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Zabel RR, Favaro RR, Groten T, Brownbill P, Jones S. Ex vivo perfusion of the human placenta to investigate pregnancy pathologies. Placenta 2022; 130:1-8. [DOI: 10.1016/j.placenta.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/26/2022] [Accepted: 10/08/2022] [Indexed: 11/07/2022]
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Kanagawa T, Ishii K, Yamamoto R, Sasahara J, Mitsuda N. Fetal Outcomes Associated with the Sequence of Doppler Deterioration in Severely Growth-Restricted Fetuses. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:2307-2315. [PMID: 33438784 DOI: 10.1002/jum.15614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 12/01/2020] [Accepted: 12/19/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Various patterns of Doppler deterioration exist in fetal growth restriction (FGR). However, the factors that differentiate these patterns are still unknown. The purpose of this study was to clarify the perinatal outcomes and factors to determine the pattern of Doppler deterioration in severe FGR. MATERIALS AND METHODS We conducted a retrospective cohort study of preterm severe FGR with Doppler abnormality, wherein the clinical features, including maternal characteristics, medical history, and sonographic findings, were compared between the patterns of Doppler deterioration. We used the multivariable logistic regression analyses to identify the factors associated with the pattern of Doppler deterioration. RESULTS Of 322 eligible fetuses, 143 had Doppler abnormalities. Fetuses with Doppler deterioration from ductus venosus uniquely featured fetal and placental-umbilical abnormalities detected after birth. Gestational age (GA) at diagnosis of FGR and at the first diagnosis of Doppler abnormality in fetuses with Doppler deterioration from middle cerebral artery (MCA) were later than those from umbilical artery. In addition, the factor associated with Doppler deterioration from MCA was 31-week GA at the first diagnosis of Doppler abnormality (adjusted odds ratio [aOR]: 26.7; 95% CI: 8.35-103), not GA at diagnosis of FGR (aOR: 1.82; 95% CI: 0.50-5.96). CONCLUSIONS Characteristics of each Doppler deterioration pattern might reflect FGR etiology. Undetectable anomalies and umbilical-placental abnormalities were found in fetuses with Doppler deterioration from the ductus venosus. Doppler deterioration from the MCA was observed after 31 weeks of gestation not only in the late-onset FGR but also in the early-onset FGR with normal umbilical artery Doppler findings.
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Affiliation(s)
- Takeshi Kanagawa
- Osaka Women's and Children's Hospital, Department of Maternal-Fetal Medicine, Osaka, Japan
| | - Keisuke Ishii
- Osaka Women's and Children's Hospital, Department of Maternal-Fetal Medicine, Osaka, Japan
| | - Ryo Yamamoto
- Osaka Women's and Children's Hospital, Department of Maternal-Fetal Medicine, Osaka, Japan
| | - Jun Sasahara
- Osaka Women's and Children's Hospital, Department of Maternal-Fetal Medicine, Osaka, Japan
| | - Nobuaki Mitsuda
- Osaka Women's and Children's Hospital, Department of Maternal-Fetal Medicine, Osaka, Japan
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Nanas I, Barbagianni M, Dadouli K, Dovolou E, Amiridis GS. Ultrasonographic findings of the corpus luteum and the gravid uterus during heat stress in dairy cattle. Reprod Domest Anim 2021; 56:1329-1341. [PMID: 34324738 DOI: 10.1111/rda.13996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/27/2021] [Indexed: 11/28/2022]
Abstract
The objectives of this study were to assess alterations in, echogenic appearance, size and blood flow in the corpus luteum, the placentomes and the blood flow in umbilical and uterine arteries that heat stress can cause in cooled pregnant dairy cows. Pregnant cows were allocated in two groups and the gravid uteri, along with the ipsilateral corpora lutea were examined during the winter (group W, n = 9) or the summer (group S, n = 10). The grey-scale ultrasound and colour flow imaging of the corpus luteum and placentome were performed. In addition, the umbilical and uterine artery diameters and haemodynamic parameters in the vessels were calculated. At the time of ultrasonographic examination, cortisol concentrations were higher, and progesterone levels tended to be lower in group S compared to group W. The grey-scale ultrasound evaluation of corpora lutea and placentomes was lower in group S compared to group W. The diameter of umbilical artery and the blood volume in the vessel were less in group S than in group W. We infer that heat stress affects foetal blood supply and possibly the structure of placentomes and corpora lutea, but it differently affects the blood flow characteristics in the umbilical and uterine arteries.
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Affiliation(s)
- Ioannis Nanas
- Clinic of Obstetrics and Reproduction, Veterinary Faculty, University of Thessaly, Karditsa, Greece
| | - Mariana Barbagianni
- Clinic of Obstetrics and Reproduction, Veterinary Faculty, University of Thessaly, Karditsa, Greece
| | - Katerina Dadouli
- Clinic of Obstetrics and Reproduction, Veterinary Faculty, University of Thessaly, Karditsa, Greece.,Laboratory of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Eleni Dovolou
- Clinic of Obstetrics and Reproduction, Veterinary Faculty, University of Thessaly, Karditsa, Greece.,Department of Animal Science, University of Thessaly, Larissa, Greece
| | - Georgios S Amiridis
- Clinic of Obstetrics and Reproduction, Veterinary Faculty, University of Thessaly, Karditsa, Greece
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Monitoring, Delivery and Outcome in Early Onset Fetal Growth Restriction. REPRODUCTIVE MEDICINE 2021. [DOI: 10.3390/reprodmed2020009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Early fetal growth restriction (FGR) remains a challenging entity associated with an increased risk of perinatal morbidity and mortality as well as maternal complications. Significant variations in clinical practice have historically characterized the management of early FGR fetuses. Nevertheless, insights into diagnosis and management options have more recently emerged. The aim of this review is to summarize the available evidence on monitoring, delivery and outcome in early-onset FGR.
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Melamed N, Baschat A, Yinon Y, Athanasiadis A, Mecacci F, Figueras F, Berghella V, Nazareth A, Tahlak M, McIntyre HD, Da Silva Costa F, Kihara AB, Hadar E, McAuliffe F, Hanson M, Ma RC, Gooden R, Sheiner E, Kapur A, Divakar H, Ayres‐de‐Campos D, Hiersch L, Poon LC, Kingdom J, Romero R, Hod M. FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction. Int J Gynaecol Obstet 2021; 152 Suppl 1:3-57. [PMID: 33740264 PMCID: PMC8252743 DOI: 10.1002/ijgo.13522] [Citation(s) in RCA: 195] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Fetal growth restriction (FGR) is defined as the failure of the fetus to meet its growth potential due to a pathological factor, most commonly placental dysfunction. Worldwide, FGR is a leading cause of stillbirth, neonatal mortality, and short- and long-term morbidity. Ongoing advances in clinical care, especially in definitions, diagnosis, and management of FGR, require efforts to effectively translate these changes to the wide range of obstetric care providers. This article highlights agreements based on current research in the diagnosis and management of FGR, and the areas that need more research to provide further clarification of recommendations. The purpose of this article is to provide a comprehensive summary of available evidence along with practical recommendations concerning the care of pregnancies at risk of or complicated by FGR, with the overall goal to decrease the risk of stillbirth and neonatal mortality and morbidity associated with this condition. To achieve these goals, FIGO (the International Federation of Gynecology and Obstetrics) brought together international experts to review and summarize current knowledge of FGR. This summary is directed at multiple stakeholders, including healthcare providers, healthcare delivery organizations and providers, FIGO member societies, and professional organizations. Recognizing the variation in the resources and expertise available for the management of FGR in different countries or regions, this article attempts to take into consideration the unique aspects of antenatal care in low-resource settings (labelled “LRS” in the recommendations). This was achieved by collaboration with authors and FIGO member societies from low-resource settings such as India, Sub-Saharan Africa, the Middle East, and Latin America.
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Affiliation(s)
- Nir Melamed
- Division of Maternal Fetal MedicineDepartment of Obstetrics and GynecologySunnybrook Health Sciences CentreUniversity of TorontoTorontoONCanada
| | - Ahmet Baschat
- Center for Fetal TherapyDepartment of Gynecology and ObstetricsJohns Hopkins UniversityBaltimoreMDUSA
| | - Yoav Yinon
- Fetal Medicine UnitDepartment of Obstetrics and GynecologySheba Medical CenterTel‐HashomerSackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
| | - Apostolos Athanasiadis
- Third Department of Obstetrics and GynecologyAristotle University of ThessalonikiThessalonikiGreece
| | - Federico Mecacci
- Maternal Fetal Medicine UnitDivision of Obstetrics and GynecologyDepartment of Biomedical, Experimental and Clinical SciencesUniversity of FlorenceFlorenceItaly
| | - Francesc Figueras
- Maternal‐Fetal Medicine DepartmentBarcelona Clinic HospitalUniversity of BarcelonaBarcelonaSpain
| | - Vincenzo Berghella
- Division of Maternal‐Fetal MedicineDepartment of Obstetrics and GynecologyThomas Jefferson UniversityPhiladelphiaPAUSA
| | - Amala Nazareth
- Jumeira Prime Healthcare GroupEmirates Medical AssociationDubaiUnited Arab Emirates
| | - Muna Tahlak
- Latifa Hospital for Women and ChildrenDubai Health AuthorityEmirates Medical AssociationMohammad Bin Rashid University for Medical Sciences, Dubai, United Arab Emirates
| | | | - Fabrício Da Silva Costa
- Department of Gynecology and ObstetricsRibeirão Preto Medical SchoolUniversity of São PauloRibeirão PretoSão PauloBrazil
| | - Anne B. Kihara
- African Federation of Obstetricians and GynaecologistsKhartoumSudan
| | - Eran Hadar
- Helen Schneider Hospital for WomenRabin Medical CenterPetach TikvaIsrael
- Sackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
| | - Fionnuala McAuliffe
- UCD Perinatal Research CentreSchool of MedicineNational Maternity HospitalUniversity College DublinDublinIreland
| | - Mark Hanson
- Institute of Developmental SciencesUniversity Hospital SouthamptonSouthamptonUK
- NIHR Southampton Biomedical Research CentreUniversity of SouthamptonSouthamptonUK
| | - Ronald C. Ma
- Department of Medicine and TherapeuticsThe Chinese University of Hong KongHong Kong SARChina
- Hong Kong Institute of Diabetes and ObesityThe Chinese University of Hong KongHong Kong SARChina
| | - Rachel Gooden
- FIGO (International Federation of Gynecology and Obstetrics)LondonUK
| | - Eyal Sheiner
- Soroka University Medical CenterBen‐Gurion University of the NegevBe’er‐ShevaIsrael
| | - Anil Kapur
- World Diabetes FoundationBagsværdDenmark
| | | | | | - Liran Hiersch
- Sourasky Medical Center and Sackler Faculty of MedicineLis Maternity HospitalTel Aviv UniversityTel AvivIsrael
| | - Liona C. Poon
- Department of Obstetrics and GynecologyPrince of Wales HospitalThe Chinese University of Hong KongShatinHong Kong SAR, China
| | - John Kingdom
- Division of Maternal Fetal MedicineDepartment of Obstetrics and GynecologyMount Sinai HospitalUniversity of TorontoTorontoONCanada
| | - Roberto Romero
- Perinatology Research BranchEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMDUSA
| | - Moshe Hod
- Helen Schneider Hospital for WomenRabin Medical CenterPetach TikvaIsrael
- Sackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
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Al Hamayel NA, Baghlaf H, Blakemore K, Crino JP, Burd I. Significance of abnormal umbilical artery Doppler studies in normally grown fetuses. Matern Health Neonatol Perinatol 2020; 6:1. [PMID: 32110420 PMCID: PMC7033920 DOI: 10.1186/s40748-020-0115-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Objective To determine whether there is a relationship between abnormal umbilical artery Doppler studies (UADS) and small for gestational age (SGA) birth weight and other adverse perinatal outcomes in fetuses that appear normally grown by ultrasound. Methods This was a retrospective study of all women who had UADS performed at or after 26 weeks of gestation at our institution between January 2005 and December 2012. Women were excluded if they had a fetal demise, a fetus with growth restriction, a fetus with congenital anomaly, or a multiple gestation. Women with missing delivery outcomes were excluded. The primary outcome was birth weight below the 10th percentile. Results There were 2744 women included in the study. Of those, 98 (3.6%) had an abnormal UADS, and 379 (13.8%) had an SGA neonate. Of the 2646 women who had a normal UADS, 353 (13.3%) women had an SGA neonate. Twenty-six (26.5%) of the 98 women who had an abnormal UADS had an SGA neonate. After adjusting for potential confounders, the adjusted odds ratio for an SGA neonate with an abnormal UADS was 2.2 (95% CI, 1.38-3.58; p < 0.05). In examining other adverse perinatal outcomes, neonatal intensive care unit (NICU) admission and low 5-min Apgar scores were 12.4 and 2.3%, respectively. The adjusted odds ratio for NICU admission was 1.84 (95% CI, 1.06-3.21; p < 0.05). Abnormal UADS was not associated with low Apgar scores (aOR 1.39: 95% CI 0.47-4.07; p > 0.05). Conclusions Our data suggest that abnormal UADS in fetuses that appear normally grown by ultrasound are associated with SGA neonates and NICU admission.
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Affiliation(s)
- Nebras Abu Al Hamayel
- Department of Gynecology and Obstetrics, Johns Hopkins University, School of Medicine, 600 N Wolfe St, Phipps 228, Baltimore, MD 21287 USA
| | - Haitham Baghlaf
- Department of Gynecology and Obstetrics, Johns Hopkins University, School of Medicine, 600 N Wolfe St, Phipps 228, Baltimore, MD 21287 USA
| | - Karin Blakemore
- Department of Gynecology and Obstetrics, Johns Hopkins University, School of Medicine, 600 N Wolfe St, Phipps 228, Baltimore, MD 21287 USA
| | - Jude P Crino
- Department of Gynecology and Obstetrics, Johns Hopkins University, School of Medicine, 600 N Wolfe St, Phipps 228, Baltimore, MD 21287 USA
| | - Irina Burd
- Department of Gynecology and Obstetrics, Johns Hopkins University, School of Medicine, 600 N Wolfe St, Phipps 228, Baltimore, MD 21287 USA
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Vascular changes in fetal growth restriction: clinical relevance and future therapeutics. J Perinatol 2019; 39:366-374. [PMID: 30518801 DOI: 10.1038/s41372-018-0287-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 09/13/2018] [Accepted: 09/17/2018] [Indexed: 01/08/2023]
Abstract
Fetal growth restriction (FGR) affects about 5-10% pregnancies and is associated with poorer outcomes in the perinatal period. Additionally, long standing epidemiological data support its association with chronic diseases such as hypertension and diabetes. Cardiac and vascular adaptations in response to chronic hypoxemia due to utero-placental insufficiency are hallmarks of fetal adaptations. Investigators have attempted to identify these changes in the placenta at the microscopic and molecular level. The ex vivo dual perfusion model of the placenta enables the study of placental haemodynamics in growth-restricted pregnancies. Persistent arterial abnormalities (thickness and stiffness) noted on vascular ultrasound during fetal life through to the young-adult age group for those affected by FGR, seem to be a plausible link between in utero events and chronic circulatory diseases. Using these, this review reflects current thought on vascular maladaptive changes in the FGR cohorts and the role in investigating current and future therapeutics.
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Hoeller A, Ehrlich L, Golic M, Herse F, Perschel FH, Siwetz M, Henrich W, Dechend R, Huppertz B, Verlohren S. Placental expression of sFlt-1 and PlGF in early preeclampsia vs. early IUGR vs. age-matched healthy pregnancies. Hypertens Pregnancy 2017; 36:151-160. [PMID: 28609172 DOI: 10.1080/10641955.2016.1273363] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To investigate whether differences between early preeclampsia and early fetal growth restriction can be explained by differential placental expression patterns of sFlt-1, Flt-1, and PlGF. METHODS Placental tissues and maternal blood samples from six cases of preeclampsia, seven IUGR, and six age-matched controls were studied for mRNA and protein levels as well as protein localization and expression intensity. RESULTS Neither placental PlGF mRNA and protein expression nor placental villous trophoblast expression intensity of PlGF was altered by placental dysfunction. CONCLUSION High sFlt-1 concentrations may account for diminished maternal serum PlGF levels.
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Affiliation(s)
- Alice Hoeller
- a Department of Obstetrics , Charité University Medicine , Berlin , Germany
| | - Laura Ehrlich
- a Department of Obstetrics , Charité University Medicine , Berlin , Germany
| | - Michaela Golic
- a Department of Obstetrics , Charité University Medicine , Berlin , Germany.,b HELIOS Clinic, Experimental and Clinical Research Center, Max-Delbrueck Center , Berlin-Buch , Germany
| | - Florian Herse
- b HELIOS Clinic, Experimental and Clinical Research Center, Max-Delbrueck Center , Berlin-Buch , Germany
| | - Frank H Perschel
- c Laboratory Medicine and Toxicology , Charité University Medicine Berlin und Labor Berlin - Charité, Vivantes GmbH , Berlin , Germany
| | - Monika Siwetz
- d Institute of Cell Biology, Histology and Embryology, Medical University of Graz , Graz , Austria
| | - Wolfgang Henrich
- a Department of Obstetrics , Charité University Medicine , Berlin , Germany
| | - Ralf Dechend
- b HELIOS Clinic, Experimental and Clinical Research Center, Max-Delbrueck Center , Berlin-Buch , Germany
| | - Berthold Huppertz
- d Institute of Cell Biology, Histology and Embryology, Medical University of Graz , Graz , Austria
| | - Stefan Verlohren
- a Department of Obstetrics , Charité University Medicine , Berlin , Germany
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Dall’Asta A, Brunelli V, Prefumo F, Frusca T, Lees CC. Early onset fetal growth restriction. Matern Health Neonatol Perinatol 2017; 3:2. [PMID: 28116113 PMCID: PMC5241928 DOI: 10.1186/s40748-016-0041-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 12/27/2016] [Indexed: 01/01/2023] Open
Abstract
Fetal growth restriction (FGR) diagnosed before 32 weeks is identified by fetal smallness associated with Doppler abnormalities and is associated with significant perinatal morbidity and mortality and maternal complications. Recent studies have provided new insights into pathophysiology, management options and postnatal outcomes of FGR. In this paper we review the available evidence regarding diagnosis, management and prognosis of fetuses diagnosed with FGR before 32 weeks of gestation.
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Affiliation(s)
- Andrea Dall’Asta
- Centre for Fetal Care, Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS United Kingdom
- Department of Obstetrics & Gynecology, University of Parma, Parma, Italy
| | - Valentina Brunelli
- Department of Obstetrics and Gynaecology, Maternal-Fetal Medicine Unit, University of Brescia, Brescia, Italy
| | - Federico Prefumo
- Department of Obstetrics and Gynaecology, Maternal-Fetal Medicine Unit, University of Brescia, Brescia, Italy
| | - Tiziana Frusca
- Department of Obstetrics & Gynecology, University of Parma, Parma, Italy
| | - Christoph C Lees
- Centre for Fetal Care, Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS United Kingdom
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Department of Development and Regeneration, KU Leuven, Belgium
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10
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Tynan D, Alphonse J, Henry A, Welsh AW. The Aortic Isthmus: A Significant yet Underexplored Watershed of the Fetal Circulation. Fetal Diagn Ther 2016; 40:81-93. [PMID: 27379710 DOI: 10.1159/000446942] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 05/11/2016] [Indexed: 11/19/2022]
Abstract
The aortic isthmus (AoI) is a unique fetal watershed with a waveform reflecting its complex haemodynamic physiology. The systolic component represents left and right ventricular systolic ejection, and the diastolic component represents comparative downstream vascular impedance between the brachiocephalic and subdiaphragmatic fetal circulations. Several indices have been devised to quantify different components of the waveform, including the pulsatility index, resistance index, isthmic flow index, and recently the isthmic systolic index. There have been promising preliminary studies applying these indices to both cardiac (congenital) and extracardiac pathologies, including intrauterine growth restriction and twin-twin transfusion syndrome. However, the waveform's multifactorial origin has proven to be challenging, and the difficulty in separating various components of the waveform could explain that AoI evaluation does not have a clear clinical utility. Further research is underway to realise the full potential of this vessel in fetal cardiac and haemodynamically compromised pathological conditions. In this review article we outline the physiological origin of this Doppler waveform, describe in detail the various published indices, summarise the published literature to date, and finally outline potential future research and hopefully clinical applications.
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Affiliation(s)
- Dominique Tynan
- Faculty of Medicine, University of New South Wales, Kensington, N.S.W., Australia
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11
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Abstract
BACKGROUND Cardiotocography (CTG) is a continuous recording of the fetal heart rate obtained via an ultrasound transducer placed on the mother's abdomen. CTG is widely used in pregnancy as a method of assessing fetal well-being, predominantly in pregnancies with increased risk of complications. OBJECTIVES To assess the effectiveness of antenatal CTG (both traditional and computerised assessments) in improving outcomes for mothers and babies during and after pregnancy. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (26 June 2015) and reference lists of retrieved studies. SELECTION CRITERIA Randomised and quasi-randomised trials that compared traditional antenatal CTG with no CTG or CTG results concealed; computerised CTG with no CTG or CTG results concealed; and computerised CTG with traditional CTG. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS Six studies (involving 2105 women) are included. Overall, the included studies were not of high quality, and only two had both adequate randomisation sequence generation and allocation concealment. All studies that were able to be included enrolled only women at increased risk of complications.Comparison of traditional CTG versus no CTG showed no significant difference identified in perinatal mortality (risk ratio (RR) 2.05, 95% confidence interval (CI) 0.95 to 4.42, 2.3% versus 1.1%, four studies, N = 1627, low quality evidence) or potentially preventable deaths (RR 2.46, 95% CI 0.96 to 6.30, four studies, N = 1627), though the meta-analysis was underpowered to assess this outcome. Similarly, there was no significant difference identified in caesarean sections (RR 1.06, 95% CI 0.88 to 1.28, 19.7% versus 18.5%, three trials, N = 1279, low quality evidence). There was also no significant difference identified for secondary outcomes related to Apgar scores less than seven at five minutes (RR 0.83, 95% CI 0.37 to 1.88, one trial, N = 396, very low quality evidence); or admission to neonatal special care units or neonatal intensive care units (RR 1.08, 95% CI 0.84 to 1.39, two trials, N = 883, low quality evidence), nor in the other secondary outcomes that were assessed.There were no eligible studies that compared computerised CTG with no CTG.Comparison of computerised CTG versus traditional CTG showed a significant reduction in perinatal mortality with computerised CTG (RR 0.20, 95% CI 0.04 to 0.88, two studies, 0.9% versus 4.2%, 469 women, moderate quality evidence). However, there was no significant difference identified in potentially preventable deaths (RR 0.23, 95% CI 0.04 to 1.29, two studies, N = 469), though the meta-analysis was underpowered to assess this outcome. There was no significant difference identified in caesarean sections (RR 0.87, 95% CI 0.61 to 1.24, 63% versus 72%, one study, N = 59, low quality evidence), Apgar scores less than seven at five minutes (RR 1.31, 95% CI 0.30 to 5.74, two studies, N = 469, very low quality evidence) or in secondary outcomes. AUTHORS' CONCLUSIONS There is no clear evidence that antenatal CTG improves perinatal outcome, but further studies focusing on the use of computerised CTG in specific populations of women with increased risk of complications are warranted.
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Affiliation(s)
- Rosalie M Grivell
- Flinders University and Flinders Medical CentreDepartment of Obstetrics and GynaecologyBedford ParkSouth AustraliaAustraliaSA 5042
| | - Zarko Alfirevic
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Gillian ML Gyte
- University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Declan Devane
- National University of Ireland GalwaySchool of Nursing and MidwiferyUniversity RoadGalwayIreland
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12
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Jones S, Bischof H, Lang I, Desoye G, Greenwood SL, Johnstone ED, Wareing M, Sibley CP, Brownbill P. Dysregulated flow-mediated vasodilatation in the human placenta in fetal growth restriction. J Physiol 2015; 593:3077-92. [PMID: 25920377 PMCID: PMC4532528 DOI: 10.1113/jp270495] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 04/22/2015] [Indexed: 11/14/2022] Open
Abstract
Increased vascular resistance and reduced fetoplacental blood flow are putative aetiologies in the pathogenesis of fetal growth restriction (FGR); however, the regulating sites and mechanisms remain unclear. We hypothesised that placental vessels dictate fetoplacental resistance and in FGR exhibit endothelial dysfunction and reduced flow-mediated vasodilatation (FMVD). Resistance was measured in normal pregnancies (n = 10) and FGR (n = 10) both in vivo by umbilical artery Doppler velocimetry and ex vivo by dual placental perfusion. Ex vivo FMVD is the reduction in fetal-side inflow hydrostatic pressure (FIHP) following increased flow rate. Results demonstrated a significant correlation between vascular resistance measured in vivo and ex vivo in normal pregnancy, but not in FGR. In perfused FGR placentas, vascular resistance was significantly elevated compared to normal placentas (58 ± 7.7 mmHg and 36.8 ± 4.5 mmHg, respectively; 8 ml min−1; means ± SEM; P < 0.0001) and FMVD was severely reduced (3.9 ± 1.3% and 9.1 ± 1.2%, respectively). In normal pregnancies only, the highest level of ex vivo FMVD was associated with the lowest in vivo resistance. Inhibition of NO synthesis during perfusion (100 μm l-NNA) moderately elevated FIHP in the normal group, but substantially in the FGR group. Human placenta artery endothelial cells from FGR groups exhibited increased shear stress-induced NO generation, iNOS expression and eNOS expression compared with normal groups. In conclusion, fetoplacental resistance is determined by placental vessels, and is increased in FGR. The latter also exhibit reduced FMVD, but with a partial compensatory increased NO generation capacity. The data support our hypothesis, which highlights the importance of FMVD regulation in normal and dysfunctional placentation.
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Affiliation(s)
- Sarah Jones
- Maternal and Fetal Health Research Centre, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, St. Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Maternal and Fetal Health Research Centre, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Helen Bischof
- Maternal and Fetal Health Research Centre, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, St. Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Maternal and Fetal Health Research Centre, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Ingrid Lang
- Institute of Cell Biology, Histology and Embryology, Medical University of Graz, Graz, Austria
| | - Gernot Desoye
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Sue L Greenwood
- Maternal and Fetal Health Research Centre, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, St. Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Maternal and Fetal Health Research Centre, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Edward D Johnstone
- Maternal and Fetal Health Research Centre, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, St. Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Maternal and Fetal Health Research Centre, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Mark Wareing
- Maternal and Fetal Health Research Centre, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, St. Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Maternal and Fetal Health Research Centre, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Colin P Sibley
- Maternal and Fetal Health Research Centre, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, St. Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Maternal and Fetal Health Research Centre, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Paul Brownbill
- Maternal and Fetal Health Research Centre, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, St. Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Maternal and Fetal Health Research Centre, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
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Seravalli V, Baschat AA. A Uniform Management Approach to Optimize Outcome in Fetal Growth Restriction. Obstet Gynecol Clin North Am 2015; 42:275-88. [DOI: 10.1016/j.ogc.2015.01.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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14
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Affiliation(s)
- Neeta L Vora
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27517, USA.
| | - Nancy Chescheir
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27517, USA
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15
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Doppler for growth restriction: the association between the cerebroplacental ratio and a reduced interval to delivery. J Perinatol 2015; 35:332-7. [PMID: 25474558 DOI: 10.1038/jp.2014.211] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 09/30/2014] [Accepted: 10/02/2014] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Evaluation of the cerebroplacental ratio (CPR) as an adjunct to umbilical artery Doppler (UA) to assess risk of delivery before 32 weeks and/or delivery within 2 weeks from diagnosis of fetal growth restriction (FGR). STUDY DESIGN In a cohort of fetuses with suspected FGR, UA Doppler was performed, and when abnormal the CPR was calculated (middle cerebral pulsatility index/umbilical artery pulsatility index). Doppler characteristics were used to determine three study groups: (1) normal UA, (2) abnormal UA with normal CPR and (3) abnormal UA with abnormal CPR. The primary outcomes were delivery before 32 weeks and delivery within 2 weeks. Adjusted odds ratio (aOR) with 95% confidence intervals (CIs) were calculated controlling for maternal age, chronic hypertension and tobacco use. We performed a linear regression analysis comparing the value of the CPR with the gestational age at delivery. Kaplan-Meier survival curve analysis with log-rank tests for probability was performed. RESULTS We included 154 patients: 91, 31 and 32 in Group 1, 2 and 3, respectively. Subjects in Group 3 had higher rates of the two primary outcomes: there was a fivefold increased risk (aOR=5.2 (95% CI=2.85-9.48)) for delivery before 32 weeks and over a fourfold increased risk for delivery within 2 weeks (aOR=4.76 (95% CI=2.32-9.76)) compared with those with a normal CPR (Group 1). In contrast, subjects in Group 2 (abnormal UA Doppler but normal CPR) had a similar rate of delivery before 32 weeks (aOR=1.16 (95% CI=0.55-2.48)) and within 2 weeks (aOR=1.07 (95% CI=0.43-2.69)). The median gestational age at delivery was 36, 36 and 29 weeks in Groups 1, 2 and 3, respectively (P<0.001). Linear regression analysis revealed a strong correlation between the value of the CPR and gestational age at delivery: R(2)=0.56, correlation coefficient=0.75. Kaplan-Meier analysis revealed a significantly decreased latency to delivery in Group 3, as opposed to Groups 1 and 2 (Cox-Mantel hazard ratio (HR) of Group 2 versus Group 1 HR=1.20 (95% CI=0.78-1.83) and Group 3 versus Group 1 HR=5.00 (95% CI=2.4-10.21)). CONCLUSION The CPR differentiates those fetuses with suspected growth restriction most at risk for delivery before 32 weeks and delivery within 2 weeks from those likely to have a more prolonged latency until delivery is required. In patients with suspected FGR and an abnormal UA, the CPR can be used to guide management decisions, such as maternal hospitalization and/or transport, aggressive fetal monitoring and antenatal corticosteroid administration.
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Regan J, Masters H, Warshak CR. Estimation of the growth rate in fetuses with an abnormal cerebroplacental ratio compared to those with suspected growth restriction without evidence of centralization of blood flow. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:837-842. [PMID: 25911717 DOI: 10.7863/ultra.34.5.837] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To evaluate the growth rate in fetuses with suspected growth restriction according to their Doppler characteristics. METHODS A retrospective cohort of fetuses with suspected growth restriction was identified. We reviewed umbilical artery and middle cerebral Doppler pulsatility indices and calculated the cerebroplacental ratio. Three study groups were determined: (1) normal umbilical artery Doppler findings; (2) abnormal umbilical artery findings with a normal cerebroplacental ratio; and (3) abnormal umbilical artery findings with an abnormal cerebroplacental ratio. The primary outcome was the growth rate as estimated by fetal biometry from serial sonographic evaluations. Analysis of the mean growth rate in each study group was performed by analysis of variance. In addition, linear regression analysis comparing the cerebroplacental ratio to the growth rate was performed. RESULTS Fetal growth restriction was suspected in 416 patients; 176 patients were included in this analysis: 113, 38, and 25 in groups 1, 2, and 3 respectively. The estimated mean (SD) growth rate in group 3 was significantly lower than in groups 1 and 2: 8.3 (4.4) versus 19.6 (6.0) and 18.6 (7.7) g/d, respectively (P < .001). Linear regression analysis revealed a strong correlation between the growth rate and cerebroplacental ratio (r = 0.76; R(2) = 0.58) as well as the birth weight and cerebroplacental ratio (r = 0.78; R(2) = 0.61). CONCLUSIONS In fetuses with suspected growth restriction and abnormal umbilical artery Doppler findings, an abnormal cerebroplacental ratio is strongly associated with reduced fetal growth. In contrast, if the cerebroplacental ratio is normal, even in the setting of abnormal umbilical artery Doppler findings, fetuses grow similarly to those with normal umbilical artery findings.
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Affiliation(s)
- Jodi Regan
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio USA.
| | - Heather Masters
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio USA
| | - Carri R Warshak
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio USA
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Abstract
Fetal growth restriction is one of the most complex problems encountered by obstetricians. Ultrasound-estimated fetal weight less than the 10th percentile for the gestational age is the most widely accepted diagnostic criterion. Management protocols vary from institution to institution. Doppler velocimetry provides valuable information about fetal status. We offer a practical approach to management and timing of delivery based on available data in the literature.
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Basaran A, Deren Ö, Buyukasik Y, Basaran M. Free protein s reference ranges in gravidas without hereditary and acquired thrombophilia. Indian J Hematol Blood Transfus 2014; 31:286-91. [PMID: 25825574 DOI: 10.1007/s12288-014-0448-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 08/05/2014] [Indexed: 11/30/2022] Open
Abstract
We carried out a retrospective cohort study to construct reference ranges for free protein S (FPS) levels during pregnancy and identify any conditions or factors that may affect FPS levels. Patients that were ordered thrombophilia screening tests during gestational period were identified. Patients demonstrated to have hereditary or acquired thrombophilia were excluded. Reference ranges were constructed using regression analysis. Outcome of the index pregnancy and pregnancy complications was used to identify any confounding factors. A total of 455 pregnant women were included. The quadratic equation for FPS according to gestational age (GA) was [75.497 + (-1.516*GA) + 0.018*GA*GA]. FPS level and GA were negatively correlated (Spearmans rho statistic [rs] = -0.436, p = 0.001). FPS level and fetal growth restriction (FGR) were negatively correlated ([rs] = -0.093, p = 0.049). FPS level and placental abruption were positively correlated ([rs] = 0.098, p = 0.039). Stepwise linear regression model constructed to predict FPS level with gestational age, placental abruption and FGR as the predictor variables. Gestational age was the only variable retaining statistically significant relation with FPS level (χ(2) = 0.216, df = 3, p = 0.001). FPS levels decrease significantly throughout gestation in gravidas without hereditary and/or acquired thrombophilias. In patients without thrombophilia FPS levels are not associated with pregnancy complications. The obtained reference intervals may be useful for the clinicians ordering FPS during pregnancy.
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Affiliation(s)
- Ahmet Basaran
- Obstetrics & Gynecology Department, Konya Training and Research Hospital, Kılıçarslan mah, Nurdağ Sk. Sinanoba sitesi, B-blok No:19 Selçuklu, 42080 Konya, Turkey
| | - Özgür Deren
- Division of Perinatology, Obstetrics & Gynecology Department, Hacettepe University School of Medicine, Ankara, Turkey
| | - Yahya Buyukasik
- Division of Hematology, Internal Medicine Department, Hacettepe University School of Medicine, Ankara, Turkey
| | - Mustafa Basaran
- Obstetrics & Gynecology Department, Konya Training and Research Hospital, Kılıçarslan mah, Nurdağ Sk. Sinanoba sitesi, B-blok No:19 Selçuklu, 42080 Konya, Turkey
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Maternal vitamin D status and small-for-gestational-age offspring in women at high risk for preeclampsia. Obstet Gynecol 2014; 123:40-48. [PMID: 24463662 DOI: 10.1097/aog.0000000000000049] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To examine the association between second-trimester maternal serum 25-hydroxyvitamin D concentrations and risk of small for gestational age (SGA) in singleton live births. METHODS We assayed serum samples at 12-26 weeks of gestation for 25-hydroxyvitamin D in a sample of participants in a multicenter clinical trial of low-dose aspirin for the prevention of preeclampsia in high-risk women (n=792). Multivariable log-binomial regression models were used to assess the association between 25-hydroxyvitamin D and risk of SGA (birth weight less than the 10 percentile for gestational age) after adjustment for confounders including maternal prepregnancy obesity, race, treatment allocation, and risk group. RESULTS Thirteen percent of neonates were SGA at birth. Mean (standard deviation) 25-hydroxyvitamin D concentrations were lower in women who delivered SGA (57.9 [29.9] nmol/L) compared with non-SGA neonates (64.8 [29.3] nmol/L, P=.028). In adjusted models, 25-hydroxyvitamin D concentrations of 50-74 nmol/L and 75 nmol/L or greater compared with less than 30 nmol/L were associated with 43% (95% confidence interval [CI] 0.33-0.99) and 54% (95% CI 0.24-0.87) reductions in risk of SGA, respectively. Race and maternal obesity each modified this association. White women with 25-hydroxyvitamin D 50 nmol/L or greater compared with less than 50 nmol/L had a 68% reduction in SGA risk (adjusted risk ratio 0.32, 95% CI 0.17-0.63) and nonobese women with 25-hydroxyvitamin D 50 nmol/L or greater compared with less than 50 nmol/L had a 50% reduction in SGA risk (adjusted risk ratio 0.50, 95% CI 0.31-0.82). There was no association between 25-hydroxyvitamin D and risk of SGA in black or obese mothers. CONCLUSION Maternal vitamin D status in the second trimester is associated with risk of SGA among all women and in the subgroups of white and nonobese women. LEVEL OF EVIDENCE II.
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Senat MV, Tsatsaris V. Surveillance anténatale, prise en charge et indications de naissance en cas de RCIU vasculaire isolé. ACTA ACUST UNITED AC 2013; 42:941-65. [DOI: 10.1016/j.jgyn.2013.09.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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21
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Salomon L, Malan V. Bilan étiologique du retard de croissance intra-utérin (RCIU). ACTA ACUST UNITED AC 2013; 42:929-40. [DOI: 10.1016/j.jgyn.2013.09.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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22
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Cerebral blood flow studies in the diagnosis and management of intrauterine growth restriction. Curr Opin Obstet Gynecol 2013; 25:138-44. [DOI: 10.1097/gco.0b013e32835e0e9c] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
BACKGROUND Cardiotocography (CTG) is a continuous recording of the fetal heart rate obtained via an ultrasound transducer placed on the mother's abdomen. CTG is widely used in pregnancy as a method of assessing fetal well-being, predominantly in pregnancies with increased risk of complications. OBJECTIVES To assess the effectiveness of antenatal CTG (both traditional and computerised assessments) in improving outcomes for mothers and babies during and after pregnancy. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (9 July 2012) and reference lists of retrieved studies. SELECTION CRITERIA Randomised and quasi-randomised trials that compared traditional antenatal CTG with no CTG or CTG results concealed; computerised CTG with no CTG or CTG results concealed; and computerised CTG with traditional CTG. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility, quality and extracted data. MAIN RESULTS Six studies (involving 2105 women) are included. Overall, the included studies were not of high quality, and only two had both adequate randomisation sequence generation and allocation concealment. All studies that were able to be included enrolled only women at increased risk of complications.Comparison of traditional CTG versus no CTG showed no significant difference identified in perinatal mortality (risk ratio (RR) 2.05, 95% confidence interval (CI) 0.95 to 4.42, 2.3% versus 1.1%, four studies, N = 1627) or potentially preventable deaths (RR 2.46, 95% CI 0.96 to 6.30, four studies, N = 1627), though the meta-analysis was underpowered to assess this outcome. Similarly, there was no significant difference identified in caesarean sections (RR 1.06, 95% CI 0.88 to 1.28, 19.7% versus 18.5%, three trials, N = 1279) nor in the secondary outcomes that were assessed.There were no eligible studies that compared computerised CTG with no CTG.Comparison of computerised CTG versus traditional CTG showed a significant reduction in perinatal mortality with computerised CTG (RR 0.20, 95% CI 0.04 to 0.88, two studies, 0.9% versus 4.2%, 469 women). However, there was no significant difference identified in potentially preventable deaths (RR 0.23, 95% CI 0.04 to 1.29, two studies, N = 469), though the meta-analysis was underpowered to assess this outcome. There was no significant difference identified in caesarean sections (RR 0.87, 95% CI 0.61 to 1.24, 63% versus 72%, one study, N = 59) or in secondary outcomes. AUTHORS' CONCLUSIONS There is no clear evidence that antenatal CTG improves perinatal outcome, but further studies focusing on the use of computerised CTG in specific populations of women with increased risk of complications are warranted.
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Affiliation(s)
- Rosalie M Grivell
- Discipline of Obstetrics and Gynaecology, The University of Adelaide, Women’s and Children’s Hospital, Adelaide, Australia.
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25
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Bar J, Schreiber L, Ben-Haroush A, Ahmed H, Golan A, Kovo M. The placental vascular component in early and late intrauterine fetal death. Thromb Res 2012; 130:901-5. [DOI: 10.1016/j.thromres.2012.09.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Revised: 09/10/2012] [Accepted: 09/18/2012] [Indexed: 11/30/2022]
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Berkley E, Chauhan SP, Abuhamad A, Abuhamad A. Doppler assessment of the fetus with intrauterine growth restriction. Am J Obstet Gynecol 2012; 206:300-8. [PMID: 22464066 DOI: 10.1016/j.ajog.2012.01.022] [Citation(s) in RCA: 136] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 01/12/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE We sought to provide evidence-based guidelines for utilization of Doppler studies for fetuses with intrauterine growth restriction (IUGR). METHODS Relevant documents were identified using PubMed (US National Library of Medicine, 1983 through 2011) publications, written in English, which describe the peripartum outcomes of IUGR according to Doppler assessment of umbilical arterial, middle cerebral artery, and ductus venosus. Additionally, the Cochrane Library, organizational guidelines, and studies identified through review of the above were utilized to identify relevant articles. Consistent with US Preventive Task Force suggestions, references were evaluated for quality based on the highest level of evidence, and recommendations were graded. RESULTS AND RECOMMENDATIONS Summary of randomized and quasirandomized studies indicates that, among high-risk pregnancies with suspected IUGR, the use of umbilical arterial Doppler assessment significantly decreases the likelihood of labor induction, cesarean delivery, and perinatal deaths (1.2% vs 1.7%; relative risk, 0.71; 95% confidence interval, 0.52-0.98). Antepartum surveillance with Doppler of the umbilical artery should be started when the fetus is viable and IUGR is suspected. Although Doppler studies of the ductus venous, middle cerebral artery, and other vessels have some prognostic value for IUGR fetuses, currently there is a lack of randomized trials showing benefit. Thus, Doppler studies of vessels other than the umbilical artery, as part of assessment of fetal well-being in pregnancies complicated by IUGR, should be reserved for research protocols.
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He Q, Ren P, Kong X, Xu W, Tang H, Yin Y, Wang Y. Intrauterine growth restriction alters the metabonome of the serum and jejunum in piglets. MOLECULAR BIOSYSTEMS 2011; 7:2147-55. [PMID: 21584308 DOI: 10.1039/c1mb05024a] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Intrauterine growth restriction (IUGR) is not only an underlying factor for stunted postnatal growth and newborn deaths, but also associated with disease prevalence, such as hypertension and diabetes, in both adult humans and animals. To investigate the metabolic status of IUGR, the differences in serum and jejunal tissue metabonome were examined in IUGR and normal weight 21 day old piglets. IUGR piglets had a significantly lower birth weight (785 ± 42 g vs. 1451 ± 124 g), weaned weight (3053 ± 375 g vs. 6489 ± 545 g) and average daily gain (108 ± 16 g vs. 240 ± 21 g) than normal weight piglets (p < 0.05). IUGR piglets also had a shorter villus height and smaller villus height to crypt depth ratio (p < 0.05) in jejunum. An NMR-based metabonomic study found that serum levels of glycoprotein, albumin and threonine were higher in IUGR than in normal weight piglets, while serum levels of HDL, lipids, unsaturated lipids, glycerophosphorylcholine, myo-inositol, citrate, glutamine and tyrosine were lower in IUGR piglets (p < 0.05). In addition, marked changes in jejunal metabolites, including elevated levels of lipids and unsaturated lipids, and decreased levels of valine, alanine, glutamine, glutamate, choline, glycerophosphorylcholine, trimethylamine-N-oxide, scyllo-inositol, lactate, creatine, glucose, galactose, phenylalanine, tyrosine, glutathione, inosine and taurine were observed in IUGR piglets (p < 0.05). These novel findings indicate that IUGR piglets have a distinctive metabolic status compared to normal weight piglets, including changes in lipogenesis, lipid oxidation, energy supply and utilization, amino acid and protein metabolism, and antioxidant ability; these changes could contribute to impaired growth and jejunal function.
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Affiliation(s)
- Qinghua He
- State Key Laboratory of Magnetic Resonance and Atomic and Molecular Physics, Wuhan Centre for Magnetic Resonance, Wuhan Institute of Physics and Mathematics, Chinese Academy of Sciences, Wuhan 430071, P.R. China
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Baschat AA, Harman CR. Discordance of arterial and venous flow velocity waveforms in severe placenta-based fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 37:369-370. [PMID: 21337657 DOI: 10.1002/uog.8926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Brown LD, Green AS, Limesand SW, Rozance PJ. Maternal amino acid supplementation for intrauterine growth restriction. Front Biosci (Schol Ed) 2011; 3:428-44. [PMID: 21196387 DOI: 10.2741/s162] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Maternal dietary protein supplementation to improve fetal growth has been considered as an option to prevent or treat intrauterine growth restriction. However, in contrast to balanced dietary supplementation, adverse perinatal outcomes in pregnant women who received high amounts of dietary protein supplementation have been observed. The responsible mechanisms for these adverse outcomes are unknown. This review will discuss relevant human and animal data to provide the background necessary for the development of explanatory hypotheses and ultimately for the development therapeutic interventions during pregnancy to improve fetal growth. Relevant aspects of fetal amino acid metabolism during normal pregnancy and those pregnancies affected by IUGR will be discussed. In addition, data from animal experiments which have attempted to determine mechanisms to explain the adverse responses identified in the human trials will be presented. Finally, we will suggest new avenues for investigation into how amino acid supplementation might be used safely to treat and/or prevent IUGR.
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Affiliation(s)
- Laura D Brown
- Department of Pediatrics, University of Colorado Denver; Aurora, CO 80045, USA
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Lee S, Walker SP. The role of ultrasound in the diagnosis and management of the growth restricted fetus. Australas J Ultrasound Med 2010; 13:31-36. [PMID: 28191088 PMCID: PMC5024867 DOI: 10.1002/j.2205-0140.2010.tb00161.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Stephen Lee
- Department of Obstetrics and GynaecologyMonash Medical CentreClaytonVictoria3168Australia; University of MelbourneDepartment of Obstetrics and GynaecologyCarltonVictoria3010Australia
| | - Susan P Walker
- Department of Perinatal MedicineMercy Hospital for WomenEast MelbourneVictoria3002Australia; University of MelbourneDepartment of Obstetrics and GynaecologyCarltonVictoria3010Australia
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Vergani P, Roncaglia N, Ghidini A, Crippa I, Cameroni I, Orsenigo F, Pezzullo J. Can adverse neonatal outcome be predicted in late preterm or term fetal growth restriction? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2010; 36:166-170. [PMID: 20131337 DOI: 10.1002/uog.7583] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To identify independent predictors of adverse neonatal outcome in cases of fetal growth restriction (FGR) at > or = 34 weeks. METHODS From a cohort of 481 FGR cases delivered at > or = 34 weeks, demographic and obstetric variables, fetal biometry and Doppler indices of the uterine, umbilical and fetal middle cerebral arteries available within 2 weeks of delivery, were related to adverse neonatal outcome, defined as admission to the neonatal intensive care unit for indications other than low birth weight alone. RESULTS Logistic regression analysis showed that gestational age (GA) at delivery (odds ratio (OR) = 0.59; 95% CI, 0.50-0.70), abdominal circumference (AC) centile (OR = 0.69; 95% CI, 0.59-0.81) and umbilical artery (UA) pulsatility index (PI) centile (OR = 1.02; 95% CI, 1.01-1.04) significantly correlated with adverse neonatal outcome. From this model we calculated a score of adverse neonatal outcome expressed by the formula: (UA-PI centile/3) - (10 x AC centile) + (10 x (40 - GA at delivery in weeks)). Receiver-operating characteristics curve analysis demonstrated that a score of > or = 25 optimally predicted adverse neonatal outcome (sensitivity of 75%, false-positive rate of 18%). Beyond 37.5 weeks, gestational age no longer had an independent impact on outcome. CONCLUSIONS In late preterm or term FGR, GA at delivery is the most important predictor of adverse neonatal outcome. At > 37.5 weeks, delivery may be the best option to minimize adverse outcome in all FGR cases. At 34-37 weeks, a score based on GA at delivery, UA-PI centile and AC centile optimally predicts adverse neonatal outcome.
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Affiliation(s)
- P Vergani
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, Monza, Italy.
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Kayem G, Haddad B. [Is it necessary to induce labor before 37 weeks of gestation in case of small for gestational age fetus?]. ACTA ACUST UNITED AC 2010; 38:496-9. [PMID: 20598618 DOI: 10.1016/j.gyobfe.2010.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The suspicion of small for gestational age fetus before 37 weeks of gestation implies to discriminate those who are physiologically small from those who have an underlying pathology leading to growth retardation. A labor induction can be needed if the risks associated to the prolongation of the pregnancy are estimated to be higher than those of prematurity and cesarean. In this case, labor induction can be discussed if the fetal vitality is normal. A continuous fetal heart monitoring during induction and labor is, in this case, strongly recommended. However, even in these optimal conditions, the risk of cesarean in case of labor induction for small for gestational age fetus before 37 weeks of gestation is of about 50 % in the rare published studies.
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Affiliation(s)
- G Kayem
- Service de gynécologie-obstétrique, centre hospitalier intercommunal de Créteil, université Paris XII, Créteil, France.
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Zhang J, Merialdi M, Platt LD, Kramer MS. Defining normal and abnormal fetal growth: promises and challenges. Am J Obstet Gynecol 2010; 202:522-8. [PMID: 20074690 DOI: 10.1016/j.ajog.2009.10.889] [Citation(s) in RCA: 176] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Revised: 07/06/2009] [Accepted: 10/29/2009] [Indexed: 11/27/2022]
Abstract
Normal fetal growth is a critical component of a healthy pregnancy and influences the long-term health of the offspring. However, defining normal and abnormal fetal growth has been a long-standing challenge in clinical practice and research. We review various references and standards that are used widely to evaluate fetal growth and discuss common pitfalls of current definitions of abnormal fetal growth. Pros and cons of different approaches to customize fetal growth standards are described. We further discuss recent advances toward an integrated definition for fetal growth restriction. Such a definition may incorporate fetal size with the status of placental health that is measured by maternal and fetal Doppler velocimetry and biomarkers, biophysical findings, and genetics. Although the concept of an integrated definition appears promising, further development and testing are required. An improved definition of abnormal fetal growth should benefit both research and clinical practice.
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Abstract
Fetal growth restriction (FGR) due to placental dysfunction has important short- and long-term impacts that may reach into adulthood. Early-onset FGR before 34 weeks' gestation shows a characteristic sequence of responses to placental dysfunction that evolves from the arterial circulation to the venous system and finally to biophysical abnormalities. In this form of FGR safe prolongation of pregnancy is a primary management goal, as gestational age at delivery, birth weight and iatrogenic premature delivery have an important impact on short-term outcome and neurodevelopment. Surveillance intervals should be adjusted based on umbilical artery and venous Doppler studies. Intervention thresholds need to be based on the balance of fetal vs. neonatal risks and therefore critically depend on gestational age. Late-onset FGR presents with subtle Doppler and biophysical abnormalities and therefore poses a diagnostic dilemma. Often unrecognized, term FGR contributes to a large proportion of adverse perinatal outcome. Monitoring intervals should be adjusted based on middle cerebral artery Doppler and fetal heart rate parameters. Delivery timing thresholds can be low. In both forms of FGR neurodevelopmental impacts of placental disease occur before clinical decisions regarding delivery timing arise. This places special emphasis on future preventative studies.
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Affiliation(s)
- Ahmet Alexander Baschat
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland, School of Medicine, Baltimore, MD 21201, USA.
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Abstract
BACKGROUND Cardiotocography (CTG) is a continuous recording of the fetal heart rate obtained via an ultrasound transducer placed on the mother's abdomen. CTG is widely used in pregnancy as a method of assessing fetal well-being, predominantly in pregnancies with increased risk of complications. OBJECTIVES To assess the effectiveness of antenatal CTG (both traditional and computerised assessments) in improving outcomes for mothers and babies during and after pregnancy. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2009). SELECTION CRITERIA Randomised and quasi-randomised trials that compared traditional antenatal CTG with no CTG or CTG results concealed; computerised CTG with no CTG or CTG results concealed; and computerised CTG with traditional CTG. DATA COLLECTION AND ANALYSIS Two authors independently assessed eligibility, quality and extracted data. MAIN RESULTS Six studies (involving 2105 women) are included. Overall, the included studies were not of high quality, and only two had both adequate randomisation sequence generation and allocation concealment. All studies that were able to be included enrolled only women at increased risk of complications.Comparison of traditional CTG versus no CTG showed no significant difference identified in perinatal mortality (risk ratio (RR) 2.05, 95% confidence interval (CI) 0.95 to 4.42, 2.3% versus 1.1%, four studies, N = 1627) or potentially preventable deaths (RR 2.46, 95% CI 0.96 to 6.30, four studies, N = 1627, though the meta-analysis was underpowered to assess this outcome. Similarly, there was no significant difference identified in caesarean sections (RR 1.06, 95% CI 0.88 to 1.28, 19.7% versus 18.5%, three trials, N = 1279) nor in the secondary outcomes that were assessed.There were no eligible studies that compared computerised CTG with no CTG.Comparison of computerised CTG versus traditional CTG showed a significant reduction in perinatal mortality with computerised CTG (RR 0.20, 95% CI 0.04 to 0.88, two studies, 0.9% versus 4.2%, 469 women, graph 3.1.1). However, there was no significant difference identified in potentially preventable deaths (RR 0.23, 95% CI 0.04 to 1.29, two studies, N = 469), though the meta-analysis was underpowered to assess this outcome. There was no significant difference identified in caesarean sections (RR 0.87, 95% CI 0.61 to 1.24, 63% versus 72%, one study, N = 59) or in secondary outcomes. AUTHORS' CONCLUSIONS There is no clear evidence that antenatal CTG improves perinatal outcome, but further studies focusing on the use of computerised CTG in specific populations of women with increased risk of complications are warranted.
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Affiliation(s)
- Rosalie M Grivell
- Discipline of Obstetrics and Gynaecology, The University of Adelaide, Women's and Children's Hospital, 72 King William Road, Adelaide, Australia, SA 5006
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Grivell RM, Alfirevic Z, Gyte GML, Devane D. Antenatal cardiotocography for fetal assessment. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2009. [DOI: 10.1002/14651858.cd007863] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Baschat AA, Viscardi RM, Hussey-Gardner B, Hashmi N, Harman C. Infant neurodevelopment following fetal growth restriction: relationship with antepartum surveillance parameters. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 33:44-50. [PMID: 19072744 DOI: 10.1002/uog.6286] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES To evaluate the relationship between fetal Doppler parameters, biophysical profile score (BPP) and neurodevelopmental delay at 2 years of corrected age in infants who had been growth-restricted in utero. METHODS This was a prospective observational study including 113 pregnancies complicated by intrauterine growth restriction (IUGR) (abdominal circumference<5th percentile and elevated umbilical artery (UA) pulsatility index). The relationships of UA, middle cerebral artery and ductus venosus (DV) Doppler features, BPP, birth acidemia (artery pH<7.0+/or base deficit>12), gestational age at delivery, birth weight and neonatal morbidity (i.e. bronchopulmonary dysplasia, >Grade 2 intraventricular hemorrhage, or necrotizing enterocolitis) with a 2-year neurodevelopmental delay were evaluated. Best Beginnings Developmental Screen, Bayley Scale of Infant Development II (BSID) and Clinical Adaptive/Clinical Linguistic Auditory Milestone Stage were used. BSID<70, cerebral palsy, abnormal tone, hearing loss and/or blindness defined neurodevelopmental delay. RESULTS Seventy-two of the 113 pregnancies completed assessment; there were 10 stillbirths, 19 neonatal deaths, three infant deaths and nine pregnancies with no follow-up. Twenty fetuses (27.8%) had UA reversed end-diastolic velocity (REDV), 34 (47.2%) abnormal DV Doppler features and 31 (43.1%) an abnormal BPP. Median gestational age at delivery and birth weight were 30.4 weeks and 933 g, respectively. Twelve infants had acidemia and 28 neonatal morbidity. There were 38 (52.8%) infants with neurodevelopmental delay, including 37 (51.4%) with abnormal tone, 20 (27.8%) with speech delay, 23 (31.9%) with an abnormal neurological examination, eight (11.1%) with a hearing deficit and six (8.3%) with cerebral palsy. Gestational age at delivery was associated with cerebral palsy (r2=0.52, P<0.0001; 92% sensitivity and 83% specificity for delivery at <27 weeks). UA-REDV was associated with global delay (r2=0.31, P=0.006) and birth weight with neurodevelopmental delay (r2=0.54, P<0.0001; 82% sensitivity and 64% specificity for BW<922 g). CONCLUSIONS Although UA-REDV is an independent contributor to poor neurodevelopment in IUGR no such effect could be demonstrated for abnormal venous Doppler findings or BPP. Gestational age and birth weight remain the predominant factors for poor neurodevelopment in growth-restricted infants.
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Affiliation(s)
- A A Baschat
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland, Baltimore, MD 21201-1703, USA.
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