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Malik N, Jain S, Ranjan R, Maurya D, Madan N, Singh UK, Malik V, Choudhary S, Singhal A, Tyagi N. Cerebroplacental Ratio as a Predictor of Perinatal Outcome in Hypertensive Disorders of Pregnancy and Its Comparison With Its Constituent Doppler Indices. Cureus 2023; 15:e49951. [PMID: 38179359 PMCID: PMC10765206 DOI: 10.7759/cureus.49951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 01/06/2024] Open
Abstract
Objective Doppler velocimetry is an established method of antepartum fetal surveillance in pre-eclampsia. Cerebroplacental ratio detects the centralization of fetal blood flow and the insufficiency in placental circulation. It is postulated to be a better marker of perinatal outcome than either vessel Doppler alone. The current study aims to assess the cerebroplacental ratio as a predictor of adverse perinatal outcomes and compare it to the systolic/diastolic (S/D) ratio of umbilical artery (UA) and middle cerebral artery (MCA) in hypertensive disorders of pregnancy. Material and methods The present prospective observational cohort study included 100 patients with hypertensive disorders of pregnancies between 32 and 37 weeks. Ultrasound with Doppler was done and the following parameters were assessed: fetal biometry, amniotic fluid index, umbilical artery pulsatility index, middle cerebral artery pulsatility index, S/D ratio of umbilical artery, S/D ratio of middle cerebral artery, and cerebroplacental ratio. Sensitivity, specificity, positive and negative predictive values were calculated for the cerebroplacental ratio and S/D ratios of umbilical and middle cerebral arteries. McNemar's test was used for the comparison of sensitivity and specificity. Results Thirty-two patients had an abnormal cerebroplacental ratio. Adverse perinatal outcomes such as a cesarean section for fetal distress, small for gestational age, APGAR < 7 at 1 and 5 minutes, NICU admission, and perinatal mortality were more in the group with abnormal cerebraplacental ratio and the difference was statistically significant. Conclusion The cerebroplacental ratio is a more reliable predictor of adverse perinatal outcomes and should be routinely calculated during obstetrical Doppler for antepartum fetal surveillance in case of hypertensive disorders of pregnancy.
It suggested that the cerebroplacental ratio may be calibrated in the software of
the Doppler ultrasonography machine for routine use in high-risk pregnancies.
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Affiliation(s)
- Neeru Malik
- Obstetrics and Gynecology, Dr. Baba Saheb Ambedkar Medical College & Hospital, Delhi, IND
| | - Sandhya Jain
- Obstetrics and Gynecology, Dr. Baba Saheb Ambedkar Medical College & Hospital, Delhi, IND
| | - Rajiv Ranjan
- Radiology, Dr. Baba Saheb Ambedkar Medical College & Hospital, Delhi, IND
| | - Divya Maurya
- Obstetrics and Gynecology, Dr. Baba Saheb Ambedkar Medical College & Hospital, Delhi, IND
| | - Nikita Madan
- Obstetrics and Gynecology, Employees' State Insurance Corporation (ESIC) Hospital & Post-Graduate Institute of Medical Science & Research (PGIMSR), Delhi, IND
| | - Uday K Singh
- Radiology, Dr. Baba Saheb Ambedkar Medical College & Hospital, Delhi, IND
| | - Vinayak Malik
- Computer Science, University of Wisconsin, Madison, USA
| | - Sanjay Choudhary
- Pediatrics and Neonatology, Dr. Baba Saheb Ambedkar Medical College & Hospital, Delhi, IND
| | - Anupa Singhal
- Obstetrics and Gynecology, Dr. Baba Saheb Ambedkar Medical College & Hospital, Delhi, IND
| | - Natasha Tyagi
- Obstetrics and Gynecology, Dr. Baba Saheb Ambedkar Medical College & Hospital, Delhi, IND
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Peguero A, Fernandez-Blanco L, Mazarico E, Benitez L, Gonzalez A, Boada D, Borràs C, Youssef L, Crispi F, Hernandez S, Figueras F. Prediction of adverse neonatal outcome at admission for early-onset preeclampsia with severe features. Pregnancy Hypertens 2023; 32:64-69. [PMID: 37116297 DOI: 10.1016/j.preghy.2023.04.004] [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: 02/09/2023] [Revised: 04/05/2023] [Accepted: 04/20/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Preeclampsia remains the leading cause of maternal morbidity and mortality. Consequently, research has focused on validating tools to predict maternal outcomes regarding clinical and biochemical features from the maternal compartment. However, preeclampsia also leads to neonatal complications due to placental insufficiency and prematurity, being the early-onset type associated with the poorest outcome. Hence, it is imperative to study whether these existing tools can predict adverse neonatal outcome. OBJECTIVE To assess the predictive value for adverse neonatal outcome of Doppler ultrasound, angiogenic factors and multi-parametric risk-score models in women with early-onset severe preeclampsia. STUDY DESIGN This is a prospective cohort study of consecutive singleton pregnancies complicated by early-onset (developed before 34 week's gestation) severe preeclampsia. RESULTS 63 women with early-onset severe preeclampsia, 18 (28.6%) presented an adverse neonatal outcome. Placental growth factor (PlGF) showed the best discrimination between neonatal outcomes among angiogenic factors. PREP-L score is a multi-parametric risk-score for the prediction of complications in early-onset preeclampsia which includes maternal characteristics and clinical and analytical data obtained at admission. Good predictive values for the prediction of neonatal complications were found with the combination of PREP-L score with advanced Doppler (AUC ROC 0.9 95% CI 0.82-0.98]) and with PlGF levels (AUC ROC 0.91 [95% CI 0.84-0.98]). CONCLUSIONS The combination of maternal risk scoring (PREP-L score) with angiogenic factors or fetal Doppler ultrasound at the time of diagnosis of early-onset preeclampsia with severe features performs well in predicting adverse neonatal outcome.
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Affiliation(s)
- Anna Peguero
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Lorena Fernandez-Blanco
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Edurne Mazarico
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Leticia Benitez
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Alba Gonzalez
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - David Boada
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Cristina Borràs
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Lina Youssef
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Fàtima Crispi
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain
| | - Sandra Hernandez
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Francesc Figueras
- BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetrícia i Neonatologia BCNatal Fetal Medicine Research Center, IDIBAPS, Universitat de Barcelona, Barcelona, Spain.
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Ali S, Heuving S, Kawooya MG, Byamugisha J, Grobbee DE, Papageorghiou AT, Klipstein-Grobusch K, Rijken MJ. Prognostic accuracy of antenatal Doppler ultrasound for adverse perinatal outcomes in low-income and middle-income countries: a systematic review. BMJ Open 2021; 11:e049799. [PMID: 34857564 PMCID: PMC8640672 DOI: 10.1136/bmjopen-2021-049799] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES This systematic review examined available literature on the prognostic accuracy of Doppler ultrasound for adverse perinatal outcomes in low/middle-income countries (LMIC). DESIGN We searched PubMed, Embase, Cochrane Library and Scopus from inception to April 2020. SETTING Observational or interventional studies from LMICs. PARTICIPANTS Singleton pregnancies of any risk profile. INTERVENTIONS Umbilical artery (UA), middle cerebral artery (MCA), cerebroplacental ratio (CPR), uterine artery (UtA), fetal descending aorta (FDA), ductus venosus, umbilical vein and inferior vena cava. PRIMARY AND SECONDARY OUTCOME MEASURES Perinatal death, stillbirth, neonatal death, expedited delivery for fetal distress, meconium-stained amniotic fluid, low birth weight, fetal growth restriction, admission to neonatal intensive care unit, neonatal acidosis, Apgar scores, preterm birth, fetal anaemia, respiratory distress syndrome, length of hospital stay, birth asphyxia and composite adverse perinatal outcomes (CAPO). RESULTS We identified 2825 records, and 30 (including 4977 women) from Africa (40.0%, n=12), Asia (56.7%, n=17) and South America (3.3%, n=01) were included. Many individual studies reported associations and promising predictive values of UA Doppler for various adverse perinatal outcomes mostly in high-risk pregnancies, and moderate to high predictive values of MCA, CPR and UtA Dopplers for CAPO. A few studies suggested that the MCA and FDA may be potent predictors of fetal anaemia. No randomised clinical trial (RCT) was found. Most studies were of suboptimal quality, poorly powered and characterised by wide variations in outcome classifications, the timing for the Doppler tests and study populations. CONCLUSION Local evidence to guide how antenatal Doppler ultrasound should be used in LMIC is lacking. Well-designed studies, preferably RCTs, are required. Standardisation of practice and classification of perinatal outcomes across countries, following the international standards, is imperative. PROSPERO REGISTRATION NUMBER CRD42019128546.
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Affiliation(s)
- Sam Ali
- Ernest Cook Ultrasound Research and Education Institute (ECUREI), Kampala, Uganda
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Simelina Heuving
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Michael G Kawooya
- Ernest Cook Ultrasound Research and Education Institute (ECUREI), Kampala, Uganda
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Diederick E Grobbee
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Aris T Papageorghiou
- Nuffield Department of Women's & Reproductive Health, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Marcus J Rijken
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
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Zytoon AA, Abd Ellatif HAE, Yousef DN. Ultrasound angiology reference standards of fetal cerebroplacental flow in normal Egyptian gestation: statistical analysis of one thousand observations. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2019. [DOI: 10.1186/s43055-019-0115-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Graupner O, Karge A, Flechsenhar S, Seiler A, Haller B, Ortiz JU, Lobmaier SM, Axt-Fliedner R, Enzensberger C, Abel K, Kuschel B. Role of sFlt-1/PlGF ratio and feto-maternal Doppler for the prediction of adverse perinatal outcome in late-onset pre-eclampsia. Arch Gynecol Obstet 2019; 301:375-385. [PMID: 31734756 DOI: 10.1007/s00404-019-05365-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 10/30/2019] [Indexed: 11/27/2022]
Abstract
PURPOSE The sFlt-1 (soluble fms-like tyrosine kinase-1)/PlGF (placental growth factor) ratio and uterine artery Doppler have shown to be helpful in the diagnosis of pre-eclampsia (PE). The predictive value of the cerebroplacental ratio (CPR) regarding adverse perinatal outcome (APO) in low-risk pregnancies is intensively discussed. We evaluated the extent to which sFlt-1/PlGF ratio and feto-maternal Doppler may be useful in predicting APO in singleton pregnancies complicated by late-onset PE and/or HELLP syndrome. METHODS This is a retrospective study from 2010 to 2018 consisting of singleton pregnancies with confirmed diagnosis of late-onset (lo ≥ 34 weeks) PE/HELLP syndrome in which sFlt-1/PlGF ratio and feto-maternal Doppler (mUtA-PI: mean uterine artery pulsatility index and CPR) were determined. The ability of sFlt-1/PlGF ratio, mUtA-PI, CPR and their combination to predict APO or SGA was evaluated using receiver operating characteristic (ROC) curves. RESULTS 67 patients were included in the final analysis. Of these, sFlt-1/PlGF was > 110 (defining angiogenic lo PE) in 40.3% (27/67), mUtA-PI was above the 95th centile in 34.3% (23/67) patients and CPR was lower than the 5th centile in 10.4% (7/67). Abnormal sFlt-1/PlGF and mUtA-PI as well as CPR were associated with a lower birth weight (BW). Late-preterm birth (< 37 weeks) as well as postnatal diagnosis of small for gestational age (SGA: BW < 3rd centile) was significantly more often in angiogenic lo PE cases. Neither sFlt-1/PIGF nor CPR or mUtA-PI were APO predictors. Only for sFlt-1/PlGF, ROC analysis revealed a significant predictive value for postnatal SGA (AUC = 0.856, p = 0.001, 95% CI 0.75-0.97). There was no statistical added value of combined SGA predictors as compared to sFlt-1/PlGF alone. CONCLUSIONS In patients with lo PE, adding sFlt-1/PlGF ratio to routine antepartum fetal surveillance may be useful to identify cases of postnatal SGA. However, further prospective studies are warranted to define the role of feto-maternal Doppler and sFlt-1/PlGF ratio as outcome predictors.
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Affiliation(s)
- Oliver Graupner
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Anne Karge
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Sarah Flechsenhar
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Alina Seiler
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bernhard Haller
- Institute for Medical Informatics, Statistics and Epidemiology (IMedIS), University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Javier U Ortiz
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Silvia M Lobmaier
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Roland Axt-Fliedner
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Christian Enzensberger
- Department of Obstetrics and Gynecology, Division of Prenatal Medicine, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Kathrin Abel
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bettina Kuschel
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
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