Early onset fetal growth restriction

Association of Amniotic Fluid Volume and Fetal Cardiac and Cerebrovascular Parameters in Fetal Growth Restriction

OBJECTIVES

To investigate the prevalence of oligohydramnios, brain sparing, and cardiac dysfunction among a cohort of fetal growth restriction (FGR).

METHODS

To assess the prevalence of oligohydramnios amongst a large sample of FGR fetuses, we screened a database of ultrasounds of FGR pregnancies from our maternal-fetal medicine clinics (clinical cohort) for diminished amniotic fluid volume. Using a threshold of a maximum vertical pocket (MVP) of <2 cm for "oligohydramnios," and 2 to 3 cm as a "reduced fluid" group, trends of Doppler values and cardiac parameters were assessed from pregnancies in an ongoing research study (comprehensive cohort).

RESULTS

In the clinical cohort, oligohydramnios was identified in only 2/229 (0.8%) and reduced fluid in 19/229 (8%). In the comprehensive cohort, oligohydramnios was seen in 3/126 (2.3%) and reduced fluid in 14/126 (11.1%). A high rate of cardiac and Doppler abnormalities were observed in the oligohydramnios group of the comprehensive cohort. The patients with oligohydramnios had a distinctly different cardiac phenotype with small (2/3 with cardiac area <5th%) (P = 0.01) and round (3/3 with global sphericity index <5th%) (P = 0.02) hearts.

CONCLUSION

Oligohydramnios, when present with FGR, is accompanied by high rates of cerebral and cardiovascular abnormalities.

Neonatal Outcomes of Infants Diagnosed with Fetal Growth Restriction during Late Pregnancy versus after Birth

Objective: The aim of this study was to investigate the potential differences in the outcomes of neonates in whom FGR was diagnosed late in pregnancy as compared to those in whom growth restriction was diagnosed after birth. Methods: A retrospective study was conducted in a tertiary medical center between 2017 and 2019. The study included women carrying a single infant with an estimated fetal weight below the tenth percentile in whom FGR was diagnosed during late pregnancy, after 32 gestational weeks (known late-onset FGR; study group) or only after birth (unknown FGR; control group). Data were collected by review of the electronic health records. The primary outcome measure was the rate of composite adverse neonatal outcome. Results: A total of 328 women were included, 77 (23.47%) in the known-FGR group and 251 (75.53%) in the unknown-FGR group. In the known-FGR group, an etiology for the FGR was identified in 28.57% cases, most commonly placental insufficiency (21.74%). Compared to the unknown-FGR group, the known-FGR group was characterized by significantly higher rates of elective cesarean delivery (15.58% vs. 9.96%, p < 0.001), preterm birth (18.18% vs. 3.98%, p < 0.01), and labor induction (67.53% vs. 21.51%, p < 0.01). A significantly higher proportion of neonates in the known-FGR group had a positive composite adverse outcome (38.96% vs. 15.53%, p < 0.01). For multivariate regression analysis adjusted for maternal age, gestational age at delivery, and mode of delivery, there was no difference between groups in the primary outcome (aOR 1.73, CI 0.89-3.35, p = 0.1). Every additional gestational week at delivery was a protective factor (aOR = 0.7, 95% CI 0.56-0.86, p < 0.01). Conclusions: A prenatal diagnosis of late-onset FGR is associated with higher intervention and preterm birth rates as compared to a diagnosis made after birth. Fetuses diagnosed with late-onset FGR during pregnancy should undergo specific and personalized assessment to determine the cause and severity of the growth delay and the best management strategy. This study highlights the importance of careful decision-making regarding the induction of labor in late-onset FGR.

Ductus arteriosus diameters in fetuses with early- and late-onset fetal growth restriction

PURPOSE

Fetal growth restriction (FGR) is a common pregnancy complication that can be associated with several adverse perinatal outcomes. One of these negative outcomes is ductus arteriosus, especially in preterm babies. In this study, intrauterine heart function and ductus diameter were evaluated in babies with FGR.

METHODS

Thirty-seven fetuses with FGR were compared with 37 normal-weight fetuses at the same gestational week. In our study, ventricular diameters, aorta, pulmonary artery, ductus arteriosus (DA), aortic arch diameter, and flow traces were examined. In addition, the aorta and aortic isthmus diameters were proportioned to the ductus diameter, and the left ventricular myocardial performance index (MPI) [(ICT + IRT)/ET] was evaluated.

RESULTS

There was no difference in DA diameters between the patient and control groups. The intragroup comparison of the cases with early- and late-onset FGR revealed no statistically significant difference between DA diameters. However, the ratios of the aortic annulus diameter/ductus diameter (AOD/DAD) and aortic isthmus diameter/ductus diameter (AID/DAD) were significantly lower in early-onset FGR because the diameter of the DA was greater. In addition, the mod-MPI values were higher in the patient group.

CONCLUSIONS

In our study, although the ductal diameters did not change significantly in the patient group, the ductal diameter was greater in the early-onset intrauterine growth restriction (FGR) group compared with other cardiac measurements. The mod-MPI value, a cardiac function indicator, was higher in fetuses with FGR. These findings may be useful for evaluating postnatal cardiac functions in FGR.

Similarity network fusion to identify phenotypes of small-for-gestational-age fetuses

Fetal growth restriction (FGR) affects 5-10% of pregnancies, is the largest contributor to fetal death, and can have long-term consequences for the child. Implementation of a standard clinical classification system is hampered by the multiphenotypic spectrum of small fetuses with substantial differences in perinatal risks. Machine learning and multiomics data can potentially revolutionize clinical decision-making in FGR by identifying new phenotypes. Herein, we describe a cluster analysis of FGR based on an unbiased machine-learning method. Our results confirm the existence of two subtypes of human FGR with distinct molecular and clinical features based on multiomic analysis. In addition, we demonstrated that clusters generated by machine learning significantly outperform single data subtype analysis and biologically support the current clinical classification in predicting adverse maternal and neonatal outcomes. Our approach can aid in the refinement of clinical classification systems for FGR supported by molecular and clinical signatures.

Scaling the EVERREST of severe, early-onset fetal growth restriction

Severe, early-onset fetal growth restriction is a leading cause of medically indicated preterm birth and substantially increases the risk for perinatal death or disability. No treatments exist to improve fetal growth or safely prolong pregnancy. Furthermore, wide-ranging phenotypes limit the accurate prediction of pregnancy outcome. In this issue of the JCI, Spencer and colleagues combine a discovery-science approach with ultrasound parameters to identify the most discriminative models for predicting either the primary outcome of fetal or neonatal death, or a secondary outcome of death or delivery at 28 weeks of gestation or earlier. Their findings can better individualize patient counseling but, just as compellingly, provide the capacity to identify those pregnancies that are at such considerable risk as to justify enrollment in paradigm-shifting interventional trials that are in the pipeline.

Soluble Vascular Adhesion Protein 1 (sVAP-1) as a biomarker for pregnancy complications: A pilot study

BACKGROUND

Vascular adhesion protein 1 (VAP-1) has been implicated in a wide range of clinical conditions. Moreover, serum levels are associated with disease prediction and progression in several clinical studies. There is a paucity of data on VAP-1 and pregnancy. Given the emerging role of VAP-1 in pregnancy, the aim of this study was to examine sVAP-1 as an early biomarker of pregnancy complications, especially hypertension during pregnancy. The objectives of the study are to associate sVAP-1 levels with other pregnancy complications, patient demographics and blood tests performed throughout pregnancy.

METHODS

We conducted a pilot study in a cohort of pregnant women (gestational week lower than 20 at the time of recruitment) attending their first antenatal ultrasound scan at the Leicester Royal Infirmary (LRI, UK). Data were both prospectively generated (from blood sample analysis) and retrospectively collected (from hospital records).

RESULTS

From July and October 2021, a total of 91 participants were enrolled. Using ELISA (enzyme-linked immunosorbent assay), we found reduced serum levels of sVAP-1 in pregnant women with either pregnancy induced hypertension (PIH) (310 ng/mL) or GDM (366.73 ng/mL) as compared to controls (427.44 ng/mL and 428.34 ng/mL, respectively). No significant difference was found between women with FGR compared to controls (424.32 ng/mL vs 424.52 ng/mL), and patients with any pregnancy complications compared to healthy pregnancies (421.28 ng/mL vs 428.34 ng/mL).

CONCLUSION

Further studies are needed to establish whether or not sVAP-1 might be considered as an early, non-invasive, and affordable biomarker to screen women who will develop PIH or GDM. Our data will aid sample size calculations for such larger studies.

Development and Validation of a Small for Gestational Age Screening Model at 21-24 Weeks Based on the Real-World Clinical Data

BACKGROUND

Small for gestational age (SGA) is a condition in which fetal birthweight is below the 10th percentile for the gestational age, which increases the risk of perinatal morbidity and mortality. Therefore, early screening for each pregnant woman is of great interest. We aimed to develop an accurate and widely applicable screening model for SGA at 21-24 gestational weeks of singleton pregnancies.

METHODS

This retrospective observational study included medical records of 23,783 pregnant women who gave birth to singleton infants at a tertiary hospital in Shanghai between 1 January 2018 and 31 December 2019. The obtained data were nonrandomly classified into training (1 January 2018 to 31 December 2018) and validation (1 January 2019 to 31 December 2019) datasets based on the year of data collection. The study variables, including maternal characteristics, laboratory test results, and sonographic parameters at 21-24 weeks of gestation were compared between the two groups. Further, univariate and multivariate logistic regression analyses were performed to identify independent risk factors for SGA. The reduced model was presented as a nomogram. The performance of the nomogram was assessed in terms of its discrimination, calibration, and clinical usefulness. Moreover, its performance was assessed in the preterm subgroup of SGA.

RESULTS

Overall, 11,746 and 12,037 cases were included in the training and validation datasets, respectively. The developed SGA nomogram, comprising 12 selected variables, including age, gravidity, parity, body mass index, gestational age, single umbilical artery, abdominal circumference, humerus length, abdominal anteroposterior trunk diameter, umbilical artery systolic/diastolic ratio, transverse trunk diameter, and fasting plasma glucose, was significantly associated with SGA. The area under the curve value of our SGA nomogram model was 0.7, indicating a good identification ability and favorable calibration. Regarding preterm SGA fetuses, the nomogram achieved a satisfactory performance, with an average prediction rate of 86.3%.

CONCLUSIONS

Our model is a reliable screening tool for SGA at 21-24 gestational weeks, especially for high-risk preterm fetuses. We believe that it will help clinical healthcare staff to arrange more comprehensive prenatal care examinations and, consequently, provide a timely diagnosis, intervention, and delivery.

Assessment of fetal cardiac morphology and functional changes in early-onset and late-onset fetal growth restriction

OBJECTIVE

To compare the fetal cardiac morphology and functions of early-onset fetal growth restriction (EO-FGR) and late-onset fetal growth restriction (LO-FGR) groups with gestational weeks-matched controls.

METHODS

A total of 164 pregnant women were included, 28 of whom were in the EO-FGR group, 54 in the LO-FGR group, and 82 in the control group. Fetal echocardiographic evaluation was performed with two-dimensional, M-mode, tissue Doppler imaging (TDI), and pulsed wave Doppler.

RESULTS

Fetal cardiac morphologic measurements and diastolic and systolic functions changed in EO-FGR and LO-FGR fetuses compared with controls. The EO- and LO-FGR fetuses had reduced right and left cardiac output, increased myocardial performance index, and significantly higher mitral and tricuspid E/E' ratios compared with controls. The EO-FGR fetuses had lower mitral and tricuspid E and E' values. In LO-FGR fetuses, mitral and tricuspid E' values were lower than in their controls (P = 0.001 and P < 0.001). On the other hand, the mitral and tricuspid E values were not significantly changed (P = 0.107 and P = 0.196).

CONCLUSION

We hypothesized that EO-FGR and LO-FGR fetuses had insufficient myocardial maturation. Especially in the LO-FGR fetuses, TDI is the earliest and most sensitive technique to show subtle changes in fetal cardiac functions.

Maternal serum midkine level in fetal growth restriction: a case-control study

OBJECTIVES

To compare maternal serum midkine (MK) level in pregnant women with idiopathic fetal growth restriction (FGR) and healthy. In addition, we assessed the value of maternal serum MK level in predicting neonatal intensive care unit (NICU) admission.

METHODS

A total of 144 pregnant women were included, 72 with idiopathic FGR and 72 healthy in this study. The control group was matched for the mother's age, parity, gestational age, and pre-pregnancy body mass index (BMI) with the idiopathic FGR group at the time of recruitment into the study and sample collection.

RESULTS

Serum MK level is higher in the idiopathic FGR than the control group (0.24 ng/mL (0.19-0.32) vs. 0.18 ng/mL (0.14-0.23), p<0.001). In addition, we compared the maternal serum MK level of those with and without NICU admission in the FGR group (0.25 ng/mL (0.19-0.37) vs. 0.21 ng/mL (0.18-0.28), p=0.014). We performed ROC curve analysis to serum MK level predicting NICU admission in the FGR group (AUC: 0.668, %95 CI [0.550, 0.785], p=0.014). A sensitivity of 63% and a specificity of 62% for the serum MK level were achieved with a cut-off value of 0.22 for NICU admission.

CONCLUSIONS

To the best of our knowledge, this study is the first to compare maternal serum MK level in pregnant women with idiopathic FGR and healthy. We showed that maternal serum MK level was significantly elevated in pregnant women with FGR than healthy.

Prediction of perinatal survival in early-onset fetal growth restriction: role of placental growth factor

OBJECTIVE

To analyze the ability to predict perinatal survival and severe neonatal morbidity of cases with early-onset fetal growth restriction (eoFGR) using maternal variables, ultrasound parameters and angiogenic markers at the time of diagnosis.

METHODS

This was a prospective observational study in a cohort of singleton pregnancies with a diagnosis of eoFGR (< 32 weeks of gestation). At diagnosis of eoFGR, complete assessment was performed, including ultrasound examination (anatomy, biometry and Doppler assessment) and maternal serum measurement of the angiogenic biomarkers, soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF). Logistic regression models for the prediction of perinatal survival (in cases diagnosed at < 28 weeks) and severe neonatal morbidity (in all liveborn cases) were calculated.

RESULTS

In total, 210 eoFGR cases were included, of which 185 (88.1%) survived perinatally. The median gestational age at diagnosis was 27 + 0 weeks. All cases diagnosed at ≥ 28 weeks survived. In cases diagnosed < 28 weeks, survivors (vs non-survivors) had a higher gestational age (26.1 vs 24.4 weeks), estimated fetal weight (EFW; 626 vs 384 g), cerebroplacental ratio (1.1 vs 0.9), PlGF (41 vs 18 pg/mL) and PlGF multiples of the median (MoM; 0.10 vs 0.06) and lower sFlt-1/PlGF ratio (129 vs 479) at the time of diagnosis (all P < 0.001). The best combination of two variables for predicting perinatal survival was provided by EFW and PlGF MoM (area under the receiver-operating-characteristics curve (AUC), 0.84 (95% CI, 0.75-0.92)). These were also the best variables for predicting severe neonatal morbidity (AUC, 0.73 (95% CI, 0.66-0.80)).

CONCLUSIONS

A model combining EFW and maternal serum PlGF predicts accurately perinatal survival in eoFGR cases diagnosed before 28 weeks of gestation. Prenatal prediction of severe neonatal morbidity in eoFGR cases is modest regardless of the model used. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Predictors of adverse perinatal outcome up to 34 weeks, a multivariable analysis study

The objective was to evaluate the best predictors of adverse perinatal outcome (APO) in foetuses examined up to 34 weeks and delivered by spontaneous or induced labour. This was a retrospective study of 129 pregnancies that underwent an ultrasound Doppler examination at 23-34 weeks and entered into labour within 30 days. Cerebroplacental ratio (CPR) and mean uterine artery pulsatility index (mUtA PI) were converted into multiples of the median (MoM) and estimated foetal weight (EFW) into centiles to adjust for gestational age (GA). Sonographic and clinical parameters were evaluated using logistic regression analysis.The multivariable model for the prediction of APO presented a notable accuracy: Detection rate (DR) was 39.5% for a false positive rate (FPR) of 5% and 56.8% for a FPR of 10%, AUC 0.82, p < .0001. Significant predictors were GA, EFW centile, and CPR MoM, but not mUtA PI MoM. Moreover, the type of labour onset did not exert any influence on APO. In conclusion, up to 34 weeks, prediction of APO after spontaneous or induced labour may be done measuring CPR and EFW.IMPACT STATEMENTWhat is already known on this subject? Earlier in pregnancy, foetal growth restriction is caused by placental disease causing progressive hemodynamic changes. These changes have been exhaustively described. Conversely, information about the best predictors of adverse outcome is scarce.What do the results of this study add? The findings of this study show that prior to 34 weeks and up to 1 month before labour, labour outcome might be predicted by gestational age, foetal cerebroplacental ratio (CPR) and estimated foetal weight (EFW).What are the implications of these findings for clinical practice and/or further research? If CPR behaves as a good marker of outcome not only at the end of pregnancy but also earlier in gestation, it might be interrogated along with EFW in foetuses attempting vaginal delivery to determine the risk of adverse outcome.

Measurement of the Brain Volume/Liver Volume Ratio by Three-Dimensional MRI in Appropriate-for-Gestational Age Fetuses and Those With Fetal Growth Restriction

BACKGROUND

Fetal growth restriction (FGR) is associated with a high fetal brain volume/liver volume (FBV/FLV) ratio. Ultrasound may not always be reliable, which has prompted further investigation of MRI techniques.

PURPOSE

To determine the relationship between FBV/FLV ratio, as measured by MRI, and gestational age (GA) in normal fetuses and those with FGR.

STUDY TYPE

Retrospective.

POPULATION

One hundred and forty seven singleton pregnancies including 105 appropriate-for-gestational age (AGA) fetuses and 42 FGR fetuses.

FIELD STRENGTH/SEQUENCE

Three-dimensional fast imaging employing steady-state acquisition at 1.5 T.

ASSESSMENT

The FBV and FLV were measured by three radiologists. The inter- and intraobserver agreements, the correlation between FBV/FLV ratio, and advancing GA were evaluated; the diagnostic value of FBV/FLV ratio was evaluated and compared with head circumference/abdominal circumference (HC/AC) ratio measured by ultrasound.

STATISTICAL TESTS

Intraclass correlation coefficient (ICC) was used to determine inter- and intraobserver agreements. Regression analysis was used to assess the correlation between FBV/FLV ratio and advancing GA. The diagnostic value of the FBV/FLV ratio was examined by the area under the receiver operating characteristic (ROC) curve.

RESULTS

The inter- and intraobserver agreements were excellent with an interobserver ICC of 0.984 and intra-observer ICCs of 0.989, 0.994, and 0.995. The FBV/FLV ratio in AGA fetuses decreased significantly with advancing GA (Pearson correlation coefficient = -0.844). The FBV/FLV ratio in FGR fetuses was significantly higher than that in AGA fetuses. To identify fetuses at high risk for FGR using the FBV/FLV ratio, the area under the ROC curve was 0.978, with an optimal cut-off value of 4.10. The sensitivity of FBV/FLV ratio in identifying FGR was significantly higher than that of HC/AC ratio (0.929 vs. 0.529).

DATA CONCLUSION

An inverse correlation exists between FBV/FLV ratio and advancing GA in normal fetuses. A high FBV/FLV ratio may be used to ascertain fetuses at high risk for FGR.

LEVEL OF EVIDENCE

3 Technical Efficacy Stage: 3.

Human placental villous stromal extracellular matrix regulates fetoplacental angiogenesis in severe fetal growth restriction

Pregnancies complicated by severe, early-onset fetal growth restriction with abnormal Doppler velocimetry (FGRadv) have a sparse villous vascular tree secondary to impaired angiogenesis. As endothelial cell (EC) and stromal matrix interactions are key regulators of angiogenesis, we investigated the role of placental stromal villous matrix on fetoplacental EC angiogenesis. We have developed a novel model of generating placental fibroblast (FB) cell-derived matrices (CDMs), allowing us to interrogate placenta-specific human EC and stromal matrix interactions and their effects on fetoplacental angiogenesis. We found that as compared with control ECs plated on control matrix, FGRadv ECs plated on FGRadv matrix exhibited severe migrational defects, as measured by velocity, directionality, accumulated distance, and Euclidean distance in conjunction with less proliferation. However, control ECs, when interacting with FGRadv CDM, also demonstrated significant impairment in proliferation and migratory properties. Conversely several angiogenic attributes were rescued in FGRadv ECs subjected to control matrix, demonstrating the importance of placental villous stromal matrix and EC-stromal matrix interactions in regulation of fetoplacental angiogenesis.

Circulating levels of Elabela in pregnant women complicated with intrauterine growth restriction

OBJECTIVE

This study aimed to detect Elabela concentrations in the serum of normotensive pregnant women complicated with intrauterine growth restriction (IUGR) and compare them with the uncomplicated healthy pregnancies.

MATERIAL AND METHODS

This prospective case-control study was performed from May 1, 2020 to September 30, 2020. Of the 92 pregnant patients included in the study, we enrolled 49 normotensive patients complicated with IUGR as the study group, and 43 normotensive healthy gestational age-matched and body mass index (BMI)-matched patients without IUGR or additional pregnancy complication as the control group. Demographic and clinical characteristics, and maternal serum Elabela concentrations were recorded.

RESULTS

Maternal serum Elabela levels were significantly lower in IUGR pregnancies (4.02±3.42 ng/mL) compared to healthy pregnant women (14.01±18.38 ng/mL, p<0.001). There was a positive intermediate correlation between maternal serum Elabela levels and the birth weight (r = 0.308, p = 0.004).

CONCLUSION

Maternal circulating levels of Elabela were significantly lower in IUGR pregnancies than in healthy pregnant women. Also, birth weight was positively correlated with maternal serum Elabela levels. We consider that Elabela might be a crucial biomarker of the pathophysiologic process in pregnancies complicated by IUGR.

Standardized healthcare pathway in intrauterine growth restriction and minimum evidence-based care

INTRODUCTION

Fetal growth restricted fetuses are less likely to receive evidence-based care; a previous work demonstrated an improvement in neonatal prognosis when fetuses with intrauterine growth restriction (IUGR) received minimum evidence based-care.

OBJECTIVE

The objective of the study was to evaluate the impact of a standardized healthcare pathway on the implementation of the recommended clinical practice in the antenatal management of IUGR fetuses, in comparison to a traditional pathway. The quality of the implementation of practice has been defined whether or not minimum evidence-based care (MEC), defined according to the recommendations of the French college of gynecologists and obstetricians (CNGOF), has been implemented.

STUDY DESIGN

From a historical cohort of 31,052 children, born at the Femme Mère Enfant Hospital (Lyon, France) between January 1st, 2011 and December 31st, 2017, we selected the population of IUGR fetuses. We compared the rate of MEC between the IUGR fetuses followed-up in the traditional healthcare pathway versus the IUGR fetuses followed-up in a standardized healthcare pathway between 2015 and 2017.

RESULTS

A total of 245 IUGR were tracked between 2015 and 2017. Over this period, 120 fetuses were followed within the traditional pathway and 125 within the IUGR pathway. The standardized pathway resulted in a higher rate of MEC (86,4%) when compared to IUGR fetuses followed-up in the traditional pathway (27,5% (OR* 20 (95 % CI 10.0-39.7). Among early-onset IUGR: 31 % received MEC in the traditional pathway versus 83 % in the standardized pathway (p<0.001). Among late-onset IUGR: 22 % received MEC in the traditional pathway versus 92 % in the standardized pathway (p<0.001). The provided care in the standardized pathway resulted in an increase of complete antenatal corticosteroid therapy (92,8 %) when compared to the traditional pathway (50.0 %; p<0.001) and a reduction of the rate of caesarean sections before labor for non-reassuring fetal heart rate (15 %) when compared to the traditional pathway (41.3 % p=0.007).

CONCLUSION

The standardized pathway improves the implementation of the local recommendations in the management of early- and late-onset IUGR. This study is the first to suggest a standardized care pathway in prenatal medicine. A medico-economic study could estimate the health care savings that such a pathway would provide by allowing a medical management in accordance with the recommendations.

Galectin-3 deficiency in pregnancy increases the risk of fetal growth restriction (FGR) via placental insufficiency

Fetal growth restriction (FGR) is the most common pregnancy complication in developed countries. Pregnancies affected by FGR, frequently concur with complications and high risk of neonatal morbidity and mortality. To date, no approved treatment is available for pregnant women affected with FGR. The objective of this study was to investigate the contribution of galectin-3 (gal-3), a β-galactoside binding protein involved in pregnancy, placental function and fetal growth. We demonstrated that lack of gal-3 during mouse pregnancy leads to placental dysfunction and drives FGR in the absence of a maternal preeclampsia syndrome. Analysis of gal-3 deficient dams revealed placental inflammation and malperfusion, as well as uterine natural killer cell infiltration with aberrant activation. Our results also show that FGR is associated with a failure to increase maternal circulating gal-3 levels during the second and third trimester in human pregnancies. Placentas from human pregnancies affected by FGR displayed lower gal-3 expression, which correlated with placental dysfunction. These data highlight the importance of gal-3 in the promotion of proper placental function, as its absence leads to placental disease and subsequent FGR.

Predictor variables in the success of slow-release dinoprostone used for cervical ripening in intrauterine growth restriction pregnancies

OBJECTIVE

This study aims to evaluate the consequences of a trigger by vaginal Dinoprotone on outcome of pregnancies with Intrauterine growth restriction (IUGR).

MATERIALS AND METHODS

This retrospective study included 161 induced IUGR fetuses (35-39 weeks). Consecutive patients who were evaluated formed the basis of the clinical outcomes. The penalized maximum likelihood estimation (PMLE) method was used instead of traditional logistic regression in order to reduce the risk of overfitting.

RESULTS

Of the 25,678 deliveries that occurred during the study period, 161 (0.6%) women underwent IUGR delivery; of these, 117 (73%) succeeded and 44 (27%) failed to achieve cervical ripening using the dinoprostone slow-release vaginal insert. Two predictors were associated with dinoprostone vaginal delivery success: Parity (OR:1.4([0.89-2.3]), and Bishop score (OR:1.54[1.23-1.94]). The PMLE model correctly classified 78% participants (c-index: 0.78).

CONCLUSION

Basic parameters such as parity and Bishop score can be used to predict successful vaginal birth following dinoprostone slow-release vaginal insert administration.

Overexpression of the aryl hydrocarbon receptor nuclear translocator partially rescues fetoplacental angiogenesis in severe fetal growth restriction

Pregnancies complicated by severe fetal growth restriction with abnormal umbilical artery Doppler velocimetry (FGRadv) are at substantial risk for adverse perinatal and long-term outcomes. Impaired angiogenesis of the placental vasculature in these pregnancies results in a sparse, poorly branched vascular tree, which structurally contributes to the abnormally elevated fetoplacental vascular resistance that is clinically manifested by absent or reversed umbilical artery Doppler indices. Previous studies have shown that aryl hydrocarbon receptor nuclear translocator (ARNT) is a key mediator of proper placental angiogenesis, and within placental endothelial cells (ECs) from human FGRadv pregnancies, low expression of ARNT leads to decreased vascular endothelial growth factor A (VEGFA) expression and deficient tube formation. Thus, the aim of the present study was to determine the effect of VEGFA administration or ARNT overexpression on angiogenic potential of FGRadv ECs. ECs were isolated and cultured from FGRadv or gestational age-matched control placentas and subjected to either vehicle vs VEGFA treatment or transduction with adenoviral-CMV (ad-CMV) vs adenoviral-ARNT (ad-ARNT) constructs. They were then assessed via wound scratch and tube formation assays. We found that VEGFA administration nominally improved FGRadv EC migration (P<0.01) and tube formation (P<0.05). ARNT overexpression led to significantly enhanced ARNT expression in FGRadv ECs (P<0.01), to a level similar to control ECs. Despite this, FGRadv EC migration (P<0.05) and tube formation (P<0.05) were still only partially rescued. This suggests that although ARNT does play a role in fetoplacental EC migration, other factors in addition to ARNT are likely also important in placental angiogenesis.

Apparent Diffusion Coefficient of the Placenta and Fetal Organs in Intrauterine Growth Restriction

PURPOSE

This study aimed to assess apparent diffusion coefficient (ADC) of the placenta and fetal organs in intrauterine growth restriction (IUGR).

MATERIALS AND METHODS

A prospective study of 30 consecutive pregnant women (aged 21-38 years with mean age of 31.5 years and a mean gestational week of 35 ± 2.3) with IUGR and 15 age-matched pregnant women was conducted. All patients and controls underwent diffusion-weighted magnetic resonance imaging. The ADCs of the placenta and fetal brain, kidney, and lung were calculated and correlated with neonates needing intensive care unit (ICU) admission.

RESULTS

There was a significant difference in ADC of the placenta and fetal brain, lung, and kidney (P = 0.001, 0.001, 0.04, and 0.04, respectively) between the patients and the controls. The cutoff ADCs of the placenta and fetal brain, lung, and kidney used to detect IUGR were 1.45, 1.15, 1.80, and 1.40 × 10 mm/s, respectively, with areas under the curve (AUCs) of 0.865, 0.858, 0.812, and 0.650, respectively, and accuracy values of 75%, 72.5%, 72.5%, and 70%, respectively. Combined ADC of the placenta and fetal organs used to detect IUGR revealed an AUC of 1.00 and an accuracy of 100%. There was a significant difference in ADC of the placenta and fetal brain, lung, and kidney between neonates needing admission and those not needing ICU admission (P = 0.001, 0.001, 0.002, and 0.002, respectively). The cutoff ADCs of the placenta and fetal brain, lung, and kidney used to define neonates needing ICU were 1.35, 1.25, 1.95, and 1.15 × 10 mm/s with AUCs of 0.955, 0.880, 0.884, and 0.793, respectively, and accuracy values of 86.7%, 46.7%, 76.7%, and 70%, respectively. Combined placental and fetal brain ADC used to define neonates needing ICU revealed an AUC of 0.968 and an accuracy of 93.3%.

CONCLUSION

Combined ADC of the placenta and fetal organs can detect IUGR, and combined ADC of the placenta and fetal brain can define fetuses needing ICU.

Assessment of fetal modified myocardial performance index in early-onset and late-onset fetal growth restriction

Aim

To investigate the changes of modified myocardial performance index (Mod‐MPI) in early‐onset and late‐onset fetal growth restriction (FGR) cases, and its association with adverse perinatal outcome.

Methods

This was a prospective study on 77 early‐onset and 100 late‐onset FGR cases. Hundred normal fetuses were matched as control groups for early‐onset and late‐onset FGR groups, respectively. Mod‐MPI and vessel Doppler parameters including umbilical artery (UA), ductus venosus (DV), and middle cerebral artery (MCA) were measured. Perinatal outcomes were followed up. Mod‐MPI of FGR cases were compared in normal Doppler, abnormal Doppler, and control groups. The association of Mod‐MPI and perinatal outcome was investigated, and further efficacy of Mod‐MPI predicting adverse outcome was studied.

Results

Compared with control groups, both abnormal and normal Doppler groups showed increased Mod‐MPI in early‐onset and late‐onset FGR, respectively. Mod‐MPI had no significant difference between abnormal and normal Doppler groups. Mod‐MPI was associated with adverse outcome in early‐onset FGR (OR = 3.307) and late‐onset FGR (OR = 3.412). The sensitivity and specificity of Mod‐MPI predicting adverse outcome were 60% and 80% when cutoff value was 0.47 in early‐onset FGR. And they were 65% and 70% when cutoff value was 0.50 in late‐onset FGR.

Conclusion

Fetal growth restriction fetuses had increased Mod‐MPI. Mod‐MPI could be used to predict adverse perinatal outcome of FGR fetuses. Mod‐MPI was an effective parameter to supplement vessels’ Doppler parameters in monitoring FGR.

Predictive accuracy of cerebroplacental ratio for adverse perinatal and neurodevelopmental outcomes in suspected fetal growth restriction: systematic review and meta-analysis

OBJECTIVE

The cerebroplacental ratio (CPR) has been proposed for the routine surveillance of pregnancies with suspected fetal growth restriction (FGR), but the predictive performance of this test is unclear. The aim of this study was to determine the accuracy of CPR for predicting adverse perinatal and neurodevelopmental outcomes in suspected FGR.

METHODS

PubMed, EMBASE, CINAHL and Lilacs were searched from inception to 31 July 2017 for cohort or cross-sectional studies reporting on the accuracy of CPR for predicting adverse perinatal and/or neurodevelopmental outcomes in singleton pregnancies with FGR suspected antenatally based on sonographic parameters. Summary receiver-operating characteristics (ROC) curves, pooled sensitivities and specificities, and summary likelihood ratios (LRs) were generated.

RESULTS

Twenty-two studies (including 4301 women) met the inclusion criteria. Summary ROC curves showed that the best predictive accuracy of CPR was for perinatal death and the worst was for neonatal acidosis, with areas under the summary ROC curves of 0.83 and 0.57, respectively. The predictive accuracy of CPR was moderate to high for perinatal death (pooled sensitivity and specificity of 93% and 76%, respectively, and summary positive and negative LRs of 3.9 and 0.09, respectively) and low for composite of adverse perinatal outcomes, Cesarean section for non-reassuring fetal status, 5-min Apgar score < 7, admission to the neonatal intensive care unit, neonatal acidosis and neonatal morbidity, with summary positive and negative LRs ranging from 1.1 to 2.5 and 0.3 to 0.9, respectively. An abnormal CPR result had moderate accuracy for predicting small-for-gestational age at birth (summary positive LR of 7.4). CPR had a higher predictive accuracy in pregnancies with suspected early-onset FGR. No study provided data for assessing the predictive accuracy of CPR for adverse neurodevelopmental outcome.

CONCLUSION

CPR appears to be useful in predicting perinatal death in pregnancies with suspected FGR. Nevertheless, before incorporating CPR into the routine clinical management of suspected FGR, randomized controlled trials should assess whether the use of CPR reduces perinatal death or other adverse perinatal outcomes. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Modified myocardial performance index and its prognostic significance for adverse perinatal outcome in early and late onset fetal growth restriction

Objective: To compare the fetal modified myocardial performance index (Mod-MPI) in appropriately grown, early (EO) and late onset (LO) fetal growth restricted (FGR) fetuses and to assess its prognostic significance for adverse perinatal outcome.Study design: In a prospective case-control study, Mod-MPI was performed in 22 and 51 fetuses with EO and LO-FGR fetuses, respectively. Mod-MPI values of FGR fetuses were compared against gestation-matched controls (34 for EO-, and 32 for LO-FGR, respectively). Correlation testing related with poor perinatal outcomes were performed.Results: Incidences of pathologic uterine artery Doppler rate, cesarean section rate, 5-min Apgar score < 7, neonatal intensive care unit (NICU) admission and perinatal mortality were significantly higher in the EO-FGR group (p < .001). There was a decrease in Mod-MPI with gestational age in the normal (Pearson's r = 0.401, p < .001), and growth-restricted fetuses (Pearson's r = 0.248, p = .034). Mean Mod-MPI values were significantly higher in both EO- and LO-FGR group than gestation-matched controls (p < .001). There was no significant correlation between Mod-MPI values and perinatal deaths (Pearson's r = 0.004, p = .987) and 5-min Apgar score < 7 (Pearson's r = 0.391, p = .088) in the EO-FGR fetuses. There was a significant negative correlation between Mod-MPI values and cerebroplacental ratio (CPR) values (Pearson's r = -0.288, p = .041); however no significant correlation between Mod-MPI values and 5-min Apgar score< 7, and fetal distress during labor (Pearson's r = 0.149, p = 0.297) in the LO-FGR fetuses was noted.Conclusion: EO and LO-FGR fetuses have significantly higher Mod-MPI values, demonstrating prenatal cardiac dysfunction. Evaluating Mod-MPI is not so effective in predicting poor perinatal outcome in both EO and LO-FGR fetuses.

Ultrasound Evaluation of Fetal Biometry and Doppler Parameters in the Third Trimester of Pregnancy Suspected of Intrauterine Growth Restriction

Purpose. The purpose of this study was to investigate fetal biometry and Doppler parameters in the third trimester of pregnancy with suspected restriction of fetal growth as potential predictors of unfavorable neonatal status. Material/Methods. The uterine artery, umbilical and middle cerebral artery, cerebroplacental ratio (CPR), and estimated fetal weight (EFW) were evaluated in a cohort of 126 pregnancies that resulted in the birth of a fetus <10 percentiles (SGA). Results. The demographic data of the studied cases did not show a significant difference between the parameters studied in the two study groups: Late SGA fetuses and Early SGA fetuses. Analyzing fetal biometry we found a significant difference for some parameters in relation to the two study groups. Our study showed that the Early SGA fetuses group had a lower birth weight, a lower gestational age at birth, an increase in the incidence of premature birth with an increase in Doppler abnormal incidence. Conclusions. Ultrasound examination and Doppler monitoring provide a non-invasive repetitive method for supervising fetuses with growth restriction in order to apply an adequate management.

Comparison of diurnal variations, gestational age and gender related differences in fetal heart rate (FHR) parameters between appropriate-for-gestational-age (AGA) and small-for-gestational-age (SGA) fetuses in the home environment

Objective

To assess the influence of gender, time of the day and gestational age on fetal heart rate (FHR) parameters between appropriate-for-gestational-age (AGA) and small-for-gestational age (SGA) fetuses using a portable fetal ECG monitor employed in the home setting.

Methods

We analysed and compared the antenatal FHR data collected in the home setting on 61 healthy pregnant women with singleton pregnancies from 24 weeks gestation. Of the 61 women, 31 had SGA fetuses (estimated fetal weight below the tenth gestational centile) and 30 were pregnant with AGA fetuses. FHR recordings were collected for up to 20 h. Two 90 min intervals were deliberately chosen retrospectively with respect to signal recording quality, one during day-time and one at night-time for comparison.

Results

Overall, success rate of the fetal abdominal ECG in the AGA fetuses was 75.7% compared to 48.6% in the SGA group. Based on randomly selected episodes of heart rate traces where recording quality exceeded 80% we were able to show a marginal difference between day and night-time recordings in AGA vs. SGA fetuses beyond 32 weeks of gestation. A selection bias in terms of covering different representation periods of fetal behavioural states cannot be excluded. In contrast to previous studies, we neither controlled maternal diet and activity nor measured maternal blood hormone and heart rate as all mothers were monitored in the home environment.

Conclusion

Based on clinically unremarkable, but statistically significant differences in the FHR parameters between the AGA and SGA group we suggest that further studies with large sample size are required to assess the clinical value of antenatal fetal ECG monitoring.

Adverse Pregnancy Outcomes of Patients with History of First-Trimester Recurrent Spontaneous Abortion

Although a history of first-trimester recurrent spontaneous abortion (FRSA) is regarded as a risk factor in antenatal care, the characteristic of subsequent pregnancy outcome is not clearly elucidated. Here, a retrospective analysis was performed on the clinical data of 492 singleton pregnant women. 164 of them with the history of FRSA were enrolled in study group, compared to 328 deliveries without the history of FRSA. For maternal outcomes, patients in the study group delivered earlier with mean gestational age and the incidences of cesarean section and postpartum hemorrhage were higher compared to the control group. For placental outcomes, the incidence of placenta-mediated pregnancy complications (PMPC) in the study group increased in terms of late-onset preeclampsia, oligohydramnios, early-onset fetal growth restriction, and second-trimester abortion. Patients in the study group were more likely to suffer from placenta accreta, placenta increta, and placenta percreta. For perinatal outcomes, the proportion of birth defects of newborns in the study group was greater. At last, logistic regression analyses showed that the history of FRSA was an independent risk factor for cesarean section and pregnancy complications. In conclusion, women with the history of FRSA are often exposed to an elevated incidence of maternal-placental-perinatal adverse pregnancy outcomes.