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Kumar M, Balyan K, Debnath E, Humtsoe B, Meena B, Ravi V, Singh S. Placental biophysical model for prediction of early onset fetal growth restriction in first and second trimester of pregnancy: A prospective cohort study. Placenta 2024; 154:153-159. [PMID: 39013215 DOI: 10.1016/j.placenta.2024.07.003] [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] [Received: 08/10/2023] [Revised: 02/26/2024] [Accepted: 07/02/2024] [Indexed: 07/18/2024]
Abstract
INTRODUCTION To assess the placental biometry, placental biomarkers and uterine artery Doppler in each trimester of pregnancy for prediction of early-onset fetal growth restriction (EO FGR). METHODS In this prospective cohort study placental biometry; biomarkers PAPP-A, sFLT-1, and PlGF along with the uterine artery blood flow evaluation was done serially at 11-14, 20-24 and 28-32 weeks of gestation. The above parameters were compared between women with early onset FGR and controls. RESULTS Out of 1008 fully followed cases, the small for gestational age fetuses were 227/1008 (22.5 %), and EO FGR were 84/1008(8.3 %).The placental length, volume, and PlGF levels were significantly lower, whereas the uterine artery PI(Ut PI) was significantly higher at all time points among cases. The sFLT-1 level showed a significant increase among cases, whereas it decreased among controls from the first to the second trimester. The detection rate using PV/UtA PI was 60 % in the first trimester and 66.7 % in the second trimester at 30 % FPR. CONCLUSION The PV/Ut PI in first and the second trimester was a good marker for the prediction of pregnancies at increased risk of developing EO FGR.
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Affiliation(s)
- Manisha Kumar
- Department of Obstetrics and Gynecology, LHMC, New Delhi, India.
| | - Kirti Balyan
- Department of Obstetrics and Gynecology, LHMC, New Delhi, India
| | - Ekta Debnath
- Department of Biochemistry, MAMC, New Delhi, India
| | - Ben Humtsoe
- Department of Obstetrics and Gynecology, LHMC, New Delhi, India
| | - Bhawana Meena
- Department of Obstetrics and Gynecology, LHMC, New Delhi, India
| | - V Ravi
- Department of Statistics, Lady Sri Ram College, New Delhi, India
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Melamed N, Okun N, Huang T, Mei-Dan E, Aviram A, Allen M, Abdulaziz KE, McDonald SD, Murray-Davis B, Ray JG, Barrett J, Kingdom J, Berger H. Maternal First-Trimester Alpha-Fetoprotein and Placenta-Mediated Pregnancy Complications. Hypertension 2023; 80:2415-2424. [PMID: 37671572 DOI: 10.1161/hypertensionaha.123.21568] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/17/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Maternal serum markers used for trisomy 21 screening are associated with placenta-mediated complications. Recently, there has been a transition from the traditional first-trimester screening (FTS) that included PAPP-A (pregnancy-associated plasma protein-A) and beta-hCG (human chorionic gonadotropin), to the enhanced FTS test, which added first-trimester AFP (alpha-fetoprotein) and PlGF (placental growth factor). However, whether elevated first-trimester AFP has a similar association with placenta-mediated complications to that observed for elevated second-trimester AFP remains unclear. Our objective was to estimate the association of first-trimester AFP with placenta-mediated complications and compare it with the corresponding associations of second-trimester AFP and other first-trimester serum markers. METHODS Retrospective population-based cohort study of women who underwent trisomy 21 screening in Ontario, Canada (2013-2019). The association of first-trimester AFP with placenta-mediated complications was estimated and compared with that of the traditional serum markers. The primary outcome was a composite of stillbirth or preterm placental complications (preeclampsia, birthweight less than third centile, or placental abruption). RESULTS A total of 244 990 and 96 167 women underwent FTS and enhanced FTS test screening, respectively. All markers were associated with the primary outcome, but the association for elevated first-trimester AFP (adjusted relative risk [aRR], 1.57 [95% CI, 1.37-1.81]) was weaker than that observed for low PAPP-A (aRR, 2.48 [95% CI, 2.2-2.8]), low PlGF (aRR, 2.28 [95% CI, 1.97-2.64]), and elevated second-trimester AFP (aRR, 1.97 [95% CI, 1.81-2.15]). When the models were adjusted for all 4 enhanced FTS test markers, elevated first-trimester AFP was no longer associated with the primary outcome (aRR, 0.77 [95% CI, 0.58-1.02]). CONCLUSIONS Unlike second-trimester AFP, elevated first-trimester AFP is not an independent risk factor for placenta-mediated complications.
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Affiliation(s)
- Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre (N.M., N.O., A.A.), University of Toronto, Toronto, Ontario, Canada
| | - Nanette Okun
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre (N.M., N.O., A.A.), University of Toronto, Toronto, Ontario, Canada
| | - Tianhua Huang
- Department of Genetics, North York General Hospital, Toronto, Ontario, Canada (T.H.)
- Better Outcomes Registry & Network (BORN) Ontario, Canada (T.H., M.A., K.E.A.)
| | - Elad Mei-Dan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North York General Hospital (E.M.-D.), University of Toronto, Toronto, Ontario, Canada
| | - Amir Aviram
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre (N.M., N.O., A.A.), University of Toronto, Toronto, Ontario, Canada
| | - Melinda Allen
- Better Outcomes Registry & Network (BORN) Ontario, Canada (T.H., M.A., K.E.A.)
| | - Kasim E Abdulaziz
- Better Outcomes Registry & Network (BORN) Ontario, Canada (T.H., M.A., K.E.A.)
| | - Sarah D McDonald
- Division of Maternal-Fetal Medicine, Departments of Obstetrics and Gynecology, Radiology, and Research Methods, Evidence & Impact (S.D.M., B.M.-D.), McMaster University, Hamilton, Ontario, Canada
| | - Beth Murray-Davis
- Division of Maternal-Fetal Medicine, Departments of Obstetrics and Gynecology, Radiology, and Research Methods, Evidence & Impact (S.D.M., B.M.-D.), McMaster University, Hamilton, Ontario, Canada
| | - Joel G Ray
- Departments of Medicine and Obstetrics and Gynaecology, St. Michael's Hospital (J.G.R.), University of Toronto, Toronto, Ontario, Canada
| | - Jon Barrett
- Departments of Obstetrics and Gynecology (J.B.), McMaster University, Hamilton, Ontario, Canada
| | - John Kingdom
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital (J.K.), University of Toronto, Toronto, Ontario, Canada
| | - Howard Berger
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, St. Michael's Hospital (H.B.), University of Toronto, Toronto, Ontario, Canada
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Contribution of Second Trimester Sonographic Placental Morphology to Uterine Artery Doppler in the Prediction of Placenta-Mediated Pregnancy Complications. J Clin Med 2022; 11:jcm11226759. [PMID: 36431236 PMCID: PMC9697802 DOI: 10.3390/jcm11226759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/27/2022] [Accepted: 11/03/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Second-trimester uterine artery Doppler is a well-established tool for the prediction of preeclampsia and fetal growth restriction. At delivery, placentas from affected pregnancies may have gross pathologic findings. Some of these features are detectable by ultrasound, but the relative importance of placental morphologic assessment and uterine artery Doppler in mid-pregnancy is presently unclear. Objective: To characterize the association of second-trimester sonographic placental morphology markers with placenta-mediated complications and determine whether these markers are predictive of placental dysfunction independent of uterine artery Doppler. Methods: This was a retrospective cohort study of patients with a singleton pregnancy at high risk of placental complications who underwent a sonographic placental study at mid-gestation (160/7−246/7 weeks’ gestation) in a single tertiary referral center between 2016−2019. The sonographic placental study included assessment of placental dimensions (length, width, and thickness), placental texture appearance, umbilical cord anatomy, and uterine artery Doppler (mean pulsatility index and early diastolic notching). Placental area and volume were calculated based on placental length, width, and thickness. Continuous placental markers were converted to multiples on medians (MoM). The primary outcome was a composite of early-onset preeclampsia and birthweight < 3rd centile. Results: A total of 429 eligible patients were identified during the study period, of whom 45 (10.5%) experienced the primary outcome. The rate of the primary outcome increased progressively with decreasing placental length, width, and area, and increased progressively with increasing mean uterine artery pulsatility index (PI). By contrast, placental thickness followed a U-shaped relationship with the primary outcome. Placental length, width, and area, mean uterine artery PI and bilateral uterine artery notching were all associated with the primary outcome. However, in the adjusted analysis, the association persisted only for placenta area (adjusted odds ratio [aOR] 0.21, 95%-confidence interval [CI] 0.06−0.73) and mean uterine artery PI (aOR 11.71, 95%-CI 3.84−35.72). The area under the ROC curve was highest for mean uterine artery PI (0.80, 95%-CI 0.71−0.89) and was significantly higher than that of placental area (0.67, 95%-CI 0.57−0.76, p = 0.44). A model that included both mean uterine artery PI and placental area did not significantly increase the area under the curve (0.82, 95%-CI 0.74−0.90, p = 0.255), and was associated with a relatively minor increase in specificity for the primary outcome compared with mean uterine artery PI alone (63% [95%-CI 58−68%] vs. 52% [95%-CI 47−57%]). Conclusion: Placental area is independently associated with the risk of placenta-mediated complications yet, when combined with uterine artery Doppler, did not further improve the prediction of such complications compared with uterine artery Doppler alone.
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Ozdemir S, Sahin O, Acar Z, Demir GZ, Ermin E, Aydin A. Prediction of Pregnancy Complications With Maternal Biochemical Markers Used in Down Syndrome Screening. Cureus 2022; 14:e23115. [PMID: 35425672 PMCID: PMC9003626 DOI: 10.7759/cureus.23115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 11/05/2022] Open
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Hu JL, Zhang YJ, Zhang JM, Zhu S, Li DM, Yin YF, Su J, Chan Y, He J, Cao YJ, Zhu BS. Pregnancy outcomes of women with elevated second-trimester maternal serum alpha-fetoprotein. Taiwan J Obstet Gynecol 2020; 59:73-78. [PMID: 32039804 DOI: 10.1016/j.tjog.2019.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2019] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE The aim of this study was to investigate the overall distribution of pregnancy outcomes in women with elevated second-trimester maternal serum alpha-fetoprotein (MS-AFP), and to determine the risk of adverse pregnancy outcomes (APOs) by MS-AFP level. MATERIALS AND METHODS We retrospectively analyzed the clinical data of 429 women with elevated MS-AFP (≥2.5 multiple of the median (MOM)) and 1555 women with normal MS-AFP (0.5-2.49MOM) from a total of 46,741 prenatally screened singleton pregnant women. The overall distribution of APOs of the two groups, the risk of APOs by MS-AFP level, and the predictive value of elevated MS-AFP to APOs were analyzed. RESULTS The incidence rate of APOs in elevated MS-AFP group was significantly higher than that in normal MS-AFP group (42.89 vs. 8.23%). In elevated MS-AFP group, the top three APOs, in term of incidence rate, were structural fetal abnormalities (7.93%), spontaneous abortion (7.46%) and preterm birth (7.23%); regarding to the risk, the top three APOs were stillbirth, spontaneous abortion and early-onset preeclampsia (odds ratio 35.98, 20.81 and 8.58 respectively). For structural fetal abnormalities, MS-AFP had predictive values for fetal open neural tube defects (ONTDs), gastroschisis and multiple malformations. CONCLUSION Elevated MS-AFP is associated with increased risks of APOs. ONTDs complicate merely a small proportion of pregnancies with elevated MS-AFP, and the rest of them have high risks of obstetric complications. MS-AFP can help to identify these women at high risk of APOs in earlier second-trimester.
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Affiliation(s)
- Ji-Lin Hu
- Faculty of Environmental Science and Engineering, Kunming University of Science and Technology, Kunming 650500, Yunnan, PR China; Medical School, Kunming University of Science and Technology, Kunming 650500, Yunnan, PR China
| | - Yang-Jia Zhang
- National Health Commission's Key Laboratory for Healthy Births in Western China, Department of Obstetrics and Gynecology, First People's Hospital of Yunnan Province, Kunming 650032, Yunnan, PR China
| | - Jin-Man Zhang
- Faculty of Environmental Science and Engineering, Kunming University of Science and Technology, Kunming 650500, Yunnan, PR China; National Health Commission's Key Laboratory for Healthy Births in Western China, Department of Obstetrics and Gynecology, First People's Hospital of Yunnan Province, Kunming 650032, Yunnan, PR China
| | - Shu Zhu
- National Health Commission's Key Laboratory for Healthy Births in Western China, Department of Obstetrics and Gynecology, First People's Hospital of Yunnan Province, Kunming 650032, Yunnan, PR China
| | - Dong-Mei Li
- National Health Commission's Key Laboratory for Healthy Births in Western China, Department of Obstetrics and Gynecology, First People's Hospital of Yunnan Province, Kunming 650032, Yunnan, PR China
| | - Yi-Fei Yin
- National Health Commission's Key Laboratory for Healthy Births in Western China, Department of Obstetrics and Gynecology, First People's Hospital of Yunnan Province, Kunming 650032, Yunnan, PR China
| | - Jie Su
- National Health Commission's Key Laboratory for Healthy Births in Western China, Department of Obstetrics and Gynecology, First People's Hospital of Yunnan Province, Kunming 650032, Yunnan, PR China
| | - Ying Chan
- National Health Commission's Key Laboratory for Healthy Births in Western China, Department of Obstetrics and Gynecology, First People's Hospital of Yunnan Province, Kunming 650032, Yunnan, PR China
| | - Jing He
- National Health Commission's Key Laboratory for Healthy Births in Western China, Department of Obstetrics and Gynecology, First People's Hospital of Yunnan Province, Kunming 650032, Yunnan, PR China
| | - Yong-Jiu Cao
- National Health Commission's Key Laboratory for Healthy Births in Western China, Department of Obstetrics and Gynecology, First People's Hospital of Yunnan Province, Kunming 650032, Yunnan, PR China
| | - Bao-Sheng Zhu
- Medical School, Kunming University of Science and Technology, Kunming 650500, Yunnan, PR China; National Health Commission's Key Laboratory for Healthy Births in Western China, Department of Obstetrics and Gynecology, First People's Hospital of Yunnan Province, Kunming 650032, Yunnan, PR China.
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Hu J, Zhang J, Chan Y, Zhu B. A rat model of placental inflammation explains the unexplained elevated maternal serum alpha-fetoprotein associated with adverse pregnancy outcomes. J Obstet Gynaecol Res 2019; 45:1980-1988. [PMID: 31381236 DOI: 10.1111/jog.14085] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 07/13/2019] [Indexed: 01/09/2023]
Abstract
AIM It has been reported in numerous studies that elevated maternal serum alpha-fetoprotein (MS-AFP) is associated with adverse pregnancy outcomes (APO), such as pre-eclampsia, stillbirth, preterm birth and fetal growth restriction. However, the mechanism linking elevated MS-AFP and APO is obscure. In this study, we tried to explore the mechanism by using pregnant rats. METHODS Lipopolysaccharide (LPS) was used to induce placental inflammation in pregnant rats. Maternal serum and placental inflammatory cytokines and placental morphology were used to assess the level of placental inflammation. The incidences of APO and the levels of MS-AFP were evaluated. The expressions of alpha-fetoprotein (AFP) in the related organs and fetal serum AFP levels were detected. RESULTS Compared to saline-treated pregnant rats, LPS led to elevated maternal serum and placental inflammatory cytokines and a higher rate of placental inflammation. Lipopolysaccharide resulted in the features of APO and at the same time elevated MS-AFP. Maternal serum alpha-fetoprotein levels were significantly correlated to the evaluation parameters of APO. Lipopolysaccharide did not increase the expressions of AFP in fetal liver, maternal liver and placenta, but reduced the fetal serum AFP levels. CONCLUSION The phenomenon that elevated MS-AFP is associated with APO, which has been reported in human pregnancies, is observed in our rat model. Placental inflammation can be the potential cause linking the two manifestations together. Although the source of elevated MS-AFP is not identified, fetal blood circulation is suspected. Our study may provide an animal model for the future studies on this subject.
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Affiliation(s)
- Jilin Hu
- Faculty of Environmental Science and Engineering, Kunming University of Science and Technology, Kunming, China.,Medical School, Kunming University of Science and Technology, Kunming, China
| | - Jinman Zhang
- Medical School, Kunming University of Science and Technology, Kunming, China.,National Health Commission's Key Laboratory for Healthy Births in Western China, Department of Obstetrics and Gynecology, First People's Hospital of Yunnan Province, Kunming, China
| | - Ying Chan
- National Health Commission's Key Laboratory for Healthy Births in Western China, Department of Obstetrics and Gynecology, First People's Hospital of Yunnan Province, Kunming, China
| | - Baosheng Zhu
- Medical School, Kunming University of Science and Technology, Kunming, China.,National Health Commission's Key Laboratory for Healthy Births in Western China, Department of Obstetrics and Gynecology, First People's Hospital of Yunnan Province, Kunming, China
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Higgins LE, Myers JE, Sibley CP, Johnstone ED, Heazell AEP. Antenatal placental assessment in the prediction of adverse pregnancy outcome after reduced fetal movement. PLoS One 2018; 13:e0206533. [PMID: 30395584 PMCID: PMC6218043 DOI: 10.1371/journal.pone.0206533] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 10/15/2018] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To assess the value of in utero placental assessment in predicting adverse pregnancy outcome after reported reduced fetal movements (RFM). METHOD A non-interventional prospective cohort study of women (N = 300) with subjective RFM at ≥28 weeks' gestation in singleton non-anomalous pregnancies at a UK tertiary maternity hospital. Clinical, sonographic (fetal weight, placental size and maternal, fetal and placental arterial Doppler) and biochemical (maternal serum hCG, hPL, progesterone, PlGF and sFlt-1) assessment was conducted. Multiple logistic regression identified combinations of measurements (models) most predictive of adverse pregnancy outcome (perinatal mortality, birth weight <10th centile, five minute Apgar score <7, umbilical arterial pH <7.1 or base excess <-10, neonatal intensive care admission). Models were compared by test performance characteristics (ROC curve, sensitivity, specificity, positive/negative predictive value, positive/negative likelihood ratios) against baseline care (estimated fetal weight centile, amniotic fluid index and gestation at presentation). RESULTS 61 (20.6%) pregnancies ended in adverse outcome. Models incorporating PlGF/sFlt-1 ratio and umbilical artery free loop Doppler impedance demonstrated modest improvement in ROC area for adverse outcome (baseline care 0.69 vs. proposed models 0.73-0.76, p<0.05). However, there was little improvement in other test characteristics (baseline vs. best proposed model: sensitivity 21.7% [95% confidence interval 13.1-33.6] vs. 35.8%% [24.4-49.3], specificity 96.6% [93.4-98.3] vs. 94.7% [90.7-97.0], PPV 61.9% [40.9-79.3] vs. 63.3% [45.5-78.1], NPV 82.8% [77.9-86.8] vs. 85.2% [80.0-89.2], positive LR 6.3 [2.8-14.6] vs. 6.7 [3.4-3.3], negative LR 0.81 [0.71-0.93] vs. 0.68 [0.55-0.83]) and wide confidence intervals. Negative post-test probability remained high (16.7% vs. 14.0%). CONCLUSION Antenatal placental assessment may improve identification of RFM pregnancies at highest risk of adverse pregnancy outcome but further work is required to understand and refine currently available outcome definitions and diagnostic techniques to improve clinical utility.
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Affiliation(s)
- Lucy E. Higgins
- Maternal and Fetal Health Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Jenny E. Myers
- Maternal and Fetal Health Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Colin P. Sibley
- Maternal and Fetal Health Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Edward D. Johnstone
- Maternal and Fetal Health Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Alexander E. P. Heazell
- Maternal and Fetal Health Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
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McLaughlin K, Wright SP, Kingdom JC, Parker JD. Clinical Validation of Non-Invasive Cardiac Output Monitoring in Healthy Pregnant Women. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:1008-1014. [DOI: 10.1016/j.jogc.2017.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/06/2017] [Accepted: 02/06/2017] [Indexed: 01/30/2023]
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Third trimester placental volume and biometry measurement: A method-development study. Placenta 2016; 42:51-8. [DOI: 10.1016/j.placenta.2016.04.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Revised: 03/14/2016] [Accepted: 04/07/2016] [Indexed: 11/22/2022]
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Mesdaghi-nia E, Behrashi M, Saeidi A, Abedzadeh Kalahroodi M. Association between PAPP-A and placental thickness. Int J Reprod Biomed 2016. [DOI: 10.29252/ijrm.14.6.421] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Introduction of a nomogram for predicting adverse pregnancy outcomes based on maternal serum markers in the quad screen test. Arch Gynecol Obstet 2015; 292:589-94. [PMID: 25773358 DOI: 10.1007/s00404-015-3685-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 03/05/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of this study was to develop a nomogram that can calculate a total score, derived from each serum marker in the quad screen test, for systematically predicting adverse pregnancy outcomes (APOs). METHODS We retrospectively reviewed 3684 singleton pregnant women who underwent a quad screen test and gave birth at a single medical centre from January 2005 to December 2010. The serum marker data from the quad screen test and pregnancy outcomes were used to construct logistic regression models for predicting the risks of APOs. APO was defined as the presence of at least one of the following: preeclampsia, preterm delivery before 34 weeks of gestation, small for gestational age, foetal loss, and foetal demise. A graphic nomogram was generated to represent the scoring model using the regression coefficient of each serum marker. RESULTS A nomogram for the prediction of APOs using each serum marker in the quad test was developed based on the logistic regression analysis. The positive predictive values for the subsequent development of an APO were ascended stepwise as the calculated score increases. The area under the receiver operating characteristic curve of this score for the prediction of APO was 0.596 (95 % confidence interval 0.569-0.623). CONCLUSIONS We here introduced a nomogram for stratifying the risk of APOs in patients with abnormal serum markers in the quad screen test. Although the validity of the nomogram is too weak to be used in clinical routine, but it may provide additional information for practitioners counselling pregnant women and for predicting APOs.
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Tancrède S, Bujold E, Giguère Y, Renald MH, Girouard J, Forest JC. Mid-Trimester Maternal Serum AFP and hCG as Markers of Preterm and Term Adverse Pregnancy Outcomes. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2015; 37:111-6. [DOI: 10.1016/s1701-2163(15)30331-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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First-trimester placental ultrasound and maternal serum markers as predictors of small-for-gestational-age infants. Am J Obstet Gynecol 2014; 211:253.e1-8. [PMID: 24607753 DOI: 10.1016/j.ajog.2014.02.033] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 02/26/2014] [Accepted: 02/28/2014] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The objective of the study was to combine early, direct assessment of the placenta with indirect markers of placental development to identify pregnancies at greatest risk of delivering small-for-gestational age infants (SGA10). STUDY DESIGN We prospectively collected 3-dimensional ultrasound volume sets, uterine artery pulsatility index, and maternal serum of singleton pregnancies at 11-14 weeks. Placental volume (PV), quotient (placental quotient [PQ] = PV/gestational age), mean placental diameter (MPD) and chorionic diameters, and the placental morphology index (PMI = MPD/PQ and adjusts the lateral placental dimensions for quotient) were measured offline. Maternal serum was assayed for placental growth factor and placental protein-13. These variables were evaluated as predictors of SGA10. RESULTS Of the 578 pregnancies included in the study, 56 (9.7%) delivered SGA10. SGA10 pregnancies had a significantly smaller PV, PQ, MPD, and mean placental diameter and higher PMI compared with normal pregnancies (P < .001 for each). Each placental measure remained significantly associated with SGA10 after adjusting for confounders and significantly improved the performance of the model using clinical variables alone (P < .04 for each) with adjusted areas under the curve ranging from 0.71 to 0.74. Uterine artery pulsatility index did not remain significantly associated with SGA10 after adjusting for confounders (P = .06). Placental growth factor was significantly lower in SGA10 pregnancies (P = .02) and remained significant in adjusted models but failed to significantly improve the predictive performance of the models as measured by area under the curve (P > .3). Placental protein-13 was not associated with SGA10 (P = .99). CONCLUSION Direct assessment of placental size and shape with 3-dimensional ultrasound can serve as the foundation upon which to build a multivariable model for the early prediction of SGA.
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Abstract
Reduced fetal movement (RFM) is commonly defined as any reduction in maternal perception of fetal activity. Perceived fetal activity may be movement of limbs, trunk or head movement, but excludes fetal hiccoughs (as this is involuntary movement). The perception of fetal movement by an expectant mother is the first, and ongoing, non-sonographic indicator of fetal viability. The “normal” pattern of fetal movements varies from pregnancy to pregnancy, and often does not become established until 28 weeks’ gestation. Many babies have particularly active periods of the day, usually corresponding to periods of maternal rest and inactivity (which may in itself reflect increased maternal awareness of fetal movement). A variable percentage of sonographically observed fetal movements are perceived by prospective mothers (commonly 30–40%, although some studies report rates as high as 80%).
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Retard de croissance intra-utérin : Dépistage, diagnostic et prise en charge. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2013. [DOI: 10.1016/s1701-2163(15)30866-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Lausman A, Kingdom J. Intrauterine growth restriction: screening, diagnosis, and management. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2013; 35:741-748. [PMID: 24007710 DOI: 10.1016/s1701-2163(15)30865-3] [Citation(s) in RCA: 192] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Intrauterine growth restriction (IUGR) is an obstetrical complication, which by definition would screen in 10% of fetuses in the general population. The challenge is to identify the subset of pregnancies affected with pathological growth restriction in order to allow intervention that would decrease morbidity and mortality. OBJECTIVE The purpose of this guideline is to provide summary statements and recommendations and to establish a framework for screening, diagnosis, and management of pregnancies affected with IUGR. METHODS Affected pregnancies are compared with pregnancies in which the fetus is at an appropriate weight for its gestational age. History, physical examination, and laboratory investigations including biochemical markers and ultrasound characteristics of IUGR are reviewed, and a management strategy is suggested. EVIDENCE Published literature in English was retrieved through searches of PubMed or MEDLINE, CINAHL, and The Cochrane Library in January 2013 using appropriate controlled vocabulary via MeSH terms (fetal growth restriction and small for gestational age) and key words (fetal growth, restriction, growth retardation, IUGR, low birth weight, small for gestational age). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). BENEFITS, HARMS, AND COSTS Implementation of the recommendations in this guideline should increase clinician recognition of IUGR and guide intervention where appropriate. Optimal long-term follow-up of neonates diagnosed as IUGR may improve their long-term health.
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Alanjari A, Wright E, Keating S, Ryan G, Kingdom J. Prenatal diagnosis, clinical outcomes, and associated pathology in pregnancies complicated by massive subchorionic thrombohematoma (Breus' mole). Prenat Diagn 2013; 33:973-8. [DOI: 10.1002/pd.4176] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 05/21/2013] [Accepted: 05/31/2013] [Indexed: 11/07/2022]
Affiliation(s)
- Abdulmohsen Alanjari
- Fetal Medicine Unit; Mount Sinai Hospital, University of Toronto; Ontario Canada
| | - Emily Wright
- Fetal Medicine Unit; Mount Sinai Hospital, University of Toronto; Ontario Canada
| | - Sarah Keating
- Department of Obstetrics and Gynaecology; Mount Sinai Hospital, University of Toronto; Ontario Canada
- Department of Pathology and Laboratory Medicine; Mount Sinai Hospital, University of Toronto; Ontario Canada
| | - Greg Ryan
- Fetal Medicine Unit; Mount Sinai Hospital, University of Toronto; Ontario Canada
| | - John Kingdom
- Fetal Medicine Unit; Mount Sinai Hospital, University of Toronto; Ontario Canada
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Collins SL, Stevenson GN, Noble JA, Impey L. Elsevier Trophoblast Research Award Lecture: Searching for an early pregnancy 3-D morphometric ultrasound marker to predict fetal growth restriction. Placenta 2013; 34 Suppl:S85-9. [PMID: 23306068 DOI: 10.1016/j.placenta.2012.11.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Revised: 11/28/2012] [Accepted: 11/29/2012] [Indexed: 10/27/2022]
Abstract
Fetal growth restriction (FGR) is a major cause of perinatal morbidity and mortality, even in term babies. An effective screening test to identify pregnancies at risk of FGR, leading to increased antenatal surveillance with timely delivery, could decrease perinatal mortality and morbidity. Placental volume, measured with commercially available packages and a novel, semi-automated technique, has been shown to predict small for gestational age babies. Placental morphology measured in 2-D in the second trimester and ex-vivo post delivery, correlates with FGR. This has also been investigated using 2-D estimates of diameter and site of cord insertion obtained using the Virtual Organ Computer-aided AnaLysis (VOCAL) software. Data is presented describing a pilot study of a novel 3-D method for defining compactness of placental shape. We prospectively recruited women with a singleton pregnancy and BMI of <35. A 3-D ultrasound scan was performed between 11 and 13 + 6 weeks' gestation. The placental volume, total placental surface area and the area of the utero-placental interface were calculated using our validated technique. From these we generated dimensionless indices including sphericity (ψ), standardised placental volume (sPlaV) and standardised functional area (sFA) using Buckingham π theorem. The marker for FGR used was small for gestational age, defined as <10th customised birth weight centile (cSGA). Regression analysis examined which of the morphometric indices were independent predictors of cSGA. Data were collected for 143 women, 20 had cSGA babies. Only sPlaV and sFA were significantly correlated to birth weight (p < 0.001). Regression demonstrated all dimensionless indices were inter-dependent co-factors. ROC curves showed no advantage for using sFA over the simpler sPlaV. The generated placental indices are not independent of placental volume this early in gestation. It is hoped that another placental ultrasound marker based on vascularity can improve the prediction of FGR offered by a model based on placental volume.
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Affiliation(s)
- S L Collins
- The Nuffield Dept. of Obstetrics & Gynaecology, University of Oxford, Oxford, UK.
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Androutsopoulos G, Gkogkos P, Decavalas G. Mid-trimester maternal serum HCG and alpha fetal protein levels: clinical significance and prediction of adverse pregnancy outcome. Int J Endocrinol Metab 2013; 11:102-6. [PMID: 23825981 PMCID: PMC3693663 DOI: 10.5812/ijem.5014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 10/02/2012] [Accepted: 10/08/2012] [Indexed: 01/20/2023] Open
Abstract
CONTEXT Maternal serum human Chorionic Gonadotropin (hCG) and Alpha Fetal Protein (AFP) were originally introduced to detect trisomy 21 and neural tube defects. However, in the absence of aneuploidy or neural tube defects, mid-trimester maternal serum hCG and/or maternal serum AFP associated with adverse pregnancy outcomes. Pregnancies with unexplained mid-trimester elevation in maternal serum hCG and/or maternal serum AFP, are at increased risk for pregnancy complications resulting from placental insufficiency. EVIDENCE ACQUISITION Mid-trimester maternal serum hCG>2.5 MoM associated with an increased risk for pregnancy complications including: late fetal loss, gestational hypertension, preeclampsia, intrauterine growth restriction (IUGR), preterm delivery and intrauterine fetal death(IUFD). Mid-trimester maternal serum AFP levels >2.5 MoM are thought to reflect a defect in placentation and associated with an increased risk for pregnancy complications including: late fetal loss, gestational hypertension, preeclampsia, IUGR, preterm delivery and IUFD. RESULTS Combined mid-trimester elevation in maternal serum hCG and AFP levels suggest a more complex type of placental pathology. They have stronger association with pregnancy complications including: late fetal loss, gestational hypertension, preeclampsia, IUGR, preterm delivery and IUFD. CONCLUSIONS Mid-trimester maternal serum hCG or AFP levels alone cannot detect all pregnant women with increased risk to develop pregnancy complications. Multiparameter testing of placental function in mid-trimester (maternal serum hCG and AFP screening, uterine artery Doppler and placental morphology) may allow us to identify women with increased risk to develop severe placental insufficiency and pregnancy complications. However, future prospective studies are needed to confirm the prognostic significance of multiparameter testing of placental function in mid-trimester.
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Affiliation(s)
- Georgios Androutsopoulos
- Department of Obstetrics and Gynaecology, University of Patras, Medical School, Rion, Greece
- Corresponding author: Georgios Androutsopoulos, Nikolaou Apostoli 21, Patra, 26332, Greece, Tel.: +30-2613604010, Fax: +30-6974088092, E-mail:
| | - Panagiotis Gkogkos
- Department of Obstetrics and Gynaecology, University of Patras, Medical School, Rion, Greece
| | - Georgios Decavalas
- Department of Obstetrics and Gynaecology, University of Patras, Medical School, Rion, Greece
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Schwartz N, Wang E, Parry S. Two-dimensional sonographic placental measurements in the prediction of small-for-gestational-age infants. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 40:674-679. [PMID: 22331557 DOI: 10.1002/uog.11136] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/30/2012] [Indexed: 05/31/2023]
Abstract
OBJECTIVES To determine the utility of two-dimensional (2D) sonographic placental measurements in the prediction of small-for-gestational-age (SGA) infants. METHODS The maximal diameter along the fetal surface of the placenta and the maximal placental thickness were measured at 18-24 weeks' gestation, and the measurements repeated in the orthogonal plane. 'Biometric lags' were calculated as the difference between sonographic gestational age, estimated using each of a number of fetal biometric measurements, and actual gestational age. These variables were analyzed individually and in combination as predictors of birth weight<10(th) percentile (SGA<10) and <5(th) percentile (SGA<5). RESULTS 1909 singleton pregnancies were included. Mean placental diameter (SGA<10, P<0.001; SGA<5, P=0.002) and thickness (SGA<10, P<0.006; SGA<5, P=0.065) were significantly smaller in SGA pregnancies. The biometric lags were greater in SGA pregnancies, the lag in abdominal circumference (AC) being the most predictive of SGA (P<0.0001). Multivariable models were significantly predictive of both SGA<10(th) percentile (area under the receiver-operating characteristics curve (AUC) =0.7404) and <5(th) percentile (AUC=0.7204), the best fitting models including AC lag and mean placental diameter and thickness. CONCLUSIONS 2D placental measurements taken in mid-gestation are significantly associated with the incidence of SGA. Biometric lags can improve the predictive ability further. These easily obtained variables should be considered in future efforts to develop a clinically useful predictive model for adverse outcome of pregnancy.
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Affiliation(s)
- N Schwartz
- Obstetrics and Gynecology; Maternal and Child Health Research Program, Hospital of the University of Pennsylvania, Philadelphia 19104, PA, USA. )
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Costantini D, Walker M, Milligan N, Keating S, Kingdom J. Pathologic basis of improving the screening utility of 2-dimensional placental morphology ultrasound. Placenta 2012; 33:845-9. [DOI: 10.1016/j.placenta.2012.07.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 06/22/2012] [Accepted: 07/13/2012] [Indexed: 01/05/2023]
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Abstract
Randomized control trials show beneficial effects of heparin in high-risk pregnancies to prevent preeclampsia and intrauterine growth restriction. However, the lack of placental pathology data in these trials challenges the assumption that heparin is a placental anticoagulant. Recent data show that placental infarction is probably associated with abnormalities in development of the placenta, characterized by poor maternal perfusion and an abnormal villous trophoblast compartment in contact with maternal blood, than with maternal thrombophilia. At-risk pregnancies may therefore be predicted by noninvasive prenatal testing of placental function in mid-pregnancy. Heparin has diverse cellular functions that include direct actions on the trophoblast. Dissecting the non-anticoagulant actions of heparin may indicate novel and safer therapeutic targets to prevent the major placental complications of pregnancy.
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Drewlo S, Czikk M, Baczyk D, Lye S, Kingdom J. Glial cell missing-1 mediates over-expression of tissue inhibitor of metalloproteinase-4 in severe pre-eclamptic placental villi. Hum Reprod 2011; 26:1025-34. [PMID: 21406447 DOI: 10.1093/humrep/der053] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Severe pre-eclampsia (sPE) causes significant maternal morbidity and intrauterine growth restriction as a result of severe placental dysfunction. Defects in the formation of both extra-villous and villous trophoblast are characteristic of this disease. The outer syncytiotrophoblast layer covering the placental villi develops syncytial knots and focal necrosis while reduced invasion of the extra-villous trophoblast results in a reduced maternal blood supply and ischemia of the placental villi. The transcription factor glial cell missing-1 (GCM1) regulates formation of both types of trophoblast. GCM1 expression is reduced in placental villi of women with sPE but the functional downstream consequences of reduced GCM1 expression are unknown. METHODS AND RESULTS In floating first trimester villous explants we demonstrated increased mRNA (2.5-fold, n = 12) and protein level (9.8-fold) of tissue inhibitor of metalloproteinase-4 (TIMP4) following repression of GCM1 (70 ± 7%) by small interfering-RNA, using RT-PCR and western blot, respectively. Similar increases in TIMP4 mRNA (4.2-fold, n = 7, P< 0.001 versus control) and protein levels were found following gene silencing of GCM1 in BeWo cells (<90% knock down of protein). TIMP4 protein was increased in placenta from women with sPE (3.5 ± 0.4 pg/µg, n = 8), compared with preterm (1.7 ± 0.17 pg/µg, n = 9) and term controls (1.6 ± 0.16 pg/µg, n = 9; P< 0.01; quantified by enzyme-linked immunosorbent assay and visualized using immunohistochemistry) with reduced GCM1 expression, mostly in the pathologic syncytial knots. CONCLUSIONS TIMP4 is a downstream target of GCM1 that may link the consequences of reduced GCM-1-directed trophoblast differentiation to histologic and functional components of disordered placentation in sPE.
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Affiliation(s)
- Sascha Drewlo
- Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, ON, Canada.
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Windrim C, Athaide G, Gerster T, Kingdom JC. Sonographic Findings and Clinical Outcomes in Women With Massive Subchorionic Hematoma Detected in the Second Trimester. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2011; 33:475-479. [DOI: 10.1016/s1701-2163(16)34881-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Sonographic Maturation of the Placenta at 30 to 34 Weeks Is Not Associated With Second Trimester Markers of Placental Insufficiency in Low-risk Pregnancies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2010; 32:1134-1139. [DOI: 10.1016/s1701-2163(16)34736-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Huang T, Hoffman B, Meschino W, Kingdom J, Okun N. Prediction of adverse pregnancy outcomes by combinations of first and second trimester biochemistry markers used in the routine prenatal screening of Down syndrome. Prenat Diagn 2010; 30:471-7. [PMID: 20440736 DOI: 10.1002/pd.2505] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To investigate the associations between four defined adverse pregnancy outcomes and levels of first and second trimester maternal serum markers focusing in particular on how well combinations of markers predict these adverse outcomes. METHODS This was a retrospective review of associations between first and second trimester serum markers and adverse pregnancy outcomes among 141 698 women who underwent prenatal screening for Down syndrome in Ontario, Canada. Detection rates (DR), false positive rates (FPR), and odds ratios were estimated using both single and combinations of markers for the adverse outcomes defined. RESULTS Women with decreased second trimester unconjugated oestriol (uE3), deceased first trimester maternal serum pregnancy-associated plasma protein A (PAPP-A), increased second trimester serum alpha fetoprotein (AFP), or increased second trimester total human chorionic gonadotrophin (hCG) were at greater risk of developing adverse pregnancy outcomes. At a 5% FPR, combinations of these markers predicted at best 33.3% of fetal loss and 31.5% of preterm births (PTB) before 32 weeks of gestation. CONCLUSION There are significant associations between the levels of first and second trimester serum markers and adverse obstetric outcomes. However, even combinations of these markers can only predict adverse obstetric outcomes with modest accuracy.
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Affiliation(s)
- Tianhua Huang
- Genetics Program, North York General Hospital, Ontario, Canada.
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HEPARIN IN HUMAN PLACENTAL DEVELOPMENT AND THE PREVENTION OF PLACENTAL COMPLICATIONS OF PREGNANCY. ACTA ACUST UNITED AC 2010. [DOI: 10.1017/s0965539510000070] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The development of effective anticoagulant drugs available for use in pregnancy has resulted in dramatic improvements for a number of potentially life-threatening conditions. These include the treatment and prevention of venous thromboembolism and the thrombotic complications of antiphospholipid antibody syndrome, as well as the management of pregnant women with mechanical heart valves. The most commonly used class of drug includes heparin, a highly-charged macro-molecule that does not cross the placenta, in contrast to the potentially teratogenic and fetotoxic oral drug warfarin. This review will focus on our current lack of understanding of the wider actions of heparin and examines the possibility that large numbers of pregnant women are presently being treated inappropriately with heparin.
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Uxa R, Baczyk D, Kingdom J, Viero S, Casper R, Keating S. Genetic Polymorphisms in the Fibrinolytic System of Placentas with Massive Perivillous Fibrin Deposition. Placenta 2010; 31:499-505. [DOI: 10.1016/j.placenta.2010.03.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Revised: 03/26/2010] [Accepted: 03/30/2010] [Indexed: 10/19/2022]
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Moslehi R, Signore C, Tamura D, Mills JL, Digiovanna JJ, Tucker MA, Troendle J, Ueda T, Boyle J, Khan SG, Oh KS, Goldstein AM, Kraemer KH. Adverse effects of trichothiodystrophy DNA repair and transcription gene disorder on human fetal development. Clin Genet 2010; 77:365-73. [PMID: 20002457 PMCID: PMC3463936 DOI: 10.1111/j.1399-0004.2009.01336.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The effects of DNA repair and transcription gene abnormalities in human pre-natal life have never been studied. Trichothiodystrophy (TTD) is a rare (affected frequency of 10(-6)) recessive disorder caused by mutations in genes involved in nucleotide excision repair (NER) pathway and in transcription. Based on our novel clinical observations, we conducted a genetic epidemiologic study to investigate gestational outcomes associated with TTD. We compared pregnancies resulting in TTD-affected offspring (n = 24) with respect to abnormalities during their antenatal and neonatal periods to pregnancies resulting in their unaffected siblings (n = 18), accounting for correlation, and to population reference values. Significantly higher incidence of several severe gestational complications was noted in TTD-affected pregnancies. Small for gestational age (SGA) <10th percentile [Relative risk (RR ) = 9.3, 95% CI = 1.4-60.5, p = 0.02], SGA <3rd percentile (RR = 7.2, 95% CI = 1.1-48.1, p = 0.04), and neonatal intensive care unit (NICU) hospitalization (RR = 6.4, 95% CI = 1.4-29.5, p = 0.02) occurred more frequently among TTD-affected neonates compared with their unaffected siblings. Compared with reference values from general obstetrical population, pregnancies that resulted in TTD-affected infants were significantly more likely to be complicated by hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome (RR = 35.7, 95% CI = 7.6-92.5, p = 0.0002), elevated mid-trimester maternal serum human chorionic gonadotropin (hCG) levels (RR = 14.3, 95% CI = 7.0-16.6, p < 0.0001), SGA <3rd percentile (RR = 13.9, 95% CI = 7.4-21.1, p < 0.0001), pre-term delivery (<32 weeks) (RR = 12.0, 95% CI = 4.9-21.6, p < 0.0001), pre-eclampsia (RR = 4.0, 95% CI = 1.6-7.4, p = 0.006), and decreased fetal movement (RR = 3.3, 95% CI = 1.6-5.2, p = 0.0018). Abnormal placental development is an underlying mechanism that may explain the constellation of observed complications in our study. Thus, we hypothesize that TTD DNA repair and transcription genes play an important role in normal human placental development.
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Affiliation(s)
- R Moslehi
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA.
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Proctor LK, Toal M, Keating S, Chitayat D, Okun N, Windrim RC, Smith GCS, Kingdom JCP. Placental size and the prediction of severe early-onset intrauterine growth restriction in women with low pregnancy-associated plasma protein-A. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 34:274-282. [PMID: 19672838 DOI: 10.1002/uog.7308] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVES Screening studies for trisomy 21 demonstrate that low maternal serum pregnancy-associated plasma protein-A (PAPP-A) at 11-13 weeks' gestation is associated with stillbirth, intrauterine growth restriction (IUGR) and pre-eclampsia in chromosomally normal fetuses. However, the strength of these associations is too weak to justify screening for these placental insufficiency syndromes. Our objective was to evaluate placental size and uterine artery (UtA) Doppler imaging as second-stage screening tests for women with low PAPP-A. METHODS We prospectively studied 90 normal singleton pregnancies with first-trimester PAPP-A </= 0.30 multiples of the median. Maternal serum alpha-fetoprotein (AFP) at 15-18 weeks' gestation, and second-trimester placental size and UtA Doppler indices were assessed as predictors of pregnancy outcome. RESULTS The risks of IUGR, preterm delivery before 32 weeks' gestation and stillbirth were significantly associated with small placental size (relative risk (RR), 3.96; 95% CI, 2.21-5.98; RR, 3.96; 95% CI, 2.21-5.98; and RR, 6.44, 95% CI, 2.74-14.54, respectively) and elevated AFP (RR, 3.67; 95% CI, 1.78-7.71; RR, 2.48; 95% CI, 1.23-4.94; and RR, 5.14; 95% CI, 1.66-16.85, respectively), but not with abnormal UtA Doppler indices. The combination of elevated AFP and small placental size further increased the risk of IUGR (RR, 4.88; 95% CI, 2.88-5.31), delivery before 32 weeks' gestation (RR, 4.25; 95% CI, 2.38-4.98) and stillbirth (RR, 7.44; 95% CI, 3.04-3.75). CONCLUSIONS Small placental size and elevated AFP, but not UtA Doppler indices, identify women with low PAPP-A at high risk of IUGR, extreme preterm delivery and stillbirth. These additional screening tests may directly improve perinatal outcomes in women with low PAPP-A.
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Affiliation(s)
- L K Proctor
- Placenta Clinic, Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario M5G 1X5, Canada
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