First-trimester Doppler investigation of the uterine circulation

Three-dimensional ultrasonographic placental volume in gestational diabetes mellitus

OBJECTIVES

We aimed to evaluate the placental volume and placental mean gray value in gestational diabetes mellitus (GDM) and healthy placentas using three-dimensional (3D) ultrasound and Virtual Organ Computer-aided AnaLysis (VOCAL).

METHODS

This case-control prospective study consisted of 39 singleton pregnancies complicated by GDM and 42 healthy singleton pregnancies matched for gestational age, maternal age and parity. Placental volume and placental volumetric mean gray values were evaluated. The placental volume (cm(3)) was analyzed using the VOCAL imaging analysis program and 3D histogram was used to calculate the volumetric mean gray value (%).

RESULTS

Placental volume was significantly larger in GDM (411.59 ± 170.82 versus 343.86 ± 128.94 cm(3); p = 0.046). There was no significant difference in mean gray value between GDM and healthy placentas (36.65 ± 7.02 versus 38.71 ± 7.91, respectively; p = 0.277). Placental volume was significantly correlated with gestational week (r = 0.219, p = 0.035) and parity (r = 0.228, p = 0.048). There was negative significant relation between placental volume and umbilical artery systolic/diastolic ratio, pulsatility index and resistance index (r = -0.278, p = 0.007; r = -0.315, p = 0.002; r = -0.322, p = 0.001, respectively).

CONCLUSIONS

Placental volume increases significantly in GDM, whereas mean gray values do not alter significantly. These data may reflect the placental changes in GDM placentas that may help to understand the pathophysiology better.

Relaxation during pregnancy: what are the benefits for mother, fetus, and the newborn? A systematic review of the literature

Previous studies have reported associations between maternal stress during pregnancy and obstetric outcomes as well as fetal development and neonatal adaptation. These findings highlight the importance of identifying pregnant women who experience severe stress and the need for interventions that commence early in pregnancy. The aim of this study was to review studies that investigated the effects of relaxation techniques during pregnancy, including maternal, fetal, and neonatal outcomes. In addition, studies examining maternal endocrine and physiological alterations were reviewed. PubMed was searched using the following key words: maternal well-being, maternal stress, relaxation techniques, pregnancy, fetal neurobehavior, fetal heart rate, neonatal adaptation, and neonatal behavior. (1) Relaxation had a positive impact on women's emotional state. (2) Pregnancy outcomes improved with fewer admissions to the hospital, fewer obstetric complications, longer gestation, reduction of caesarean sections, and fewer postpartum complications. (3) Fetal heart rate and fetal motor activity were reduced as a result of relaxation and therefore interpreted as improved result. (4) Higher-birth-weight and improved performance on the Neonatal Behavioral Assessment Scale was related to relaxation. (5) Relaxation training was associated with reductions in maternal physiological and endocrine measures. Relaxation during pregnancy is associated with salutogenic effects that include regulation of emotional states and physiology. Relaxation is also associated with positive effects both on fetal behavior and on obstetric and neonatal outcomes. Identifying pregnant women at risk and instituting treatment early in pregnancy could improve obstetric and developmental outcomes for both the mother and her fetus.

First-trimester screening for large-for-gestational-age infants

OBJECTIVES

To examine the relationship between newborn birth weight and first-trimester uterine artery (UtA) pulsatility index (PI), maternal characteristics, serum pregnancy-associated plasma protein-A (PAPP-A), free β-human chorionic gonadotropin (β-hCG) and fetal nuchal translucency (NT) thickness. We also examined the results of screening for large-for-gestational-age (LGA) neonates by an integrated first-trimester approach incorporating these parameters.

METHODS

We evaluated maternal characteristics, fetal NT, PAPP-A, free β-hCG and UtA-PI in 2097 singleton pregnancies at 11 + 0 to 13 + 6 weeks' gestation. Linear models based on quasi Akaike's Information Criterion were used to determine the best predictive model for fetal birth weight. The patient-specific risk of delivering an LGA infant was derived from multiple logistic regression analysis and the performance of screening was determined by receiver-operating characteristics curve analysis.

RESULTS

The best predictive models for fetal birth weight included UtA-PI, PAPP-A, NT, parity, maternal age, smoking status, weight, height and free β-hCG. In pregnancies delivering LGA newborns compared with non-LGA pregnancies, PAPP-A and NT thickness were significantly increased (P = 0.016 and 0.001, respectively) and UtA-PI was significantly decreased (P = 0.011). A combination of maternal factors with PAPP-A, fetal NT and UtA-PI identified 34.4% of LGA newborns for a false-positive rate of 10%.

CONCLUSIONS

This study showed an association between newborn birth weight and maternal factors, and first-trimester PAPP-A, β-hCG, fetal NT and UtA-PI. Together, these factors can be used to identify over a third of pregnancies that will deliver LGA infants.

Inhibin A, activin A, placental growth factor and uterine artery Doppler pulsatility index in the prediction of pre-eclampsia

OBJECTIVES

To evaluate whether the measurement of maternal serum inhibin A, activin A and placental growth factor (PlGF) at 12 + 0 to 16 + 0 weeks of gestation alone or in combination with second-trimester uterine artery Doppler pulsatility index (PI) is useful in predicting pre-eclampsia.

METHODS

This was a case-control study of pre-eclampsia. From pregnant women attending their first antenatal examination at 12-16 weeks we collected serum samples and stored them at - 80 °C. All patients also underwent uterine artery Doppler examination to measure the PI at 22-24 weeks' gestation. We retrieved for analysis frozen samples from women who then developed pre-eclampsia, as well as three control samples per woman, matched for gestational age and storage time. Inhibin A, activin A and PlGF were measured using an enzyme-linked immunosorbent assay (ELISA) by an examiner who was blinded to the pregnancy outcome.

RESULTS

There were 31 cases with pre-eclampsia and 93 controls. Second-trimester uterine artery PI and marker levels were expressed as multiples of the median (MoM). The uterine artery PI was increased in pregnancies with pre-eclampsia compared with controls (mean ± SD, 1.45 ± 0.31 MoM vs. 1.02 ± 0.25 MoM, P < 0.001), as were the level of inhibin A (mean ± SD, 1.57 ± 0.34 MoM vs. 1.08 ± 0.43 MoM, P < 0.001) and the level of activin A (mean ± SD, 1.68 ± 0.38 MoM vs. 1.06 ± 0.42 MoM, P < 0.001). The level of PlGF was decreased in pre-eclampsia compared with controls (mean ± SD, 0.69 ± 0.23 MoM vs. 1.00 ± 0.26 MoM, P < 0.001). Receiver-operating characteristics curves were analyzed for controls and cases and areas under the curve (AUC) were 0.796 (95% CI, 0.712-0.880, P < 0.001) for inhibin A, 0.823 (95% CI, 0.746-0.899, P < 0.001) for activin A, 0.831 (95% CI, 0.752-0.910, P < 0.001) for PlGF and 0.851 (95% CI, 0.783-0.920, P < 0.001) for uterine artery PI. The combination of activin A, inhibin A and PI using logistic regression analysis yielded an AUC of 0.907 (95% CI, 0.830-0.938, P < 0.001) with a sensitivity of 87% and a specificity of 80%. The combination of activin A, PlGF and PI gave an AUC of 0.925 (95% CI, 0.852-0.978, P < 0.001) with a sensitivity of 90% and a specificity of 80%. Combining all four markers gave an AUC of 0.941 (95% CI, 0.891-0.990, P < 0.001) with a sensitivity of 93% and a specificity of 80%.

CONCLUSION

Early second-trimester serum inhibin A, activin A, PlGF and second-trimester uterine artery Doppler PI may add further information for the prediction of pre-eclampsia. The combination of the three serum markers and uterine artery Doppler PI has the highest prediction value for pre-eclampsia.

Uterine artery Doppler at 11 + 0 to 13 + 6 weeks in the prediction of pre-eclampsia

OBJECTIVE

To determine the performance of screening for pre-eclampsia (PET) by maternal characteristics and uterine artery pulsatility index (PI) at 11 + 0 to 13 + 6 weeks' gestation.

METHODS

In women with singleton pregnancies attending for routine care at 11 + 0 to 13 + 6 weeks' gestation we recorded maternal variables and measured the uterine artery PI. We identified 107 cases that subsequently developed PET and 5041 that were unaffected by PET, gestational hypertension or delivery of newborns with birth weight below the 10(th) centile. A multivariate Gaussian model was fitted to the distribution of log multiples of the median (MoM) PI in the PET and unaffected groups. Likelihood ratios for log MoM PI were computed and used together with maternal variables to produce patient-specific risks for each case. Predicted detection rates (DR) and false-positive rates (FPR) were calculated by taking the proportions with risks above a given risk threshold.

RESULTS

In the unaffected group log MoM PI was influenced by maternal ethnic origin, body mass index, previous history of PET and fetal crown-rump length. In the prediction of PET significant contributions were provided by log MoM PI, ethnic origin, body mass index and previous and family history of PET. For an FPR of 10% the DRs of all PET and PET leading to delivery before 34 weeks' gestation by log MoM PI and maternal variables were 61.7% and 81.8%, respectively.

CONCLUSION

Maternal variables together with uterine artery PI at 11 + 0 to 13 + 6 weeks' gestation provide sensitive prediction of the development of PET, especially of severe early-onset PET.

Uterine artery Doppler in the prediction of adverse pregnancy outcome

PURPOSE OF REVIEW

To review publications, published during the past year, that have examined uterine artery Doppler findings in women with adverse pregnancy outcome.

RECENT FINDINGS

Almost two-thirds of stillbirths that occur in the early preterm period (up to 32 weeks) can be predicted by uterine artery Doppler at 23 weeks. First trimester screening studies have shown that an abnormal result increases the risk of subsequent fetal growth restriction, and such women are at particularly high risk when indices remain abnormal in the second trimester. Studies combining uterine artery Doppler with maternal serum markers have demonstrated that measurement of first-trimester maternal serum pregnancy-associated plasma protein A and free beta human chorionic gonadotrophin improve sensitivities of second-trimester Doppler. As these are frequently measured in Down syndrome screening and they lend themselves in screening for pre-eclampsia. Women with abnormal first and second-trimester serum markers constitute a high-risk group. Maternal serum placental protein 13 remains a promising method for early screening, although a recent study suggests lower sensitivities than initially reported.

SUMMARY

Uterine artery Doppler screening identifies women at high risk for developing adverse pregnancy outcomes. Detection rates may be increased and false positive rates reduced by combination with maternal characteristics or serum markers.