Comparison of color Doppler uterine artery indices in a population at high risk for adverse outcome at 24 weeks' gestation

COVID-19 during pregnancy could potentially affect placental function

OBJECTIVE

COVID-19 is an ongoing pandemic and has been extensively studied. However, the effects of COVID-19 during pregnancy, particularly on placental function, have not been verified. In this study, we used blood oxygen level-dependent magnetic resonance imaging (BOLD-MRI) to evaluate whether COVID-19 incidence during pregnancy has any lasting effects with respect to placental oxygenation.

METHODS

This is a case-control study, in which eight cases of singleton pregnancies before 30 weeks gestation with COVID-19 mothers were included. Placental oxygenation was evaluated using BOLD-MRI after 32 weeks of gestation. BOLD-MRI was consecutively performed under normoxia (21% O2), hyperoxia (100% O2), and normoxia for 4 min each. Individual placental time-activity curves were evaluated to calculate the peak score (peakΔR2*) and the time from the start of maternal oxygen administration to the time of peakΔR2* (time to peakΔR2*). Eighteen COVID-19-free normal pregnancies from a previous study were used as the control group.

RESULTS

No significant differences were found between the two groups regarding maternal background, number of days of delivery, birth weight, and placental weight. The parameter peakΔR2* was significantly decreased in the COVID-19 group (8 ± 3 vs. 5 ± 1, p < .001); however, there was no significant difference in time to peakΔR2* (458 ± 74 s vs. 471 ± 33 s, p = .644).

CONCLUSIONS

In this study, BOLD-MRI was used to evaluate placental oxygenation during pregnancy in COVID-19-affected patients. COVID-19 during pregnancy decreased placental oxygenation even post-illness, but had no effect on fetal growth; further investigation of the possible effects of COVID-19 on the fetus and mother is warranted.

Evaluation of placental oxygenation in fetal growth restriction using blood oxygen level-dependent magnetic resonance imaging

INTRODUCTION

Abnormalities in placental function can lead to fetal growth restriction (FGR), but there is no consensus on their evaluation. Using blood oxygen level-dependent magnetic resonance imaging (BOLD MRI), we compared placental oxygenation between FGR cases and previously reported normal pregnancies.

METHODS

Eight singleton pregnant women (>32 weeks of gestation) diagnosed with fetal growth failure during pregnancy were recruited. BOLD MRI was consecutively performed under normoxia (21% O₂), hyperoxia (100% O₂), and normoxia for 4 min each. Each placental time-activity curve was evaluated to calculate the peak score (peakΔR2*) and the time from the start of maternal oxygen administration to the time of peakΔR2* (time to peakΔR2*). In six of the eight FGR cases, placental FGR-related pathological findings were evaluated after delivery.

RESULTS

The parameter peakΔR2* was significantly decreased in the FGR group (8 ± 3 vs 6 ± 1, p < 0.001), but there was no significant difference in time to peakΔR2* (458 ± 74 s vs 468 ± 57 s, p = 0.750). The findings in the six FGR cases assessed for placental pathologies included chorangiosis in two cases, avascular chorions in two cases, placental infarction in two cases, and syncytial knot formation in one case.

DISCUSSION

The peakΔR2* values were lower in the FGR group than in the normal pregnancy group. This suggests that oxygenation of the placenta is decreased in the FGR group compared to the normal group, and this may be related to FGR. Placental pathology also revealed findings possibly related to FGR, suggesting that low peakΔR2* values in the FGR group may reflect placental dysfunction.

Evaluation of placental oxygenation index using blood oxygen level-dependent magnetic resonance imaging (BOLD-MRI) during normal late pregnancy

AIM

Noninvasive blood oxygen level-dependent magnetic resonance imaging (BOLD-MRI) has recently been used to evaluate placental oxygenation. However, this method still has unresolved problems, such as long testing times and lack of normal values set. In the present study, we used a shorter protocol in BOLD-MRI and established normal values for placental oxygenation in late pregnancy.

METHODS

We recruited 18 healthy singleton pregnant women (>32 weeks of gestation) who had a normal body size before pregnancy and a normal course of pregnancy. They underwent BOLD-MRI with three consecutive 4-min periods of different oxygenation: normoxia (21% O₂), hyperoxia (10 L O₂/min), and then normoxia. Placental time-activity curves were presented as signal intensity change relative to baseline (ΔR2*). The time from starting maternal oxygen administration to peak ΔR2*. To assess the relationship between peak ΔR2* values and placenta-related parameters and fetal development, the correlation between peak ΔR2*, placental weight, and neonatal birth weight was evaluated using Spearman's rank correlation test.

RESULTS

In all cases, the BOLD signal was elevated by maternal oxygen administration, with the peak resolving within 4 min after the end of oxygen administration. Peak ΔR2* and time to peak ΔR2* during oxygenation were 7.99 ± 2.58, and 458.1 ± 73.9 s, respectively. There was a significant correlation between peak ΔR2* and neonatal birth weight (percentile) (r = 0.537, p = .022), and between placental weight and neonatal birth weight (r = 0.769, p < .01).

CONCLUSIONS

In all cases, the BOLD signal increased with maternal hyperoxia using this protocol. So, 4 min observation following maternal oxygen administration is sufficient for peak ΔR2* evaluation. These reference values set in this study may be one of the indicators of BOLD signal changes in normal pregnancies after 32 weeks of gestation.

Risk stratification for early-onset fetal growth restriction in women with abnormal serum biomarkers: a retrospective cohort study

Abnormal maternal serum biomarkers (AMSB), identified through the aneuploidy screening programme, are frequent incidental findings in pregnancy. They are associated with fetal growth restriction (FGR), but previous studies have not examined whether this association is with early-onset (< 34 weeks) or late-onset (> 34 weeks) FGR; as a result there is no consensus on management. The aims of this study were to determine the prevalence and phenotype of FGR in women with AMSB and test the predictive value of placental sonographic screening to predict early-onset FGR. 1196 pregnant women with AMSB underwent a 21-24 week "placental screen" comprising fetal and placental size, and uterine artery Doppler. Multivariable regression was used to calculate a predictive model for early-onset FGR (birthweight centile < 3rd/< 10th with absent umbilical end-diastolic flow, < 34 weeks). FGR prevalence was high (10.3%), however early-onset FGR was uncommon (2.3%). Placental screening effectively identified early-onset (area under the curve (AUC) 0.93, 95% confidence interval (CI) 0.87-1.00), but not late-onset FGR (AUC 0.70, 95% CI 0.64-0.75). Internal validation demonstrated robust performance for detection/exclusion of early-onset FGR. In this cohort, utilisation of our proposed algorithm with targeted fetal growth and Doppler surveillance, compared with universal comprehensive surveillance would have avoided 1044 scans, potentiating significant cost-saving for maternity services.

Associations of maternal metabolic profile with placental and fetal cerebral and cardiac hemodynamics

OBJECTIVE

Maternal obesity and metabolic health affect pregnancy outcomes. We examined whether maternal metabolic profiles are associated with placental and fetal hemodynamics.

STUDY DESIGN

In a population-based prospective cohort study among 1175 women we examined the associations of an adverse maternal metabolic profile in early pregnancy with placental, fetal cerebral and cardiac hemodynamic development. We obtained maternal pre-pregnancy BMI by questionnaire and measured blood pressure, cholesterol, triglycerides and glucose concentrations at a median gestational age of 12.6 (95 % range 9.6-17.1) weeks. An adverse maternal metabolic profile was defined as ≥4 risk factors. Placental and fetal hemodynamics were measured by pulsed-wave-Doppler at a median gestational age of 30.3 (95 % range 28.8-32.3) weeks.

RESULTS

An adverse maternal metabolic profile was associated with a 0.29 Z-score higher (95 %CI 0.08-0.50) fetal cerebral middle artery pulsatility index (PI), but not with placental or fetal cardiac hemodynamic patterns. When the individual components of an adverse maternal metabolic profile were assessed, we observed that higher maternal total cholesterol and triglyceride concentrations were associated with a higher cerebral middle artery PI (Z-score, 0.09 (95 %CI 0.02-0.15), 0.09 (95 %CI 0.03-0.15) per Z-score increase). Higher total and HDL maternal cholesterol concentrations were also associated with a higher aorta ascendens peak systolic velocity (PSV) Z-score, 0.08 (95 %CI 0.01-0.14)), and a larger left cardiac output (Z-score, 0.08 (95 %CI 0.00-0.15), respectively).

CONCLUSION

An adverse maternal metabolic profile, especially higher cholesterol and triglycerides concentrations, are associated with increased fetal cerebral vascular resistance and larger fetal aorta ascendens diameter, PSV and left cardiac output, but not with placental vascular resistance indices. Further studies are needed to identify long-term consequences of the observed associations.

Arterial and Venous Doppler in Evaluation of the "At-Risk" Fetus

Our practice utilizes Doppler ultrasound as one of the most objective and effective methods to assess at-risk pregnancies. This review will discuss the application of arterial and venous Doppler techniques in assessing and managing various diseases and conditions for high-risk fetuses.

Early onset fetal growth restriction

Fetal growth restriction remains a challenging entity with significant variations in clinical practice around the world. The different etiopathogenesis of early and late fetal growth restriction with their distinct progression of fetal severity and outcomes, compounded by doctors and patient anxiety adds to the quandary involving its management. This review summarises the literature around diagnosing and monitoring early onset fetal growth restriction (early onset FGR) with special emphasis on optimal timing of delivery as guided by recent research advances.

Maternal uterine artery Doppler in the first and second trimesters as screening method for hypertensive disorders and adverse perinatal outcomes in low-risk pregnancies

Objective

To assess the maternal demographic characteristics and uterine artery (UA) Doppler parameters at first and second trimesters of pregnancy as predictors for hypertensive disorders (HDs) and adverse perinatal outcomes.

Methods

This prospective cohort study comprised 162 singleton low-risk women undergoing routine antenatal care. The left and right UA were assessed by color and pulsed Doppler and the mean pulsatility and resistance indices as well as the presence of a bilateral protodiastolic notch were recorded at 11 to 14 and 20 to 24 weeks' gestation. Multilevel regression analysis was used to determine the effects of maternal characteristics and abnormal UA Doppler parameters on the incidence of HD, small for gestational age newborn, cesarean section rate, Apgar score <7 at 1st and 5th minute, and admission to the neonatal intensive care unit.

Results

Fifteen women (9.2%) developed HD. UA mean resistance index (RI), UA mean pulsatility index, and parity were independent predictors of HD. Compared to the pregnancies with a normal UA mean RI at the first and second trimesters, pregnancies with UA mean RI >95th percentile only at the first trimester showed an increased risk for HD (odds ratio, 23.25; 95% confidence interval, 3.47 to 155.73; P<0.01). Similar result was found for UA mean pulsatility index >95th percentile (odds ratio, 9.84; 95% confidence interval, 1.05 to 92.10; P=0.05). The model including maternal age, maternal and paternal ethnicity, occupation, parity and UA mean RI increased the relative risk for HD (area under receiver operating characteristics, 0.81).

Conclusion

A first-trimester screening combining maternal characteristics and UA Doppler parameters is useful to predict HD in a low-risk population.

Apelin in Normal Pregnancy and Pregnancies Complicated by Placental Insufficiency

INTRODUCTION

Apelin is a potent inotropic agent and causes endothelium-mediated vasodilation. Its cardiovascular profile suggests a role in the regulation of gestational hemodynamics.

METHODS

We longitudinally assessed maternal serum apelin levels and hemodynamics (cardiac output and total peripheral resistance) between 20 and 34 weeks gestation in 18 women at high risk of placental dysfunction. Placental apelin staining was assessed by immunohistochemistry in placentas from uncomplicated pregnancies (n = 6), preterm deliveries (n = 6), preeclampsia (PET, n = 8), and isolated intrauterine growth restriction (IUGR, n = 8). Placental apelin gene expression was assessed by quantitative polymerase chain reaction.

RESULTS

In the high-risk cohort, 4 fetuses developed isolated IUGR and 6 women developed PET. We obtained a median of 5 (range 2-9) hemodynamic and apelin measurements per woman. Apelin levels throughout gestation were best fitted by a quadratic curve. Apelin levels between 20 and 26 weeks gestation correlated with total peripheral resistance (r = .57, P = .01) and showed a trend toward an inverse correlation with stroke volume (r = -.42, P = .08). Apelin serum levels were 30% lower in pregnancies complicated by IUGR than in uncomplicated pregnancies or in women with preeclampsia (P = .009). Placental apelin gene expression was similar in IUGR, PET, preterm, and term normal placentas. Apelin staining was seen both in syncytiotrophoblast and stroma of the placental villi. In IUGR placentas, apelin staining was strongly decreased in both compartments compared to normals. Preeclamptic placentas showed an intermediate staining.

CONCLUSIONS

Apelin levels mirror the cardiovascular changes seen in pregnancy. Serum and placental apelin levels are decreased in IUGR.

Associations of maternal retinal vasculature with subsequent fetal growth and birth size

OBJECTIVE

We aimed to study the maternal retinal microvasculature at mid-trimester and its relationship with subsequent fetal growth and birth size.

METHODS

We recruited 732 pregnant women aged 18-46 years in the first trimester with singleton pregnancies. All had retinal photography and fetal scan performed at 26-28 weeks gestation, and subsequent fetal scan at 32-34 weeks gestation. Infant anthropometric measurements were done at birth. Retinal microvasculature was measured using computer software from the retinal photographs.

RESULTS

In multiple linear regression models, each 10 μm narrowing in maternal retinal arteriolar caliber was associated with decreases of 1.36 mm in fetal head circumference at 32-34 weeks gestation, as well as decreases of 1.50 mm and 2.30 mm in infant head circumference and birth length at delivery, respectively. Each standard deviation decrease in maternal retinal arteriolar fractal dimension was associated with decreases of 1.55 mm in fetal head circumference at 32-34 weeks gestation, as well as decreases of 1.08 mm and 46.42 g in infant head circumference and birth weight at delivery, respectively.

CONCLUSIONS

Narrower retinal arteriolar caliber and a sparser retinal vascular network in mothers, reflecting a suboptimal uteroplacental microvasculature during mid-pregnancy, were associated with poorer fetal growth and birth size.

Uterine Artery Doppler of the Gravid Uterus as a Predictor Identifying At-Risk Pregnancies

Uterine artery Doppler has been a useful aid in the sonographic evaluation of uteroplacental hemodynamics of the gravid uterus. Pulsatility index, resistive index, and systolic/diastolic ratio can be calculated and interpreted in the evaluation of blood flow. The waveform itself can be evaluated for diastolic notching and used to interpret the qualitative appearance of the blood flow. In addition to the hemodynamic characteristics, practitioners have incorporated maternal serum tests to attempt to isolate at-risk candidates. This article summarizes the effectiveness of each methodology, with a primary focus on an at-risk population, since studies of low-risk populations have not demonstrated significant sensitivity for prediction of complications such as pre-eclampsia, placental abruptia, or fetal demise.

Angiogenic factors and uterine Doppler velocimetry in early- and late-onset preeclampsia

OBJECTIVE

To assess correlations between maternal serum levels of pro- and anti-angiogenic factors with uterine perfusion in women with early- compared with late-onset preeclampsia, and in healthy pregnant women.

DESIGN

Case-control study.

SETTING

Antenatal care clinic located within a hospital (São Bernardo do Campo, Brazil).

POPULATION

We enrolled 54 preeclamptic and 54 healthy control women who were coming for routine ultrasound at 28-36 weeks' gestation.

METHODS

All participants had uterine artery and umbilical Doppler studies and a blood sample to assess maternal serum levels of soluble fms-like tyrosine kinase-1, soluble endoglin, adiponectin and plasminogen activator inhibitor-1. All angiogenic factors were measured using enzyme-linked immunosorbent assay.

MAIN OUTCOME MEASURES

Levels of pro- and anti-angiogenic factors in maternal serum, and uterine artery Doppler findings.

RESULTS

Concentrations of soluble fms-like tyrosine kinase-1 and soluble endoglin were significantly higher in preeclamptic than control women (p < 0.0001 and p < 0.0001, respectively), especially in those with early-onset (<34 weeks) preeclampsia. These two anti-angiogenic mediators were significantly correlated with increased uterine artery Doppler in the preeclamptic women. Plasminogen activator inhibitor-1 levels were significantly higher in preeclampsia (p = 0.03) but unrelated to uterine artery resistance. Adiponectin levels were similar in cases and controls, independent of body mass index and unrelated to uterine artery resistance.

CONCLUSION

Preeclamptic patients have increased soluble fms-like tyrosine kinase-1 and soluble endoglin serum levels and this increase is directly correlated with uterine artery resistance, especially in those with early-onset preeclampsia.

Childhood kidney outcomes in relation to fetal blood flow and kidney size

Impaired fetal abdominal blood flow may lead to smaller kidneys and subsequent impaired kidney function in later life. In a prospective cohort study among 923 pregnant women and their children, we measured fetal growth, kidney volumes, and umbilical and cerebral artery blood flow (median gestational age of 30.3 weeks; 95% range, 28.5-32.7 weeks). We used a higher umbilical/cerebral artery pulsatility index ratio as an indicator of preferential fetal blood flow to the upper body parts at the expense of the intra-abdominal organs. At a median age of 5.9 years (95% range, 5.7-6.6 years), we measured childhood kidney volumes, creatinine and cystatin C blood levels, microalbuminuria, BP, and eGFR. A preferential fetal blood flow to the upper body parts at the expense of the intra-abdominal organs associated only with a smaller combined kidney volume in childhood. Fetal combined kidney volume positively associated with childhood combined kidney volume and eGFR, and inversely associated with childhood creatinine and cystatin C levels (all P values <0.05), but did not associate with childhood microalbuminuria and BP. Children within the highest tertile of fetal umbilical/cerebral ratio and the lowest tertile of fetal combined kidney volume had the lowest eGFR (difference, -6.36 ml/min per 1.73 m(2); 95% confidence interval, -11.78 to -0.94 compared with children within the middle tertiles). These data suggest that impaired fetal blood to the abdominal organs and smaller fetal kidney size are associated with subclinical changes in kidney outcomes in school-aged children.

A role for Nrf2 in redox signalling of the invasive extravillous trophoblast in severe early onset IUGR associated with preeclampsia

BACKGROUND

Preeclampsia (PE) is characterized by increased lipid oxidation and diminished antioxidant capacity, while intrauterine growth restriction (IUGR) is characterized by impaired invasion of the extravillous trophoblast. Vascular endothelial growth factor (VEGF) has been reported to be altered in preeclampsia. A relationship between VEGF and nuclear factor erythroid 2-related factor-2 (Nrf2) has been shown in vitro, where VEGF prevents oxidative damage via activation of the Nrf2 pathway. In this study the expression of Nrf2, VEGF and 4-hydroxynonenal (4-HNE), was determined in interstitial and endovascular/intramural extravillous trophoblast (EVT) in normal pregnancies and those complicated by severe early onset IUGR associated with preeclampsia IUGR/PE.

MATERIALS AND METHODS

Full-thickness uterine tissues derived from caesarean hysterectomies performed in 5 healthy normotensive women delivering term infants and 6 women with severe early onset IUGR with preeclampsia (29-34 weeks gestation) were analyzed. Interstitial and endovascular extravillous trophoblast were quantified after immunohistochemical staining of paraffin sections using antibodies against Nrf2, 4-HNE, VEGF, and cytokeratin 7.

RESULTS

Uterine tissues from women suffering from severe early onset IUGR/PE were characterized by reduced invasion of extravillous trophoblast into the endometrial and myometrial segments of spiral arteries in the placental bed. Extravillous trophoblast showed an increased cytoplasmic expression of Nrf2 and 4-HNE in IUGR/PE cases. The increased expression of Nrf2 in cases of IUGR/PE was associated with decreased expression of VEGF in these cells compared to controls.

CONCLUSION

Our data suggests that besides villous cytotrophoblast, also the extravillous trophoblast is a source of Nrf2-dependent genes. VEGF deficiency may cause higher oxidative stress in extravillous trophoblast in cases with IUGR/PE. The resulting reduced basal defence against oxidative stress and the higher vulnerability to oxidative damage may play a role in the limited trophoblast invasion into spiral arteries in cases suffering from severe early onset IUGR/PE.

Beyond the placental bed: placental and systemic determinants of the uterine artery Doppler waveform

The uterine artery Doppler waveform has been extensively investigated, though its widespread clinical use as a predictor of adverse pregnancy outcome remains under debate. The determinants of the waveform have classically been ascribed to transformation of the spiral arteries and the development of a low resistance uteroplacental circulation, failure of which predisposes to pre-eclampsia, fetal growth restriction and other adverse outcomes. It has become increasingly evident that although spiral artery transformation determines in some part the characteristics of the Doppler waveform, factors pertaining to maternal vascular and endothelial function are also important.

Repercussões da cicatriz uterina resultante de cesariana prévia na dopplervelocimetria das artérias uterinas entre 26 e 32 semanas

OBJETIVO: Avaliar as repercussões da cicatriz uterina na dopplervelocimetria das artérias uterinas, entre 26 e 32 semanas, em gestantes primíparas com uma cesariana prévia, considerando quando esta foi realizada fora (cesárea eletiva) ou durante o trabalho de parto. MATERIAIS E MÉTODOS: Estudo prospectivo transversal em 45 gestantes, divididas em três grupos: 17 gestantes com cicatriz prévia resultante de cesariana eletiva (grupo A); 14 gestantes com uma cicatriz prévia oriunda de cesariana executada em trabalho de parto (grupo B); 14 gestantes cujo único parto anterior foi realizado por via vaginal (grupo C). A dopplervelocimetria das artérias uterinas foi realizada pela via abdominal. Foram calculados as médias, medianas e desvios-padrão (DP) para cada grupo em estudo. Em relação ao índice de pulsatilidade, a comparação dos grupos foi conduzida pelo teste não paramétrico de Kruskal-Wallis. RESULTADOS: Os valores médios do índice de pulsatilidade no grupo A variaram de 0,60 a 1,60 (média: 0,90; DP: 0,29), no grupo B, de 0,53 a 1,43 (média: 0,87; DP: 0,24), e no grupo C, de 0,65 a 1,65 (média: 1,01; DP: 0,37); p = 0,6329. CONCLUSÃO: Não houve repercussões da cicatriz de cesariana prévia na dopplervelocimetria das artérias uterinas avaliadas de 26 a 32 semanas de gestação.

First-trimester uterine artery Doppler indices in the prediction of small-for-gestational age pregnancy and intrauterine growth restriction

OBJECTIVES

To assess the relationship of first-trimester uterine artery Doppler indices with subsequent delivery of small-for-gestational age (SGA) neonates or intrauterine growth restriction (IUGR).

METHODS

This was a prospective study in which uterine artery Doppler assessment was performed at 11-14 weeks in 3010 women with singleton pregnancies. Resistance indices (RI) and incidence of bilateral notching were compared between women with normal pregnancies (n = 2445) and those who delivered: SGA neonates (birth weight < 10th centile) (n = 377); SGA neonates who had been affected by pre-eclampsia (n = 27); IUGR neonates (birth weight < 10th centile and abnormal Doppler indices) with delivery > or = 37 weeks (n = 62); and IUGR neonates requiring preterm delivery (delivery < 37 weeks) (n = 36).

RESULTS

The first-trimester uterine artery mean RI and prevalence of bilateral notching were significantly higher in women destined to deliver SGA neonates than in women with normal pregnancies (median uterine artery RI, 0.74 vs. 0.70, P < 0.001; prevalence of bilateral notches, 56% vs. 43%, P < 0.001). The areas under the receiver-operating characteristics curves for the prediction of SGA without pre-eclampsia, IUGR, preterm IUGR and SGA with pre-eclampsia were 0.602, 0.687, 0.776 and 0.708, respectively. There was a statistically significant inverse relationship between mean uterine artery RI and gestational age at delivery in the SGA pregnancies without pre-eclampsia (R = - 0.329, P = 0.01).

CONCLUSIONS

There is a significant relationship between first-trimester uterine artery Doppler RI and the subsequent development of SGA. The sensitivity of first-trimester uterine artery Doppler is greater for SGA with pre-eclampsia than it is for IUGR alone. This could be because these two entities may have different underlying placental abnormalities that are detected variably on first-trimester uterine artery Doppler evaluation.

The significance of uterine notching in Doppler sonography in early pregnancy as a predictor for pathologic outcome of the pregnancy

INTRODUCTION

Doppler sonography of maternal vessels as a predictor for preeclampsia is an established screening method in the second trimester. Considering the first trimester its benefit has not been conclusively proven so far. Up to now the flow pattern of maternal vessels in the first trimester has only been insufficiently characterized and documented. Thus, there are only few pieces of information concerning the predictive value of the different kinds of flow patterns during the early pregnancy as regards the pathological and physiological outcome of the pregnancy. This survey aimed at evaluating the significance and the clinical importance of Doppler sonographical examinations of the Aa. uterinae during early pregnancy. It had to be analyzed whether various perfusions can be applied as a predictive value for the specific development during the pregnancy and whether therefore a risk group for pregnancy-associated hypertension can already be detected during the early pregnancy.

MATERIALS AND METHODS

A non-selected collective of 104 pregnant patients was examined with Doppler sonography and retrospectively divided into a standard collective and a high-risk collective. The standard collective contained 89 patients, who in the course of their pregnancy remained without any pathological findings. Fifteen patients, who were assigned to the high-risk collective, either developed a pregnancy-induced hypertension during their pregnancy or an intrauterine fetal growth retardation. The Doppler-sonographic examination of the Aa. uterinae was applied for the first time between the 6 and 8 weeks gestation (WG), then in the 9 WG, 10 WG, 11 WG, between the 12 and 14 WG, as well as between the 20 and 24 WG.

RESULTS

Contrary to published data, there can be traced a completely transformed flow pattern in the Aa. uterinae already during the first trimester to an increasing extent. This correlates with a positive outcome of the pregnancy. There is a definite association between pathological Doppler sonography in the first third of the pregnancy and the development of a uteroplacental insufficiency as well as a pregnancy-associated hypertension (SIH) in the further course of the pregnancy.

CONCLUSION

Doppler sonography is an approved method in order to become early attentive of a reduced uterine blood flow. Applying Doppler sonographic treatment of the maternal vessels, uteroplacental insufficiency can be traced at an early stage. Pregnancies, which might develop a pregnancy-associated hypertension (SIH) or a placental insufficiency, can be detected during the early pregnancy to decrease the morbidity rate and the mortality of premature newborns. Further studies in larger collectives are necessary to obtain adequate solid datasets and to further evaluate the clinical meaning and the significance concerning pathological maternal Doppler parameters.

Divergent trophoblast invasion and apoptosis in placental bed spiral arteries from pregnancies complicated by maternal anemia and early-onset preeclampsia/intrauterine growth restriction

OBJECTIVE

Impaired trophoblast invasion into spiral arteries is associated with early-onset intrauterine growth restriction and preeclampsia. We compared trophoblast invasion into spiral arteries in pregnancies with maternal anemia or early-onset preeclampsia/intrauterine growth restriction and related these findings to trophoblast apoptosis.

STUDY DESIGN

Full-thickness uterine wall samples were obtained from women with early-onset preeclampsia/intrauterine growth restriction (n = 6), normal pregnancies (n = 5), and chronic anemia (n = 8). Trophoblast invasion into the walls of spiral arteries was quantified by morphometric analysis of paraffin sections stained with anticytokeratin 18, antiactin, and anticytokeratin 18 neoepitope (M30) antibodies.

RESULTS

Trophoblast invasion into spiral arteries was increased in anemic pregnancies (mean [SD]: 206 [46] cell profiles/mm2) and severely impaired in preeclamptic/intrauterine growth restriction pregnancies (17 [6]), compared with normal subjects (149 [52]). Spiral artery lumen area was increased in anemia (0.07 [0.03] mm2) versus normal pregnancies (0.09 [0.04] mm2) and reduced in preeclampsia/intrauterine growth restriction (0.04 [0.02] mm2). Trophoblast apoptosis was similar in anemic (4.2% [3.4%]) and normal (5.0% [1.9%]) pregnancies but increased in preeclampsia/intrauterine growth restriction (12% [5.6%]).

CONCLUSION

Trophoblast invasion into the placental bed in early-onset preeclampsia/intrauterine growth restriction is limited by increased apoptosis, resulting in narrower spiral arteries, which is in contrast to findings in anemia.

First trimester uterine artery Doppler abnormalities predict subsequent intrauterine growth restriction

OBJECTIVE

This study was undertaken to evaluate the association between uterine artery Doppler velocimetry performed between 10 and 14 weeks gestation and intrauterine growth restriction (IUGR).

STUDY DESIGN

Uterine artery Doppler velocimetry data were collected on 1067 women enrolled in the FASTER trial at the University of Colorado site. The data were analyzed by using univariate and multivariable logistic regression analysis.

RESULTS

The uterine artery mean resistance index (RI) for the entire cohort was equal on the right and left sides (0.59 +/- 0.14). Of the 1067 women, 34.2% had unilateral or bilateral diastolic notches, 1 notch was observed in 23.8%, and bilateral notches in 10.4%. Women with a high uterine artery mean RI (> or = 75th percentile) were 5.5 times more likely to have IUGR (95% CI 1.6-18.7). There was no significant relationship between notching and IUGR.

CONCLUSION

Elevated first trimester uterine artery mean RI is significantly associated with IUGR.

Quad Screen as a Predictor of Adverse Pregnancy Outcome

OBJECTIVE

To estimate the effect of second-trimester levels of maternal serum alpha-fetoprotein (AFP), human chorionic gonadotrophin (hCG), unconjugated estriol (uE3), and inhibin A (the quad screen) on obstetric complications by using a large, prospectively collected database (the FASTER database).

METHODS

The FASTER trial was a multicenter study that evaluated first- and second-trimester screening programs for aneuploidy in women with singleton pregnancies. As part of this trial, patients had a quad screen drawn at 15-18 6/7 weeks. We analyzed the data to identify associations between the quad screen markers and preterm birth, intrauterine growth restriction, preeclampsia, and fetal loss. Our analysis was performed by evaluating the performance characteristics of quad screen markers individually and in combination. Crude and adjusted effects were estimated by multivariable logistic regression analysis. Patients with fetal anomalies were excluded from the analysis.

RESULTS

We analyzed data from 33,145 pregnancies. We identified numerous associations between the markers and the adverse outcomes. There was a relatively low, but often significant, risk of having an adverse pregnancy complication if a patient had a single abnormal marker. However, the risk of having an adverse outcome increased significantly if a patient had 2 or more abnormal markers. The sensitivity and positive predictive values using combinations of markers is relatively low, although superior to using individual markers.

CONCLUSION

These data suggest that components of the quad screen may prove useful in predicting adverse obstetric outcomes. We also showed that the total number and specific combinations of abnormal markers are most useful in predicting the risk of adverse perinatal outcome.