Fetal Doppler Hypoxic index for the prediction of abnormal fetal heart rate at delivery in chronic fetal distress

High-risk factors for adverse pregnancy outcomes in systemic lupus erythaematosus: a retrospective study of a Chinese population

OBJECTIVE

To clarify high-risk factors for adverse pregnancy outcomes (APOs) in systemic lupus erythaematosus (SLE).

DESIGN

A retrospective chart review study.

SETTING

Data were collected in a tertiary medical centre, Shanghai, China, from November 2010 to December 2018.

PARTICIPANTS

A total of 513 pregnancies with SLE were retrospectively analysed. Twenty-seven patients who underwent artificial abortions due to personal reasons were excluded.

PRIMARY OUTCOME MEASURES

APOs were primary outcomes, including foetal loss, premature birth, small for gestational age (SGA), asphyxia neonatorum, composite foetal APOs and hypertensive disorders of pregnancy (HDP). Multivariable logistic regression and Spearman correlation analysis were performed to determine the risk factors for APOs in SLE.

RESULTS

Risk factors for foetal loss included prepregnancy hypertension, hypocomplementaemia-C3, anticardiolipin antibodies-IgM positivity and disease flares during pregnancy. Risk factors for premature birth included disease flares, use of immunosuppressive agents and HDP. Moreover, twin pregnancy, disease flares and HDP were risk factors for SGA, and prepregnancy hypertension was an independent risk factor for asphyxia neonatorum. Independent risk factors for composite foetal APOs included twin pregnancy, prepregnancy hypertension, disease flares during pregnancy, HDP, hypocomplementaemia-C3 and the use of immunosuppressive agents. Risk factors for SLE complicated with HDP included prepregnancy hypertension, renal disorders and thrombocytopaenia. Conversely, the use of aspirin was a protective factor against foetal loss and premature birth. The ds-DNA value had a low diagnostic value for APOs, whereas the extent of complement reduction may predict the incidence of composite foetal APOs and foetal loss. Proteinuria occurring in the first 20 gestational weeks may lead to APOs.

CONCLUSION

Established risk factors for each APO were identified in this study. Indicators with more predictive significance have been screened out from conventional indicators, which may help clinicians predict the pregnancy outcome of patients with SLE more accurately and minimise the incidence of APOs.

Cerebro-placental ratio as a prognostic factor of fetal outcome in pregnancy complicated by maternal sickle cell disease

OBJECTIVES

To assess the role of the cerebro-placental ratio (CPR) in predicting adverse fetal outcomes among women with sickle cell disease (SCD).

METHODS

A prospective cohort study at Korle-Bu Teaching Hospital, Accra, Ghana, between January and June 2016. Pregnant women with SCD at 34 gestational weeks or more underwent weekly fetal umbilical and middle cerebral artery Doppler assessment until delivery. Participants were categorized into two study arms based on CPR (<1.1 or ≥1.1). The primary outcome, a composite of adverse perinatal outcomes including intrauterine growth restriction, stillbirth, low birthweight, and neonatal intensive care unit admission, was compared between groups.

RESULTS

Overall, 48 pregnant women with SCD were enrolled, and 5 had a fetus with CPR less than 1.1. Low CPR (<1.1) had a sensitivity and specificity of 29.4% and 100%, respectively, for predicting composite adverse perinatal outcomes. Sensitivity and specificity were, respectively, 100% and 93.5% for predicting stillbirth, and 40.2% and 97.4% for predicting low birthweight. Perinatal outcomes did not differ between the two major sickle cell genotypes (hemoglobin SS and hemoglobin SC).

CONCLUSIONS

Among women with SCD, CPR less than 1.1 was associated with adverse perinatal outcomes, particularly low birthweight and stillbirth.

Impact of maternal fasting on fetal well-being parameters and fetal-neonatal outcome: a case-control study

OBJECTIVE

To assess the impact of maternal fasting on fetal well-being parameters and neonatal outcome.

METHODS

Two-hundred ten healthy women with singleton uncomplicated pregnancies at 36-40 weeks' gestation who had fasted for 12-16 h were defined as the study group with 240 healthy non-fasted pregnant women matched for age, parity and gestational age were defined as the control group. Both groups were subjected to tests of fetal well-being in the form of non-stress test (NST), modified biophysical profile and Doppler indices of the umbilical and middle cerebral arteries (MCA). Women were followed-up till delivery to record the obstetric outcome.

RESULTS

There was no significant difference between the two groups regarding the reactivity of NST, modified biophysical scores, Doppler indices of the umbilical and MCA (resistive index, pulsatility index and systolic/diastolic ratio) and the cerebroplacental ratio (p > 0.05). There was no significant difference between the two groups regarding the gestational age at delivery, mode of delivery, neonatal weight, 5-min Apgar scores and admission to neonatal intensive care unit (p > 0.05).

CONCLUSIONS

Short-term maternal fasting has no deleterious effect on fetal well-being parameters or neonatal outcome. Pregnant women who desire fasting, should be reassured regarding the health of their babies.

Cerebroplacental ratio in prediction of adverse perinatal outcome and fetal heart rate disturbances in uncomplicated pregnancy at 40 weeks and beyond

INTRODUCTION

The aim of the study was to determine the usefulness of Doppler velocimetry, based on cerebroplacental ratio (C/U) evaluation, in predicting intrapartum fetal heart rate abnormalities and adverse neonatal outcome in uncomplicated pregnancies at 40 weeks and beyond.

MATERIAL AND METHODS

One hundred and forty-eight women in uncomplicated pregnancies, between 40 and 42 completed weeks, were divided into control and study groups: with the absence (n = 79) and with the presence of a fetal brain-sparing effect (n = 69), respectively. Pulsatility and resistance indices in the middle cerebral, the umbilical artery and the C/U ratio were evaluated daily by Doppler ultrasonography. C/U < 1.1 was reported as suggestive of a brain-sparing effect. Abnormal flow indices were analyzed and compared to adverse pregnancy and neonatal outcome determinants.

RESULTS

In the abnormal C/U group the abnormal CTG records were significantly more frequently observed (62.3%) than in normal C/U group (19.0%) (p = 0.0001). The comparison of selected Doppler indices revealed that C/U showed the highest sensitivity in prediction of both the intrapartum abnormal FHR (74.1%) and the adverse neonatal outcome (87.8%).

CONCLUSIONS

The C/U index shows the highest sensitivity in prediction of FHR abnormalities and adverse neonatal outcome in uncomplicated pregnancies at 40 weeks and beyond. The C/U index is useful in clinical practice in antenatal monitoring of these women in order to select those at high risk of intra- and postpartum complications.

Fetal cerebrovascular response to chronic hypoxia—implications for the prevention of brain damage

Fetal hypoxia is one of the leading causes of perinatal morbidity and mortality. One of the most severe sequels of fetal hypoxic insult is the development of perinatal brain lesions resulting in a spectrum of neurological disabilities, from minor cerebral disorders to cerebral palsy. One of the most important fetal adaptive responses to hypoxia is redistribution of blood flow towards the fetal brain, known as the 'brain sparing effect'. The fetal blood flow redistribution in favor of the fetal brain can be detected and quantified by the Doppler cerebral/umbilical ratio (C/U ratio = cerebral resistance index (CRI)/umbilical resistance index (URI)). Our studies on animal models and human fetuses have demonstrated clearly that this phenomenon cannot prevent the development of perinatal brain lesions in the case of severe or prolonged hypoxia. Fetal deterioration in chronic and severe hypoxia is characterized by the disappearance of the physiological cerebral vascular variability (vasoconstriction and vasodilatation), followed by an increase in cerebral vascular resistance. However, our latest study on growth-restricted and hypoxic human fetuses has shown that perinatal brain lesions can develop even before the loss of cerebrovascular variability. The fetal exposure to hypoxia can be quantified by using a new vascular score, the hypoxia index. This parameter, which takes into account the degree as well as duration of fetal hypoxia, can be calculated by summing the daily % C/U ratio reduction from the cut-off value 1 over the period of observation. According to our results, the use of this parameter, which calculates the cumulative, relative oxygen deficit, could allow for the first time the sensitive and reliable prediction and even prevention of adverse neurological outcome in pregnancies complicated by fetal hypoxia.

New Doppler index for prediction of perinatal brain damage in growth-restricted and hypoxic fetuses

OBJECTIVE

To evaluate the new vascular score, hypoxia index (HI), in the prediction of sonographically detected structural brain lesions in neonates within the first week after delivery of growth-restricted fetuses.

METHODS

This prospective study included 29 growth-restricted fetuses delivered between 31 and 40 gestational weeks. Doppler umbilical artery (UA) and middle cerebral artery (MCA) resistance indices (RI) were recorded at 48-h intervals for at least 2 weeks before delivery. The cerebroumbilical ratio (C/U ratio = MCA-RI/UA-RI) and the HI (the sum of the daily reductions in C/U ratio, i.e. percentage below the cut-off value of 1, over the period of observation) were calculated. After delivery, neonatal outcome was evaluated according to obstetric parameters and ultrasound examinations of the brain. Doppler indices, C/U ratio and HI, as well as neonatal clinical and biochemical parameters, were tested as potential predictors of brain lesions using the C4.5 data-mining algorithm.

RESULTS

Neonatal brain lesions were detected in 13 growth-restricted fetuses. Of all the parameters tested by the C4.5 data-mining algorithm, only HI was identified as a predictor of neonatal brain lesions. HI also showed better correlation with neonatal biochemical parameters, such as umbilical venous partial pressure of oxygen and umbilical venous pH, compared with the C/U ratio.

CONCLUSIONS

HI, which takes into account cumulative oxygen deficit, could significantly improve the prediction of a poor neurological outcome in pregnancies complicated by growth restriction and hypoxia.

Middle cerebral artery blood flow velocities and pulsatility index and the cerebroplacental pulsatility ratio: longitudinal reference ranges and terms for serial measurements

OBJECTIVES

To establish reference ranges suitable for serial assessments of the fetal middle cerebral (MCA) and umbilical (UA) artery blood flow velocities, pulsatility index (PI) and cerebroplacental pulsatility ratio and to provide terms for calculating conditional reference intervals suitable for individual serial measurements.

METHODS

This was a longitudinal study of 161 singleton pregnancies. Using Doppler ultrasound, MCA and UA blood velocities and PI were determined three to five times at 3-5-week intervals over a gestational age range of 19-41 weeks. Polynomial regression lines for the 95th, 50th and 5th percentiles were calculated for the peak systolic velocity (PSV), time-averaged maximum velocity (TAMXV), PI and cerebroplacental ratio. Terms for calculating conditional reference intervals were established.

RESULTS

Based on 566 observations our new longitudinal reference ranges for fetal middle cerebral PSV, TAMXV and PI provided terms for calculating conditional reference intervals (i.e. predicting expected 95% confidence limits based on a previous measurement), and correspondingly for the cerebroplacental ratio (n = 550). The reference ranges were at some variance with those of previous cross-sectional studies. The narrow 95% confidence limits for the 5(th) and 95(th) percentiles ensured reliable ranges.

CONCLUSIONS

We have established longitudinal reference ranges appropriate for the serial assessment of MCA blood velocities and PI and cerebroplacental ratio. Particularly the terms for calculating conditional ranges based on a previous observation make this system more appropriate for longitudinal monitoring than are cross-sectional data.