grazie 1, 80138, Naples, Italy
| | - G Riemma
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", Largo Madonna delle Grazie 1, 80138, Naples, Italy
| | - A Schiattarella
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", Largo Madonna delle Grazie 1, 80138, Naples, Italy
| | - A Conte
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", Largo Madonna delle Grazie 1, 80138, Naples, Italy
| | - S Hidar
- Obstetrics and Gynecology Department, F. Hached University Teaching Hospital, 4000, Sousse, Tunisia
| | - M Torella
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", Largo Madonna delle Grazie 1, 80138, Naples, Italy
| | - N Colacurci
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", Largo Madonna delle Grazie 1, 80138, Naples, Italy
| | - P De Franciscis
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", Largo Madonna delle Grazie 1, 80138, Naples, Italy
| | - M Morlando
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", Largo Madonna delle Grazie 1, 80138, Naples, Italy
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8
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Mylrea-Foley B, Napolitano R, Gordijn S, Wolf H, Lees CC, Stampalija T. Do differences in diagnostic criteria for late fetal growth restriction matter? Am J Obstet Gynecol MFM 2023; 5:101117. [PMID: 37544409 DOI: 10.1016/j.ajogmf.2023.101117] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/26/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Criteria for diagnosis of fetal growth restriction differ widely according to national and international guidelines, and further heterogeneity arises from the use of different biometric and Doppler reference charts, making the diagnosis of fetal growth restriction highly variable. OBJECTIVE This study aimed to compare fetal growth restriction definitions between Delphi consensus and Society for Maternal-Fetal Medicine definitions, using different standards/charts for fetal biometry and different reference ranges for Doppler velocimetry parameters. STUDY DESIGN From the TRUFFLE 2 feasibility study (856 women with singleton pregnancy at 32+0 to 36+6 weeks of gestation and at risk of fetal growth restriction), we selected 564 women with available mid-pregnancy biometry. For the comparison, we used standards/charts for estimated fetal weight and abdominal circumference from Hadlock, INTERGROWTH-21st, and GROW and Chitty. Percentiles for umbilical artery pulsatility index and its ratios with middle cerebral artery pulsatility index were calculated using Arduini and Ebbing reference charts. Sensitivity and specificity for low birthweight and adverse perinatal outcome were evaluated. RESULTS Different combinations of definitions and reference charts identified substantially different proportions of fetuses within our population as having fetal growth restriction, varying from 38% (with Delphi consensus definition, INTERGROWTH-21st biometric standards, and Arduini Doppler reference ranges) to 93% (with Society for Maternal-Fetal Medicine definition and Hadlock biometric standards). None of the different combinations tested appeared effective, with relative risk for birthweight <10th percentile between 1.4 and 2.1. Birthweight <10th percentile was observed most frequently when selection was made with the GROW/Chitty charts, slightly less with the Hadlock standard, and least frequently with the INTERGROWTH-21st standard. Using the Ebbing Doppler reference ranges resulted in a far higher proportion identified as having fetal growth restriction compared with the Arduini Doppler reference ranges, whereas Delphi consensus definition with Ebbing Doppler reference ranges produced similar results to those of the Society for Maternal-Fetal Medicine definition. Application of Delphi consensus definition with Arduini Doppler reference ranges was significantly associated with adverse perinatal outcome, with any biometric standards/charts. The Society for Maternal-Fetal Medicine definition could not accurately detect adverse perinatal outcome irrespective of estimated fetal weight standard/chart used. CONCLUSION Different combinations of fetal growth restriction definitions, biometry standards/charts, and Doppler reference ranges identify different proportions of fetuses with fetal growth restriction. The difference in adverse perinatal outcome may be modest, but can have a significant impact in terms of rate of intervention.
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Affiliation(s)
- Bronacha Mylrea-Foley
- Institute of Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom (Drs Mylrea-Foley and Lees); Department of Fetal Medicine, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (Drs Mylrea-Foley and Lees)
| | - Raffaele Napolitano
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, United Kingdom (Dr Napolitano); Fetal Medicine Unit, University College London Hospitals NHS Foundation Trust, London, United Kingdom (Dr Napolitano)
| | - Sanne Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands (Dr Gordijn)
| | - Hans Wolf
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center (Location AMC), University of Amsterdam, Amsterdam, The Netherlands (Dr Wolf)
| | - Christoph C Lees
- Institute of Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom (Drs Mylrea-Foley and Lees); Department of Fetal Medicine, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (Drs Mylrea-Foley and Lees).
| | - Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy (Dr Stampalija); Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy (Dr Stampalija)
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9
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Miranda J, Paules C, Noell G, Youssef L, Paternina-Caicedo A, Crovetto F, Cañellas N, Garcia-Martín ML, Amigó N, Eixarch E, Faner R, Figueras F, Simões RV, Crispi F, Gratacós E. Similarity network fusion to identify phenotypes of small-for-gestational-age fetuses. iScience 2023; 26:107620. [PMID: 37694157 PMCID: PMC10485038 DOI: 10.1016/j.isci.2023.107620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/19/2023] [Accepted: 08/09/2023] [Indexed: 09/12/2023] Open
Abstract
Fetal growth restriction (FGR) affects 5-10% of pregnancies, is the largest contributor to fetal death, and can have long-term consequences for the child. Implementation of a standard clinical classification system is hampered by the multiphenotypic spectrum of small fetuses with substantial differences in perinatal risks. Machine learning and multiomics data can potentially revolutionize clinical decision-making in FGR by identifying new phenotypes. Herein, we describe a cluster analysis of FGR based on an unbiased machine-learning method. Our results confirm the existence of two subtypes of human FGR with distinct molecular and clinical features based on multiomic analysis. In addition, we demonstrated that clusters generated by machine learning significantly outperform single data subtype analysis and biologically support the current clinical classification in predicting adverse maternal and neonatal outcomes. Our approach can aid in the refinement of clinical classification systems for FGR supported by molecular and clinical signatures.
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Affiliation(s)
- Jezid Miranda
- BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universidad de Cartagena, Cartagena de Indias, Colombia
| | - Cristina Paules
- BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
- Aragon Institute of Health Research (IIS Aragon), Obstetrics Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Guillaume Noell
- University of Barcelona, Biomedicine Department, IDIBAPS, Centre for Biomedical Research on Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Lina Youssef
- BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | | | - Francesca Crovetto
- BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Nicolau Cañellas
- Metabolomics Platform, IISPV, DEEiA, Universidad Rovira i Virgili, Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), Tarragona, Spain
| | - María L. Garcia-Martín
- BIONAND, Andalusian Centre for Nanomedicine and Biotechnology, Junta de Andalucía, Universidad de Málaga, Málaga, Spain
| | | | - Elisenda Eixarch
- BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Rosa Faner
- University of Barcelona, Biomedicine Department, IDIBAPS, Centre for Biomedical Research on Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Francesc Figueras
- BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Rui V. Simões
- BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
- Institute for Research & Innovation in Health (i3S), University of Porto, Porto, Portugal
| | - Fàtima Crispi
- BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Eduard Gratacós
- BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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10
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Stumpfe FM, Mayr A, Schneider MO, Kehl S, Stübs F, Antoniadis S, Titzmann A, Pontones CA, Bayer CM, Beckmann MW, Faschingbauer F. Cerebroplacental versus Umbilicocerebral Ratio-Analyzing the Predictive Value Regarding Adverse Perinatal Outcomes in Low- and High-Risk Fetuses at Term. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1385. [PMID: 37629674 PMCID: PMC10456565 DOI: 10.3390/medicina59081385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/27/2023]
Abstract
Background and Objectives: The aim of this study was to investigate the prediction of adverse perinatal outcomes using the cerebroplacental (CPR) and umbilicocerebral (UCR) ratios in different cohorts of singleton pregnancies. Materials and Methods: In this retrospective cohort study, we established our own Multiple of Median (MoM) for CPR and UCR. The predictive value for both ratios was studied in the following outcome parameters: emergency cesarean delivery, operative intervention (OI), OI due to fetal distress, 5-min Apgar < 7, admission to neonatal intensive care unit, and composite adverse perinatal outcome. The performance of the ratios was assessed in the following cohorts: total cohort (delivery ≥ 37 + 0 weeks gestation, all birth weight centiles), low-risk cohort (delivery ≥ 37 + 0 weeks gestation, birth weight ≥ 10. centile), prolonged pregnancy cohort (delivery ≥ 41 + 0 weeks gestation, birth weight ≥ 10. centile) and small-for-gestational-age fetuses (delivery ≥ 37 + 0 weeks gestation, birth weight < 10. centile). The underlying reference values for MoM were estimated using quantile regression depending on gestational age. Prediction performance was evaluated using logistic regression models assessing the corresponding Brier score, combining discriminatory power and calibration. Results: Overall, 3326 cases were included. Across all cohorts, in the case of a significant association between a studied outcome parameter and CPR, there was an association with UCR, respectively. The Brier score showed only minimal differences for both ratios. Conclusions: Our study provides further evidence regarding predictive values of CPR and UCR. The results of our study suggest that reversal of CPR to UCR does not improve the prediction of adverse perinatal outcomes.
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Affiliation(s)
- Florian M. Stumpfe
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (F.M.S.)
| | - Andreas Mayr
- Department of Medical Biometry, Informatics and Epidemiology, Faculty of Medicine, University of Bonn, 53127 Bonn, Germany
| | - Michael O. Schneider
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (F.M.S.)
| | - Sven Kehl
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (F.M.S.)
| | - Frederik Stübs
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (F.M.S.)
| | - Sophia Antoniadis
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (F.M.S.)
| | - Adriana Titzmann
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (F.M.S.)
| | - Constanza A. Pontones
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (F.M.S.)
| | | | - Matthias W. Beckmann
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (F.M.S.)
| | - Florian Faschingbauer
- Department of Obstetrics and Gynecology, University Hospital of Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (F.M.S.)
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11
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Peasley R, Rangel LAA, Casagrandi D, Donadono V, Willinger M, Conti G, Seminara Y, Marlow N, David AL, Attilakos G, Pandya P, Zaikin A, Peebles D, Napolitano R. Management of late-onset fetal growth restriction: pragmatic approach. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:106-114. [PMID: 36864542 DOI: 10.1002/uog.26190] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 02/08/2023] [Accepted: 02/15/2023] [Indexed: 07/02/2023]
Abstract
OBJECTIVES There is limited prospective evidence to guide the management of late-onset fetal growth restriction (FGR) and its differentiation from small-for-gestational age. The aim of this study was to assess prospectively a novel protocol in which ultrasound criteria were used to classify women with suspected late FGR into two groups: those at low risk, who were managed expectantly until the anticipated date of delivery, and those at high risk, who were delivered soon after 37 weeks of gestation. We also compared the outcome of this prospective cohort with that of a historical cohort of women presenting similarly with suspected late FGR, in order to evaluate the impact of the new protocol. METHODS This was a prospective study of women with a non-anomalous singleton pregnancy at ≥ 32 weeks' gestation attending a tertiary hospital in London, UK, between February 2018 and September 2019, with estimated fetal weight (EFW) ≤ 10th centile, or EFW > 10th centile in addition to a decrease in fetal abdominal circumference of ≥ 50 centiles compared with a previous scan, umbilical artery Doppler pulsatility index > 95th centile or cerebroplacental ratio < 5th centile. Women were classified as low or high risk based on ultrasound and Doppler criteria. Women in the low-risk group were delivered by 41 weeks of gestation, unless they subsequently met high-risk criteria, whereas women in the high-risk group (EFW < 3rd centile, umbilical artery Doppler pulsatility index > 95th centile or EFW between 3rd and 10th centiles (inclusive) with abdominal circumference drop or abnormal Dopplers) were delivered at or soon after 37 weeks. The primary outcome was adverse neonatal outcome and included hypothermia, hypoglycemia, neonatal unit admission, jaundice requiring treatment, suspected infection, feeding difficulties, 1-min Apgar score < 7, hospital readmission and any severe adverse neonatal outcome (perinatal death, resuscitation using inotropes or mechanical ventilation, 5-min Apgar score < 7, metabolic acidosis, sepsis, and cerebral, cardiac or respiratory morbidity). Secondary outcomes were adverse maternal outcome (operative delivery for abnormal fetal heart rate) and severe adverse neonatal outcome. Women managed according to the new protocol were compared with a historical cohort of 323 women delivered prior to the implementation of the new protocol, for whom management was guided by individual clinician expertise. RESULTS Over 18 months, 321 women were recruited to the prospective cohort, of whom 156 were classified as low risk and 165 were high risk. Adverse neonatal outcome was significantly less common in the low-risk compared with the high-risk group (45% vs 58%; adjusted odds ratio (aOR), 0.6 (95% CI, 0.4-0.9); P = 0.022). There was no significant difference in the rate of adverse maternal outcome (18% vs 24%; aOR, 0.7 (95% CI, 0.4-1.2); P = 0.142) or severe adverse neonatal outcome (3.8% vs 8.5%; aOR, 0.5 (95% CI, 0.2-1.3); P = 0.153) between the low- and high-risk groups. Compared with women in the historical cohort classified retrospectively as low risk, low-risk women managed under the new protocol had a lower rate of adverse neonatal outcome (45% vs 58%; aOR, 0.6 (95% CI, 0.4-0.9); P = 0.026). CONCLUSIONS Appropriate risk stratification to guide management of late FGR was associated with a reduced rate of adverse neonatal outcome in low-risk pregnancies. In clinical practice, a policy of expectantly managing women with a low-risk late-onset FGR pregnancy at term could improve neonatal and long-term development. Randomized controlled trials are needed to assess the effect of an evidence-based conservative management protocol for late FGR on perinatal morbidity and mortality and long-term neurodevelopment. © 2023 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)
- R Peasley
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - L A Abrego Rangel
- Department of Women's Cancer, Institute for Women's Health, University College London, London, UK
- Department of Mathematics, University College London, London, UK
| | - D Casagrandi
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - V Donadono
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - M Willinger
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - G Conti
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - Y Seminara
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - N Marlow
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - A L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
- National Institute for Health Research, University College London Hospitals Biomedical Research Centre, University College London, London, UK
| | - G Attilakos
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - P Pandya
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - A Zaikin
- Department of Women's Cancer, Institute for Women's Health, University College London, London, UK
- Department of Mathematics, University College London, London, UK
| | - D Peebles
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
- National Institute for Health Research, University College London Hospitals Biomedical Research Centre, University College London, London, UK
| | - R Napolitano
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
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12
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Familiari A, Napolitano R, Visser GHA, Lees C, Wolf H, Prefumo F. Antenatal corticosteroids and perinatal outcome in late fetal growth restriction: analysis of prospective cohort. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:191-197. [PMID: 36412975 PMCID: PMC10108243 DOI: 10.1002/uog.26127] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/21/2022] [Accepted: 10/27/2022] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To evaluate the role of antenatal administration of corticosteroids for fetal lung maturation on the short-term perinatal outcome of pregnancy complicated by late fetal growth restriction (FGR). METHODS This cohort study was a secondary analysis of a multicenter prospective observational study, the TRUFFLE-2 feasibility study, conducted between 2017 and 2018 in 33 European perinatal centers. The study included women with a singleton pregnancy from 32 + 0 to 36 + 6 weeks of gestation with a fetus considered at risk for FGR, defined as estimated fetal weight (EFW) and/or fetal abdominal circumference < 10th percentile, or umbilicocerebral ratio (UCR) ≥ 95th percentile or a drop of more than 40 percentile points in abdominal circumference measurement from the 20-week scan. For the purposes of the current study, we identified women who received a single course of steroids to improve fetal lung maturation before delivery. Each exposed pregnancy was matched with one that did not receive antenatal corticosteroids (ACS) (control), based on gestational age at delivery and birth weight. The primary adverse outcome was a composite of abnormal condition at birth, major neonatal morbidity or perinatal death. RESULTS A total of 86 pregnancies that received ACS were matched to 86 controls. The two groups were similar with respect to gestational age (33.1 vs 33.3 weeks), EFW (1673 vs 1634 g) and UCR (0.68 vs 0.62) at inclusion, and gestational age at delivery (35.5 vs 35.9 weeks) and birth weight (1925 vs 1948 g). No significant differences were observed between the exposed and non-exposed groups in the incidence of composite adverse outcome (28% vs 24%; P = 0.73) or any of its elements. CONCLUSION The present data do not show a beneficial effect of steroids on short-term outcome of fetuses with late FGR. © 2023 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)
- A. Familiari
- Department of Woman and Child Health and Public HealthFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
| | - R. Napolitano
- Elizabeth Garrett Anderson Institute for Women's HealthUniversity College LondonLondonUK
- Fetal Medicine UnitUniversity College London Hospitals NHS Foundation TrustLondonUK
| | - G. H. A. Visser
- Department of ObstetricsUniversity Medical CenterUtrechtThe Netherlands
| | - C. Lees
- Centre for Fetal Care, Department of Obstetrics and GynaecologyQueen Charlotte's and Chelsea Hospital, Imperial College LondonLondonUK
| | - H. Wolf
- Department of Obstetrics and GynecologyAmsterdam University Medical Center (Location AMC), University of AmsterdamAmsterdamThe Netherlands
| | - F. Prefumo
- Obstetrics and Gynecology UnitIRCCS Istituto Giannina GasliniGenoaItaly
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13
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Mylrea-Foley B, Wolf H, Stampalija T, Lees C, Arabin B, Berger A, Bergman E, Bhide A, Bilardo CM, Breeze AC, Brodszki J, Calda P, Cetin I, Cesari E, Derks J, Ebbing C, Ferrazzi E, Ganzevoort W, Frusca T, Gordijn SJ, Gyselaers W, Hecher K, Klaritsch P, Krofta L, Lindgren P, Lobmaier SM, Marlow N, Maruotti GM, Mecacci F, Myklestad K, Napolitano R, Prefumo F, Raio L, Richter J, Sande RK, Thornton J, Valensise H, Visser GHA, Wee L. Longitudinal Doppler Assessments in Late Preterm Fetal Growth Restriction. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2023; 44:56-67. [PMID: 34768305 DOI: 10.1055/a-1511-8293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
PURPOSE To assess the longitudinal variation of the ratio of umbilical and cerebral artery pulsatility index (UCR) in late preterm fetal growth restriction (FGR). MATERIALS AND METHODS A prospective European multicenter observational study included women with a singleton pregnancy, 32+ 0-36+ 6, at risk of FGR (estimated fetal weight [EFW] or abdominal circumference [AC] < 10th percentile, abnormal arterial Doppler or fall in AC from 20-week scan of > 40 percentile points). The primary outcome was a composite of abnormal condition at birth or major neonatal morbidity. UCR was categorized as normal (< 0.9) or abnormal (≥ 0.9). UCR was assessed by gestational age at measurement interval to delivery, and by individual linear regression coefficient in women with two or more measurements. RESULTS 856 women had 2770 measurements; 696 (81 %) had more than one measurement (median 3 (IQR 2-4). At inclusion, 63 (7 %) a UCR ≥ 0.9. These delivered earlier and had a lower birth weight and higher incidence of adverse outcome (30 % vs. 9 %, relative risk 3.2; 95 %CI 2.1-5.0) than women with a normal UCR at inclusion. Repeated measurements after an abnormal UCR at inclusion were abnormal again in 67 % (95 %CI 55-80), but after a normal UCR the chance of finding an abnormal UCR was 6 % (95 %CI 5-7 %). The risk of composite adverse outcome was similar using the first or subsequent UCR values. CONCLUSION An abnormal UCR is likely to be abnormal again at a later measurement, while after a normal UCR the chance of an abnormal UCR is 5-7 % when repeated weekly. Repeated measurements do not predict outcome better than the first measurement, most likely due to the most compromised fetuses being delivered after an abnormal UCR.
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Affiliation(s)
- Bronacha Mylrea-Foley
- Institute for Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, UK
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London W12 0HS
| | - Hans Wolf
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center (Location AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Christoph Lees
- Institute for Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, UK
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London W12 0HS
- Department of Gynecology and Obstetrics, UZ Leuven and Department of Regeneration and Development, KU Leuven, Leuven, Belgium
| | - B Arabin
- Department of Obstetrics Charite, Humboldt University Berlin and Clara Angela Foundation, Berlin, Germany
| | - A Berger
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria
| | - E Bergman
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - A Bhide
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust and Molecular & Clinical Sciences Research Institute, St George's, University of London, London, UK
| | - C M Bilardo
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, University of Amsterdam, location VUMC, Amsterdam, The Netherlands
| | - A C Breeze
- Fetal Medicine Unit, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - J Brodszki
- Department of Pediatric Surgery and Neonatology, Lund University, Skane University Hospital, Lund, Sweden
| | - P Calda
- Department of Obstetrics and Gynaecology, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - I Cetin
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - E Cesari
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - J Derks
- Department of Perinatal Medicine, University of Utrecht, Utrecht, The Netherlands
| | - C Ebbing
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
| | - E Ferrazzi
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - W Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center (Location AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - T Frusca
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - S J Gordijn
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - W Gyselaers
- Faculty of Medicine and Life Sciences, Hasselt University, Agoralaan, Diepenbeek, Belgium, Department of Obstetrics & Gynaecology, Ziekenhuis Oost-Limburg, Genk and Department Physiology, Hasselt University, Diepenbeek, Belgium
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - P Klaritsch
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - L Krofta
- Institute for the Care of Mother and Child, Prague, Czech Republic and Third Medical Faculty, Charles University, Prague, Czech Republic
| | - P Lindgren
- Center for Fetal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - S M Lobmaier
- Department of Obstetrics and Gynecology, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - N Marlow
- UCL Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - G M Maruotti
- Department of Neurosciences, Reproductive and Dentistry Sciences, University of Naples 'Federico II', Naples, Italy
| | - F Mecacci
- Department of Health Sciences, University of Florence, Obstetrics and Gynecology, Careggi University Hospital, Florence, Italy
| | | | - R Napolitano
- UCL Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - F Prefumo
- Department of Obstetrics and Gynecology, ASST Spedali Civili di Brescia and University of Brescia, Brescia, Italy
| | - L Raio
- Department of Obstetrics & Gynecology, University Hospital of Bern, Bern, Switzerland
| | - J Richter
- Department of Gynecology and Obstetrics, UZ Leuven and Department of Regeneration and Development, KU Leuven, Leuven, Belgium
| | - R K Sande
- Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger and Department of Clinical Science, University of Bergen, Bergen, Norway
| | - J Thornton
- School of Clinical Sciences, University of Nottingham, Division of Obstetrics and Gynaecology, Maternity Department, City Hospital, Nottingham, UK
| | - H Valensise
- Department of Surgery, Division of Obstetrics and Gynecology, Tor Vergata, University, Policlinico Casilino Hospital, Rome, Italy
| | - G H A Visser
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
| | - L Wee
- The Princess Alexandra Hospital NHS Trust, Harlow, UK
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14
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Stampalija T, Wolf H, Mylrea-Foley B, Marlow N, Stephens KJ, Shaw CJ, Lees CC. Reduced fetal growth velocity and weight loss are associated with adverse perinatal outcome in fetuses at risk of growth restriction. Am J Obstet Gynecol 2023; 228:71.e1-71.e10. [PMID: 35752304 DOI: 10.1016/j.ajog.2022.06.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/15/2022] [Accepted: 06/16/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Although fetal size is associated with adverse perinatal outcome, the relationship between fetal growth velocity and adverse perinatal outcome is unclear. OBJECTIVE This study aimed to evaluate the relationship between fetal growth velocity and signs of cerebral blood flow redistribution, and their association with birthweight and adverse perinatal outcome. STUDY DESIGN This study was a secondary analysis of the TRUFFLE-2 multicenter observational prospective feasibility study of fetuses at risk of fetal growth restriction between 32+0 and 36+6 weeks of gestation (n=856), evaluated by ultrasound biometry and umbilical and middle cerebral artery Doppler. Individual fetal growth velocity was calculated from the difference of birthweight and estimated fetal weight at 3, 2, and 1 week before delivery, and by linear regression of all available estimated fetal weight measurements. Fetal estimated weight and birthweight were expressed as absolute value and as multiple of the median for statistical calculation. The coefficients of the individual linear regression of estimated fetal weight measurements (growth velocity; g/wk) were plotted against the last umbilical-cerebral ratio with subclassification for perinatal outcome. The association of these measurements with adverse perinatal outcome was assessed. The adverse perinatal outcome was a composite of abnormal condition at birth or major neonatal morbidity. RESULTS Adverse perinatal outcome was more frequent among fetuses whose antenatal growth was <100 g/wk, irrespective of signs of cerebral blood flow redistribution. Infants with birthweight <0.65 multiple of the median were enrolled earlier, had the lowest fetal growth velocity, higher umbilical-cerebral ratio, and were more likely to have adverse perinatal outcome. A decreasing fetal growth velocity was observed in 163 (19%) women in whom the estimated fetal weight multiple of the median regression coefficient was <-0.025, and who had higher umbilical-cerebral ratio values and more frequent adverse perinatal outcome; 67 (41%; 8% of total group) of these women had negative growth velocity. Estimated fetal weight and umbilical-cerebral ratio at admission and fetal growth velocity combined by logistic regression had a higher association with adverse perinatal outcome than any of those parameters separately (relative risk, 3.3; 95% confidence interval, 2.3-4.8). CONCLUSION In fetuses at risk of late preterm fetal growth restriction, reduced growth velocity is associated with an increased risk of adverse perinatal outcome, irrespective of signs of cerebral blood flow redistribution. Some fetuses showed negative growth velocity, suggesting catabolic metabolism.
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Affiliation(s)
- Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, Istituto di Ricovero e Cura a Carattere Scientifico Burlo Garofolo, Trieste, Italy; Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Hans Wolf
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center (Location AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Bronacha Mylrea-Foley
- Institute of Developmental and Reproductive Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom; Department of Fetal Medicine, Queen Charlotte's and Chelsea Hospital, Imperial College National Health Service Trust, London, United Kingdom
| | - Neil Marlow
- Institute for Womens Health, University College London, London, United Kingdom
| | - Katie J Stephens
- Department of Fetal Medicine, Queen Charlotte's and Chelsea Hospital, Imperial College National Health Service Trust, London, United Kingdom
| | - Caroline J Shaw
- Institute of Developmental and Reproductive Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom; Department of Fetal Medicine, Queen Charlotte's and Chelsea Hospital, Imperial College National Health Service Trust, London, United Kingdom
| | - Christoph C Lees
- Institute of Developmental and Reproductive Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom; Department of Fetal Medicine, Queen Charlotte's and Chelsea Hospital, Imperial College National Health Service Trust, London, United Kingdom.
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15
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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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16
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Fantasia I, Zamagni G, Lees C, Mylrea‐Foley B, Monasta L, Mullins E, Prefumo F, Stampalija T. Current practice in the diagnosis and management of fetal growth restriction: An international survey. Acta Obstet Gynecol Scand 2022; 101:1431-1439. [PMID: 36214456 PMCID: PMC9812103 DOI: 10.1111/aogs.14466] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/08/2022] [Accepted: 09/15/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The aim of this survey was to evaluate the current practice in respect of diagnosis and management of fetal growth restriction among obstetricians in different countries. MATERIAL AND METHODS An e-questionnaire was sent via REDCap with "click thru" links in emails and newsletters to obstetric practitioners in different countries and settings with different levels of expertise. Clinical scenarios in early and late fetal growth restriction were given, followed by structured questions/response pairings. RESULTS A total of 275 participants replied to the survey with 87% of responses complete. Participants were obstetrician/gynecologists (54%; 148/275) and fetal medicine specialists (43%; 117/275), and the majority practiced in a tertiary teaching hospital (56%; 153/275). Delphi consensus criteria for fetal growth restriction diagnosis were used by 81% of participants (223/275) and 82% (225/274) included a drop in fetal growth velocity in their diagnostic criteria for late fetal growth restriction. For early fetal growth restriction, TRUFFLE criteria were used for fetal monitoring and delivery timing by 81% (223/275). For late fetal growth restriction, indices of cerebral blood flow redistribution were used by 99% (250/252), most commonly cerebroplacental ratio (54%, 134/250). Delivery timing was informed by cerebral blood flow redistribution in 72% (176/244), used from ≥32 weeks of gestation. Maternal biomarkers and hemodynamics, as additional tools in the context of early-onset fetal growth restriction (≤32 weeks of gestation), were used by 22% (51/232) and 46% (106/230), respectively. CONCLUSIONS The diagnosis and management of fetal growth restriction are fairly homogeneous among different countries and levels of practice, particularly for early fetal growth restriction. Indices of cerebral flow distribution are widely used in the diagnosis and management of late fetal growth restriction, whereas maternal biomarkers and hemodynamics are less frequently assessed but more so in early rather than late fetal growth restriction. Further standardization is needed for the definition of cerebral blood flow redistribution.
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Affiliation(s)
- Ilaria Fantasia
- Unit of Fetal Medicine and Prenatal DiagnosisInstitute for Maternal and Child Health—IRCCS “Burlo Garofolo”TriesteItaly
| | - Giulia Zamagni
- Clinical Epidemiology and Public Health Research UnitInstitute for Maternal and Child Health—IRCCS "Burlo Garofolo"TriesteItaly
| | - Christoph Lees
- Imperial College London, Obstetrics and GynecologyQueen Charlotte's & Chelsea Hospital LondonLondonUK
| | - Bronacha Mylrea‐Foley
- Imperial College London, Obstetrics and GynecologyQueen Charlotte's & Chelsea Hospital LondonLondonUK
| | - Lorenzo Monasta
- Clinical Epidemiology and Public Health Research UnitInstitute for Maternal and Child Health—IRCCS "Burlo Garofolo"TriesteItaly
| | - Edward Mullins
- Imperial College London, Obstetrics and GynecologyQueen Charlotte's & Chelsea Hospital LondonLondonUK
| | - Federico Prefumo
- Obstetrics and Gynecology UnitIRCCS Giannina Gaslini InstituteGenoaItaly
| | - Tamara Stampalija
- Unit of Fetal Medicine and Prenatal DiagnosisInstitute for Maternal and Child Health—IRCCS “Burlo Garofolo”TriesteItaly,Department of Medical, Surgical and Health SciencesUniversity of TriesteTriesteItaly
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17
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Gordijn SJ, Ganzevoort W. Search for the best prediction model, definition and growth charts for fetal growth restriction using a composite of adverse perinatal outcomes: a catch-22? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:305-306. [PMID: 35869942 DOI: 10.1002/uog.26037] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 06/15/2023]
Affiliation(s)
- S J Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - W Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
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18
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Smies M, Damhuis SE, Duijnhoven RG, Leemhuis AG, Gordijn SJ, Ganzevoort W. Study protocol for a randomized trial on timely delivery versus expectant management in late preterm small for gestational age pregnancies with an abnormal umbilicocerebral ratio (UCR): the DRIGITAT study. Trials 2022; 23:619. [PMID: 35915472 PMCID: PMC9344701 DOI: 10.1186/s13063-022-06561-w] [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: 02/10/2022] [Accepted: 07/18/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The clinical inability to correctly identify late fetal growth restriction (FGR) within a group of fetuses who are identified as small for gestational age (SGA) is an everyday problem for all obstetrician-gynecologists. This leads to substantial overtreatment of healthy small fetuses but also inadequate detection of the growth-restricted fetuses that may benefit from timely delivery. Redistribution of the fetal circulation, signaled by an abnormal ratio of the Doppler velocity flow profiles of the umbilical artery and the middle cerebral artery, more specifically an increased umbilicocerebral ratio (UCR) (or its inverse: a decreased cerebroplacental ratio (CPR)), is an adaptation to chronic hypoxemia and nutritional scarcity with long-term consequences in survivors. The relevance of an abnormal UCR has been signaled extensively, and there is a general consensus that it is a signal of FGR, independent of size, with a strong association with poor outcomes. Yet, in the current literature, no comparisons of a monitoring-delivery strategy based on unfavorable UCR have been published. The objective of the Doppler Ratio In fetal Growth restriction Intervention Trial At (near) Term (DRIGITAT) is to evaluate if the timing of the delivery based on an abnormal UCR in late preterm fetuses identified as SGA improves neurodevelopmental outcomes at 2 years of age. METHODS The DRIGITAT study is a national multicenter cohort study of women with singleton pregnancies between 32 and 37 weeks of gestation identified as SGA, with a nested randomized controlled trial (RCT) in case of an abnormal UCR (> 0.8). Recruiting centers are in The Netherlands. In the nested RCT, women are randomized to either immediate induction of labor or expectant management from 34 weeks in case of severely abnormal size (EFW or FAC < p3) and from 36 weeks in case of mildly abnormal size (EFW or FAC p3-p10). The primary outcome measure is the 7-point average difference in the composite cognitive score (CCS) and composite motor score (CMS) on the Bayley-3 at 2 years. Secondary outcome measures include a composite outcome of neonatal morbidity, perinatal mortality, mode of delivery, maternal quality of life, costs, and predictive value of serum biomarkers. Analyses will be by intention to treat. The required sample size is determined for the nested RCT as 185 patients. DISCUSSION This study will provide insight into the diagnostic efficacy of UCR measurement in the evaluation of SGA fetuses in order to differentiate the healthy SGA fetus from the growth-restricted fetus and to determine if a fetus with abnormal UCR benefits from early delivery. TRIAL REGISTRATION Healthcare Evaluation Netherlands NTR6663 . Registered on 14 August 2017.
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Affiliation(s)
- M Smies
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - S E Damhuis
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - R G Duijnhoven
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - A G Leemhuis
- Department of Neonatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - S J Gordijn
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - W Ganzevoort
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.
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19
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Graupner O, Kuschel B, Axt-Fliedner R, Enzensberger C. New Markers for Placental Dysfunction at Term - Potential for More. Geburtshilfe Frauenheilkd 2022; 82:719-726. [PMID: 35815096 PMCID: PMC9262629 DOI: 10.1055/a-1761-1337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/03/2022] [Indexed: 11/23/2022] Open
Abstract
The remaining placental reserve capacity at term plays a decisive role in the perinatal morbidity of mother and child. Considering advances made in the field of fetal monitoring, the
routine examination methods currently used at term or late term may be insufficient to detect subclinical placental dysfunction (PD). The aim of this study is to offer an up-to-date,
narrative review of the literature in the context of detecting PD at term using complementary ultrasound markers and biomarkers. Parameters of fetomaternal Doppler ultrasound and fetal
cardiac function, as well as (anti-)angiogenic factors in maternal serum are potential PD markers. These may help identify patients that may benefit from an elective, early induction of
labor at term, thereby potentially reducing morbidity and mortality. However, their value in terms of the optimal date of delivery must first be determined in randomized controlled trials on
a large number of cases.
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Affiliation(s)
- Oliver Graupner
- Klinik für Gynäkologie und Geburtsmedizin, Universitätsklinikum Aachen, RWTH Aachen, Aachen.,Frauenklinik und Poliklinik, Universitätsklinikum rechts der Isar, Technische Universität München, München
| | - Bettina Kuschel
- Frauenklinik und Poliklinik, Universitätsklinikum rechts der Isar, Technische Universität München, München
| | - Roland Axt-Fliedner
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum UKGM, Justus-Liebig-Universität Gießen, Gießen
| | - Christian Enzensberger
- Klinik für Gynäkologie und Geburtsmedizin, Universitätsklinikum Aachen, RWTH Aachen, Aachen
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20
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Preventing Stillbirth: A Review of Screening and Prevention Strategies. MATERNAL-FETAL MEDICINE 2022. [DOI: 10.1097/fm9.0000000000000160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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21
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Gyselaers W, Lees C. Maternal Low Volume Circulation Relates to Normotensive and Preeclamptic Fetal Growth Restriction. Front Med (Lausanne) 2022; 9:902634. [PMID: 35755049 PMCID: PMC9218216 DOI: 10.3389/fmed.2022.902634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/04/2022] [Indexed: 11/13/2022] Open
Abstract
This narrative review summarizes current evidence on the association between maternal low volume circulation and poor fetal growth. Though much work has been devoted to the study of cardiac output and peripheral vascular resistance, a low intravascular volume may explain why high vascular resistance causes hypertension in women with preeclampsia (PE) that is associated with fetal growth restriction (FGR) and, at the same time, presents with normotension in FGR itself. Normotensive women with small for gestational age babies show normal gestational blood volume expansion superimposed upon a constitutionally low intravascular volume. Early onset preeclampsia (EPE; occurring before 32 weeks) is commonly associated with FGR, and poor plasma volume expandability may already be present before conception, thus preceding gestational volume expansion. Experimentally induced low plasma volume in rodents predisposes to poor fetal growth and interventions that enhance plasma volume expansion in FGR have shown beneficial effects on intrauterine fetal condition, prolongation of gestation and birth weight. This review makes the case for elevating the maternal intravascular volume with physical exercise with or without Nitric Oxide Donors in FGR and EPE, and evaluating its role as a potential target for prevention and/or management of these conditions.
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Affiliation(s)
- Wilfried Gyselaers
- Department of Obstetrics, Ziekenhuis Oost Limburg, Genk, Belgium.,Department of Physiology, Hasselt University, Hasselt, Belgium
| | - Christoph Lees
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom.,Department of Metabolism, Digestion and Reproduction, Institute for Reproductive and Developmental Biology, Imperial College London, London, United Kingdom.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, London, United Kingdom
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22
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Mylrea-Foley B, Thornton JG, Mullins E, Marlow N, Hecher K, Ammari C, Arabin B, Berger A, Bergman E, Bhide A, Bilardo C, Binder J, Breeze A, Brodszki J, Calda P, Cannings-John R, Černý A, Cesari E, Cetin I, Dall'Asta A, Diemert A, Ebbing C, Eggebø T, Fantasia I, Ferrazzi E, Frusca T, Ghi T, Goodier J, Greimel P, Gyselaers W, Hassan W, Von Kaisenberg C, Kholin A, Klaritsch P, Krofta L, Lindgren P, Lobmaier S, Marsal K, Maruotti GM, Mecacci F, Myklestad K, Napolitano R, Ostermayer E, Papageorghiou A, Potter C, Prefumo F, Raio L, Richter J, Sande RK, Schlembach D, Schleußner E, Stampalija T, Thilaganathan B, Townson J, Valensise H, Visser GHA, Wee L, Wolf H, Lees CC. Perinatal and 2-year neurodevelopmental outcome in late preterm fetal compromise: the TRUFFLE 2 randomised trial protocol. BMJ Open 2022; 12:e055543. [PMID: 35428631 PMCID: PMC9014041 DOI: 10.1136/bmjopen-2021-055543] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Following the detection of fetal growth restriction, there is no consensus about the criteria that should trigger delivery in the late preterm period. The consequences of inappropriate early or late delivery are potentially important yet practice varies widely around the world, with abnormal findings from fetal heart rate monitoring invariably leading to delivery. Indices derived from fetal cerebral Doppler examination may guide such decisions although there are few studies in this area. We propose a randomised, controlled trial to establish the optimum method of timing delivery between 32 weeks and 36 weeks 6 days of gestation. We hypothesise that delivery on evidence of cerebral blood flow redistribution reduces a composite of perinatal poor outcome, death and short-term hypoxia-related morbidity, with no worsening of neurodevelopmental outcome at 2 years. METHODS AND ANALYSIS Women with non-anomalous singleton pregnancies 32+0 to 36+6 weeks of gestation in whom the estimated fetal weight or abdominal circumference is <10th percentile or has decreased by 50 percentiles since 18-32 weeks will be included for observational data collection. Participants will be randomised if cerebral blood flow redistribution is identified, based on umbilical to middle cerebral artery pulsatility index ratio values. Computerised cardiotocography (cCTG) must show normal fetal heart rate short term variation (≥4.5 msec) and absence of decelerations at randomisation. Randomisation will be 1:1 to immediate delivery or delayed delivery (based on cCTG abnormalities or other worsening fetal condition). The primary outcome is poor condition at birth and/or fetal or neonatal death and/or major neonatal morbidity, the secondary non-inferiority outcome is 2-year infant general health and neurodevelopmental outcome based on the Parent Report of Children's Abilities-Revised questionnaire. ETHICS AND DISSEMINATION The Study Coordination Centre has obtained approval from London-Riverside Research Ethics Committee (REC) and Health Regulatory Authority (HRA). Publication will be in line with NIHR Open Access policy. TRIAL REGISTRATION NUMBER Main sponsor: Imperial College London, Reference: 19QC5491. Funders: NIHR HTA, Reference: 127 976. Study coordination centre: Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS with Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University. IRAS Project ID: 266 400. REC reference: 20/LO/0031. ISRCTN registry: 76 016 200.
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Affiliation(s)
- Bronacha Mylrea-Foley
- Institute for Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Jim G Thornton
- Department of Obstetrics and Gynaecology, University of Nottingham, City hospital, Nottingham, UK
| | - Edward Mullins
- Institute for Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Neil Marlow
- Elizabeth Garrett Anderson Institute for Women's Health University College London, London, UK
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christina Ammari
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Birgit Arabin
- Department of Obstetrics Charite, Humboldt University of Berlin, Berlin, Germany
| | - Astrid Berger
- Department of Gynecology and Obstetrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Eva Bergman
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Amarnath Bhide
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Caterina Bilardo
- Department of Obstetrics Amsterdam, Vrije Universiteit Amsterdam, Noord-Holland, The Netherlands
| | - Julia Binder
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - Andrew Breeze
- Fetal medicine Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jana Brodszki
- Department of Obstetrics and Gynecology, Lund Skanes universitetssjukhus Lund, Skåne, Sweden
| | - Pavel Calda
- Department of Obstetrics and Gynaecology, Charles University, Praha, Czech Republic
| | | | - Andrej Černý
- Department of Obstetrics & Gynaecology, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Elena Cesari
- Department of Obstetrics and Gynecology, Vittore Buzzi Hospital, University of Milan, Milan, Italy
| | - Irene Cetin
- Department of Obstetrics and Gynecology, Vittore Buzzi Hospital, University of Milan, Milan, Italy
| | | | - Anke Diemert
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Ilaria Fantasia
- Unit of Fetal Medicine and Prenatal Diagnosis, RCCS materno infantile Burlo Garofolo Dipartimento di Pediatria, Trieste, Italy
| | - Enrico Ferrazzi
- Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, ltaly
| | | | - Tullio Ghi
- Department of Obstetrics & Gynecology, University of Parma, Parma, Italy
| | - Jenny Goodier
- Institute for Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Patrick Greimel
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Wilfried Gyselaers
- Department of Obstetrics and Gynecology, Hospital Oost-Limburg, Genk, Belgium
| | - Wassim Hassan
- Obstetrics & Gynaecology, East Suffolk and North Essex NHS Foundation Trust, Colchester Hospital, Colchester, UK
| | | | - Alexey Kholin
- National Medical Research Center for Obstetrics, Gynecology & Perinatology, Moscow, Russia
| | - Philipp Klaritsch
- Division of Obstetrics and Maternal Fetal Medicine, Medical University of Graz, Graz, Austria
| | - Ladislav Krofta
- Institute for Care of Mother and Child, Prague, Czech Republic
| | - Peter Lindgren
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention & Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Silvia Lobmaier
- Department of Obstetrics and Gynecology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Karel Marsal
- Obstetrics and Gynaecology, Faculty of Medicine, Lunds Universitet, Lund, Sweden
| | - Giuseppe M Maruotti
- Department of Neurosciences, Reproductive and Dentistry Sciences, Federico II University Hospital, Napoli, Italy
| | - Federico Mecacci
- High Risk Pregnancy Unit, University Hospital Careggi, Firenze, Italy
| | - Kirsti Myklestad
- Department of Obstetrics, Children's and Women's Health, St Olavs Hospital University Hospital, Trondheim, Norway
| | - Raffaele Napolitano
- Elizabeth Garrett Anderson Institute for Women's Health University College London, London, UK
| | - Eva Ostermayer
- Department of Obstetrics and Gynecology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Aris Papageorghiou
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK,Molecular & Clinical Sciences Research Institute, St George’s, University of London, London, UK
| | - Claire Potter
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Federico Prefumo
- Department of Obstetrics and Gynaecology, Università degli Studi di Brescia, Brescia, Italy
| | - Luigi Raio
- Department of Obstetrics and Gynaecology, University of Bern, Bern, Switzerland
| | - Jute Richter
- Department of Gynecology and Obstetrics, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Ragnar Kvie Sande
- Department of Obstetrics and Gynaecology, Stavanger University Hospital, Stavanger, Norway
| | - Dietmar Schlembach
- Vivantes Network for Health, Clinicum Neukoelln, Clinic for Obstetric Medicine, Berlin, Germany
| | | | - Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, RCCS materno infantile Burlo Garofolo Dipartimento di Pediatria, Trieste, Italy
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK,Molecular & Clinical Sciences Research Institute, St George’s, University of London, London, UK
| | - Julia Townson
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Herbert Valensise
- Division of Obstetrics and Gynaecology Policlinico Casilino, Roma, Italy
| | - Gerard HA Visser
- Department of Obstetrics, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Ling Wee
- Obstetrics And Gynaecology, Princess Alexandra Hospital NHS Trust, Harlow, UK
| | - Hans Wolf
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Christoph C Lees
- Imperial College London, Obstetrics and Gynaecology, Queen Charlotte's & Chelsea Hospital London, London, UK
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Lees CC, Romero R, Stampalija T, Dall'Asta A, DeVore GA, Prefumo F, Frusca T, Visser GHA, Hobbins JC, Baschat AA, Bilardo CM, Galan HL, Campbell S, Maulik D, Figueras F, Lee W, Unterscheider J, Valensise H, Da Silva Costa F, Salomon LJ, Poon LC, Ferrazzi E, Mari G, Rizzo G, Kingdom JC, Kiserud T, Hecher K. Clinical Opinion: The diagnosis and management of suspected fetal growth restriction: an evidence-based approach. Am J Obstet Gynecol 2022; 226:366-378. [PMID: 35026129 PMCID: PMC9125563 DOI: 10.1016/j.ajog.2021.11.1357] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 11/22/2021] [Accepted: 11/22/2021] [Indexed: 11/01/2022]
Abstract
This study reviewed the literature about the diagnosis, antepartum surveillance, and time of delivery of fetuses suspected to be small for gestational age or growth restricted. Several guidelines have been issued by major professional organizations, including the International Society of Ultrasound in Obstetrics and Gynecology and the Society for Maternal-Fetal Medicine. The differences in recommendations, in particular about Doppler velocimetry of the ductus venosus and middle cerebral artery, have created confusion among clinicians, and this review has intended to clarify and highlight the available evidence that is pertinent to clinical management. A fetus who is small for gestational age is frequently defined as one with an estimated fetal weight of <10th percentile. This condition has been considered syndromic and has been frequently attributed to fetal growth restriction, a constitutionally small fetus, congenital infections, chromosomal abnormalities, or genetic conditions. Small for gestational age is not synonymous with fetal growth restriction, which is defined by deceleration of fetal growth determined by a change in fetal growth velocity. An abnormal umbilical artery Doppler pulsatility index reflects an increased impedance to flow in the umbilical circulation and is considered to be an indicator of placental disease. The combined finding of an estimated fetal weight of <10th percentile and abnormal umbilical artery Doppler velocimetry has been widely accepted as indicative of fetal growth restriction. Clinical studies have shown that the gestational age at diagnosis can be used to subclassify suspected fetal growth restriction into early and late, depending on whether the condition is diagnosed before or after 32 weeks of gestation. The early type is associated with umbilical artery Doppler abnormalities, whereas the late type is often associated with a low pulsatility index in the middle cerebral artery. A large randomized clinical trial indicated that in the context of early suspected fetal growth restriction, the combination of computerized cardiotocography and fetal ductus venosus Doppler improves outcomes, such that 95% of surviving infants have a normal neurodevelopmental outcome at 2 years of age. A low middle cerebral artery pulsatility index is associated with an adverse perinatal outcome in late fetal growth restriction; however, there is no evidence supporting its use to determine the time of delivery. Nonetheless, an abnormality in middle cerebral artery Doppler could be valuable to increase the surveillance of the fetus at risk. We propose that fetal size, growth rate, uteroplacental Doppler indices, cardiotocography, and maternal conditions (ie, hypertension) according to gestational age are important factors in optimizing the outcome of suspected fetal growth restriction.
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Affiliation(s)
- Christoph C Lees
- Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom.
| | - 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; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI
| | - Tamara Stampalija
- Department of Obstetrics and Gynecology, Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, Scientific Institute for Research, Hospitalization and Healthcare Burlo Garofolo, Trieste, Italy; Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Andrea Dall'Asta
- Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Greggory A DeVore
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Federico Prefumo
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Tiziana Frusca
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Gerard H A Visser
- Department of Obstetrics, University Medical Center, Utrecht, The Netherlands
| | - John C Hobbins
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO
| | - Ahmet A Baschat
- Department of Gynecology and Obstetrics, John Hopkins Center for Fetal Therapy, Johns Hopkins University, Baltimore, MD
| | - Caterina M Bilardo
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, the Netherlands
| | - Henry L Galan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital of Colorado, Aurora, CO
| | | | - Dev Maulik
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Francesc Figueras
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Pavilion for Women, Houston, TX
| | - Julia Unterscheider
- Department of Maternal-Fetal Medicine, Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Australia
| | - Herbert Valensise
- University of Rome Tor Vergata, Rome, Italy; Department of Surgery, Policlinico Casilino, Rome, Italy
| | - Fabricio Da Silva Costa
- Maternal-Fetal Medicine Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia; School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Laurent J Salomon
- Obstétrique et Plateforme LUMIERE, Hôpital Necker-Enfants Malades (AP-HP) et Université de Paris, Paris, France
| | - Liona C Poon
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong, Special Administrative Region of China
| | - Enrico Ferrazzi
- Department of Woman, Child and Neonate, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giancarlo Mari
- Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Giuseppe Rizzo
- Università di Roma Tor Vergata, Department of Obstetrics and Gynecology, Fondazione Policinico Tor Vergata, Rome, Italy; The First I.M. Sechenov Moscow State Medical University, Department of Obstetrics and Gynaecology, Moscow, Russian Federation
| | - John C Kingdom
- Placenta Program, Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Torvid Kiserud
- Department of Obstetrics and Gynecology, Haukeland University Hospital, and Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Dall'Asta A, Stampalija T, Mecacci F, Minopoli M, Schera GBL, Cagninelli G, Ottaviani C, Fantasia I, Barbieri M, Lisi F, Simeone S, Ghi T, Frusca T. Ultrasound prediction of adverse perinatal outcome at diagnosis of late-onset fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:342-349. [PMID: 34159652 PMCID: PMC9313890 DOI: 10.1002/uog.23714] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To evaluate the relationship between Doppler and biometric ultrasound parameters measured at diagnosis and perinatal adverse outcome in a cohort of late-onset growth-restricted (FGR) fetuses. METHODS This was a multicenter retrospective study of data obtained between 2014 and 2019 including non-anomalous singleton pregnancies complicated by late-onset FGR (≥ 32 weeks), which was defined either as abdominal circumference (AC) or estimated fetal weight (EFW) < 10th percentile for gestational age or as reduction of the longitudinal growth of AC by over 50 percentiles compared to ultrasound scan performed between 18 and 32 weeks of gestation. We evaluated the association between sonographic findings at diagnosis of FGR and composite adverse perinatal outcome (CAPO), defined as stillbirth or at least two of the following: obstetric intervention due to intrapartum fetal distress, neonatal acidemia, birth weight < 3rd percentile and transfer to the neonatal intensive care unit (NICU). RESULTS Overall, 468 cases with complete biometric and umbilical, fetal middle cerebral and uterine artery (UtA) Doppler data were included, of which 53 (11.3%) had CAPO. On logistic regression analysis, only EFW percentile was associated independently with CAPO (P = 0.01) and NICU admission (P < 0.01), while the mean UtA pulsatility index (PI) multiples of the median (MoM) > 95th percentile at diagnosis was associated independently with obstetric intervention due to intrapartum fetal distress (P = 0.01). The model including baseline pregnancy characteristics and the EFW percentile was associated with an area under the receiver-operating-characteristics curve of 0.889 (95% CI, 0.813-0.966) for CAPO (P < 0.001). A cut-off value for EFW corresponding to the 3.95th percentile was found to discriminate between cases with and those without CAPO, yielding a sensitivity of 58.5% (95% CI, 44.1-71.9%), specificity of 69.6% (95% CI, 65.0-74.0%), positive predictive value of 19.8% (95% CI, 13.8-26.8%) and negative predictive value of 92.9% (95% CI, 89.5-95.5%). CONCLUSIONS Retrospective data from a large cohort of late-onset FGR fetuses showed that EFW at diagnosis is the only sonographic parameter associated independently with the occurrence of CAPO, while mean UtA-PI MoM > 95th percentile at diagnosis is associated independently with intrapartum distress leading to obstetric intervention. © 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)
- A. Dall'Asta
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and GynecologyUniversity of ParmaParmaItaly
| | - T. Stampalija
- Unit of Fetal Medicine and Prenatal DiagnosisInstitute for Maternal and Child Health IRCCS Burlo GarofoloTriesteItaly
- Department of MedicineSurgery and Health Sciences, University of TriesteTriesteItaly
| | - F. Mecacci
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and GynecologyUniversity of FlorenceFlorenceItaly
| | - M. Minopoli
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and GynecologyUniversity of ParmaParmaItaly
| | - G. B. L. Schera
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and GynecologyUniversity of ParmaParmaItaly
| | - G. Cagninelli
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and GynecologyUniversity of ParmaParmaItaly
| | - C. Ottaviani
- Unit of Fetal Medicine and Prenatal DiagnosisInstitute for Maternal and Child Health IRCCS Burlo GarofoloTriesteItaly
| | - I. Fantasia
- Unit of Fetal Medicine and Prenatal DiagnosisInstitute for Maternal and Child Health IRCCS Burlo GarofoloTriesteItaly
| | - M. Barbieri
- Unit of Fetal Medicine and Prenatal DiagnosisInstitute for Maternal and Child Health IRCCS Burlo GarofoloTriesteItaly
| | - F. Lisi
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and GynecologyUniversity of FlorenceFlorenceItaly
| | - S. Simeone
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and GynecologyUniversity of FlorenceFlorenceItaly
| | - T. Ghi
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and GynecologyUniversity of ParmaParmaItaly
| | - T. Frusca
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and GynecologyUniversity of ParmaParmaItaly
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An integrated approach based on advanced CTG parameters and Doppler measurements for late growth restriction management. BMC Pregnancy Childbirth 2021; 21:775. [PMID: 34784882 PMCID: PMC8594236 DOI: 10.1186/s12884-021-04235-0] [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: 02/23/2021] [Accepted: 10/15/2021] [Indexed: 11/22/2022] Open
Abstract
Background The clinical diagnosis of late Fetal Growth Restriction (FGR) involves the integration of Doppler ultrasound data and Fetal Heart Rate (FHR) monitoring through computer assisted computerized cardiotocography (cCTG). The aim of the study was to evaluate the diagnostic power of combined Doppler and cCTG parameters by contrasting late FGR –and healthy controls. Methods The study was conducted from January 2018 to May 2020. Only pregnant women who had the last Doppler measurement obtained within 1 week before delivery and cCTG performed within 24 h before delivery were included in the study. Two hundred forty-nine pregnant women fulfilling the inclusion criteria were enrolled in the study; 95 were confirmed as late FGR and 154 were included in the control group. Results Among the extracted cCTG parameters, Delta Index, Short Term Variability (STV), Long Term Variability (LTV), Acceleration and Deceleration Phase Rectified Slope (APRS, DPRS) values were lower in the late FGR participants compared to the control group. In the FGR cohort, Delta, STV, APRS, and DPRS were found different when stratifying by MCA_PI (MCA_PI <5th centile or > 5th centile). STV and DPRS were the only parameters to be found different when stratifying by (UA_PI >95th centile or UA_PI <95th centile). Additionally, we measured the predictive power of cCTG parameters toward the identification of associated Doppler measures using figures of merit extracted from ROC curves. The AUC of ROC curves were accurate for STV (0,70), Delta (0,68), APRS (0,65) and DPRS (0,71) when UA_PI values were > 95th centile while, the accuracy attributable to the prediction of MCA_PI was 0.76, 0.77, 0.73, and 0.76 for STV, Delta, APRS, and DPRS, respectively. An association of UA_PI>95th centile and MCA_PI<5th centile with higher risk for NICU admission, was observed, while CPR < 5th centile resulted not associated with any perinatal outcome. Values of STV, Delta, APRS, DPRS were significantly lower for FGR neonates admitted to NICU, compared with the uncomplicated FGR cohort. Conclusions The results of this study show the contribution of advanced cCTG parameters and fetal Doppler to the identification of late FGR and the association of those parameters with the risk for NICU admission. Trial registration Retrospectively registered.
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张 伊. Recent research on the influence of intrauterine growth restriction on the structure and function of the nervous system. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:1184-1189. [PMID: 34753552 PMCID: PMC8580033 DOI: 10.7499/j.issn.1008-8830.2108044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/22/2021] [Indexed: 11/21/2022]
Abstract
Intrauterine growth restriction (IUGR) is caused by many factors, and most newborns with IUGR are small for gestational age (SGA). SGA infants have a relatively high risk of death and disease in the perinatal period, and the nervous system already has structural changes in the uterus, including the reduction of brain volume and gray matter volume, accompanied by abnormal imaging and pathological changes. IUGR fetuses undergo intrauterine blood flow redistribution to protect brain blood supply, and there are still controversies over the clinical effect of brain protection mechanism. SGA infants have a relatively high risk of abnormal cognitive, motor, language, and behavioral functions in the neonatal period and childhood, and preterm infants tend to have a higher degree of neurological impairment than full-term infants. Early intervention may help to improve the function of the nervous system.
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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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Bahia MLR, Velarde GC, Silva FCD, Araujo Júnior E, Sá RAMD. Adverse perinatal outcomes in fetuses with severe late-onset fetal growth restriction. J Matern Fetal Neonatal Med 2021; 35:8666-8672. [PMID: 34702116 DOI: 10.1080/14767058.2021.1995858] [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
OBJECTIVE To evaluate perinatal outcomes in fetuses with severe late-onset fetal growth restriction. METHODS This was a retrospective and observational cohort study in which pregnant women diagnosed with late-onset fetal growth restriction assisted at perinatal maternity birth from 2010 to 2017 were included. The outcomes were intensive care unit (ICU) admission and perinatal complications, such as neonatal death, intraventricular hemorrhage, periventricular leukomalacia, hypoxic-ischemic encephalopathy, necrotizing enterocolitis, bronchopulmonary dysplasia, and sepsis. RESULTS We selected 277 pregnant women, of whom 124 newborns (44.76%) went to the ICU. The chance of a newborn needing ICU decreases by 62, 7, and 9% according to an increase of one gestational week, 1 cm of the abdominal circumference, or 1 cm of the amniotic fluid index, respectively. Oligohydramnios increases the risk of going to the ICU by 2.13 times. The increase in the umbilical artery pulsatility index (PI) Doppler increases the chance of ICU admission by 7.9 times. The normal middle cerebral artery PI Doppler and the normal cerebroplacental ratio reduce the risk of ICU admission. CONCLUSION The estimated fetal weight, abdominal circumference, and amniotic fluid index diagnosed severe late-onset fetal growth restriction. With the decrease in middle cerebral artery PI Doppler, there is a greater probability of admission to the ICU, with the most common complications being intraventricular hemorrhage and necrotizing enterocolitis.
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Affiliation(s)
- Maria Luiza Rozo Bahia
- Post-Graduate Program in Medical Science, Fluminense Federal University (UFF), Niterói, Brazil.,Fetal Medicine Unit, Perinatal Rede D'Or São Luiz, Rio de Janeiro, Brazil
| | - Guillermo Coca Velarde
- Post-Graduate Program in Medical Science, Fluminense Federal University (UFF), Niterói, Brazil
| | - Fernanda Campos da Silva
- Post-Graduate Program in Medical Science, Fluminense Federal University (UFF), Niterói, Brazil.,Fetal Medicine Unit, Perinatal Rede D'Or São Luiz, Rio de Janeiro, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Renato Augusto Moreira de Sá
- Post-Graduate Program in Medical Science, Fluminense Federal University (UFF), Niterói, Brazil.,Fetal Medicine Unit, Perinatal Rede D'Or São Luiz, Rio de Janeiro, Brazil
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Self A, Papageorghiou AT. Ultrasound Diagnosis of the Small and Large Fetus. Obstet Gynecol Clin North Am 2021; 48:339-357. [PMID: 33972070 DOI: 10.1016/j.ogc.2021.03.003] [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] [Indexed: 11/18/2022]
Abstract
Antenatal imaging is crucial in the management of high-risk pregnancies. Accurate dating relies on acquisition of reliable and reproducible ultrasound images and measurements. Quality image acquisition is necessary for assessing fetal growth and performing Doppler measurements to help diagnose pregnancy complications, stratify risk, and guide management. Further research is needed to ascertain whether current methods for estimating fetal weight can be improved with 3-dimensional ultrasound or magnetic resonance imaging; optimize dating with late initiation of prenatal care; minimize under-diagnosis of fetal growth restriction; and identify the best strategies to make ultrasound more available in low-income and middle-income countries.
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Affiliation(s)
- Alice Self
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Aris T Papageorghiou
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK.
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Lees C, Stampalija T, Hecher K. Re: Outcome-based comparison of SMFM and ISUOG definitions of fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:493-494. [PMID: 34468059 DOI: 10.1002/uog.23747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 07/06/2021] [Indexed: 06/13/2023]
Affiliation(s)
- C Lees
- Imperial College School of Medicine, Imperial College London, London, UK
- Department of Fetal Medicine, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - T Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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Graupner O, Enzensberger C. Prediction of Adverse Pregnancy Outcome Related to Placental Dysfunction Using the sFlt-1/PlGF Ratio: A Narrative Review. Geburtshilfe Frauenheilkd 2021; 81:948-954. [PMID: 34393258 PMCID: PMC8354351 DOI: 10.1055/a-1403-2576] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 02/27/2021] [Indexed: 12/18/2022] Open
Abstract
The sFlt-1 (soluble fms-like tyrosine kinase-1)/PlGF (placental growth factor) ratio is a helpful tool for the prediction and diagnosis of preeclampsia (PE). Current data even show that the ratio has the potential to predict adverse pregnancy outcomes (APO) caused by placental pathologies. The aim of this article is to give a brief overview of recent findings on APO predictions based on the sFlt-1/PlGF ratio. The focus is on obstetric pathologies related to placental dysfunction (PD) such as PE and/or fetal growth restriction (FGR). New uses of the sFlt-1/PlGF ratio as a predictor of APO demonstrate its potential with regard to planning hospitalization and corticosteroid administration and the optimal timing of delivery. However, prospective interventional studies are warranted to define the exact role of the sFlt-1/PlGF ratio as a predictor of adverse pregnancy outcomes caused by placental pathologies.
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Affiliation(s)
- Oliver Graupner
- Department of Obstetrics and Gynecology, University Hospital Aachen, RWTH University, Aachen, Germany.,Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University, Munich, Germany
| | - Christian Enzensberger
- Department of Obstetrics and Gynecology, University Hospital Aachen, RWTH University, Aachen, Germany
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Mylrea-Foley B, Lees C. Clinical monitoring of late fetal growth restriction. Minerva Obstet Gynecol 2021; 73:462-470. [PMID: 34319059 DOI: 10.23736/s2724-606x.21.04845-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Late fetal growth restriction (FGR) poses its own challenges in respect of diagnosis, surveillance and delivery timing. Perinatal morbidity is relatively rare, and mortality extremely unusual, but given that late FGR is much more frequent than early FGR, the burden on neonatal services must not be underestimated. Doppler findings are more subtle than in early FGR, and growth rate rather than absolute fetal size may be important in defining the condition. Though umbilical artery Doppler changes form the basis for triggering delivery: reversed end diastolic flow at 32 weeks, absent at 34 weeks and raised PI at 36 weeks, other modalities of monitoring - for example cardiotocography and cerebral Doppler - are important in surveillance and timing follow up of the condition.
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Affiliation(s)
| | - Christoph Lees
- Imperial College London, London, UK - .,Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College NHS Trust, London, UK
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33
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Lees C, Stampalija T, Hecher K. Diagnosis and management of fetal growth restriction: the ISUOG guideline and comparison with the SMFM guideline. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:884-887. [PMID: 34077604 DOI: 10.1002/uog.23664] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 06/12/2023]
Affiliation(s)
- C Lees
- Institute for Reproductive and Developmental Biology, Imperial College London, London, UK
- Department of Development & Regeneration, KU Leuven, Leuven, Belgium
| | - T Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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34
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Abuhamad A, Martins JG, Biggio JR. Diagnosis and management of fetal growth restriction: the SMFM guideline and comparison with the ISUOG guideline. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:880-883. [PMID: 34077605 DOI: 10.1002/uog.23663] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/06/2021] [Accepted: 04/09/2021] [Indexed: 06/12/2023]
Affiliation(s)
- A Abuhamad
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - J G Martins
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - J R Biggio
- Ochsner Health System, New Orleans, LA, USA
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Stampalija T, Ciardo C, Barbieri M, Risso FM, Travan L. Neurodevelopment of infant with late fetal growth restriction. Minerva Obstet Gynecol 2021; 73:482-489. [PMID: 33949822 DOI: 10.23736/s2724-606x.21.04807-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Late fetal growth restriction has increasingly gain interest. Differently from early fetal growth restriction, the severity of this condition and the impact on perinatal mortality and morbidity is less severe. Nevertheless, there is some evidence to suggest that fetuses exposed to growth restriction late in pregnancy are at increased risk of neurological dysfunction and behavioral impairment. The aim of our review was to discuss the available evidence on the neurodevelopmental outcome in fetuses exposed to growth restriction late in pregnancy. Cerebral blood flow redistribution, a Doppler hallmark of late fetal growth restriction, has been associated with this increased risk, although there are still some controversies. Currently, most of the available studies are heterogeneous and do not distinguish between early and late fetal growth restriction when evaluating the long-term outcome, thus, making the correlation between late fetal growth restriction and neurological dysfunction difficult to interpret. The available evidence suggests that fetuses exposed to late growth restriction are at increased risk of neurological dysfunction and behavioral impairment. The presence of the cerebral blood flow redistribution seems to be associated with adverse neurodevelopmental outcome, however, from the present literature the causality cannot be ascertained.
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Affiliation(s)
- Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy - .,Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy -
| | - Claudia Ciardo
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Moira Barbieri
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Francesco M Risso
- Division of Neonatology, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Laura Travan
- Division of Neonatology, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
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36
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Marasciulo F, Orabona R, Fratelli N, Fichera A, Valcamonico A, Ferrari F, Odicino FE, Sartori E, Prefumo F. Preeclampsia and late fetal growth restriction. Minerva Obstet Gynecol 2021; 73:435-441. [PMID: 33949823 DOI: 10.23736/s2724-606x.21.04809-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
There is a strong but complex relationship between fetal growth restriction and preeclampsia. According to the International Society for the Study of Hypertension in Pregnancy the coexistence of gestational hypertension and fetal growth restriction identifies preeclampsia with no need for other signs of maternal organ impairment. While early-onset fetal growth restriction and preeclampsia are often strictly associated, such association becomes looser in the late preterm and term periods. The incidence of preeclampsia decreases dramatically from early preterm fetal growth restriction (39-43%) to late preterm fetal growth restriction (9-32%) and finally to term fetal growth restriction (4-7%). Different placental and cardiovascular mechanism underlie this trend: isolated fetal growth restriction has less frequent placental vascular lesions than fetal growth restriction associated with preeclampsia; moreover, late preterm and term fetal growth restriction show different patterns of maternal cardiac output and peripheral vascular resistance in comparison with preeclampsia. Consequently, current strategies for first trimester screening of placental dysfunction, originally implemented for preeclampsia, do not perform well for late-onset fetal growth restriction: the sensitivity of first trimester combined screening for small-for-gestational age newborns delivered at less than 32 weeks is 56-63%, and progressively decreases for those delivered at 32-36 weeks (43-48%) or at term (21-26%). Moreover, while the test is more sensitive for small-for-gestational age associated with preeclampsia at any gestational age, its sensitivity is much lower for small-for-gestational age without preeclampsia at 32-36 weeks (31-37%) or at term (19-23%).
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Affiliation(s)
- Francesco Marasciulo
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Rossana Orabona
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Nicola Fratelli
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Anna Fichera
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Adriana Valcamonico
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Federico Ferrari
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Franco E Odicino
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Enrico Sartori
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Federico Prefumo
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy -
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Farsetti D, Pometti F, Tiralongo GM, Lo Presti D, Pisani I, Gagliardi G, Vasapollo B, Novelli GP, Valensise H. Distinction between SGA and FGR by means of fetal umbilical vein flow and maternal hemodynamics. J Matern Fetal Neonatal Med 2021; 35:6593-6599. [PMID: 33938366 DOI: 10.1080/14767058.2021.1918091] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To improve identification of fetal growth restriction (FGR) by means of umbilical venous flow (QUV) and maternal hemodynamics, including systemic vascular resistance (SVR) and cardiac output (CO), in order to distinguish between FGR and SGA. METHODS We enrolled 68 pregnancies (36 SGA, 8 early FGR and 24 late FGR) who underwent a complete fetal hemodynamic examination including QUV and a noninvasive maternal hemodynamics assessment by means of USCOM. RESULTS In comparison with SGA, QUV and corrected for estimated fetal weight QUV (cQUV) were significantly lower in early and late-FGR. In addition, maternal CO was lower in early and late-FGR, while SVR was lower only in early-onset FGR. According to ROC analysis, cQUV centile (AUC 0.92, 0.72) was the best parameter for the prediction of SGA before and after 32 weeks, followed by SVR and CO. For all parameters, the prediction was always better in the case of early-onset FGR <32 weeks. CONCLUSIONS UV flow and maternal hemodynamics examination are useful tools to accurately discern between SGA and FGR.
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Affiliation(s)
- Daniele Farsetti
- Department of Surgery, University of Rome Tor Vergata, Rome, Italy.,Department of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy
| | - Francesca Pometti
- Department of Surgery, University of Rome Tor Vergata, Rome, Italy.,Department of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy
| | | | - Damiano Lo Presti
- Department of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy
| | - Ilaria Pisani
- Department of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy
| | - Giulia Gagliardi
- Department of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy
| | - Barbara Vasapollo
- Department of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy
| | - Gian Paolo Novelli
- Department of Integrated Care Processes, Fondazione PTV Policlinico Tor Vergata, Rome, Italy
| | - Herbert Valensise
- Department of Surgery, University of Rome Tor Vergata, Rome, Italy.,Department of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy
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38
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Granozio G, Napolitano R. Quality control of fetal biometric evaluation and Doppler ultrasound. Minerva Obstet Gynecol 2021; 73:415-422. [PMID: 33904693 DOI: 10.23736/s2724-606x.21.04795-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In recent years quality control in obstetric ultrasound has become recommended and an essential component of obstetric scanning. This is to minimize the inaccuracy and variability related to fetal measurements, to provide an effective quality assurance system to sonographers to certify their practice and decrease the impact of medical litigations. For a quality control system in obstetric ultrasound to be useful clinically, multiple strategies need to be employed: certified training, practical standardization exercise, image storing, qualitative and quantitative quality control. Qualitative quality control consists of the evaluation of images obtained for fetal biometry and Doppler scans using an objective score against predefined criteria. Quantitative quality control consists of analyzing quantitatively the performance of a sonographer and the impact on measurements values. Quantitative analysis could be performed either using estimates of intraobserver or interobserver reproducibility of plane acquisition and caliper placements.
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Affiliation(s)
- Giovanni Granozio
- Fetal Medicine Unit, University College London Hospitals, NHS Foundation Trust, London, UK
| | - Raffaele Napolitano
- Fetal Medicine Unit, University College London Hospitals, NHS Foundation Trust, London, UK - .,Elisabeth Garret Andersson Institute for Women's Health, University College London, London, UK
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39
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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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40
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Fetal Umbilical Vein Flow in the Classification of Fetuses with Growth Restriction. REPRODUCTIVE MEDICINE 2021. [DOI: 10.3390/reprodmed2010006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Objectives: To assess umbilical vein (UV) blood flow in fetal growth restriction (FGR) and in pregnancy with small for gestational age (SGA) fetus. To evaluate the predictive capacity of UV blood flow (QUV) in the discrimination of SGA fetuses from FGR before and after 32 weeks of pregnancy. Methods: Sixty-five women with a recent diagnosis of FGR or SGA fetuses were enrolled and underwent a complete fetal Doppler examination comprehending QUV. We collected SGA (n = 34), early-FGR (n = 9), and late-FGR (n = 22) fetuses. Results: UV diameter was lower in early and late-FGR compared to SGA, while time-averaged maximum velocity (TAMXV) was lower only in early-FGR. UV blood flow (QUV) and QUV corrected for estimated fetal weight (cQUV) were significantly lower in early-FGR and late-FGR compared to SGA. The receiver operating characteristic (ROC) curves analysis of cQUV showed a significant predictive capacity for SGA diagnosis before and after 32 weeks. Conclusions: The evaluation of UV blood flow allows distinguishing SGA fetuses from FGR. The assessment of UV flow should be taken into consideration in future research of new parameters to differentiate SGA from FGR.
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Is the Cerebro-Placental Ratio Sufficient to Predict Adverse Neonatal Outcome in Small for Gestational Age Fetuses > 34 Weeks of Gestation? REPRODUCTIVE MEDICINE 2021. [DOI: 10.3390/reprodmed2010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Fetuses with an estimated weight (EFW) below the 10th percentile are at risk for adverse perinatal outcome and clinical management remains a challenge. We examined EFW and cerebro-placental ratio (CPR) with regard to their predictive capability in the management and outcome of such cases. Fetuses were first diagnosed as small after 34 weeks of gestation with an actual EFW below the 10th percentile at our tertiary academic center. We determined the optimum cutoff value for CPR and EFW in predicting adverse neonatal outcome. Mean gestational age at diagnosis was 36 weeks. One hundred and two cases were included in our study. We determined a CPR of 1.4 and an EFW of 2152 g to be the best cutoff value for predicting adverse fetal outcome, with an area under the curve (AUC) of 0.65 (95% CI 0.54–0.76); p = 0.009, and 0.76 (95% CI 0.66–0.86); p < 0.0001, respectively. However, when comparing EFW with CPR, EFW seems to be slightly better in predicting adverse fetal outcome in our group. While the use of CPR alone for the management of small fetuses is not sufficient, it is an important additional tool that may be of value in the clinical setting.
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42
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Baschat AA. Considering evidence in the management of fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:25-28. [PMID: 33387406 DOI: 10.1002/uog.23557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 06/12/2023]
Affiliation(s)
- A A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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43
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Di Mascio D, Herraiz I, Villalain C, Buca D, Morales-Rosello J, Loscalzo G, Sileo FG, Finarelli A, Bertucci E, Facchinetti F, Rizzo G, Brunelli R, Giancotti A, Muzii L, Maruotti GM, Carbone L, D'Amico A, Tinari S, Morelli R, Cerra C, Nappi L, Greco P, Liberati M, Galindo A, D'Antonio F. Comparison between Cerebroplacental Ratio and Umbilicocerebral Ratio in Predicting Adverse Perinatal Outcome in Pregnancies Complicated by Late Fetal Growth Restriction: A Multicenter, Retrospective Study. Fetal Diagn Ther 2021; 48:448-456. [PMID: 34130275 DOI: 10.1159/000516443] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 04/01/2021] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The role of cerebroplacental ratio (CPR) or umbilicocerebral ratio (UCR) to predict adverse intrapartum and perinatal outcomes in pregnancies complicated by late fetal growth restriction (FGR) remains controversial. METHODS This was a multicenter, retrospective cohort study involving 5 referral centers in Italy and Spain, including singleton pregnancies complicated by late FGR, as defined by Delphi consensus criteria, with a scan 1 week prior to delivery. The primary objective was to compare the diagnostic accuracy of the CPR and UCR for the prediction of a composite adverse outcome, defined as the presence of either an adverse intrapartum outcome (need for operative delivery/cesarean section for suspected fetal distress) or an adverse perinatal outcome (intrauterine death, Apgar score <7 at 5 min, arterial pH <7.1, base excess of >-11 mEq/mL, or neonatal intensive care unit admission). RESULTS Median CPR absolute values (1.11 vs. 1.22, p = 0.018) and centiles (3 vs. 4, p = 0.028) were lower in pregnancies with a composite adverse outcome than in those without it. Median UCR absolute values (0.89 vs. 0.82, p = 0.018) and centiles (97 vs. 96, p = 0.028) were higher. However, the area under the curve, 95% confidence interval for predicting the composite adverse outcome showed a poor predictive value: 0.580 (0.512-0.646) for the raw absolute values of CPR and UCR, and 0.575 (0.507-0.642) for CPR and UCR centiles adjusted for gestational age. The use of dichotomized values (CPR <1, UCR >1 or CPR <5th centile, UCR >95th centile) did not improve the diagnostic accuracy. CONCLUSION The CPR and UCR measured in the week prior delivery are of low predictive value to assess adverse intrapartum and perinatal outcomes in pregnancies with late FGR.
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Affiliation(s)
- Daniele Di Mascio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Ignacio Herraiz
- Fetal Medicine Unit, Maternal and Child Health and Development Network, Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, Complutense University of Madrid, Madrid, Spain
| | - Cecilia Villalain
- Fetal Medicine Unit, Maternal and Child Health and Development Network, Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, Complutense University of Madrid, Madrid, Spain
| | - Danilo Buca
- Center for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Jose Morales-Rosello
- Servicio de Obstetricia y Ginecología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Gabriela Loscalzo
- Servicio de Obstetricia y Ginecología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Filomena Giulia Sileo
- Prenatal Medicine Unit, Obstetrics and Gynecology Unit, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Alessandra Finarelli
- Prenatal Medicine Unit, Obstetrics and Gynecology Unit, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Emma Bertucci
- Prenatal Medicine Unit, Obstetrics and Gynecology Unit, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Facchinetti
- Prenatal Medicine Unit, Obstetrics and Gynecology Unit, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Giuseppe Rizzo
- Division of Maternal Fetal Medicine, Università di Roma Tor Vergata, Rome, Italy
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russian Federation
| | - Roberto Brunelli
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Antonella Giancotti
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Ludovico Muzii
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Maria Maruotti
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Luigi Carbone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Alice D'Amico
- Center for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Sara Tinari
- Center for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Roberta Morelli
- Center for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Chiara Cerra
- Center for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Luigi Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynaecology, University of Foggia, Foggia, Italy
| | - Pantaleo Greco
- Department of Morphology, Surgery and Experimental Medicine, Institute of Obstetrics and Gynaecology, University of Ferrara, Ferrara, Italy
| | - Marco Liberati
- Center for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Alberto Galindo
- Fetal Medicine Unit, Maternal and Child Health and Development Network, Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, Complutense University of Madrid, Madrid, Spain
| | - Francesco D'Antonio
- Center for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
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Stephens KJ, Kaza N, Shaw CJ, Lees CC. Fetal weight change close to term is proportional to the birthweight percentile. Eur J Obstet Gynecol Reprod Biol 2020; 257:84-87. [PMID: 33370667 DOI: 10.1016/j.ejogrb.2020.12.023] [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] [Received: 11/10/2020] [Revised: 11/29/2020] [Accepted: 12/09/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To investigate the relationship between the difference in estimated fetal weight and birthweight at or close to term, and in relation to Doppler parameters. STUDY DESIGN A cohort study of all term singleton pregnancies who underwent an ultrasound within two weeks of delivery after 36 weeks at one institution in one calendar year. When available, Doppler measurements of umbilical and middle cerebral artery pulsatility index were recorded. Data were analysed by Pearson rank correlation. RESULTS Of 8517 eligible deliveries, 885 women had an ultrasound scan within 2 weeks of delivery. Mean daily differences between estimated fetal weight and birth weight were: those born <10th percentile lost 26 g per day (95 % CI -36 to -16), 10-50th percentile gained 7 g per day (95 % CI -2 to 15), 50th-90th percentile gained 27 g per day (95 % CI 19-35) and >90th percentile gained 48 g per day (95 % CI 32-64). There was a negative correlation between umbilical: middle cerebral artery pulsatility index and the change in weight per day (n = 348, p = 0.001, r = 0.17). CONCLUSIONS Difference in the estimated fetal weight and birthweight, expressed as grams growth per day, is proportional to the birthweight percentile. Fetuses with a birthweight >10th percentile gain weight, while those with a birthweight <10th percentile apparently decline in weight between their final ultrasound estimated fetal weight and delivery. In babies with the smallest or apparent negative weight gain there was an association with Doppler parameters that signified hypoxia indicating fetal growth at term may be restricted by impaired placental function. Estimated fetal weight may be a poor predictor of birthweight for reasons other than ultrasound or algorithmic error.
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Affiliation(s)
- Katie J Stephens
- Queen Charlotte's & Chelsea Hospital, Du Cane Road, London W12 0HS, United Kingdom
| | - Nandita Kaza
- Queen Charlotte's & Chelsea Hospital, Du Cane Road, London W12 0HS, United Kingdom
| | - Caroline J Shaw
- Institute of Reproductive and Developmental Biology, Imperial College London, W12 0HS, United Kingdom
| | - Christoph C Lees
- Queen Charlotte's & Chelsea Hospital, Du Cane Road, London W12 0HS, United Kingdom; Department of Obstetrics & Gynaecology, KU Leuven, 3000 Leuven, Belgium.
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45
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Mylrea-Foley B, Bhide A, Mullins E, Thornton J, Marlow N, Stampalija T, Napolitano R, Lees CC. Building consensus: thresholds for delivery in TRUFFLE-2 randomized intervention study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:285-287. [PMID: 32533800 DOI: 10.1002/uog.22124] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/06/2020] [Accepted: 03/13/2020] [Indexed: 06/11/2023]
Affiliation(s)
- B Mylrea-Foley
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - A Bhide
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust and Molecular & Clinical Sciences Research Institute, St George's University of London, London, UK
| | - E Mullins
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - J Thornton
- School of Clinical Sciences, University of Nottingham, Division of Obstetrics and Gynaecology, Maternity Department, City Hospital, Nottingham, UK
| | - N Marlow
- UCL Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - T Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - R Napolitano
- UCL Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - C C Lees
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College NHS Trust, London, UK
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46
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Lees CC, Stampalija T, Baschat A, da Silva Costa F, Ferrazzi E, Figueras F, Hecher K, Kingdom J, Poon LC, Salomon LJ, Unterscheider J. ISUOG Practice Guidelines: diagnosis and management of small-for-gestational-age fetus and fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:298-312. [PMID: 32738107 DOI: 10.1002/uog.22134] [Citation(s) in RCA: 326] [Impact Index Per Article: 81.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 06/11/2020] [Indexed: 06/11/2023]
Affiliation(s)
- C C Lees
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Development & Regeneration, KU Leuven, Leuven, Belgium
| | - T Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
- Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - A Baschat
- The Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - F da Silva Costa
- Ritchie Centre, Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Victoria, Australia
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - E Ferrazzi
- Department of Woman, Child and Neonate, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - F Figueras
- Fetal Medicine Research Center, BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, University of Barcelona, Barcelona, Spain
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- J. Kingdom, Placenta Program, Maternal-Fetal Medicine Division, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - L C Poon
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong SAR
| | - L J Salomon
- Obstétrique et Plateforme LUMIERE, Hôpital Necker-Enfants Malades (AP-HP) et Université de Paris, Paris, France
| | - J Unterscheider
- Department of Maternal Fetal Medicine, Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
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47
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Wolf H, Stampalija T, Monasta L, Lees CC. Reply. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:292-293. [PMID: 32738108 DOI: 10.1002/uog.22144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- H Wolf
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center (Location AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - T Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - L Monasta
- Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - C C Lees
- Imperial College School of Medicine, Imperial College London, London, UK
- Department of Fetal Medicine, Queen Charlotte's and Chelsea Hospital, Imperial College NHS Trust, London, UK
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