Fetal Growth Restriction - Diagnostic Work-up, Management and Delivery

Cerebroplacental versus Umbilicocerebral Ratio-Analyzing the Predictive Value Regarding Adverse Perinatal Outcomes in Low- and High-Risk Fetuses at Term

Background and Objectives: The aim of this study was to investigate the prediction of adverse perinatal outcomes using the cerebroplacental (CPR) and umbilicocerebral (UCR) ratios in different cohorts of singleton pregnancies. Materials and Methods: In this retrospective cohort study, we established our own Multiple of Median (MoM) for CPR and UCR. The predictive value for both ratios was studied in the following outcome parameters: emergency cesarean delivery, operative intervention (OI), OI due to fetal distress, 5-min Apgar < 7, admission to neonatal intensive care unit, and composite adverse perinatal outcome. The performance of the ratios was assessed in the following cohorts: total cohort (delivery ≥ 37 + 0 weeks gestation, all birth weight centiles), low-risk cohort (delivery ≥ 37 + 0 weeks gestation, birth weight ≥ 10. centile), prolonged pregnancy cohort (delivery ≥ 41 + 0 weeks gestation, birth weight ≥ 10. centile) and small-for-gestational-age fetuses (delivery ≥ 37 + 0 weeks gestation, birth weight < 10. centile). The underlying reference values for MoM were estimated using quantile regression depending on gestational age. Prediction performance was evaluated using logistic regression models assessing the corresponding Brier score, combining discriminatory power and calibration. Results: Overall, 3326 cases were included. Across all cohorts, in the case of a significant association between a studied outcome parameter and CPR, there was an association with UCR, respectively. The Brier score showed only minimal differences for both ratios. Conclusions: Our study provides further evidence regarding predictive values of CPR and UCR. The results of our study suggest that reversal of CPR to UCR does not improve the prediction of adverse perinatal outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Exploration of fetal growth restriction induced by vitamin D deficiency in rats via Hippo-YAP signaling pathway

INTRODUCTION

Maternal vitamin D deficiency (VDD) is associated with intrauterine growth restriction (IUGR), but the exact mechanism remains unclear. Here we explored the mechanism through which VDD induced IUGR.

METHODS

Female SD rats were fed a control normal diet (VD > 800 IU/Kg) or VDD diet (VD: 0 IU/Kg) for 8 weeks. Then, females were mated with 12-week-old male SD rats, and fetal and placental tissue were collected on the gestational day 13 (GD13) or 18 (GD18) to analyze the effects of VDD on pregnancy outcome and embryonic development. In vitro, the VDR gene of HTR-8/SVneo cells was knocked down to establish VDD model. Then, HTR-8/SVneo cells were treated with the MST1/2 inhibitor XMU-MP-1 or 0.1 μM/L calcitriol for 24 h (h). The mechanism of Hippo-YAP signaling pathway in VDD-induced placental dysplasia was further investigated by western blot, invasion assay, wound healing assay and Hoechst/PI staining.

RESULTS

The IUGR of the pregnant rats in the VDD group was significant, the placental structure and function were damaged, and there was an obvious inflammatory response, accompanied by a significant increase in the level of the transcription co-activator YAP phosphorylation. In vitro, VDD significantly inhibited the migratory and invasive abilities of HTR-8/SVneo cells, accompanied by decreased EMT capacity and increased apoptosis. When intervening with XMU-MP-1 in advance, we found that the effects of VDD were neutralized by Hippo-YAP signaling blocker.

DISCUSSION

Maternal VDD causes placental dysplasia and IUGR, and these abnormal changes may be associated with the activation of Hippo-YAP signaling pathway.

Induction of Labor at Term with Oral Misoprostol or as a Vaginal Insert and Dinoprostone Vaginal Insert – A Multicenter Prospective Cohort Study

Introduction The efficacy, safety, and perinatal outcome of oral misoprostol (OM), a misoprostol vaginal insert (MVI), and a dinoprostone vaginal insert (DVI) for induction of labor at term was examined in a prospective multicenter cohort study (ethics committee vote 4154–07/14). The primary aims of the study were the induction-birth interval (IBI), the cumulative delivery rates after 12 h, 24 h, and 48 h as well as the mode of delivery.

Method 322 pregnant women were included in four German tertiary perinatal centers (MVI 110, DVI 64, OM 148). They did not vary in age or BMI. Statistical analysis was carried out using a multivariate linear regression analysis and binary logistic regression analysis.

Results With regards to the median IBI, MVI and OM were equally effective and superior to the DVI (MVI 823 min [202, 5587]; DVI 1226 min [209, 4909]; OM 847 min [105, 5201]; p = 0.006). Within 24 hours, 64% were able to deliver with DVI, 85.5% with MVI and 87.5% with OM (p < 0.01). The rates of secondary Caesarean sections (MVI 24.5%; DVI 26.6%; OM 18.9%) did not differ significantly. Uterine tachysystole was found in 20% with MVI, 4.7% with DVI and 1.4% with OM (p < 0.001). A uterine rupture did not occur in any of the cases. Perinatal acidosis occurred (umbilical cord arterial pH < 7.10) in 8.3% with MVI, 4.7 with DVI and 1% with OM (p = 0.32). Neonatal condition was only impaired in three cases (5-minute Apgar score < 5).

Summary Induction of labor at term using the prostaglandins misoprostol and dinoprostone is an effective intervention that is safe for the mother and child. Oral application of misoprostol demonstrated the highest efficacy while maintaining a favorable safety profile.

Pr-AKI: Acute Kidney Injury in Pregnancy – Etiology, Diagnostic Workup, Management

Despite significant improvements in inpatient and outpatient management, pregnancy-related acute kidney injury (Pr-AKI) remains an important risk factor for early and late maternal and fetal morbidity and mortality. There is a discrepancy between the incidence of Pr-AKI in developing and in developed countries, with the former experiencing a decrease and the latter an increase in Pr-AKI in recent decades. Whereas septic and hemorrhagic complications predominated in the past, nowadays hypertensive disorders and thrombotic microangiopathy are the leading causes of Pr-AKI. Modern lifestyles and the availability and widespread use of in-vitro fertilization techniques in industrialized countries have allowed more women of advanced age to become pregnant. This has led to a rise in the percentage of high-risk pregnancies due to the disorders and comorbidities inherent to or accompanying aging, such as diabetes, arterial hypertension and preexisting chronic kidney disease. Last but not least, the heterogeneity of symptoms, the often overlapping clinical and laboratory characteristics and the pathophysiological changes related to pregnancy make the diagnosis and management of Pr-AKI a difficult and challenging task for the treating physician. In addition to general supportive management strategies such as volume substitution, blood pressure control, prevention of seizures or immediate delivery, each disease entity requires a specific therapy to reduce maternal and fetal complications. In this review, we used the current literature to provide a summary of the physiologic and pathophysiologic changes in renal physiology which occur during pregnancy. In the second part, we present common and rare disorders which lead to Pr-AKI and provide an overview of the available treatment options.

Use of intravoxel incoherent motion MRI to assess placental perfusion in normal and Fetal Growth Restricted pregnancies on their third trimester

INTRODUCTION

Intravoxel Incoherent Motion (IVIM) MRI is a non-invasive, in vivo techniques which can assess placental perfusion quantitatively, and be useful for evaluating placental microcirculation. Our primary aim was to investigate whether fetal growth restriction (FGR) pregnancies have different placental perfusion and diffusion compared with normal pregnancies using IVIM. A secondary aim was to investigate correlations between placental IVIM parameters and gestational age in normal pregnancy.

METHODS

This study population included 17 FGR pregnancies and 36 normal pregnancies between 28 + 3 to 38 + 0 weeks. All women underwent a MRI examination including an IVIM sequence with 9 b-values on a 3.0 T MRI system. The standard diffusion coefficeint (D), pseudodiffusion (D*) and perfusion fraction (f) were calculated.

RESULTS

Placental f was significantly lower in the FGR group than that in the normal group (33.96 ± 2.62(%) vs 38.48 ± 5.31(%), p = 0.002). Placental D and D* in two groups showed no statistical significance (P > 0.05). Placental f moderately increased with increasing gestational age in normal pregnancies (r = 0.411, p = 0.013), and there existed a negative correlation between D values and gestational age (r = -0.390, p = 0.019).

DISCUSSION

The f values are able to distinguish FGR from normal pregnancies. It can be uses as a feasible index to evaluate placenta perfusion. Gestational age-associated changes in placental IVIM parameters likely reveal trajectories of microvascular perfusion fraction and diffusion characteristics in the normal developing placenta.

Adverse perinatal outcomes in fetuses with severe late-onset fetal growth restriction

OBJECTIVE

To evaluate perinatal outcomes in fetuses with severe late-onset fetal growth restriction.

METHODS

This was a retrospective and observational cohort study in which pregnant women diagnosed with late-onset fetal growth restriction assisted at perinatal maternity birth from 2010 to 2017 were included. The outcomes were intensive care unit (ICU) admission and perinatal complications, such as neonatal death, intraventricular hemorrhage, periventricular leukomalacia, hypoxic-ischemic encephalopathy, necrotizing enterocolitis, bronchopulmonary dysplasia, and sepsis.

RESULTS

We selected 277 pregnant women, of whom 124 newborns (44.76%) went to the ICU. The chance of a newborn needing ICU decreases by 62, 7, and 9% according to an increase of one gestational week, 1 cm of the abdominal circumference, or 1 cm of the amniotic fluid index, respectively. Oligohydramnios increases the risk of going to the ICU by 2.13 times. The increase in the umbilical artery pulsatility index (PI) Doppler increases the chance of ICU admission by 7.9 times. The normal middle cerebral artery PI Doppler and the normal cerebroplacental ratio reduce the risk of ICU admission.

CONCLUSION

The estimated fetal weight, abdominal circumference, and amniotic fluid index diagnosed severe late-onset fetal growth restriction. With the decrease in middle cerebral artery PI Doppler, there is a greater probability of admission to the ICU, with the most common complications being intraventricular hemorrhage and necrotizing enterocolitis.

Doppler Ultrasonography of the Fetal Tibial Artery in High-Risk Pregnancy and Its Value in Predicting and Monitoring Fetal Hypoxia in IUGR Fetuses

Background and Objectives: Intrauterine growth restriction (IUGR) is the term used to describe a fetus whose estimated weight is less than the 10th percentile of its age growth curve. IUGR is the second most common cause of perinatal death. In many cases there is a deficiency in the standardization of optimal management, prenatal follow-up and timing of delivery. Doppler examination is the most sensitive test that can assess the condition of the fetus and indicate fetal intrauterine hypoxia. Numerous studies of the fetal intrauterine state focus on the umbilical artery and the fetal cerebral blood vessels, while the peripheral arteries have so far received insufficient attention. Materials and Methods: We present a case of an IUGR fetus monitored with a non-stress test (NST) and a Doppler examination of the fetal arteries (tibial, umbilical, middle cerebral and uterine) and the ductus venosus. In this case the first early sign of fetal hypoxia was revealed by blood flow changes in the tibial artery. Results: We hypothesize that peripheral vascular changes (in the tibial artery) may more accurately reflect the onset of deterioration in the condition of the IUGR fetus, such that peripheral blood flow monitoring ought to be employed along with other techniques already in use. Conclusion: This paper describes the clinical presentation of an early detection of late IUGR hypoxia and claims that blood flow changes in the tibial artery signal the worsening of the fetus’s condition.

miRNAs and Their Gene Targets-A Clue to Differentiate Pregnancies with Small for Gestational Age Newborns, Intrauterine Growth Restriction, and Preeclampsia

Despite the differences in the clinical manifestations of major obstetric syndromes, such as preeclampsia (PE) and intrauterine growth restriction (IUGR), their pathogenesis is based on the dysregulation of proliferation, differentiation, and invasion of cytotrophoblast cells that occur in the developing placenta, decidual endometrium, and myometrial parts of the spiral arteries. To understand the similarities and differences in the molecular mechanisms of PE and IUGR, samples of the placental bed and placental tissue were analyzed using protein mass spectrometry and the deep sequencing of small RNAs, followed by validation of the data obtained by quantitative RT-PCR in real time. A comparison of the transcriptome and proteomic profiles in the samples made it possible to conclude that the main changes in the molecular profile in IUGR occur in the placental bed, in contrast to PE, in which the majority of molecular changes occurs in the placenta. In placental bed samples, significant changes in the ratio of miRNA and its potential target gene expression levels were revealed, which were unique for IUGR (miR-30c-5p/VIM, miR-28-3p/VIM, miR-1-3p/ANXA2, miR-30c-5p/FBN1; miR-15b-5p/MYL6), unique for PE (miR-185-3p/FLNA), common for IUGR and PE (miR-30c-5p/YWHAZ and miR-654-3p/FGA), but all associated with abnormality in the hemostatic and vascular systems as well as with an inflammatory process at the fetal‒maternal interface.

Curcumin: Could This Compound Be Useful in Pregnancy and Pregnancy-Related Complications?

Curcumin, the main polyphenol contained in turmeric root (Curcuma longa), has played a significant role in medicine for centuries. The growing interest in plant-derived substances has led to increased consumption of them also in pregnancy. The pleiotropic and multi-targeting actions of curcumin have made it very attractive as a health-promoting compound. In spite of the beneficial effects observed in various chronic diseases in humans, limited and fragmentary information is currently available about curcumin’s effects on pregnancy and pregnancy-related complications. It is known that immune-metabolic alterations occurring during pregnancy have consequences on both maternal and fetal tissues, leading to short- and long-term complications. The reported anti-inflammatory, antioxidant, antitoxicant, neuroprotective, immunomodulatory, antiapoptotic, antiangiogenic, anti-hypertensive, and antidiabetic properties of curcumin appear to be encouraging, not only for the management of pregnancy-related disorders, including gestational diabetes mellitus (GDM), preeclampsia (PE), depression, preterm birth, and fetal growth disorders but also to contrast damage induced by natural and chemical toxic agents. The current review summarizes the latest data, mostly obtained from animal models and in vitro studies, on the impact of curcumin on the molecular mechanisms involved in pregnancy pathophysiology, with the aim to shed light on the possible beneficial and/or adverse effects of curcumin on pregnancy outcomes.