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Morris RK, Johnstone E, Lees C, Morton V, Smith G. Investigation and Care of a Small-for-Gestational-Age Fetus and a Growth Restricted Fetus (Green-top Guideline No. 31). BJOG 2024; 131:e31-e80. [PMID: 38740546 DOI: 10.1111/1471-0528.17814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Key recommendations
All women should be assessed at booking (by 14 weeks) for risk factors for fetal growth restriction (FGR) to identify those who require increased surveillance using an agreed pathway [Grade GPP]. Findings at the midtrimester anomaly scan should be incorporated into the fetal growth risk assessment and the risk assessment updated throughout pregnancy. [Grade GPP]
Reduce smoking in pregnancy by identifying women who smoke with the assistance of carbon monoxide (CO) testing and ensuring in‐house treatment from a trained tobacco dependence advisor is offered to all pregnant women who smoke, using an opt‐out referral process. [Grade GPP]
Women at risk of pre‐eclampsia and/or placental dysfunction should take aspirin 150 mg once daily at night from 12+0–36+0 weeks of pregnancy to reduce their chance of small‐for‐gestational‐age (SGA) and FGR. [Grade A]
Uterine artery Dopplers should be carried out between 18+0 and 23+6 weeks for women at high risk of fetal growth disorders [Grade B]. In a woman with normal uterine artery Doppler and normal fetal biometry at the midtrimester scan, serial ultrasound scans for fetal biometry can commence at 32 weeks. Women with an abnormal uterine artery Doppler (mean pulsatility index > 95th centile) should commence ultrasound scans at 24+0–28+6 weeks based on individual history. [Grade B]
Women who are at low risk of FGR should have serial measurement of symphysis fundal height (SFH) at each antenatal appointment after 24+0 weeks of pregnancy (no more frequently than every 2 weeks). The first measurement should be carried out by 28+6 weeks. [Grade C]
Women in the moderate risk category are at risk of late onset FGR so require serial ultrasound scan assessment of fetal growth commencing at 32+0 weeks. For the majority of women, a scan interval of four weeks until birth is appropriate. [Grade B]
Maternity providers should ensure that they clearly identify the reference charts to plot SFH, individual biometry and estimated fetal weight (EFW) measurements to calculate centiles. For individual biometry measurements the method used for measurement should be the same as those used in the development of the individual biometry and fetal growth chart [Grade GPP]. For EFW the Hadlock three parameter model should be used. [Grade C]
Maternity providers should ensure that they have guidance that promotes the use of standard planes of acquisition and calliper placement when performing ultrasound scanning for fetal growth assessment. Quality control of images and measurements should be undertaken. [Grade C]
Ultrasound biometry should be carried out every 2 weeks in fetuses identified to be SGA [Grade C]. Umbilical artery Doppler is the primary surveillance tool and should be carried out at the point of diagnosis of SGA and during follow‐up as a minimum every 2 weeks. [Grade B]
In fetuses with an EFW between the 3rd and 10th centile, other features must be present for birth to be recommended prior to 39+0 weeks, either maternal (maternal medical conditions or concerns regarding fetal movements) or fetal compromise (a diagnosis of FGR based on Doppler assessment, fetal growth velocity or a concern on cardiotocography [CTG]) [Grade C]. For fetuses with an EFW or abdominal circumference less than the 10th centile where FGR has been excluded, birth or the initiation of induction of labour should be considered at 39+0 weeks after discussion with the woman and her partner/family/support network. Birth should occur by 39+6 weeks. [Grade B]
Pregnancies with early FGR (prior to 32+0 weeks) should be monitored and managed with input from tertiary level units with the highest level neonatal care. Care should be multidisciplinary by neonatology and obstetricians with fetal medicine expertise, particularly when extremely preterm (before 28 weeks) [Grade GPP]. Fetal biometry in FGR should be repeated every 2 weeks [Grade B]. Assessment of fetal wellbeing can include multiple modalities but must include computerised CTG and/or ductus venous. [Grade B]
In pregnancies with late FGR, birth should be initiated from 37+0 weeks to be completed by 37+6 weeks [Grade A]. Decisions for birth should be based on fetal wellbeing assessments or maternal indication. [Grade GPP]
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Kleuskens DG, Van Veen CMC, Groenendaal F, Ganzevoort W, Gordijn SJ, Van Rijn BB, Lely AT, Schuit E, Kooiman J. Prediction of fetal and neonatal outcomes after preterm manifestations of placental insufficiency: systematic review of prediction models. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:644-652. [PMID: 37161550 DOI: 10.1002/uog.26245] [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: 12/19/2022] [Revised: 03/31/2023] [Accepted: 05/01/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVES To identify all prediction models for fetal and neonatal outcomes in pregnancies with preterm manifestations of placental insufficiency (gestational hypertension, pre-eclampsia, HELLP syndrome or fetal growth restriction with its onset before 37 weeks' gestation) and to assess the quality of the models and their performance on external validation. METHODS A systematic literature search was performed in PubMed, Web of Science and EMBASE. Studies describing prediction models for fetal/neonatal mortality or significant neonatal morbidity in patients with preterm placental insufficiency disorders were included. Data extraction was performed using the CHARMS checklist. Risk of bias was assessed using PROBAST. Literature selection and data extraction were performed by two researchers independently. RESULTS Our literature search yielded 22 491 unique publications. Fourteen were included after full-text screening of 218 articles that remained after initial exclusions. The studies derived a total of 41 prediction models, including four models in the setting of pre-eclampsia or HELLP, two models in the setting of fetal growth restriction and/or pre-eclampsia and 35 models in the setting of fetal growth restriction. None of the models was validated externally, and internal validation was performed in only two studies. The final models contained mainly ultrasound (Doppler) markers as predictors of fetal/neonatal mortality and neonatal morbidity. Discriminative properties were reported for 27/41 models (c-statistic between 0.6 and 0.9). Only two studies presented a calibration plot. The risk of bias was assessed as unclear in one model and high for all other models, mainly owing to the use of inappropriate statistical methods. CONCLUSIONS We identified 41 prediction models for fetal and neonatal outcomes in pregnancies with preterm manifestations of placental insufficiency. All models were considered to be of low methodological quality, apart from one that had unclear methodological quality. Higher-quality models and external validation studies are needed to inform clinical decision-making based on prediction models. © 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)
- D G Kleuskens
- Department of Obstetrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | - C M C Van Veen
- Department of Obstetrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | - F Groenendaal
- Department of Neonatology, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | - W Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - S J Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - B B Van Rijn
- Department of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - A T Lely
- Department of Obstetrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | - E Schuit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J Kooiman
- Department of Obstetrics, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
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Spencer R, Maksym K, Hecher K, Maršál K, Figueras F, Ambler G, Whitwell H, Nené NR, Sebire NJ, Hansson SR, Diemert A, Brodszki J, Gratacós E, Ginsberg Y, Weissbach T, Peebles DM, Zachary I, Marlow N, Huertas-Ceballos A, David AL. Maternal PlGF and umbilical Dopplers predict pregnancy outcomes at diagnosis of early-onset fetal growth restriction. J Clin Invest 2023; 133:e169199. [PMID: 37712421 PMCID: PMC10503803 DOI: 10.1172/jci169199] [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: 02/01/2023] [Accepted: 06/27/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUNDSevere, early-onset fetal growth restriction (FGR) causes significant fetal and neonatal mortality and morbidity. Predicting the outcome of affected pregnancies at the time of diagnosis is difficult, thus preventing accurate patient counseling. We investigated the use of maternal serum protein and ultrasound measurements at diagnosis to predict fetal or neonatal death and 3 secondary outcomes: fetal death or delivery at or before 28+0 weeks, development of abnormal umbilical artery (UmA) Doppler velocimetry, and slow fetal growth.METHODSWomen with singleton pregnancies (n = 142, estimated fetal weights [EFWs] below the third centile, less than 600 g, 20+0 to 26+6 weeks of gestation, no known chromosomal, genetic, or major structural abnormalities) were recruited from 4 European centers. Maternal serum from the discovery set (n = 63) was analyzed for 7 proteins linked to angiogenesis, 90 additional proteins associated with cardiovascular disease, and 5 proteins identified through pooled liquid chromatography and tandem mass spectrometry. Patient and clinician stakeholder priorities were used to select models tested in the validation set (n = 60), with final models calculated from combined data.RESULTSThe most discriminative model for fetal or neonatal death included the EFW z score (Hadlock 3 formula/Marsal chart), gestational age, and UmA Doppler category (AUC, 0.91; 95% CI, 0.86-0.97) but was less well calibrated than the model containing only the EFW z score (Hadlock 3/Marsal). The most discriminative model for fetal death or delivery at or before 28+0 weeks included maternal serum placental growth factor (PlGF) concentration and UmA Doppler category (AUC, 0.89; 95% CI, 0.83-0.94).CONCLUSIONUltrasound measurements and maternal serum PlGF concentration at diagnosis of severe, early-onset FGR predicted pregnancy outcomes of importance to patients and clinicians.TRIAL REGISTRATIONClinicalTrials.gov NCT02097667.FUNDINGThe European Union, Rosetrees Trust, Mitchell Charitable Trust.
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Affiliation(s)
- Rebecca Spencer
- UCL Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, United Kingdom
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Kasia Maksym
- UCL Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, United Kingdom
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karel Maršál
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| | - Francesc Figueras
- Institut D’Investigacions Biomèdiques August Pi í Sunyer, University of Barcelona, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Barcelona, Spain
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, United Kingdom
| | - Harry Whitwell
- UCL Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, United Kingdom
- National Phenome Centre and Imperial Clinical Phenotyping Centre, Department of Metabolism, Digestion and Reproduction and
- Section of Bioanalytical Chemistry, Division of Systems Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Nuno Rocha Nené
- UCL Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, United Kingdom
| | - Neil J. Sebire
- Population, Policy and Practice Department, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Stefan R. Hansson
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| | - Anke Diemert
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jana Brodszki
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| | - Eduard Gratacós
- Institut D’Investigacions Biomèdiques August Pi í Sunyer, University of Barcelona, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Barcelona, Spain
| | - Yuval Ginsberg
- UCL Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, United Kingdom
- Department of Obstetrics and Gynecology, Rambam Medical Centre, Haifa, Israel
| | - Tal Weissbach
- UCL Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, United Kingdom
- Department of Obstetrics and Gynecology, Sheba Medical Center Tel Hashomer, Tel Aviv, Israel
| | - Donald M. Peebles
- UCL Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, United Kingdom
| | - Ian Zachary
- Division of Medicine, Faculty of Medical Sciences, University College London, United Kingdom
| | - Neil Marlow
- UCL Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, United Kingdom
| | - Angela Huertas-Ceballos
- Neonatal Department, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Anna L. David
- UCL Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, United Kingdom
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Liu B, Thilaganathan B, Bhide A. Correlation of short-term variation derived from novel ambulatory fetal electrocardiography monitor with computerized cardiotocography. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:758-764. [PMID: 36864543 DOI: 10.1002/uog.26191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/10/2023] [Accepted: 02/14/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To compare short-term variation (STV) outputs from a novel self-applied non-invasive fetal electrocardiography (NIFECG) device with those obtained on computerized cardiotocography (cCTG). Technological and algorithmic limitations and mitigation strategies were also evaluated. METHODS This was a prospective cohort study of women with a singleton pregnancy over 28 + 0 weeks' gestation attending a tertiary London hospital for cCTG assessment between June 2021 and June 2022. Women underwent concurrent monitoring with both NIFECG and cCTG for up to 1 h. Postprocessing of NIFECG data using various filtering methods produced NIFECG-STV (eSTV) values, which were compared with cCTG-STV (cSTV) outputs. Linear correlation, mean bias, precision and limits of agreement were assessed for STV derived by the different methods of computation and mathematical correction. RESULTS Overall, 306 concurrent NIFECG and cCTG traces were collected from 285 women. Fully filtered eSTV was correlated very strongly with cSTV (r = 0.911, P < 0.001), but generated results only in 142/306 (46.4%) 1-h traces owing to the removal of traces with lower-quality signals. Partial filtering generated more eSTV data (98.4%), but with a weak correlation with cSTV (r = 0.337, P < 0.001). The difference in STV between the monitors (eSTV - cSTV) increased with signal loss; in traces with > 60% signal loss, the values became highly discrepant. Removal of traces with > 60% signal loss resulted in a stronger correlation with cSTV, while still generating eSTV results for 65% of traces. Correcting these remaining eSTV values for signal loss using linear regression analysis further improved correlation with cSTV (r = 0.839, P < 0.001). CONCLUSIONS The discrepancy between STV computed by NIFECG and cCTG necessitates signal filtering, exclusion of poor-quality traces and eSTV correction. This study demonstrates that, with such correction, NIFECG is able to produce STV values that are strongly correlated with those of cCTG. This evidence base for NIFECG monitoring and interpretation is a promising step forward in the development of safe and effective at-home fetal heart-rate monitoring. © 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)
- B Liu
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - A Bhide
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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5
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Liu B, Thilaganathan B, Bhide A. Phase-rectified signal averaging: correlation between two monitors and relationship with short-term variation of fetal heart rate. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:765-772. [PMID: 36864541 DOI: 10.1002/uog.26192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/10/2023] [Accepted: 02/14/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To establish the correlation between phase-rectified signal averaging (PRSA) outputs obtained from a novel self-applicable non-invasive fetal electrocardiography (NIFECG) monitor with those from computerized cardiotocography (cCTG). A secondary objective was to evaluate the potential for remote assessment of fetal wellbeing by determining the relationship between PRSA and short-term variation (STV). METHODS This was a prospective observational study of women with a singleton pregnancy over 28 + 0 weeks' gestation attending a London teaching hospital for cCTG assessment. Participants underwent concurrent cCTG and NIFECG monitoring for up to 60 min. Averaged accelerative (AAC) and decelerative (ADC) capacities and STV were derived by postprocessing and filtration of signals, generating fully (F) and partially (P) filtered results. Linear correlation and accuracy and precision analysis were performed to assess the relationship between PRSA outputs from cCTG and NIFECG, using varying anchor thresholds, and their association with STV. RESULTS A total of 306 concurrent cCTG and NIFECG traces were collected from 285 women. F-filtered NIFECG PRSA (eAAC/eADC) results were generated from 65% of traces, whereas cCTG PRSA (cAAC/cADC) outputs were generated from all. Strong correlations were observed between cAAC and F-filtered eAAC (r = 0.879, P < 0.001) and between cADC and F-filtered eADC (r = 0.895, P < 0.001). NIFECG anchor detection decreased significantly with increasing signal loss, and NIFECG PRSA indices showed considerable deviation from those of cCTG when derived from traces in which fewer than 100 anchors were detected. Removing anchor filters from NIFECG traces to generate P-filtered PRSA outputs weakened the correlation (AAC: r = 0.505, P < 0.001; ADC: r = 0.560, P < 0.001). Lowering the anchor threshold to 100 increased the yield of eAAC and eADC outputs to approximately 74%, whilst maintaining strong correlation with cAAC (r = 0.839, P < 0.001) and cADC (r = 0.815, P < 0.001), respectively. Both cAAC and cADC showed a very strong linear relationship with cCTG STV (r = 0.928, P < 0.001 and r = 0.911, P < 0.001, respectively). Similar findings were observed with eAAC (r = 0.825, P < 0.001) and eADC (r = 0.827, P < 0.001). CONCLUSIONS PRSA appears to be a method of fetal assessment equivalent to STV, but, due to its innate ability to eliminate artifacts, it generates interpretable NIFECG traces with high accuracy at a higher rate. These findings raise the possibility of self-applied at-home or remote fetal heart-rate monitoring with automated reporting, thus enabling increased surveillance in high-risk women without impacting on service demand. © 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)
- B Liu
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - A Bhide
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Liu B, Marler E, Thilaganathan B, Bhide A. Ambulatory antenatal fetal electrocardiography in high-risk pregnancies (AMBER): protocol for a pilot prospective cohort study. BMJ Open 2023; 13:e062448. [PMID: 37055213 PMCID: PMC10106038 DOI: 10.1136/bmjopen-2022-062448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
INTRODUCTION Fetal heart rate (FHR) monitoring is a vital aspect of fetal well-being assessment, and the current method of computerised cardiotocography (cCTG) is limited to the hospital setting. Non-invasive fetal ECG (NIFECG) has the ability to produce FHR patterns through R wave detection while eliminating confusion with maternal heart rate, but is presently limited to research use. Femom is a novel wireless NIFECG device that is designed to be placed without professional assistance, while connecting to mobile applications. It has the ability to achieve home FHR monitoring thereby allowing more frequent monitoring, earlier detection of deterioration, while reducing hospital attendances. This study aims to assess the feasibility, reliability, and accuracy of femom (NIFECG) by comparing its outputs to cCTG monitoring. METHODS AND ANALYSIS This is a single-centred, prospective pilot study, taking place in a tertiary maternity unit. Women with a singleton pregnancy over 28+0 weeks' gestation who require antenatal cCTG monitoring for any clinical indication are eligible for recruitment. Concurrent NIFECG and cCTG monitoring will take place for up to 60 min. NIFECG signals will be postprocessed to produce FHR outputs such as baseline FHR and short-term variation (STV). Signal acceptance criteria is set as <50% of signal loss for the trace duration. Correlation, precision and accuracy studies will be performed to compare the STV and baseline FHR values produced by both devices. The impact of maternal and fetal characteristics on the effectiveness of both devices will be investigated. Other non-invasive electrophysiological assessment parameters will be assessed for its correlation with the STV, ultrasound assessments and maternal and fetal risk factors. ETHICS AND DISSEMINATION Approval has been obtained from South-East Scotland Research Ethics Committee 02 and MHRA. The results of this study will be published in peer-reviewed journals, and presented at international conferences. TRIAL REGISTRATION NUMBER NCT04941534.
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Affiliation(s)
- Becky Liu
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, London, UK
| | - Emily Marler
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, London, UK
| | - Amarnath Bhide
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, London, UK
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Bujorescu DL, Ratiu A, Citu C, Gorun F, Gorun OM, Crisan DC, Cozlac AR, Chiorean-Cojocaru I, Tunescu M, Popa ZL, Folescu R, Motoc A. Appropriate Delivery Timing in Fetuses with Fetal Growth Restriction to Reduce Neonatal Complications: A Case-Control Study in Romania. J Pers Med 2023; 13:jpm13040645. [PMID: 37109031 PMCID: PMC10145500 DOI: 10.3390/jpm13040645] [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: 02/24/2023] [Revised: 04/05/2023] [Accepted: 04/05/2023] [Indexed: 04/29/2023] Open
Abstract
(1) Background: The main challenge in cases of early onset fetal growth restriction is management (i.e., timing of delivery), trying to determine the optimal balance between the opposing risks of stillbirth and prematurity. The aim of this study is to determine the likelihood of neonatal complications depending on the time of birth based on Doppler parameters in fetuses with early onset fetal growth restriction; (2) Methods: A case-control study of 205 consecutive pregnant women diagnosed with early onset FGR was conducted at the Obstetrics Clinic of the Municipal Emergency Hospital in Timisoara, Romania; The case group included newborns who were delivered at the onset of umbilical arteries absent/reversed end-diastolic flow, and the control included infants delivered at the onset of reversed/absent ductus venosus A-wave. (3) Results: The overall neonatal mortality rate was 2.0%, and there was no significant statistical difference between the two study groups. In infants delivered up to 30 gestational weeks, grades III/IV intraventricular hemorrhage and bronchopulmonary dysplasia were statistically significantly more frequent in the control group. Moreover, univariate binomial logistic regression analysis on fetuses born under 30 gestational weeks shows that those included in the control group are 30 times more likely to develop bronchopulmonary dysplasia and 14 times more likely to develop intraventricular hemorrhage grades III/IV; (4) Conclusions: Infants delivered according to the occurrence of umbilical arteries absent/reversed end-diastolic flow are less likely to develop intraventricular hemorrhage grades III/IV and bronchopulmonary dysplasia.
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Affiliation(s)
- Daniela-Loredana Bujorescu
- Doctoral School, "Victor Babes" University of Medicine and Pharmacy Timisoara, 2 Eftimie Murgu Square, 300041 Timisoara, Romania
| | - Adrian Ratiu
- Department of Obstetrics and Gynecology, "Victor Babes" University of Medicine and Pharmacy Timisoara, 2 Eftimie Murgu Square, 300041 Timisoara, Romania
| | - Cosmin Citu
- Department of Obstetrics and Gynecology, "Victor Babes" University of Medicine and Pharmacy Timisoara, 2 Eftimie Murgu Square, 300041 Timisoara, Romania
| | - Florin Gorun
- Department of Obstetrics and Gynecology, Municipal Emergency Clinical Hospital Timisoara, 22-24 16 December 1989 Street, 300172 Timisoara, Romania
| | - Oana Maria Gorun
- Doctoral School, "Victor Babes" University of Medicine and Pharmacy Timisoara, 2 Eftimie Murgu Square, 300041 Timisoara, Romania
| | - Doru Ciprian Crisan
- Department of Obstetrics and Gynecology, "Victor Babes" University of Medicine and Pharmacy Timisoara, 2 Eftimie Murgu Square, 300041 Timisoara, Romania
| | - Alina-Ramona Cozlac
- Cardiology Department, "Victor Babes" University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania
| | | | - Mihaela Tunescu
- Neonatology Clinic, Municipal Emergency Clinical Hospital Timisoara, 22-24 16 December 1989 Street, 300172 Timisoara, Romania
| | - Zoran Laurentiu Popa
- Department of Obstetrics and Gynecology, "Victor Babes" University of Medicine and Pharmacy Timisoara, 2 Eftimie Murgu Square, 300041 Timisoara, Romania
| | - Roxana Folescu
- Department of Balneology, Medical Recovery and Rheumatology, Family Discipline, Center for Preventive Medicine, Center for Advanced Research in Cardiovascular Pathology and Hemostaseology, "Victor Babes" University of Medicine and Pharmacy Timisoara, 2 Eftimie Murgu Square, 300041 Timisoara, Romania
| | - Andrei Motoc
- Department of Anatomy and Embryology, "Victor Babes" University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania
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Guinamant J, Winer N, Rozé JC, Arthuis C. [Medical termination of pregnancy for isolated intrauterine growth retardation beyond 24 weeks and more than 450g]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2023; 51:166-171. [PMID: 36372155 DOI: 10.1016/j.gofs.2022.11.003] [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: 12/06/2021] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Fetal growth restriction (FGR) is an obstetric complication responsible for increased perinatal morbidity and mortality. In some severe and early FGR situations, termination of pregnancy (TOP) may be considered. The main objective of our study was to describe the population of fetuses for whom a TOP was performed for isolated FGR beyond 24 days' gestation and for a birth weight>450g and to analyze the immediate outcome, at 2 and 5 years, of term- and weight-matched neonates born in a context of severe FGR after 24 weeks' gestation and over 450g. MATERIAL AND METHODS We conducted an observational, descriptive, retrospective, uni-centric study between 2008 and 2018. The primary endpoint was survival at maternity discharge, 2 years and 5 years in these children. Secondary endpoints were assessment of immediate and longer-term postnatal morbidity. Twenty-five patients (36%) were selected for the study with a fetus weight>450g and term>24 weeks. Each fetus with an TOP was matched (on gestational age and weight) with two live-born children from the perinatal network cohort to assess immediate discharge outcome, and then at 2 and 5 years. RESULTS The mortality rate was 24%. In neonatal management, for 67% (n=17) of the newborns the evolution was complicated by death or at least two sequelae (bronchopulmonary dysplasia, hyaline membrane disease stage≥2, intraventricular of grade 3 and 4, ulcerative colitis requiring surgery, retinopathy of prematurity stage 2 and more) at discharge. In 32% (n=8) of cases, there was at least one sequela at discharge. Regardless of gestational age at birth, development at 2 years was normal for 48% (n=11/23) of them and abnormal for 22% (n=5) and development at 5 years was normal for 56% (n=9/16) of them and abnormal for 19% (n=5). CONCLUSION An ultrasound evaluation in a reference center as well as additional information by the obstetrician and neonatologist ensures the most appropriate informed involvement of the couple in the medical decisions before and after birth.
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Affiliation(s)
- J Guinamant
- Service de gynécologie obstétrique, centre hospitalier universitaire de Nantes, hôpital mère-enfant-adolescent, 38, boulevard Jean-Monnet, NUN INRAE UMR 1280 Phan, 44000 Nantes, France
| | - N Winer
- Service de gynécologie obstétrique, centre hospitalier universitaire de Nantes, hôpital mère-enfant-adolescent, 38, boulevard Jean-Monnet, NUN INRAE UMR 1280 Phan, 44000 Nantes, France
| | - J-C Rozé
- Service de pédiatrie, centre hospitalier universitaire de Nantes, CIC et hôpital mère-enfant-adolescent, 38, boulevard Jean-Monnet, 44000 Nantes, France
| | - C Arthuis
- Service de gynécologie obstétrique, centre hospitalier universitaire de Nantes, hôpital mère-enfant-adolescent, 38, boulevard Jean-Monnet, NUN INRAE UMR 1280 Phan, 44000 Nantes, France; Elsan santé atlantique, service gynécologie obstétrique et diagnostic anténatal, 44819 St-Herblain, France.
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9
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Tica OS, Tica AA, Cojocaru D, Tica I, Petcu CL, Cojocaru V, Alexandru DO, Tica VI. Maternal Steroids on Fetal Doppler Indices, in Growth-Restricted Fetuses with Abnormal Umbilical Flow from Pregnancies Complicated with Early-Onset Severe Preeclampsia. Diagnostics (Basel) 2023; 13:diagnostics13030428. [PMID: 36766533 PMCID: PMC9914710 DOI: 10.3390/diagnostics13030428] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/18/2023] [Accepted: 01/20/2023] [Indexed: 01/26/2023] Open
Abstract
Corticoids are largely used for fetal interest in expected preterm deliveries. This study went further, evaluating the effect of maternal administration of dexamethasone (Dex) on the umbilical artery (UA), middle cerebral artery (MCA), and ductus venous (DV) spectrum, in growth-restricted fetuses, with the absent end-diastolic flow (AEDF) in UA, from singleton early-onset severe preeclamptic pregnancies. Supplementary, the impact on both uterine arteries (UTAs) flow was also evaluated. In 68.7% of cases, the EDF was transiently restored (trAEDF group), in the rest of 31.2% remained persistent absent (prAEDF group). UA-PI significantly decreased in the first day after Dex (day 1/0; p < 0.05), reaching its minimum during day 2 (day 2/1; p > 0.05), revealing a significant recovery to day 4 (day 4/2; p < 0.05), in both groups. The MCA-PI decreased from day 1 until day 3 in both groups, but significantly only in the trAEDF group (p = 0.030 vs. p = 0.227. The DV-PI's decrease (during day 1) and the CPR's increase (between days 0 and 2) were not significant in both groups. UTAs-PIs did not vary. The prAEDF group had a significantly increased rate of antenatal worsening Doppler and a poorer perinatal outcome compared with the trAEDF group. In conclusion, Dex transiently restored the AEDF in UA in the majority of cases, a "positive" effect being a useful marker for better perinatal prognosis. UA-PI significantly decreased in all cases. The improvement in umbilical circulation probably was responsible for the short but not significant DV-PI reduction. MCA-PI decreased only in sensitive cases, probably due to an already cerebral "full" vasodilation in the prAEDF group. Furthermore, the CPR's nonsignificant improvement was the result of a stronger effect of Dex on UA-PI than on MCA-PI. Finally, despite the same etiology, it was only a weak correlation between the severity of the umbilical and uterine abnormal spectrum.
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Affiliation(s)
- Oana Sorina Tica
- Department of “Mother and Child”, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Craiova County Emergency Hospital, 200642 Craiova, Romania
| | - Andrei Adrian Tica
- Craiova County Emergency Hospital, 200642 Craiova, Romania
- Department of Pharmacology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Correspondence: (A.A.T.); (I.T.)
| | - Doriana Cojocaru
- Department of Anesthesiology and Intensive Care, “Nicolae Testemitanu” State University of Medicine and Pharmacy Chisinau, 2004 Chisinau, Moldova
- “Timofei Mosneaga” Republican Clinical Hospital, 2025 Chisinau, Moldova
| | - Irina Tica
- Department of Internal Medicine, Faculty of Medicine, University “Ovidius” Constanta, 900527 Constanța, Romania
- Constanta County Emergency Hospital, 900591 Constanța, Romania
- Correspondence: (A.A.T.); (I.T.)
| | - Cristian Lucian Petcu
- Department of Biophysics, Faculty of Dental Medicine, University “Ovidius” Constanta, 900527 Constanța, Romania
| | - Victor Cojocaru
- Department of Anesthesiology and Intensive Care, “Nicolae Testemitanu” State University of Medicine and Pharmacy Chisinau, 2004 Chisinau, Moldova
- “Timofei Mosneaga” Republican Clinical Hospital, 2025 Chisinau, Moldova
| | - Dragos Ovidiu Alexandru
- Department of Biostatistics, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Vlad Iustin Tica
- Constanta County Emergency Hospital, 900591 Constanța, Romania
- Department of Obstetrics and Gynecology, Faculty of Medicine, University “Ovidius” Constanta, 900527 Constanța, Romania
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10
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Zizzo AR, Hansen J, Peteren OB, Mølgaard H, Uldbjerg N, Kirkegaard I. Growth-restricted human fetuses have preserved respiratory sinus arrhythmia but reduced heart rate variability estimates of vagal activity during quiescence. Physiol Rep 2022; 10:e15458. [PMID: 36411966 PMCID: PMC9812234 DOI: 10.14814/phy2.15458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/17/2022] [Accepted: 08/21/2022] [Indexed: 11/23/2022] Open
Abstract
The aim was to assess the association between fetal growth restriction (FGR) and fetal heart rate variability (FHRV) in relation to fetal movements. A prospective observational cohort study was performed. Non-invasive fetal electrocardiography (NI-FECG) allowed beat-to-beat assessments with <5% corrections of RR intervals. FHRV analyses included: Root mean square of successive RR interval differences (RMSSD), high frequency power (HF power), and low frequency power (LF power). Fetal movements were categorized by continuous ultrasound scanning. We enrolled 36 singleton pregnant women expecting a small fetus (< the 2.3 percentile of mean weight for gestational age) diagnosed by ultrasound, of whom 25 presented with a birthweight < the 2.3 percentile. Among these, 11 were excluded due to low quality NI-FECG recordings, leaving 14 women with 28 recordings eligible for inclusion in the analyses. The control group consisted of 22 healthy fetuses with birthweights between the 10th and the 90th percentile (average for gestational age [AGA]). In FGR fetuses the HRV response to respiratory activity was comparable to that of AGA fetuses. RMSSD (Ratio 1.54 [95% CI: 1.33; 1.79]) and HF power (Ratio 2.88 [95% CI: 2.12; 3.91]) increased, whereas LF/HF power (Ratio: 0.44 [95% CI: 0.31;0.63]) decreased. However, during fetal quiescence, FGR fetuses differed significantly from AGA fetuses. Compared to AGA fetuses, FGR fetuses displayed lower RMSSD (Ratio 0.77 (95% CI: 0.58; 1.02)) and HF power (Ratio 0.56 (95% CI:0.32; 0.98)). This reduction was associated with the severity of the FGR. In conclusion, FGR fetuses displayed a respiratory sinus arrhythmia (RSA) comparable to AGA fetuses; however, more important, parameters representing cardiac vagal activity were impaired in FGR fetuses during quiescence. RSA may constitute an intrinsic function of the cardiovascular system, which is unaffected by fetal compromise. However, the basic cardiac outflow assessed during fetal quiescence indicates a suppressed cardiac vagal activity in the FGR fetuses.
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Affiliation(s)
- Anne Rahbek Zizzo
- Department of Obstetrics and GynaecologyAarhus University HospitalAarhus NDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - John Hansen
- Department of Health Science and TechnologyAalborg UniversityAalborgDenmark
| | - Olav Bjørn Peteren
- Department of ObstetricsCopenhagen University HospitalCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Henning Mølgaard
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
- Department of CardiologyAarhus University HospitalAarhus NDenmark
| | - Niels Uldbjerg
- Department of Obstetrics and GynaecologyAarhus University HospitalAarhus NDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Ida Kirkegaard
- Department of Obstetrics and GynaecologyAarhus University HospitalAarhus NDenmark
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11
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Pham M, Dean P, McCulloch M, Vergales J. Association Between Pulsatility Index and the Development of Necrotizing Enterocolitis in Infants with Congenital Heart Disease. Pediatr Cardiol 2022; 43:1156-1162. [PMID: 35192021 DOI: 10.1007/s00246-022-02839-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 01/27/2022] [Indexed: 11/26/2022]
Abstract
Infants with congenital heart disease are known to have higher rates of necrotizing enterocolitis (NEC) which is associated with poorer outcomes. Although the etiology is recognized as distinct from the premature neonatal population, there is not a universal consensus regarding etiology or specific risk factors. In this retrospective single-institution case-control study, we assessed whether aortic pulsatility index (PI) as detected via ultrasound might be associated with NEC in neonates undergoing cardiac surgical repair within the first month of life. The study identified 30 participants who developed NEC and 50 matched controls. Baseline demographic and surgical characteristics were similar between groups. Patients who developed NEC had higher mortality (26% vs 4%, p < 0.01). Standard PI and the modified pulsatility values were calculated manually and underwent logistic regression. The median log PI of the NEC cohort was higher compared to the lowest control PI (0.68 vs 0.48, p = 0.03); the median log PI of the NEC cohort was significantly lower than the highest PI of the control cohort (0.61 vs 0.98, p = 0.05). The modified pulsatility index demonstrated similar trends with the median log MODPI of the NEC cohort being significantly greater than that of the control cohort (3.9 vs. 3.1, p = 0.01). Infants with congenital heart disease who develop NEC have a higher PI and MODPI when compared to the lowest control PI. This suggests that infants with a higher baseline PI may be at increased risk for developing NEC.
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Affiliation(s)
- Michael Pham
- Department of Pediatric Cardiology, University of Virginia, Charlottesville, VA, USA.
| | - Peter Dean
- Department of Pediatric Cardiology, University of Virginia, Charlottesville, VA, USA
| | - Michael McCulloch
- Department of Pediatric Cardiology, University of Virginia, Charlottesville, VA, USA
| | - Jeffrey Vergales
- Department of Pediatric Cardiology, University of Virginia, Charlottesville, VA, USA
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12
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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: 65] [Impact Index Per Article: 32.5] [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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13
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Morsing E, Brodszki J, Thuring A, Maršál K. Infant outcome after active management of early-onset fetal growth restriction with absent or reversed umbilical artery blood flow. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:931-941. [PMID: 32862450 PMCID: PMC8252652 DOI: 10.1002/uog.23101] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/10/2020] [Accepted: 08/23/2020] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To describe the short- and long-term outcomes of infants with early-onset fetal growth restriction (FGR) and umbilical artery absent or reversed end-diastolic flow (AREDF), delivered before 30 weeks' gestation and managed proactively. METHODS This was a retrospective cohort study of fetuses delivered for fetal indication before 30 completed weeks' gestation that had early-onset FGR (defined as estimated fetal weight more than 2 SD below the mean) with AREDF in the umbilical artery (FGR group), at the level-3 perinatal unit in Lund, Sweden, between 1998 and 2015. Perinatal outcome and neurodevelopment at ≥ 2 years of age in surviving infants were compared with those of a group of infants without small-for-gestational-age birth weight or any known fetal Doppler changes delivered before 30 weeks in Lund during the corresponding time period (non-FGR group). In the FGR group, the main indication for delivery was the Doppler finding of AREDF in the umbilical artery. RESULTS There were 139 fetuses (of which 26% were a twin/triplet) in the FGR group and 946 fetuses (of which 28% were a twin/triplet) in the non-FGR group. The FGR infants had a median birth weight of 630 g (range, 340-1165 g) and gestational age at birth of 187 days (range, 164-209 days), as compared with 950 g (range, 470-2194 g) and 185 days (range, 154-209 days), respectively, in the non-FGR group. The rate of fetal mortality did not differ between the two groups (5.0% and 5.4% in the FGR and non-FGR groups, respectively). All seven intrauterine deaths in the FGR group occurred before 26 weeks' gestation. In the FGR group compared with the non-FGR group, severe intraventricular hemorrhage was less frequent and bronchopulmonary dysplasia and septicemia were more frequent (P = 0.008, P < 0.001 and P = 0.017, respectively). In the FGR group, the survival rate at 2 years (83% of liveborn infants) and the rate of cerebral palsy (7%) did not differ significantly from those in the non-FGR group (82% and 8%, respectively). The rate of survival without neurodevelopmental impairment was higher in the non-FGR group (83%) than in the FGR group (62%) (P < 0.001), as well as in infants in the FGR group delivered at or after 26 weeks (72%) compared with those delivered before 26 weeks (40%) (P = 0.003). Within the FGR group, outcomes were similar between twins and singletons and, in those who survived beyond 2 years, outcomes were similar between fetuses with absent and those with reversed end-diastolic flow in the umbilical artery. CONCLUSIONS Infants delivered very preterm after severe FGR with AREDF in the umbilical artery had a similar rate of survival as did non-FGR infants of corresponding gestational age; however, they were at higher risk of neurodevelopmental impairment, the risk being most pronounced following birth before 26 weeks. Gestational age remains an important factor associated with the prognosis of early-onset FGR; nevertheless, the present results support the hypothesis, which should be tested prospectively, that fetuses with early-onset FGR and umbilical artery AREDF may benefit from early intervention rather than expectant management, and that umbilical artery Doppler findings could be incorporated into clinical protocols for cases very early in gestation. © 2020 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)
- E. Morsing
- Pediatrics, Department of Clinical SciencesLund UniversityLundSweden
| | - J. Brodszki
- Obstetrics and Gynecology, Department of Clinical SciencesLund UniversityLundSweden
| | - A. Thuring
- Obstetrics and Gynecology, Department of Clinical SciencesLund UniversityLundSweden
| | - K. Maršál
- Obstetrics and Gynecology, Department of Clinical SciencesLund UniversityLundSweden
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14
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Meler E, Martínez J, Boada D, Mazarico E, Figueras F. Doppler studies of placental function. Placenta 2021; 108:91-96. [PMID: 33857819 DOI: 10.1016/j.placenta.2021.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 02/18/2021] [Accepted: 03/22/2021] [Indexed: 12/18/2022]
Abstract
Placental-associated diseases account for most cases of adverse perinatal outcome in developing countries. Doppler evaluation has been incorporated as a predictive parameter at early pregnancy for high-risk placental disease, in the diagnosis and management of those fetuses with impaired intrauterine growth and for the evaluation of fetal wellbeing in those high-risk pregnancies. Uterine Doppler at second trimester predicts most instances of early-onset preeclampsia and intrauterine growth restriction. However, the growing evidence of an effective early propylactic strategy, has turned Uterine Doppler an essential parameter to be included in first trimester predictive algorithms. Umbilical artery Doppler helps in the identification of small-for-gestational-age fetuses at higher risk, and is one of the essential vessels in the assessment of fetal hypoxia impairment, especially in the early cases. It helps in the decision timing for ending the pregnancy improving thus perinatal outcomes. Moreover, in high-risk pregnancies, umbilical artery Doppler has demonstrated to reduce the risk of perinatal deaths and the risk of obstetric interventions. On the other hand, middle cerebral artery Doppler reflects fetal adaptation to hypoxia, and with the cerebroplacental ratio, they improve the detection of fetuses a high risk of adverse perinatal outcome, mostly of those late small fetuses, where most instances of adverse outcome occur in fetuses with normal umbilical artery. Ductus venosous Doppler waveform is a surrogate parameter of the fetal base-acid status. Its use has demonstrated to improve perinatal outcomes, mainly reducing the risk of fetal intrauterine death. Alone or in combination with computerized CTG, it helps tailoring the best moment to end the pregnancy among early cases.
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Affiliation(s)
- Eva Meler
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, And Center for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain.
| | - Judit Martínez
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, And Center for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - David Boada
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, And Center for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Edurne Mazarico
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, And Center for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Francesc Figueras
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, And Center for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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Melamed N, Baschat A, Yinon Y, Athanasiadis A, Mecacci F, Figueras F, Berghella V, Nazareth A, Tahlak M, McIntyre HD, Da Silva Costa F, Kihara AB, Hadar E, McAuliffe F, Hanson M, Ma RC, Gooden R, Sheiner E, Kapur A, Divakar H, Ayres‐de‐Campos D, Hiersch L, Poon LC, Kingdom J, Romero R, Hod M. FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction. Int J Gynaecol Obstet 2021; 152 Suppl 1:3-57. [PMID: 33740264 PMCID: PMC8252743 DOI: 10.1002/ijgo.13522] [Citation(s) in RCA: 187] [Impact Index Per Article: 62.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Fetal growth restriction (FGR) is defined as the failure of the fetus to meet its growth potential due to a pathological factor, most commonly placental dysfunction. Worldwide, FGR is a leading cause of stillbirth, neonatal mortality, and short- and long-term morbidity. Ongoing advances in clinical care, especially in definitions, diagnosis, and management of FGR, require efforts to effectively translate these changes to the wide range of obstetric care providers. This article highlights agreements based on current research in the diagnosis and management of FGR, and the areas that need more research to provide further clarification of recommendations. The purpose of this article is to provide a comprehensive summary of available evidence along with practical recommendations concerning the care of pregnancies at risk of or complicated by FGR, with the overall goal to decrease the risk of stillbirth and neonatal mortality and morbidity associated with this condition. To achieve these goals, FIGO (the International Federation of Gynecology and Obstetrics) brought together international experts to review and summarize current knowledge of FGR. This summary is directed at multiple stakeholders, including healthcare providers, healthcare delivery organizations and providers, FIGO member societies, and professional organizations. Recognizing the variation in the resources and expertise available for the management of FGR in different countries or regions, this article attempts to take into consideration the unique aspects of antenatal care in low-resource settings (labelled “LRS” in the recommendations). This was achieved by collaboration with authors and FIGO member societies from low-resource settings such as India, Sub-Saharan Africa, the Middle East, and Latin America.
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Affiliation(s)
- Nir Melamed
- Division of Maternal Fetal MedicineDepartment of Obstetrics and GynecologySunnybrook Health Sciences CentreUniversity of TorontoTorontoONCanada
| | - Ahmet Baschat
- Center for Fetal TherapyDepartment of Gynecology and ObstetricsJohns Hopkins UniversityBaltimoreMDUSA
| | - Yoav Yinon
- Fetal Medicine UnitDepartment of Obstetrics and GynecologySheba Medical CenterTel‐HashomerSackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
| | - Apostolos Athanasiadis
- Third Department of Obstetrics and GynecologyAristotle University of ThessalonikiThessalonikiGreece
| | - Federico Mecacci
- Maternal Fetal Medicine UnitDivision of Obstetrics and GynecologyDepartment of Biomedical, Experimental and Clinical SciencesUniversity of FlorenceFlorenceItaly
| | - Francesc Figueras
- Maternal‐Fetal Medicine DepartmentBarcelona Clinic HospitalUniversity of BarcelonaBarcelonaSpain
| | - Vincenzo Berghella
- Division of Maternal‐Fetal MedicineDepartment of Obstetrics and GynecologyThomas Jefferson UniversityPhiladelphiaPAUSA
| | - Amala Nazareth
- Jumeira Prime Healthcare GroupEmirates Medical AssociationDubaiUnited Arab Emirates
| | - Muna Tahlak
- Latifa Hospital for Women and ChildrenDubai Health AuthorityEmirates Medical AssociationMohammad Bin Rashid University for Medical Sciences, Dubai, United Arab Emirates
| | | | - Fabrício Da Silva Costa
- Department of Gynecology and ObstetricsRibeirão Preto Medical SchoolUniversity of São PauloRibeirão PretoSão PauloBrazil
| | - Anne B. Kihara
- African Federation of Obstetricians and GynaecologistsKhartoumSudan
| | - Eran Hadar
- Helen Schneider Hospital for WomenRabin Medical CenterPetach TikvaIsrael
- Sackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
| | - Fionnuala McAuliffe
- UCD Perinatal Research CentreSchool of MedicineNational Maternity HospitalUniversity College DublinDublinIreland
| | - Mark Hanson
- Institute of Developmental SciencesUniversity Hospital SouthamptonSouthamptonUK
- NIHR Southampton Biomedical Research CentreUniversity of SouthamptonSouthamptonUK
| | - Ronald C. Ma
- Department of Medicine and TherapeuticsThe Chinese University of Hong KongHong Kong SARChina
- Hong Kong Institute of Diabetes and ObesityThe Chinese University of Hong KongHong Kong SARChina
| | - Rachel Gooden
- FIGO (International Federation of Gynecology and Obstetrics)LondonUK
| | - Eyal Sheiner
- Soroka University Medical CenterBen‐Gurion University of the NegevBe’er‐ShevaIsrael
| | - Anil Kapur
- World Diabetes FoundationBagsværdDenmark
| | | | | | - Liran Hiersch
- Sourasky Medical Center and Sackler Faculty of MedicineLis Maternity HospitalTel Aviv UniversityTel AvivIsrael
| | - Liona C. Poon
- Department of Obstetrics and GynecologyPrince of Wales HospitalThe Chinese University of Hong KongShatinHong Kong SAR, China
| | - John Kingdom
- Division of Maternal Fetal MedicineDepartment of Obstetrics and GynecologyMount Sinai HospitalUniversity of TorontoTorontoONCanada
| | - Roberto Romero
- Perinatology Research BranchEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMDUSA
| | - Moshe Hod
- Helen Schneider Hospital for WomenRabin Medical CenterPetach TikvaIsrael
- Sackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
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Bansode SA, Balakrishnan B, Batra M, Sreeja PS, Swapneel NP, Gopinathan KK. Retrograde Flow in the Aortic Isthmus: Trigger to Deliver Growth Restricted Fetuses Between 30 and 34 Weeks of Gestation? JOURNAL OF FETAL MEDICINE 2021. [DOI: 10.1007/s40556-020-00281-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Gusar V, Ganichkina M, Chagovets V, Kan N, Sukhikh G. MiRNAs Regulating Oxidative Stress: A Correlation with Doppler Sonography of Uteroplacental Complex and Clinical State Assessments of Newborns in Fetal Growth Restriction. J Clin Med 2020; 9:jcm9103227. [PMID: 33050114 PMCID: PMC7650709 DOI: 10.3390/jcm9103227] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/29/2020] [Accepted: 10/06/2020] [Indexed: 02/08/2023] Open
Abstract
Overproduction of reactive oxygen species (ROS) and, as a result, uncontrolled oxidative stress (OS) can play a central role in disorders of fetal hemodynamics and subsequent development of adverse perinatal outcomes in newborns with fetal growth restriction (FGR). Given the epigenetic nature of such disorders, the aim of our study was to evaluate the expression of miRNAs associated with OS and endothelial dysfunction (miR-27a-3p, miR-30b-5p, miR-125b-5p, miR-221-3p, miR-451a and miR-574-3p) in umbilical cord blood using real-time quantitative RT-PCR. ΜiRNA expression was evaluated in patients with FGR delivery before (n = 9 pregnant) and after 34 weeks of gestation (n = 13 pregnant), and the control groups corresponding to the main groups by gestational age (13 pregnant women in each group, respectively). A significant increase in miR-451a expression was detected in late-onset FGR and correlations with fetoplacental and cerebral circulation were established (increase of resistance in the umbilical artery (pulsatility index, PI UA (umbilical artery): r = −0.59, p = 0.001) and a decrease in cerebral blood flow (CPR: r = 0.48, p = 0.009)). The change in miR-125b-5p expression in the placenta is associated with reduced Doppler of cerebral hemodynamics (CPR: r = 0.73, p = 0.003; PI MCA (middle cerebral artery): r = 0.79, p = 0.0007), and newborn weight (r = 0.56, p = 0.04) in early-onset FGR. In addition, significant changes in miR-125b-5p and miR-451a expression in umbilical cord blood plasma were found in newborns with neonatal respiratory distress syndrome (NRDS) (in early-onset FGR) and very low birth weight (VLBW) (in late-onset FGR). A number of key signaling pathways have been identified in which the regulation of the studied miRNAs is involved, including angiogenesis, neurotrophin signaling pathway and oxidative stress response. In general, our study showed that changes of the redox homeostasis in the mother-placenta-fetus system in FGR and subsequent perinatal outcomes may be due to differential expression of oxidative stress-associated miRNAs.
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Affiliation(s)
- Vladislava Gusar
- Laboratory of Applied Transcriptomics, Federal State Budget Institution “National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Healthcare of the Russian Federation”, Oparin str. 4, 117997 Moscow, Russia
- Correspondence: or ; Tel.: +7-916-283-72-10
| | - Mariya Ganichkina
- Obstetric Physiological Department, Federal State Budget Institution “National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Healthcare of the Russian Federation”, Oparin str. 4, 117997 Moscow, Russia;
| | - Vitaliy Chagovets
- Laboratory of Proteomics and Metabolomics of Human Reproduction, Federal State Budget Institution “National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Healthcare of the Russian Federation”, Oparin str. 4, 117997 Moscow, Russia;
| | - Nataliya Kan
- Department for Obstetrics and Gynecology, Professional Education Department, Federal State Budget Institution “National Medical Research Center for Obstetrics, Gynecology and/Perinatology named after Academician V.I. Kulakov of the Ministry of Healthcare of the Russian Federation”, Oparin str. 4, 117997 Moscow, Russia;
| | - Gennadiy Sukhikh
- Federal State Budget Institution “National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Healthcare of the Russian Federation”, Oparin str. 4, 117997 Moscow, Russia;
- Department of Obstetrics, Gynecology, Perinatology and Reproductive Medicine, Institute of Professional Education, Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Bolshaya Pirogovskaya str., 2, 119991 Moscow, Russia
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Senra JC, Yoshizaki CT, Doro GF, Ruano R, Gibelli MABC, Rodrigues AS, Koch VHK, Krebs VLJ, Zugaib M, Francisco RPV, Bernardes LS. Kidney impairment in fetal growth restriction: three-dimensional evaluation of volume and vascularization. Prenat Diagn 2020; 40:1408-1417. [PMID: 32583885 DOI: 10.1002/pd.5778] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 02/28/2020] [Accepted: 06/16/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVES Renal development is impaired in fetal growth restriction (FGR). Renal size can be considered a surrogate of renal function in childhood, and could be impaired in that condition. Our aim was to evaluate the ratio of total renal volume, measured by three-dimensional ultrasound, to estimated fetal weight (TRV/EFW) among fetuses with and without growth restriction. Furthermore, we correlated TRV/EFW with fetal Doppler velocimetry and renal vascularization indexes and evaluated the association of renal volume and vascular parameters with adverse neonatal events in growth-restricted fetuses. METHODS In a retrospective cohort, TRV and renal vascularization of growth-restricted and normal fetuses were evaluated by three-dimensional ultrasonography and VOCAL technique. Independent samples t-tests and Mann-Whitney test were used for comparisons between groups. Logistic regression model was applied to evaluate the association between renal characteristics and adverse neonatal events. RESULTS Seventy-one growth-restricted fetuses were compared to 194 controls. The TRV/EFW was lower in the growth-restricted group (P < .001). In our sample, this ratio did not correlate with Doppler velocimetry parameters, renal vascular indexes or any adverse neonatal events. CONCLUSION The TRV/EFW ratio is decreased in FGR. Further studies are needed to investigate the association of this ratio with long-term renal outcomes.
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Affiliation(s)
- Janaína Campos Senra
- Department of Obstetrics and Gynecology, Clinics Hospital, University of São Paulo, São Paulo, Brazil
| | - Carlos Tadashi Yoshizaki
- Department of Obstetrics and Gynecology, Clinics Hospital, University of São Paulo, São Paulo, Brazil
| | - Giovana Farina Doro
- Department of Obstetrics and Gynecology, Clinics Hospital, University of São Paulo, São Paulo, Brazil
| | - Rodrigo Ruano
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | | | - Agatha Sacramento Rodrigues
- Statistician, Department of Obstetrics and Gynecology, Clinics Hospital, University of São Paulo, São Paulo, Brazil
| | - Vera Hermina Kalika Koch
- Pediatric Nephrology Unit, Department of Pediatrics, Clinics Hospital, University of São Paulo, São Paulo, Brazil
| | - Vera Lúcia Jornada Krebs
- Neonatal Unit, Department of Pediatrics, Clinics Hospital, University of São Paulo, São Paulo, Brazil
| | - Marcelo Zugaib
- Department of Obstetrics and Gynecology, Clinics Hospital, University of São Paulo, São Paulo, Brazil
| | | | - Lisandra Stein Bernardes
- Department of Obstetrics and Gynecology, Clinics Hospital, University of São Paulo, São Paulo, Brazil
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Aski SK, Akbari R, Hantoushzadeh S, Ghotbizadeh F. A bibliometric analysis of Intrauterine Growth Restriction research. Placenta 2020; 95:106-120. [PMID: 32452397 DOI: 10.1016/j.placenta.2020.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 03/24/2020] [Indexed: 12/15/2022]
Abstract
Intrauterine growth restriction (IUGR) is not a new subject in pregnancy. Nevertheless, this concept has newly begun to be integrated into pregnancy studies. We recognized articles that were published in English from 1977 to 2019 through electronic searches of the Web of Science™ database. The WoS database was searched for all published articles that compared preeclampsia from 1977 to January 2020. About 1469 documents in obstetrics and gynecology areas were analyzed in WoS database. VOSviewer software was employed to visualize the networks. The survey resulted in a 1469 published documents from 1977 to 2020. 'Gratacos' from Spain and 'Cetin' from Italy contributed the most publications. The greatest contribution came from the 'USA' (n = 498), 'Italy' (n = 155), and 'England' (n = 147). Furthermore, our results found that among these journals, the 'AJOG' (n = 318) and the 'Reproductive Sciences' (n = 209) published the largest number of papers. The top 100 most cited papers showed that 30% were reported in the 'AJOG'. About half the articles were published in the last decade and the most common studies were research paper (77%). The co-occurrence and co-citation analysis showed that the study formed four clusters. Finally, the strategic map was designed. We found that there existed an increasing trend in the large amount of publication on IUGR from 1977 to 2020. The number of studies in IUGR has substantially improved in the last decade. Authors from the 'USA' appeared the most proactive in addressing the IUGR area. By studying these articles, we propose important to support not only for grinding the IUGR challenges field but also for designing a new trend in this area.
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Affiliation(s)
- Soudabeh Kazemi Aski
- Reproductive Health Research Center, Department of Obstetrics & Gynecology, Rasht, Iran.
| | - Razieh Akbari
- Department of Obstetrics and Gynecology, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - Sedigheh Hantoushzadeh
- Department of Obstetrics and Gynecology, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - Fahimeh Ghotbizadeh
- Department of Obstetrics and Gynecology, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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20
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Ganzevoort W, Thornton JG, Marlow N, Thilaganathan B, Arabin B, Prefumo F, Lees C, Wolf H. Comparative analysis of 2-year outcomes in GRIT and TRUFFLE trials. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:68-74. [PMID: 31125465 PMCID: PMC6973288 DOI: 10.1002/uog.20354] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/06/2019] [Accepted: 05/10/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To explore the effect on perinatal outcome of different fetal monitoring strategies for early-onset fetal growth restriction (FGR). METHODS This was a cohort analysis of individual participant data from two European multicenter trials of fetal monitoring methods for FGR: the Growth Restriction Intervention Study (GRIT) and the Trial of Umbilical and Fetal Flow in Europe (TRUFFLE). All women from GRIT (n = 238) and TRUFFLE (n = 503) who were randomized between 26 and 32 weeks' gestation were included. The women were grouped according to intervention and monitoring method: immediate delivery (GRIT) or delayed delivery with monitoring by conventional cardiotocography (CTG) (GRIT), computerized CTG (cCTG) only (GRIT and TRUFFLE) or cCTG and ductus venosus (DV) Doppler (TRUFFLE). The primary outcome was survival without neurodevelopmental impairment at 2 years of age. RESULTS Gestational age at delivery and birth weight were similar in both studies. Fetal death rate was similar between the GRIT and TRUFFLE groups, but neonatal and late death were more frequent in GRIT (18% vs 6%; P < 0.01). The rate of survival without impairment at 2 years was lowest in pregnancies that underwent immediate delivery (70% (95% CI, 61-78%)) or delayed delivery with monitoring by CTG (69% (95% CI, 57-82%)), increased in those monitored using cCTG only in both GRIT (80% (95% CI, 68-91%)) and TRUFFLE (77% (95% CI, 70-84%)), and was highest in pregnancies monitored using cCTG and DV Doppler (84% (95% CI, 80-89%)) (P < 0.01 for trend). CONCLUSIONS This analysis supports the hypothesis that the optimal method for fetal monitoring in pregnancies complicated by early-onset FGR is a combination of cCTG and DV Doppler assessment. TRIAL REGISTRATION GRIT ISRCTN41358726 and TRUFFLE ISRCTN56204499. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- W. Ganzevoort
- Department of ObstetricsAmsterdam University Medical CenterAmsterdamThe Netherlands
| | - J. G. Thornton
- Division of Child Health, Obstetrics and Gynaecology, School of MedicineUniversity of Nottingham, Nottingham City HospitalNottinghamUK
| | - N. Marlow
- Department of Academic NeonatologyUCL Institute for Women's HealthLondonUK
| | - B. Thilaganathan
- Fetal Medicine UnitSt George's University Hospitals NHS Foundation Trust, University of LondonLondonUK
- Vascular Biology and Research Centre, Molecular & Clinical Sciences Research InstituteSt George's University of LondonLondonUK
| | - B. Arabin
- Center for Mother and Child of the Philipps UniversityMarburgGermany
| | - F. Prefumo
- Maternal–Fetal Medicine UnitUniversity of BresciaBresciaItaly
| | - C. Lees
- Department of Obstetrics & GynaecologyRosie HospitalCambridgeUK
- Department of Obstetrics and GynecologyKU LeuvenBelgium
| | - H. Wolf
- Department of ObstetricsAmsterdam University Medical CenterAmsterdamThe Netherlands
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Bruin CM, Ganzevoort W, Schuit E, Mensing van Charante NA, Wolf H. Inter- and intra-observer variability in fetal ductus venosus blood flow measurements in high-risk fetuses at 26-32 weeks. Eur J Obstet Gynecol Reprod Biol 2019; 243:67-71. [PMID: 31675632 DOI: 10.1016/j.ejogrb.2019.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/12/2019] [Accepted: 10/17/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Early preterm fetal growth restriction is a significant contributor to perinatal morbidity and mortality. The ductus venosus pulsatility index for veins (DV PIV) is proposed as a monitoring tool because it appears to improve perinatal outcomes. The test characteristics and robustness of DV PIV have been inadequately described. The aim of this study was to investigate inter- and intra-observer variability of DV PIV. STUDY DESIGN Nineteen women with a gestational age between 26 and 32 completed weeks were included in this study. Doppler sonographic fetal assessment was performed by two independent maternal-fetal medicine specialists. Each sonographer alternately performed three flow tracings for each participant, in the absence of the other sonographer (six tracings in total per patient). DV PIV was calculated automatically from stored tracings by a third researcher. Inter- and intra-observer variability of DV PIV and limits of agreement were assessed using the Bland-Altman method. Comparison of the distribution was performed with Kendall's related samples test, and the intraclass correlation coefficient (ICC) was calculated. RESULTS In total, 114 DV measurements were taken from 19 participants with a median age of 31 years [interquartile range (IQR) 26-34 years] at a median gestational age of 28 weeks (IQR 27-29 weeks). The proportional limits of agreement for intra-observer variation were -0.48 to 0.48 and -0.39 to 0.62 for the two observers. ICCs were 0.66 [95% confidence interval (CI) 0.42-0.84] and 0.68 (95% CI 0.45-0.85). The proportional limits of agreement for inter-observer variation were -0.29 to 0.19 with an ICC of 0.89 (95% CI 0.73-0.96). CONCLUSION Inter-observer variation was far less than intra-observer variation, probably due to mitigation of biological variation by averaging three measurements. DV PIV has acceptable test characteristics for use in a clinical setting when the average of at least three consecutive measurements is used.
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Affiliation(s)
- Clara M Bruin
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ewoud Schuit
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Nico A Mensing van Charante
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Gynaecology, Dijklander Ziekenhuis, Hoorn, the Netherlands
| | - Hans Wolf
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Preeclampsia: Risk Factors, Diagnosis, Management, and the Cardiovascular Impact on the Offspring. J Clin Med 2019; 8:jcm8101625. [PMID: 31590294 PMCID: PMC6832549 DOI: 10.3390/jcm8101625] [Citation(s) in RCA: 146] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 09/22/2019] [Accepted: 10/02/2019] [Indexed: 12/20/2022] Open
Abstract
Hypertensive disorders of pregnancy affect up to 10% of pregnancies worldwide, which includes the 3%–5% of all pregnancies complicated by preeclampsia. Preeclampsia is defined as new onset hypertension after 20 weeks’ gestation with evidence of maternal organ or uteroplacental dysfunction or proteinuria. Despite its prevalence, the risk factors that have been identified lack accuracy in predicting its onset and preventative therapies only moderately reduce a woman’s risk of preeclampsia. Preeclampsia is a major cause of maternal morbidity and is associated with adverse foetal outcomes including intra-uterine growth restriction, preterm birth, placental abruption, foetal distress, and foetal death in utero. At present, national guidelines for foetal surveillance in preeclamptic pregnancies are inconsistent, due to a lack of evidence detailing the most appropriate assessment modalities as well as the timing and frequency at which assessments should be conducted. Current management of the foetus in preeclampsia involves timely delivery and prevention of adverse effects of prematurity with antenatal corticosteroids and/or magnesium sulphate depending on gestation. Alongside the risks to the foetus during pregnancy, there is also growing evidence that preeclampsia has long-term adverse effects on the offspring. In particular, preeclampsia has been associated with cardiovascular sequelae in the offspring including hypertension and altered vascular function.
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Effects of gestational hypertension in the pulsatility index of the middle cerebral and umbilical artery, cerebro-placental ratio, and associated adverse perinatal outcomes. JOURNAL OF RADIATION RESEARCH AND APPLIED SCIENCES 2019. [DOI: 10.1016/j.jrras.2018.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Bornstein E, Chervenak FA. Ultrasound Doppler waveform assessment: the story continues. J Perinat Med 2019; 47:139-141. [PMID: 30689548 DOI: 10.1515/jpm-2018-0387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Eran Bornstein
- Lenox Hill Hospital, Northwell Health, New York, NY 10075, USA
- Zucker School of Medicine at HOFSTRA/Northwell, New York, NY 11549, USA
| | - Frank A Chervenak
- Lenox Hill Hospital, Northwell Health, New York, NY, USA
- Zucker School of Medicine at HOFSTRA/Northwell, New York, NY, USA
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Pels A, Mensing van Charante NA, Vollgraff Heidweiller-Schreurs CA, Limpens J, Wolf H, de Boer MA, Ganzevoort W. The prognostic accuracy of short term variation of fetal heart rate in early-onset fetal growth restriction: A systematic review. Eur J Obstet Gynecol Reprod Biol 2019; 234:179-184. [PMID: 30710764 DOI: 10.1016/j.ejogrb.2019.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 01/03/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Cardiotocography (CTG) is an important tool for fetal surveillance in severe early-onset fetal growth restriction (FGR). Assessment of the CTG is usually performed visually (vCTG). However, it is suggested that computerized analysis of the CTG (cCTG) including short term variability (STV) could more accurately detect fetal compromise. The objective of this study was to systematically review the literature on the association between cCTG and perinatal outcome and the comparison of cCTG with vCTG. STUDY DESIGN A systematic search was performed in MEDLINE, EMBASE and Google Scholar. Studies were included that assessed prognostic accuracy of STV or compared STV to vCTG in patients with FGR. Risk of bias and concerns about applicability were assessed with the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) instrument. RESULTS Of the 885 records identified in the search, five cohort studies (387 patients) were included. We found no randomized studies comparing STV with visual CTG in patients with FGR. The risk of bias of all studies was generally judged as 'low'. One small study found an association of low STV with neonatal acidosis. One study observed no association of STV with long-term outcome. Composite analysis of all five studies showed a non-significant relative risk for acidosis after a low STV of 1.4 (95% CI 0.6-3.2, N = 387). Further meta-analysis was hampered due to heterogeneity in outcome reporting and use of different thresholds. CONCLUSION The evidence from the included studies did not support an association of STV and short or long term outcome. However, available data are limited and heterogeneous, and influenced by management based on STV. Solid evidence from a randomized controlled trial comparing STV with vCTG including long term infant outcome is needed before STV can be used clinically for timing of delivery in patients with FGR.
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Affiliation(s)
- A Pels
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynecology, Meibergdreef 9, Amsterdam, the Netherlands.
| | - N A Mensing van Charante
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynecology, Meibergdreef 9, Amsterdam, the Netherlands
| | | | - J Limpens
- Amsterdam UMC, University of Amsterdam, Medical Library, Meibergdreef 9, Amsterdam, the Netherlands
| | - H Wolf
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynecology, Meibergdreef 9, Amsterdam, the Netherlands
| | - M A de Boer
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Obstetrics and Gynecology, De Boelelaan 1117, Amsterdam, the Netherlands
| | - W Ganzevoort
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynecology, Meibergdreef 9, Amsterdam, the Netherlands
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Papastefanou I, Chrelias C, Siristatidis C, Kappou D, Eleftheriades M, Kassanos D. Placental volume at 11 to 14 gestational weeks in pregnancies complicated with fetal growth restriction and preeclampsia. Prenat Diagn 2018; 38:928-935. [PMID: 30188581 DOI: 10.1002/pd.5356] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 08/26/2018] [Accepted: 08/29/2018] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The study aims to evaluate the predictive value of first trimester placental volume in pregnancies destined to develop fetal growth restriction (FGR) and preeclampsia (PE). METHODS Prospective observational study including placentas from 34 FGR, 12 PE, 15 GH (gestational hypertension) pregnancies, and 265 controls. Placental volume (PV) was obtained using VOCAL technique, and a z score was calculated (z-PV). The association of PV with other first trimester variables and maternal characteristics was assessed with Spearman's correlation. RESULTS PV increased exponentially with crown-rump length (CRL) and was unrelated to maternal factors (weight, age, parity, and smoking status) as well as first trimester uterine artery Doppler, free β-hCG, nuchal translucency, or fetal heart rate. However, PV was positively associated with maternal height, CRL, PAPP-A, and birth weight. z-PV was a strong predictor for FGR with abnormal fetal Dopplers (AUC = 0.9472, P < 0.001). z-PV provided moderate prediction of FGR with normal fetal Dopplers (AUC = 0.8396, P < 0.001), PE (AUC = 0.8312, P < 0.001), and GH (AUC = 0.7640, P < 0.001). The addition of maternal weight, PAPP-A, β-hCG, and uterine artery Doppler improved our models. CONCLUSION At 11 to 14 weeks, PV is an independent predictor of pregnancy complications related to placental insufficiency, and the predictive ability is greater for FGR pregnancies with abnormal fetal Dopplers.
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Affiliation(s)
- Ioannis Papastefanou
- Fetal Medicine Unit, 3rd Department of Obstetrics and Gynaecology, Athens Medical School, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - Charalambos Chrelias
- Fetal Medicine Unit, 3rd Department of Obstetrics and Gynaecology, Athens Medical School, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - Charalambos Siristatidis
- Fetal Medicine Unit, 3rd Department of Obstetrics and Gynaecology, Athens Medical School, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - Dimitra Kappou
- Department of Obstetrics and Gynaecology, Royal Free Hospital, London, UK
| | - Makarios Eleftheriades
- 2nd Department of Obstetrics and Gynecology, University of Athens Medical School, Aretaieio Hospital, Athens, Greece
| | - Dimitrios Kassanos
- Fetal Medicine Unit, 3rd Department of Obstetrics and Gynaecology, Athens Medical School, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
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Walton RB, Reed LC, Estrada SM, Schmiedecke SS, Villazana-Kretzer DL, Napolitano PG, Ieronimakis N. Evaluation of Sildenafil and Tadalafil for Reversing Constriction of Fetal Arteries in a Human Placenta Perfusion Model. Hypertension 2018; 72:167-176. [PMID: 29735634 DOI: 10.1161/hypertensionaha.117.10738] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 12/28/2017] [Accepted: 04/11/2018] [Indexed: 11/16/2022]
Abstract
Fetal growth restriction resulting from reduced placental blood perfusion is a major cause of neonatal morbidity and mortality. Aside from intense surveillance and early delivery, there is no treatment for fetal growth restriction. A potential treatment associated with placental vasoconstriction is the class of PDE5 (phosphodiesterase type 5) inhibitors such as sildenafil, which is known to cross the placenta. In contrast, tadalafil, a more potent and selective PDE5 inhibitor has not been studied in pregnancy or experimental models of fetal growth restriction. Therefore, we compared the efficacy of these 2 PDE5 inhibitors for reversing vasoconstriction in an ex vivo human placental model and evaluating molecular and physiological responses. Sildenafil and tadalafil were infused into the intervillous space in a preconstricted human placental dual cotyledon, dual perfusion assay for the comparison of arteriole pressures and molecular indicators of drug inhibition. Results indicate a decrease arterial pressure with sildenafil citrate compared with controls, whereas tadalafil showed no difference. PDE5 and endothelial nitric oxide synthase activity were altered with sildenafil but not tadalafil. Sildenafil citrate improved preconstricted placental arterial perfusion in a human placental model, whereas tadalafil showed no response. It is possible that tadalafil did not cross the human placental barrier or was degraded by trophoblasts. This study supports human clinical trials exploring sildenafil as a potential treatment for improving fetal blood flow in fetal growth restriction associated with vasoconstriction.
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Affiliation(s)
- Robert B Walton
- From the Department of Obstetrics and Gynecology (R.B.W., L.C.R., S.M.E., S.S.S., D.L.V.-K., P.G.N.)
| | - Luckey C Reed
- From the Department of Obstetrics and Gynecology (R.B.W., L.C.R., S.M.E., S.S.S., D.L.V.-K., P.G.N.)
| | - Sarah M Estrada
- From the Department of Obstetrics and Gynecology (R.B.W., L.C.R., S.M.E., S.S.S., D.L.V.-K., P.G.N.)
| | - Stacey S Schmiedecke
- From the Department of Obstetrics and Gynecology (R.B.W., L.C.R., S.M.E., S.S.S., D.L.V.-K., P.G.N.)
| | - Diana L Villazana-Kretzer
- From the Department of Obstetrics and Gynecology (R.B.W., L.C.R., S.M.E., S.S.S., D.L.V.-K., P.G.N.)
| | - Peter G Napolitano
- From the Department of Obstetrics and Gynecology (R.B.W., L.C.R., S.M.E., S.S.S., D.L.V.-K., P.G.N.)
| | - Nicholas Ieronimakis
- Department of Clinical Investigation (N.I.), Madigan Army Medical Center, Joint Base Lewis-McCord, Tacoma, WA.
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Planning management and delivery of the growth-restricted fetus. Best Pract Res Clin Obstet Gynaecol 2018; 49:53-65. [PMID: 29606482 DOI: 10.1016/j.bpobgyn.2018.02.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 02/23/2018] [Accepted: 02/23/2018] [Indexed: 11/22/2022]
Abstract
A uniform approach to management of fetal growth restriction (FGR) improves outcome, prevents stillbirth, and allows appropriately timed delivery. An estimated fetal weight below the tenth percentile with coexisting abnormal umbilical artery (UA), middle cerebral artery (MCA), or cerebroplacental ratio Doppler index best identifies the small fetus requiring surveillance. Placental perfusion defects are more common earlier in gestation; accordingly, early-onset (≤32 weeks of gestation) and late-onset (>32 weeks) FGR differ in clinical phenotype. In early-onset FGR, progression of UA Doppler abnormality determines clinical acceleration, while abnormal ductus venosus (DV) Doppler precedes deterioration of biophysical variables and stillbirth. Accordingly, late DV Doppler changes, abnormal biophysical variables, or an abnormal cCTG require delivery. In late-onset FGR, MCA Doppler abnormalities precede deterioration and stillbirth. However, from 34 to 38 weeks, randomized evidence on optimal delivery timing is lacking. From 38 weeks onward, the balance of neonatal versus fetal risks favors delivery.
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Gordijn SJ, Beune IM, Ganzevoort W. Building consensus and standards in fetal growth restriction studies. Best Pract Res Clin Obstet Gynaecol 2018; 49:117-126. [PMID: 29576470 DOI: 10.1016/j.bpobgyn.2018.02.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 02/15/2018] [Indexed: 12/26/2022]
Abstract
Fetal growth restriction is a pathologic condition in which the fetus fails to reach its biologically based growth potential. There is inconsistency in terminology, definition, monitoring, and management, both in clinical practice and in the existing literature. This hampers interpretation and comparison of cohorts and studies. Standardization is essential. With the lack of a golden standard, or the opportunity to come to empirical evidence, consensus procedures can help to establish standardization. Consensus procedures provide no new information but formulate an agreement (as second best in the absence of robust evidence) for clinical and/or research practice on the basis of existing data. Consensus agreements need to be updated when new evidence becomes available and can change over time. In this chapter, we address the different issues that lack uniformity in FGR studies and management. Furthermore, we discuss several consensus methods and recent consensus procedures regarding fetal growth restriction.
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Affiliation(s)
- Sanne Jehanne Gordijn
- University Medical Center Groningen, University of Groningen, PO Box 30001, CB20, 9700 RB, Groningen, The Netherlands.
| | - Irene Maria Beune
- University Medical Center Groningen, University of Groningen, PO Box 30001, CB20, 9700 RB, Groningen, The Netherlands.
| | - Wessel Ganzevoort
- Academisch Medisch Centrum, Universiteit van Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
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Frusca T, Todros T, Lees C, Bilardo CM. Outcome in early-onset fetal growth restriction is best combining computerized fetal heart rate analysis with ductus venosus Doppler: insights from the Trial of Umbilical and Fetal Flow in Europe. Am J Obstet Gynecol 2018; 218:S783-S789. [PMID: 29422211 DOI: 10.1016/j.ajog.2017.12.226] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 12/19/2017] [Accepted: 12/21/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Early-onset fetal growth restriction represents a particular dilemma in clinical management balancing the risk of iatrogenic prematurity with waiting for the fetus to gain more maturity, while being exposed to the risk of intrauterine death or the sequelae of acidosis. OBJECTIVE The Trial of Umbilical and Fetal Flow in Europe was a European, multicenter, randomized trial aimed to determine according to which criteria delivery should be triggered in early fetal growth restriction. We present the key findings of the primary and secondary analyses. STUDY DESIGN Women with fetal abdominal circumference <10th percentile and umbilical pulsatility index >95th percentile between 26-32 weeks were randomized to 1 of 3 monitoring and delivery protocols. These were: fetal heart rate variability based on computerized cardiotocography; and early or late ductus venosus Doppler changes. A safety net based on fetal heart rate abnormalities or umbilical Doppler changes mandated delivery irrespective of randomized group. The primary outcome was normal neurodevelopmental outcome at 2 years. RESULTS Among 511 women randomized, 362/503 (72%) had associated hypertensive conditions. In all, 463/503 (92%) of fetuses survived and cerebral palsy occurred in 6/443 (1%) with known outcome. Among all women there was no difference in outcome based on randomized group; however, of survivors, significantly more fetuses randomized to the late ductus venosus group had a normal outcome (133/144; 95%) than those randomized to computerized cardiotocography alone (111/131; 85%). In 118/310 (38%) of babies delivered <32 weeks, the indication was safety-net criteria: 55/106 (52%) in late ductus venosus, 37/99 (37%) in early ductus venosus, and 26/105 (25%) in computerized cardiotocography groups. Higher middle cerebral artery impedance adjusted for gestation was associated with neonatal survival without severe morbidity (odds ratio, 1.24; 95% confidence interval, 1.02-1.52) and infant survival without neurodevelopmental impairment at 2 years (odds ratio, 1.33; 95% confidence interval, 1.03-1.72) although birthweight and gestational age were more important determinants. CONCLUSION Perinatal and 2-year outcome was better than expected in all randomized groups. Among survivors, 2-year neurodevelopmental outcome was best in those randomized to delivery based on late ductus venosus changes. Given a high rate of delivery based on the safety-net criteria, deciding delivery based on late ductus venosus changes and abnormal computerized fetal heart rate variability seems prudent. There is no rationale for delivery based on cerebral Doppler changes alone. Of note, most women with early-onset fetal growth restriction develop hypertension.
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Affiliation(s)
- Tiziana Frusca
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - Tullia Todros
- Department of Obstetrics and Gynecology, University of Turin, Turin, Italy
| | - Christoph Lees
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium.
| | - Caterina M Bilardo
- Department of Obstetrics, Gynecology, and VU University Medical Centre, Amsterdam and University Medical Centre Groningen, University of Groningen, The Netherlands
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31
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Caradeux J, Martinez-Portilla RJ, Basuki TR, Kiserud T, Figueras F. Risk of fetal death in growth-restricted fetuses with umbilical and/or ductus venosus absent or reversed end-diastolic velocities before 34 weeks of gestation: a systematic review and meta-analysis. Am J Obstet Gynecol 2018; 218:S774-S782.e21. [PMID: 29233550 DOI: 10.1016/j.ajog.2017.11.566] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/31/2017] [Accepted: 11/08/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of the study was to establish the risk of fetal death in early-onset growth-restricted fetuses with absent or reversed end-diastolic velocities in the umbilical artery or ductus venosus. DATA SOURCES A systematic search was performed to identify relevant studies published in English, Spanish, French, Italian, or German using the databases PubMed, ISI Web of Science, and SCOPUS, without publication time restrictions. STUDY ELIGIBILITY CRITERIA The study criteria included observational cohort studies and randomized controlled trials of early-onset growth-restricted fetuses (diagnosed before 34 weeks of gestation), with information on the rate of fetal death occurring before 34 weeks of gestation and absent or reversed end-diastolic velocities in the umbilical artery and/or ductus venosus. STUDY APPRAISAL AND SYNTHESIS METHODS For quality assessment, 2 reviewers independently assessed the risk of bias using the Newcastle-Ottawa Scale for observational studies and the Cochrane Collaboration's tool for randomized trials. For the meta-analysis, odds ratio for both fixed and random-effects models (weighting by inverse of variance) were used. Heterogeneity between studies was assessed using tau2, χ2 (Cochrane Q), and I2 statistics. Publication bias was assessed by a funnel plot for meta-analyses and quantified by the Egger method. RESULTS A total of 31 studies were included in this meta-analysis. The odds ratios for fetal death (random-effects models) were 3.59 (95% confidence interval, 2.3-5.6), 7.27 (95% confidence interval, 4.6-11.4), and 11.6 (95% confidence interval, 6.3-19.7) for growth-restricted fetuses with umbilical artery absent end-diastolic velocities, umbilical artery reversed end-diastolic velocities, and ductus venosus absent or reversed end-diastolic velocities, respectively. There was no substantial heterogeneity among studies for any of the analyses. CONCLUSION Early-onset growth-restricted fetuses with either umbilical artery or ductus venosus absent or reserved end-diastolic velocities are at a substantially increased risk for fetal death.
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Affiliation(s)
- J Caradeux
- Fetal i+D Fetal Medicine Research Center, BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, University of Barcelona, Barcelona, Spain; Fetal Medicine Unit, Clínica Dávila, Santiago, Chile
| | - R J Martinez-Portilla
- Fetal i+D Fetal Medicine Research Center, BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, University of Barcelona, Barcelona, Spain; Fetal Medicine Unit, Clínica Hospital Sinaí, Xalapa Veracruz, México
| | - T R Basuki
- Fetal i+D Fetal Medicine Research Center, BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, University of Barcelona, Barcelona, Spain
| | - T Kiserud
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway; Research Group for Pregnancy, Fetal Development, and Birth, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - F Figueras
- Fetal i+D Fetal Medicine Research Center, BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, University of Barcelona, Barcelona, Spain; Center for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain.
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Crispi F, Miranda J, Gratacós E. Long-term cardiovascular consequences of fetal growth restriction: biology, clinical implications, and opportunities for prevention of adult disease. Am J Obstet Gynecol 2018; 218:S869-S879. [PMID: 29422215 DOI: 10.1016/j.ajog.2017.12.012] [Citation(s) in RCA: 195] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 12/04/2017] [Accepted: 12/06/2017] [Indexed: 02/07/2023]
Abstract
In the modern world, cardiovascular disease is a leading cause of death for both men and women. Epidemiologic studies consistently have suggested an association between low birthweight and/or fetal growth restriction and increased rate of cardiovascular mortality in adulthood. Furthermore, experimental and clinical studies have demonstrated that sustained nutrient and oxygen restriction that are associated with fetal growth restriction activate adaptive cardiovascular changes that might explain this association. Fetal growth restriction results in metabolic programming that may increase the risk of metabolic syndrome and, consequently, of cardiovascular morbidity in the adult. In addition, fetal growth restriction is strongly associated with fetal cardiac and arterial remodeling and a subclinical state of cardiovascular dysfunction. The cardiovascular effects ocurring in fetal life, includes cardiac morphology changes, subclinical myocardial dysfunction, arterial remodeling, and impaired endothelial function, persist into childhood and adolescence. Importantly, these changes have been described in all clinical presentations of fetal growth restriction, from severe early- to milder late-onset forms. In this review we summarize the current evidence on the cardiovascular effects of fetal growth restriction, from subcellular to organ structure and function as well as from fetal to early postnatal life. Future research needs to elucidate whether and how early life cardiovascular remodeling persists into adulthood and determines the increased cardiovascular mortality rate described in epidemiologic studies.
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Echocardiographic Techniques of Deformation Imaging in the Evaluation of Maternal Cardiovascular System in Patients with Complicated Pregnancies. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4139635. [PMID: 28904957 PMCID: PMC5585628 DOI: 10.1155/2017/4139635] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 07/17/2017] [Indexed: 11/21/2022]
Abstract
Cardiovascular diseases (CVD) represent the leading cause of maternal mortality and morbidity. Knowledge of CVD in women is constantly evolving and data are emerging that female-specific risk factors as complications of pregnancy are conditions associated with an increased risk for the long-term development of CVD. Echocardiography is a safe and effective imaging technique indicated in symptomatic or asymptomatic pregnant women with congenital heart diseases who require close monitoring of cardiac function. Deformation imaging is an echocardiographic technique used to assess myocardial function by measuring the actual deformation of the myocardium through the cardiac cycle. Speckle-tracking echocardiography (STE) is a two-dimensional (2D) technique which has been found to be more accurate than tissue Doppler to assess both left ventricular (LV) and right ventricular (RV) myocardial function. The use of 2D STE however might present some technical issues due to the tomographic nature of the technique and the motion in the three-dimensional space of the myocardial speckles. This has promoted the use of 3D STE to track the motion of the speckles in the 3D space. This review will focus on the clinical value of the new echocardiographic techniques of deformation imaging used to assess the maternal cardiovascular system in complicated pregnancies.
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Doro GF, Senra JC, Rodrigues AS, Miyadahira S, Ribeiro RL, Francisco RPV, Bernardes LS. Renal vascularization indexes and fetal hemodynamics in fetuses with growth restriction. Prenat Diagn 2017. [DOI: 10.1002/pd.5099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Giovana Farina Doro
- Department of Obstetrics and Gynecology, Clinics Hospital; University of São Paulo; São Paulo Brazil
| | - Janaína Campos Senra
- Department of Obstetrics and Gynecology, Clinics Hospital; University of São Paulo; São Paulo Brazil
| | - Agatha Sacramento Rodrigues
- Statistician at the Department of Obstetrics and Gynecology, Clinics Hospital; University of São Paulo; São Paulo Brazil
| | - Seizo Miyadahira
- Department of Obstetrics and Gynecology, Clinics Hospital; University of São Paulo; São Paulo Brazil
| | - Renata Lopes Ribeiro
- Department of Obstetrics and Gynecology, Clinics Hospital; University of São Paulo; São Paulo Brazil
| | | | - Lisandra Stein Bernardes
- Department of Obstetrics and Gynecology, Clinics Hospital; University of São Paulo; São Paulo Brazil
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Abstract
BACKGROUND Abnormal blood flow patterns in fetal circulation detected by Doppler ultrasound may indicate poor fetal prognosis. It is also possible that false positive Doppler ultrasound findings could lead to adverse outcomes from unnecessary interventions, including preterm delivery. OBJECTIVES The objective of this review was to assess the effects of Doppler ultrasound used to assess fetal well-being in high-risk pregnancies on obstetric care and fetal outcomes. SEARCH METHODS We updated the search of Cochrane Pregnancy and Childbirth's Trials Register on 31 March 2017 and checked reference lists of retrieved studies. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of Doppler ultrasound for the investigation of umbilical and fetal vessels waveforms in high-risk pregnancies compared with no Doppler ultrasound. Cluster-randomised trials were eligible for inclusion but none were identified. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked. We assessed the quality of evidence using the GRADE approach. MAIN RESULTS Nineteen trials involving 10,667 women were included. Risk of bias in trials was difficult to assess accurately due to incomplete reporting. None of the evidence relating to our main outcomes was graded as high quality. The quality of evidence was downgraded due to missing information on trial methods, imprecision in risk estimates and heterogeneity. Eighteen of these studies compared the use of Doppler ultrasound of the umbilical artery of the unborn baby with no Doppler or with cardiotocography (CTG). One more recent trial compared Doppler examination of other fetal blood vessels (ductus venosus) with computerised CTG.The use of Doppler ultrasound of the umbilical artery in high-risk pregnancy was associated with fewer perinatal deaths (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.52 to 0.98, 16 studies, 10,225 babies, 1.2% versus 1.7 %, number needed to treat (NNT) = 203; 95% CI 103 to 4352, evidence graded moderate). The results for stillbirths were consistent with the overall rate of perinatal deaths, although there was no clear difference between groups for this outcome (RR 0.65, 95% CI 0.41 to 1.04; 15 studies, 9560 babies, evidence graded low). Where Doppler ultrasound was used, there were fewer inductions of labour (average RR 0.89, 95% CI 0.80 to 0.99, 10 studies, 5633 women, random-effects, evidence graded moderate) and fewer caesarean sections (RR 0.90, 95% CI 0.84 to 0.97, 14 studies, 7918 women, evidence graded moderate). There was no comparative long-term follow-up of babies exposed to Doppler ultrasound in pregnancy in women at increased risk of complications.No difference was found in operative vaginal births (RR 0.95, 95% CI 0.80 to 1.14, four studies, 2813 women), nor in Apgar scores less than seven at five minutes (RR 0.92, 95% CI 0.69 to 1.24, seven studies, 6321 babies, evidence graded low). Data for serious neonatal morbidity were not pooled due to high heterogeneity between the three studies that reported it (1098 babies) (evidence graded very low).The use of Doppler to evaluate early and late changes in ductus venosus in early fetal growth restriction was not associated with significant differences in any perinatal death after randomisation. However, there was an improvement in long-term neurological outcome in the cohort of babies in whom the trigger for delivery was either late changes in ductus venosus or abnormalities seen on computerised CTG. AUTHORS' CONCLUSIONS Current evidence suggests that the use of Doppler ultrasound on the umbilical artery in high-risk pregnancies reduces the risk of perinatal deaths and may result in fewer obstetric interventions. The results should be interpreted with caution, as the evidence is not of high quality. Serial monitoring of Doppler changes in ductus venosus may be beneficial, but more studies of high quality with follow-up including neurological development are needed for evidence to be conclusive.
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Affiliation(s)
- Zarko Alfirevic
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Tamara Stampalija
- Institute for Maternal and Child Health, IRCCS Burlo GarofoloUnit of Prenatal DiagnosisTriesteItaly
| | - Therese Dowswell
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Ganzevoort W, Mensing Van Charante N, Thilaganathan B, Prefumo F, Arabin B, Bilardo CM, Brezinka C, Derks JB, Diemert A, Duvekot JJ, Ferrazzi E, Frusca T, Hecher K, Marlow N, Martinelli P, Ostermayer E, Papageorghiou AT, Schlembach D, Schneider KTM, Todros T, Valcamonico A, Visser GHA, Van Wassenaer-Leemhuis A, Lees CC, Wolf H. How to monitor pregnancies complicated by fetal growth restriction and delivery before 32 weeks: post-hoc analysis of TRUFFLE study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:769-777. [PMID: 28182335 DOI: 10.1002/uog.17433] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 01/22/2017] [Accepted: 01/23/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVES In the recent TRUFFLE study, it appeared that, in pregnancies complicated by fetal growth restriction (FGR) between 26 and 32 weeks' gestation, monitoring of the fetal ductus venosus (DV) waveform combined with computed cardiotocography (CTG) to determine timing of delivery increased the chance of infant survival without neurological impairment. However, concerns with the interpretation were raised, as DV monitoring appeared to be associated with a non-significant increase in fetal death, and some infants were delivered after 32 weeks, at which time the study protocol no longer applied. This secondary sensitivity analysis of the TRUFFLE study focuses on women who delivered before 32 completed weeks' gestation and analyzes in detail the cases of fetal death. METHODS Monitoring data of 317 pregnancies with FGR that delivered before 32 weeks were analyzed, excluding those with absent outcome data or inevitable perinatal death. Women were allocated randomly to one of three groups of indication for delivery according to the following monitoring strategies: (1) reduced fetal heart rate short-term variation (STV) on CTG; (2) early changes in fetal DV waveform; and (3) late changes in fetal DV waveform. Primary outcome was 2-year survival without neurological impairment. The association of the last monitoring data before delivery and infant outcome was assessed by multivariable analysis. RESULTS Two-year survival without neurological impairment occurred more often in the two DV groups (both 83%) than in the CTG-STV group (77%), however, the difference was not statistically significant (P = 0.21). Among the surviving infants in the DV groups, 93% were free of neurological impairment vs 85% of surviving infants in the CTG-STV group (P = 0.049). All fetal deaths (n = 7) occurred in the groups with DV monitoring. Of the monitoring parameters obtained shortly before fetal death in these seven cases, an abnormal CTG was observed in only one case. Multivariable regression analysis of factors at study entry demonstrated that a later gestational age, higher estimated fetal weight-to-50th percentile ratio and lower umbilical artery pulsatility index (PI)/fetal middle cerebral artery-PI ratio were significantly associated with normal outcome. Allocation to DV monitoring had a smaller effect on outcome, but remained in the model (P < 0.1). Abnormal fetal arterial Doppler before delivery was significantly associated with adverse outcome in the CTG-STV group. In contrast, abnormal DV flow was the only monitoring parameter associated with adverse outcome in the DV groups, while fetal arterial Doppler, STV below the cut-off used in the CTG-STV group and recurrent decelerations in fetal heart rate were not. CONCLUSIONS In accordance with the findings of the TRUFFLE study on monitoring and intervention management of very preterm FGR, we found that the proportion of infants surviving without neuroimpairment was not significantly different when the decision for delivery was based on changes in DV waveform vs reduced STV on CTG. The uneven distribution of fetal deaths towards the DV groups was probably a chance effect, and neurological outcome was better among surviving children in these groups. Before 32 weeks, delaying delivery until abnormalities in DV-PI or STV and/or recurrent decelerations in fetal heat rate occur, as defined by the study protocol, is likely to be safe and possibly benefits long-term outcome. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- W Ganzevoort
- Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam, The Netherlands
| | - N Mensing Van Charante
- Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam, The Netherlands
| | - B Thilaganathan
- Fetal Medicine Unit, St George's, University of London & St George's University Hospitals NHS Foundation Trust, Molecular and Clinical Sciences Research Institute, London, UK
| | - F Prefumo
- Maternal Fetal Medicine Unit, University of Brescia, Brescia, Italy
| | - B Arabin
- Center for Mother and Child of the Phillips University, Marburg, Germany
| | - C M Bilardo
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, University Medical Centre Groningen, Groningen, The Netherlands
| | - C Brezinka
- Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria
| | - J B Derks
- Perinatal Center, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - A Diemert
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J J Duvekot
- Division of Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC, Rotterdam, The Netherlands
| | - E Ferrazzi
- Children's Hospital, Buzzi, University of Milan, Milan, Italy
| | - T Frusca
- Department of Obstetrics and Gynecology, Maggiore Hospital, University of Parma, Parma, Italy
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - N Marlow
- University College London Institute for Women's Health Ringgold Standard Institution - Neonatology, London, UK
| | - P Martinelli
- Department of Gynecology and Obstetrics, University Federico II of Naples, Naples, Italy
| | - E Ostermayer
- Section of Perinatal Medicine, Department of Obstetrics and Gynecology, Technical University, Munich, Germany
| | - A T Papageorghiou
- Fetal Medicine Unit, St George's, University of London & St George's University Hospitals NHS Foundation Trust, Molecular and Clinical Sciences Research Institute, London, UK
| | - D Schlembach
- Department of Obstetrics, Vivantes Clinic Neukölln, Berlin, Germany
| | - K T M Schneider
- Section of Perinatal Medicine, Department of Obstetrics and Gynecology, Technical University, Munich, Germany
| | - T Todros
- Department of Obstetrics and Gynecology, University of Turin, Turin, Italy
| | - A Valcamonico
- Department of Obstetrics and Gynecology, Maggiore Hospital, University of Parma, Parma, Italy
| | - G H A Visser
- Perinatal Center, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - A Van Wassenaer-Leemhuis
- Department of Neonatology, Emma Children's Hospital Academic Medical Centre, Amsterdam, The Netherlands
| | - C C Lees
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - H Wolf
- Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam, The Netherlands
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Amorim-Costa C, Gaio AR, Ayres-de-Campos D, Bernardes J. Longitudinal changes of cardiotocographic parameters throughout pregnancy: a prospective cohort study comparing small-for-gestational-age and normal fetuses from 24 to 40 weeks. J Perinat Med 2017; 45:493-501. [PMID: 27474837 DOI: 10.1515/jpm-2016-0065] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 06/03/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare longitudinal trends of cardiotocographic (CTG) parameters between small-for-gestational-age (SGA) and normal fetuses, from 24 to 41 weeks of pregnancy. METHODS A prospective cohort study was carried out in singleton pregnancies without fetal malformations. At least one CTG was performed in each of the following intervals: 24-26 weeks+6 days, 27-29 weeks+6 days, 30-32 weeks+6 days, 33-35 weeks+6 days, 36-38 weeks+6 days and ≥39 weeks. Tracings were analyzed using the Omniview-SisPorto® 3.6 system. Cases with a normal pregnancy outcome, including a birthweight ≥10th percentile for gestational age, were compared with two groups of SGA fetuses: with birthweight <10th percentile (SGA<p10) and <3rd percentile (SGA<p3; a subgroup of the latter). Generalized linear mixed-effects models were used for analysis. RESULTS A total of 176 fetuses (31 SGA) and 1256 tracings (207 from SGA fetuses) were evaluated. All CTG parameters changed significantly throughout pregnancy in the three groups, with a decreasing baseline and probability of decelerations, and an increasing average long-term variability (LTV), average short-term variability (STV) and accelerations. Baseline showed a more pronounced decrease (steeper slope) in SGA fetuses, being higher in these cases at earlier gestational ages and lower later in pregnancy. Average LTV was significantly lower in SGA<p3 fetuses, but a parallel increase occurred in all groups. There was a considerable inter-fetal variability within each group. CONCLUSION A unique characterization of CTG trends throughout gestation in SGA fetuses was provided. A steeper descent of the baseline was reported for the first time. The findings raise the possibility of clinical application of computerized CTG analysis in screening and management of fetal growth restriction.
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Amorim-Costa C, de Campos DA, Bernardes J. Cardiotocographic parameters in small-for-gestational-age fetuses: How do they vary from normal at different gestational ages? A study of 11687 fetuses from 25 to 40 weeks of pregnancy. J Obstet Gynaecol Res 2017; 43:476-485. [PMID: 28165176 DOI: 10.1111/jog.13235] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 09/16/2016] [Accepted: 10/07/2016] [Indexed: 11/26/2022]
Abstract
AIM The aim of this study was to assess how cardiotocographic (CTG) parameters differ between small-for-gestational-age (SGA) and normal fetuses at different gestational ages. METHODS This was a retrospective cross-sectional study using the first antepartum tracing of singleton pregnancies with no malformations. Fetuses with birthweight ≥10th percentile for gestational age and other normal pregnancy outcome criteria (term birth, normal umbilical artery pH and Apgar scores, no intensive care unit admission) were compared with fetuses with birthweight <10th and <3rd percentiles for gestational age (SGA < p10 and SGA < p3, a subgroup of the latter). Each CTG parameter was compared, by gestational age, using both statistical tests and percentile curves derived from normal outcome cases. Tracings were analyzed with the OmniviewSisPorto® 3.7 system. RESULTS A total of 11 687 tracings (from the same number of fetuses) were analyzed: 9701 normal, 1986 SGA < p10, and 543 SGA < p3. SGA fetuses had lower long- and short-term variability, and number of accelerations, with more pronounced differences between around 28 and 35 weeks. In contrast, baseline was lower in SGA fetuses from 34 weeks onwards. All differences were more pronounced for SGA < p3 fetuses. Similar trends throughout gestation occurred in all groups: decrease in baseline, and increase in long- and short-term variability, and accelerations. CONCLUSIONS This study represents an important step for accurate CTG interpretation in SGA fetuses and, consequently, management of fetal growth restriction (FGR), as it contributes to differentiate between maturational CTG changes that occur physiologically throughout pregnancy, and possible signs of fetal compromise in FGR.
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Affiliation(s)
- Célia Amorim-Costa
- Department of Obstetrics and Gynecology, Medical School, University of Porto, Porto, Portugal.,Institute for Research and Innovation in Health (Instituto de Investigação e Inovação em Saúde - I3S) and Institute of Biomedical Engineering (Instituto de Engenharia Biomédica - INEB), University of Porto, Portugal.,Center for Research in Health Technologies and Information Systems (CINTESIS), Porto Medical School, University of Porto, Porto, Portugal
| | - Diogo Ayres de Campos
- Department of Obstetrics and Gynecology, Medical School, University of Porto, Porto, Portugal.,Institute for Research and Innovation in Health (Instituto de Investigação e Inovação em Saúde - I3S) and Institute of Biomedical Engineering (Instituto de Engenharia Biomédica - INEB), University of Porto, Portugal.,Center for Research in Health Technologies and Information Systems (CINTESIS), Porto Medical School, University of Porto, Porto, Portugal.,Department of Obstetrics and Gynecology, S. João Hospital, Porto, Portugal
| | - João Bernardes
- Department of Obstetrics and Gynecology, Medical School, University of Porto, Porto, Portugal.,Institute for Research and Innovation in Health (Instituto de Investigação e Inovação em Saúde - I3S) and Institute of Biomedical Engineering (Instituto de Engenharia Biomédica - INEB), University of Porto, Portugal.,Center for Research in Health Technologies and Information Systems (CINTESIS), Porto Medical School, University of Porto, Porto, Portugal.,Department of Obstetrics and Gynecology, S. João Hospital, Porto, Portugal.,Department of Obstetrics and Gynecology, Hospital Pedro Hispano, Matosinhos, Portugal
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Spencer R, Ambler G, Brodszki J, Diemert A, Figueras F, Gratacós E, Hansson SR, Hecher K, Huertas-Ceballos A, Marlow N, Marsál K, Morsing E, Peebles D, Rossi C, Sebire NJ, Timms JF, David AL. EVERREST prospective study: a 6-year prospective study to define the clinical and biological characteristics of pregnancies affected by severe early onset fetal growth restriction. BMC Pregnancy Childbirth 2017. [PMID: 28114884 DOI: 10.1186/s12884‐017‐1226‐7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fetal growth restriction (FGR) is a serious obstetric condition for which there is currently no treatment. The EVERREST Prospective Study has been designed to characterise the natural history of pregnancies affected by severe early onset FGR and establish a well phenotyped bio-bank. The findings will provide up-to-date information for clinicians and patients and inform the design and conduct of the EVERREST Clinical Trial: a phase I/IIa trial to assess the safety and efficacy of maternal vascular endothelial growth factor (VEGF) gene therapy in severe early onset FGR. Data and samples from the EVERREST Prospective Study will be used to identify ultrasound and/or biochemical markers of prognosis in pregnancies with an estimated fetal weight (EFW) <3rd centile between 20+0 and 26+6 weeks of gestation. METHODS This is a 6 year European multicentre prospective cohort study, recruiting women with a singleton pregnancy where the EFW is <3rd centile for gestational age and <600 g at 20+0 to 26+6 weeks of gestation. Detailed data are collected on: maternal history; antenatal, peripartum, and postnatal maternal complications; health economic impact; psychological impact; neonatal condition, progress and complications; and infant growth and neurodevelopment to 2 years of corrected age in surviving infants. Standardised longitudinal ultrasound measurements are performed, including: fetal biometry; uterine artery, umbilical artery, middle cerebral artery, and ductus venosus Doppler velocimetry; and uterine artery and umbilical vein volume blood flow. Samples of maternal blood and urine, amniotic fluid (if amniocentesis performed), placenta, umbilical cord blood, and placental bed (if caesarean delivery performed) are collected for bio-banking. An initial analysis of maternal blood samples at enrolment is planned to identify biochemical markers that are predictors for fetal or neonatal death. DISCUSSION The findings of the EVERREST Prospective Study will support the development of a novel therapy for severe early onset FGR by describing in detail the natural history of the disease and by identifying women whose pregnancies have the poorest outcomes, in whom a therapy might be most advantageous. The findings will also enable better counselling of couples with affected pregnancies, and provide a valuable resource for future research into the causes of FGR. TRIAL REGISTRATION NCT02097667 registered 31st October 2013.
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Affiliation(s)
- Rebecca Spencer
- Institute for Women's Health, University College London, London, UK. .,Institute for Women's Health, University College London and NIHR University College London Hospitals Biomedical Research Centre, London, UK.
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Jana Brodszki
- Department of Clinical Sciences Lund, Obstetrics and Gynecology, Skane University Hospital, Lund University, Lund, Sweden
| | - Anke Diemert
- Obstetrics and Fetal Medicine Unit, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Francesc Figueras
- BCNatal, Hospital Clinic and Hospital Sant Joan de Deu, University of Barcelona, CIBERER and IDIBAPS, Barcelona, Spain
| | - Eduard Gratacós
- BCNatal, Hospital Clinic and Hospital Sant Joan de Deu, University of Barcelona, CIBERER and IDIBAPS, Barcelona, Spain
| | - Stefan R Hansson
- Department of Clinical Sciences Lund, Obstetrics and Gynecology, Skane University Hospital, Lund University, Lund, Sweden
| | - Kurt Hecher
- Obstetrics and Fetal Medicine Unit, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | | | - Neil Marlow
- Institute for Women's Health, University College London and NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Karel Marsál
- Department of Clinical Sciences Lund, Obstetrics and Gynecology, Skane University Hospital, Lund University, Lund, Sweden
| | - Eva Morsing
- Department of Clinical Sciences Lund, Obstetrics and Gynecology, Skane University Hospital, Lund University, Lund, Sweden
| | - Donald Peebles
- Institute for Women's Health, University College London and NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | | | - Neil J Sebire
- Paediatric and Developmental Pathology, Great Ormond Street Hospital, London, UK
| | - John F Timms
- Institute for Women's Health, University College London, London, UK
| | - Anna L David
- Institute for Women's Health, University College London and NIHR University College London Hospitals Biomedical Research Centre, London, UK
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40
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Spencer R, Ambler G, Brodszki J, Diemert A, Figueras F, Gratacós E, Hansson SR, Hecher K, Huertas-Ceballos A, Marlow N, Marsál K, Morsing E, Peebles D, Rossi C, Sebire NJ, Timms JF, David AL. EVERREST prospective study: a 6-year prospective study to define the clinical and biological characteristics of pregnancies affected by severe early onset fetal growth restriction. BMC Pregnancy Childbirth 2017; 17:43. [PMID: 28114884 PMCID: PMC5259830 DOI: 10.1186/s12884-017-1226-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 01/14/2017] [Indexed: 11/10/2022] Open
Abstract
Background Fetal growth restriction (FGR) is a serious obstetric condition for which there is currently no treatment. The EVERREST Prospective Study has been designed to characterise the natural history of pregnancies affected by severe early onset FGR and establish a well phenotyped bio-bank. The findings will provide up-to-date information for clinicians and patients and inform the design and conduct of the EVERREST Clinical Trial: a phase I/IIa trial to assess the safety and efficacy of maternal vascular endothelial growth factor (VEGF) gene therapy in severe early onset FGR. Data and samples from the EVERREST Prospective Study will be used to identify ultrasound and/or biochemical markers of prognosis in pregnancies with an estimated fetal weight (EFW) <3rd centile between 20+0 and 26+6 weeks of gestation. Methods This is a 6 year European multicentre prospective cohort study, recruiting women with a singleton pregnancy where the EFW is <3rd centile for gestational age and <600 g at 20+0 to 26+6 weeks of gestation. Detailed data are collected on: maternal history; antenatal, peripartum, and postnatal maternal complications; health economic impact; psychological impact; neonatal condition, progress and complications; and infant growth and neurodevelopment to 2 years of corrected age in surviving infants. Standardised longitudinal ultrasound measurements are performed, including: fetal biometry; uterine artery, umbilical artery, middle cerebral artery, and ductus venosus Doppler velocimetry; and uterine artery and umbilical vein volume blood flow. Samples of maternal blood and urine, amniotic fluid (if amniocentesis performed), placenta, umbilical cord blood, and placental bed (if caesarean delivery performed) are collected for bio-banking. An initial analysis of maternal blood samples at enrolment is planned to identify biochemical markers that are predictors for fetal or neonatal death. Discussion The findings of the EVERREST Prospective Study will support the development of a novel therapy for severe early onset FGR by describing in detail the natural history of the disease and by identifying women whose pregnancies have the poorest outcomes, in whom a therapy might be most advantageous. The findings will also enable better counselling of couples with affected pregnancies, and provide a valuable resource for future research into the causes of FGR. Trial registration NCT02097667 registered 31st October 2013. Electronic supplementary material The online version of this article (doi:10.1186/s12884-017-1226-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rebecca Spencer
- Institute for Women's Health, University College London, London, UK. .,Institute for Women's Health, University College London and NIHR University College London Hospitals Biomedical Research Centre, London, UK.
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Jana Brodszki
- Department of Clinical Sciences Lund, Obstetrics and Gynecology, Skane University Hospital, Lund University, Lund, Sweden
| | - Anke Diemert
- Obstetrics and Fetal Medicine Unit, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Francesc Figueras
- BCNatal, Hospital Clinic and Hospital Sant Joan de Deu, University of Barcelona, CIBERER and IDIBAPS, Barcelona, Spain
| | - Eduard Gratacós
- BCNatal, Hospital Clinic and Hospital Sant Joan de Deu, University of Barcelona, CIBERER and IDIBAPS, Barcelona, Spain
| | - Stefan R Hansson
- Department of Clinical Sciences Lund, Obstetrics and Gynecology, Skane University Hospital, Lund University, Lund, Sweden
| | - Kurt Hecher
- Obstetrics and Fetal Medicine Unit, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | | | - Neil Marlow
- Institute for Women's Health, University College London and NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Karel Marsál
- Department of Clinical Sciences Lund, Obstetrics and Gynecology, Skane University Hospital, Lund University, Lund, Sweden
| | - Eva Morsing
- Department of Clinical Sciences Lund, Obstetrics and Gynecology, Skane University Hospital, Lund University, Lund, Sweden
| | - Donald Peebles
- Institute for Women's Health, University College London and NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | | | - Neil J Sebire
- Paediatric and Developmental Pathology, Great Ormond Street Hospital, London, UK
| | - John F Timms
- Institute for Women's Health, University College London, London, UK
| | - Anna L David
- Institute for Women's Health, University College London and NIHR University College London Hospitals Biomedical Research Centre, London, UK
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41
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Dall’Asta A, Brunelli V, Prefumo F, Frusca T, Lees CC. Early onset fetal growth restriction. Matern Health Neonatol Perinatol 2017; 3:2. [PMID: 28116113 PMCID: PMC5241928 DOI: 10.1186/s40748-016-0041-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 12/27/2016] [Indexed: 01/01/2023] Open
Abstract
Fetal growth restriction (FGR) diagnosed before 32 weeks is identified by fetal smallness associated with Doppler abnormalities and is associated with significant perinatal morbidity and mortality and maternal complications. Recent studies have provided new insights into pathophysiology, management options and postnatal outcomes of FGR. In this paper we review the available evidence regarding diagnosis, management and prognosis of fetuses diagnosed with FGR before 32 weeks of gestation.
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Affiliation(s)
- Andrea Dall’Asta
- Centre for Fetal Care, Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS United Kingdom
- Department of Obstetrics & Gynecology, University of Parma, Parma, Italy
| | - Valentina Brunelli
- Department of Obstetrics and Gynaecology, Maternal-Fetal Medicine Unit, University of Brescia, Brescia, Italy
| | - Federico Prefumo
- Department of Obstetrics and Gynaecology, Maternal-Fetal Medicine Unit, University of Brescia, Brescia, Italy
| | - Tiziana Frusca
- Department of Obstetrics & Gynecology, University of Parma, Parma, Italy
| | - Christoph C Lees
- Centre for Fetal Care, Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS United Kingdom
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Department of Development and Regeneration, KU Leuven, Belgium
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42
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Korkalainen N, Räsänen J, Kaukola T, Kallankari H, Hallman M, Mäkikallio K. Fetal hemodynamics and adverse outcome in primary school-aged children with fetal growth restriction: a prospective longitudinal study. Acta Obstet Gynecol Scand 2016; 96:69-77. [DOI: 10.1111/aogs.13052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 10/19/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Noora Korkalainen
- Department of Obstetrics and Gynecology; Oulu University Hospital; Oulu Finland
- PEDEGO Research Unit; University of Oulu; Oulu Finland
| | - Juha Räsänen
- Department of Obstetrics and Gynecology; Oulu University Hospital; Oulu Finland
- PEDEGO Research Unit; University of Oulu; Oulu Finland
- Department of Obstetrics and Gynecology; University Hospital of Helsinki and University of Helsinki; Helsinki Finland
| | - Tuula Kaukola
- PEDEGO Research Unit; University of Oulu; Oulu Finland
- Department of Pediatrics; Oulu University Hospital; Oulu Finland
| | - Hanna Kallankari
- PEDEGO Research Unit; University of Oulu; Oulu Finland
- Department of Pediatrics; Oulu University Hospital; Oulu Finland
| | - Mikko Hallman
- PEDEGO Research Unit; University of Oulu; Oulu Finland
- Department of Pediatrics; Oulu University Hospital; Oulu Finland
| | - Kaarin Mäkikallio
- Department of Obstetrics and Gynecology; Oulu University Hospital; Oulu Finland
- PEDEGO Research Unit; University of Oulu; Oulu Finland
- Department of Obstetrics and Gynecology; University Hospital of Turku and University of Turku; Turku Finland
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Tanis JC, Schmitz DM, Boelen MR, Casarella L, van den Berg PP, Bilardo CM, Bos AF. Relationship between general movements in neonates who were growth restricted in utero and prenatal Doppler flow patterns. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:772-778. [PMID: 26935604 DOI: 10.1002/uog.15903] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 01/27/2016] [Accepted: 02/24/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To investigate whether Doppler pulsatility indices (PIs) of the fetal circulation in cases of fetal growth restriction (FGR) are associated with the general movements (GMs) of the neonate after birth. METHODS This was a prospective observational cohort study including pregnancies with FGR diagnosed between June 2012 and September 2014. A diagnosis of FGR was based on an abdominal circumference or estimated fetal weight < 10th percentile (in conjuction with abnormal Doppler) or declining fetal growth of at least 30 percentiles with respect to previous size measurements. Doppler parameters of the umbilical artery (UA), fetal middle cerebral artery (MCA) and ductus venosus (DV) were measured maximally 1 week prior to delivery. Cerebroplacental ratio (CPR) was calculated as MCA-PI divided by UA-PI. We assessed the quality of neonatal GMs 7 days after birth, around the due date if cases were born preterm, and at 3 months post-term. We performed a detailed analysis of the motor repertoire by calculating a motor optimality score (MOS). RESULTS Forty-eight FGR cases were included with a median gestational age at delivery of 35 (range, 26-40) weeks. UA-PI, MCA-PI and CPR correlated strongly (ρ, -0.374 to 0.472; P < 0.01) with the MOS on day 7 after birth, but DV-PI did not. Doppler PI measurements did not correlate with MOS at 3 months post-term. CONCLUSION Fetal arterial Doppler measurements are associated with the quality of neonatal GMs 1 week after birth, but this association is no longer evident at 3 months post-term. Brain sparing in particular is associated strongly with GMs of an abnormal quality. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J C Tanis
- Department of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Fetal Medicine, Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - D M Schmitz
- Department of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - M R Boelen
- Department of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - L Casarella
- Department of Fetal Medicine, Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - P P van den Berg
- Department of Fetal Medicine, Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - C M Bilardo
- Department of Fetal Medicine, Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A F Bos
- Department of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Nawathe A, Lees C. Early onset fetal growth restriction. Best Pract Res Clin Obstet Gynaecol 2016; 38:24-37. [PMID: 27693119 DOI: 10.1016/j.bpobgyn.2016.08.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 08/26/2016] [Accepted: 08/30/2016] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Aamod Nawathe
- Queen Charlotte's and Chelsea Hospital, London, W120HS, UK.
| | - Christoph Lees
- Queen Charlotte's and Chelsea Hospital, London, W120HS, UK.
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Tanis JC, Boelen MR, Schmitz DM, Casarella L, van der Laan ME, Bos AF, Bilardo CM. Correlation between Doppler flow patterns in growth-restricted fetuses and neonatal circulation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:210-216. [PMID: 26358663 DOI: 10.1002/uog.15744] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 08/08/2015] [Accepted: 09/02/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To investigate whether prenatal Doppler parameters in growth-restricted fetuses are correlated with neonatal circulatory changes. METHODS In 43 cases of suspected fetal growth restriction (FGR), serial Doppler measurements of umbilical artery (UA) and middle cerebral artery (MCA) pulsatility index (PI) were performed. The last measurement, closest to delivery (< 1 week before birth), was used for analysis. Neonatal circulation was assessed for 2 h/day on Days 1-5, 8 and 15 by near-infrared spectroscopy (NIRS) of the cerebral, renal and splanchnic regions. We calculated fractional tissue oxygen extraction (FTOE) as: (arterial oxygen saturation - NIRS value)/arterial oxygen saturation. The following ratios were calculated: cerebroplacental ratio (CPR; MCA-PI/UA-PI), cerebrorenal ratio (CRR; cerebral/renal FTOE) and cerebrosplanchnic ratio (CSR; cerebral/splanchnic FTOE). Spearman's rank correlation coefficient (ρ) was calculated between prenatal Doppler parameters and neonatal NIRS variables. These analyses were carried out for the entire group, and separately for cases of early FGR (delivered < 34 weeks) and late FGR (≥ 34 weeks). RESULTS Fetal Doppler parameters correlated with neonatal NIRS variables on Days 1-3: UA-PI correlated with renal FTOE (Day 1: ρ = 0.454, P < 0.01) and CRR (Day 1: ρ = -0.517, P < 0.001). MCA-PI correlated with cerebral FTOE on Day 2 (ρ = 0.469, P < 0.01), approached statistical significance on Day 3 but was not correlated on Day 1. CPR correlated with CRR (Day 1: ρ = 0.474, P < 0.01). Most associations lost their statistical significance when early and late FGR subgroups were considered separately. CONCLUSION Low MCA-PI and low CPR, indicating brain sparing before birth, are associated with low CRR after birth, indicating relatively greater blood flow to the cerebrum than to the renal region. Based on the results of this study, it could be speculated that if brain sparing is present in the fetal circulation, it persists during the first 3 days after birth. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J C Tanis
- Department of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Fetal Medicine, Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - M R Boelen
- Department of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - D M Schmitz
- Department of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - L Casarella
- Department of Fetal Medicine, Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - M E van der Laan
- Department of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A F Bos
- Department of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - C M Bilardo
- Department of Fetal Medicine, Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Human fetal growth restriction: a cardiovascular journey through to adolescence. J Dev Orig Health Dis 2016; 7:626-635. [DOI: 10.1017/s2040174416000337] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Intrauterine growth restriction has been noted to adversely impact morbidity and mortality in the neonatal period as well as cardiovascular well-being in adolescence and adulthood. Recent data based on a wide range of ultrasound parameters during fetal and neonatal life has noted early and persistent involvement of the cardiovascular system. Some of these measures are predictive of long-term morbidities. Assessment of vascular mechanics is a new and novel concept in this population, and opens up avenues for diagnosis, monitoring and evaluation of the likely effectiveness of interventions. Prevention of these adverse vascular and cardiac outcomes secondary to fetal growth restriction may be feasible and of clinical relevance. This review focuses on growth restriction in humans with respect to cardiovascular remodeling and dysfunction during fetal life, persistence of functional cardiac impairment during early childhood and adolescence, and possible preventive strategies.
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Agrawal C, Agrawal KK, Gandhi S. Assessment of fetal growth using the ratio of the transverse cerebellar diameter to abdominal circumference. Int J Gynaecol Obstet 2016; 135:33-7. [PMID: 27350231 DOI: 10.1016/j.ijgo.2016.03.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 03/05/2016] [Accepted: 06/01/2016] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To evaluate use of the transverse cerebellar diameter to abdominal circumference (TCD/AC) ratio in predicting intrauterine growth restriction (IUGR). METHODS A prospective observational study was conducted at a prenatal clinic in Udaipur, India, between August 2011 and December 2012. Women with a singleton pregnancy and a confirmed gestational age of 20-36 weeks were enrolled. Transverse cerebellar diameter and abdominal circumference were measured by ultrasonography on two prenatal visits at early (20-28 weeks) and late (30-36 weeks) gestation. A TCD/AC ratio above the 90th percentile was considered to indicate IUGR. Birth weight was recorded. RESULTS Overall, 100 women completed the study. Among 15 neonates with IUGR, the mean TCD/AC ratio was 14.17 ± 0.89 at early gestation and 15.61 ± 1.18 at late gestation. The TCD/AC ratio for appropriate-for-gestational-age neonates was significantly lower: 13.50 ± 0.97 and 13.80 ± 0.97 at early and late gestation, respectively (P<0.05 for both). Among 14 fetuses with a TCD/AC ratio above the 90th percentile at early gestation, 9 (64%) were small for gestational age, 5 (36%) were appropriate for gestational age, and none was large for gestational age at the neonatal examination. CONCLUSION The TCD/AC ratio was fairly accurate in recognizing abnormal fetal growth at an early gestational age.
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Affiliation(s)
- Charusmita Agrawal
- Department of Obstetrics and Gynaecology, SMS Medical College, Jaipur, India.
| | | | - Sudha Gandhi
- Department of Obstetrics and Gynaecology, RNT Medical College, Udaipur, India
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Kapaya H, Jacques R, Rahaim N, Anumba D. "Does short-term variation in fetal heart rate predict fetal acidaemia?" A systematic review and meta-analysis. J Matern Fetal Neonatal Med 2016; 29:4070-7. [PMID: 26902464 DOI: 10.3109/14767058.2016.1156670] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the association of short-term variation (STV) of the fetal heart rate in predicting fetal acidaemia at birth. METHODS The search strategy employed searching of electronic databases (MEDLINE, Web of Science, Scopus, and Google Scholar) and reference lists of relevant studies. Data were extracted from studies, adhering strictly to the following criteria: singleton pregnancy at ≥24 weeks' gestation, computerized CTG (index test) and calculation of STV before delivery. The outcome measure was arterial pH assessed in cord blood obtained at birth. RESULTS Meta-analysis showed moderate accuracy of STV in predicting fetal acidaemia with a sensitivity of 0.57 (95% CI: 0.45-0.68), specificity of 0.81 (95% CI: 0.69-0.89), positive likelihood ratio of 3.14 (95% CI: 2.13-4.63) and negative likelihood ratio of 0.58, (95% CI: 0.46-0.72). However, in intra-uterine growth restricted fetuses, a small improvement in detecting acidaemia was observed; with a sensitivity of 0.63 (95% CI: 0.49-0.75) and negative likelihood ratio of 0.50 (95% CI: 0.31-0.80). CONCLUSION STV appears to be a moderate predictor for fetal acidaemia. However, its usefulness as a stand-alone test in predicting acidaemia in clinical setting remains to be determined.
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Affiliation(s)
- Habiba Kapaya
- a Department of Human Metabolism , Academic Unit of Reproductive & Developmental Medicine , Sheffield , UK
| | - Richard Jacques
- b School of Health and Related Research (ScHARR), University of Sheffield , Sheffield , UK
| | - Nadia Rahaim
- a Department of Human Metabolism , Academic Unit of Reproductive & Developmental Medicine , Sheffield , UK
| | - Dilly Anumba
- a Department of Human Metabolism , Academic Unit of Reproductive & Developmental Medicine , Sheffield , UK
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Nassr AA, Youssef AA, Zakherah MS, Ismail AM, Brost BC. Clinical application of fetal left modified myocardial performance index in the evaluation of fetal growth restriction. J Perinat Med 2015; 43:749-54. [PMID: 24706424 DOI: 10.1515/jpm-2014-0018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 03/17/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This study aims to evaluate cardiac function in fetuses with intrauterine growth restriction (IUGR) compared with healthy fetuses, using the left modified myocardial performance index (MPI) and the association between MPI and perinatal outcome. METHODS Pregnant women between 34 and 39 weeks of gestation, who met the criteria for IUGR and were scheduled for delivery at an Egyptian tertiary medical center, were prospectively enrolled in the study. Women in the same gestational-age group with uncomplicated pregnancies were included as a control group. MPI was measured in all fetuses. The IUGR group was analyzed based on normal and abnormal umbilical artery (UA) Doppler. Perinatal outcomes were recorded. RESULTS The mean left MPI was significantly higher in IUGR fetuses with abnormal UA Doppler (mean 0.58±SD 0.093) compared with healthy fetuses (mean 0.45±SD 0.070) (P<0.001). IUGR fetuses with abnormal left MPI showed significantly worse perinatal outcome and increased morbidity compared with the control group. IUGR fetuses with abnormal left MPI also showed significantly worse perinatal outcome compared with IUGR fetuses with normal MPI (whether the UA Doppler was normal or abnormal). The fetal MPI was associated with the severity of fetal compromise in IUGR fetuses based on the perinatal outcome. CONCLUSION MPI is a potentially useful tool in evaluating fetuses with suspected IUGR, which is crucial in classifying IUGR pregnancies into critical and non-critical cases and in predicting neonatal outcome.
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Lee VR, Pilliod RA, Frias AE, Rasanen JP, Shaffer BL, Caughey AB. When is the optimal time to deliver late preterm IUGR fetuses with abnormal umbilical artery Dopplers? J Matern Fetal Neonatal Med 2015; 29:690-5. [DOI: 10.3109/14767058.2015.1018170] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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