Can increased nuchal translucency in the first trimester of pregnancy predict gestational diabetes mellitus

Increased nuchal translucency and pregnancy outcomes: experience of Başkent University Ankara Hospital

Objective:

First trimester nuchal translucency (NT) measurement is considered to be an important tool in antenatal follow-up. This study aimed to evaluate the outcomes of pregnancies with increased NT at Başkent University Ankara Hospital between 2004 and 2016.

Materials and Methods:

Patients with NT measurements ≥1.5 multiples of median (MoM) were divided into two groups; group I included increased NT cases without fetal anomalies (either abnormal fetal karyotype or congenital structural anomalies) or loss (intrauterine fetal death), and group II included increased NT cases with fetal anomalies or loss. The groups were compared with each other with respect to maternal demographic features and NT measurements.

Results:

Karyotype analyses were normal in 73.1% of cases with increased NT (57/78). Among those, 21.1% (12/57) had structural anomalies, and to specify, 9.6% (5/52 over 18 weeks) had cardiac anomalies. Although maternal demographic features did not differ significantly, NT measurements, both as millimeters and MoM, were significantly higher in group II (p<0.05). According to the receiver operating characteristic (ROC) curves, the optimal cut-off values for NT measurements for predicting fetal anomalies or loss were 3.05 mm and 2.02 MoM. NT measurement >7 millimeters or NT MoM >4.27 resulted in poor fetal outcomes without exception.

Conclusion:

Higher NT measurements indicate poorer pregnancy outcomes. Our study indicates that fetal echocardiography must be considered for all cases with increased NT.

Fetal nuchal translucency: is there an association with birthweight and neonatal wellbeing?

Objective

To evaluate the relationship between nuchal translucency (NT) values with birthweight and the wellbeing of the newborn.

Materials and Methods

This retrospective cohort study that included 508 patients made use of data on healthy full-term, singleton, live birth newborns in a university hospital between 2016 and 2018. The relationship between the NT multiple of the median (MoM) value and maternal body mass index, birthweight, sex, need for neonatal intensive care unit (NICU), and APGAR scores was evaluated. Similarly, the relationship between birthweight and NT MoM, and biochemical data in the first trimester was also evaluated.

Results

There was a positive correlation between NT and birthweight (p<0.001). The need for NICU admission increased (p=0.001), and APGAR 1st minute scores decreased (p=0.001) with increasing NT, and APGAR 5th minute scores remained unchanged (p=0.057).

Conclusion

The present study identified a positive correlation between first trimester NT and birthweight, and a negative correlation with the wellbeing of the neonate.

Is there any relationship between adverse pregnancy outcome and first trimester nuchal translucency measurements in normal karyotype fetuses?

AIM

This study aims to research whether there is a relationship between first trimester nuchal translucency (NT) measurements and pregnancy complications such as gestational diabetes mellitus (GDM), gestational hypertension (GHT), intrauterine growth restriction (IUGR) and oligohydramnios.

METHOD

This study included 225 singleton pregnancies attending Canakkale Onsekiz Mart University Obstetrics and Gynecology clinic for all monitoring and examinations, and gave birth at our clinic between January 2011 and December 2012. Data sources were clinical records and the hospital's automation system, and the study was planned as retrospective cohort. NT measurement was made between 10 weeks 3 days and 13 weeks 6 days gestation. For data analysis, the chi-square, Mann-Whitney U test and Spearman correlation were used.

RESULTS

Of pregnancies, in the study, 5 (2.2%) developed GDM, 6 (2.6%) developed GHT, 2 (0.89%) developed IUGR and 10 (4.4%) developed oligohydramnios. There was no correlation identified between NT measurements and development of GDM, GHT, IUGR and oligohydramnios.

CONCLUSION

There was no relationship found between first trimester NT measurements and complications that could develop in pregnancy. For the first time in the literature, NT and oligohydramnios were studied and no relationship was observed.

First-trimester screening for large-for-gestational-age infants

OBJECTIVES

To examine the relationship between newborn birth weight and first-trimester uterine artery (UtA) pulsatility index (PI), maternal characteristics, serum pregnancy-associated plasma protein-A (PAPP-A), free β-human chorionic gonadotropin (β-hCG) and fetal nuchal translucency (NT) thickness. We also examined the results of screening for large-for-gestational-age (LGA) neonates by an integrated first-trimester approach incorporating these parameters.

METHODS

We evaluated maternal characteristics, fetal NT, PAPP-A, free β-hCG and UtA-PI in 2097 singleton pregnancies at 11 + 0 to 13 + 6 weeks' gestation. Linear models based on quasi Akaike's Information Criterion were used to determine the best predictive model for fetal birth weight. The patient-specific risk of delivering an LGA infant was derived from multiple logistic regression analysis and the performance of screening was determined by receiver-operating characteristics curve analysis.

RESULTS

The best predictive models for fetal birth weight included UtA-PI, PAPP-A, NT, parity, maternal age, smoking status, weight, height and free β-hCG. In pregnancies delivering LGA newborns compared with non-LGA pregnancies, PAPP-A and NT thickness were significantly increased (P = 0.016 and 0.001, respectively) and UtA-PI was significantly decreased (P = 0.011). A combination of maternal factors with PAPP-A, fetal NT and UtA-PI identified 34.4% of LGA newborns for a false-positive rate of 10%.

CONCLUSIONS

This study showed an association between newborn birth weight and maternal factors, and first-trimester PAPP-A, β-hCG, fetal NT and UtA-PI. Together, these factors can be used to identify over a third of pregnancies that will deliver LGA infants.

First trimester prediction of small- and large-for-gestation neonates by an integrated model incorporating ultrasound parameters, biochemical indices and maternal characteristics

OBJECTIVE

To identify maternal/pregnancy characteristics, first trimester ultrasound parameters and biochemical indices which are significant independent predictors of small-for-gestational age (SGA) and large-for-gestational age (LGA) neonates.

DESIGN

Retrospective cross-sectional study.

SETTING

Two fetal Medicine Units.

POPULATION

4 702 singleton pregnancies presenting for screening for chromosomal abnormalities by nuchal translucency and maternal serum biochemistry at 11-14 weeks.

METHODS

Reference ranges for birthweight applied to our population were constructed by the Royston and Wright method. Multiple logistic regression was applied to develop first trimester prediction models for SGA and LGA.

MAIN OUTCOME MEASURES

Birth of SGA or LGA neonate.

RESULTS

Maternal height, parity, smoking, assisted conception, delta crown-rump length, delta nuchal translucency, free beta human chorionic gonadotrophin and pregnancy-associated plasma protein-A were significant independent predictors of SGA. Maternal weight and height, smoking, delta crown-rump length and delta nuchal translucency were significant independent predictors of LGA. Models for SGA (AUC=0.7296, CI: 0.69-0.76, p<0.0001) and LGA (AUC=0.6901, CI: 0.65-0.72, p<0.0001) were derived, applicable to routine obstetric population at low risk for these conditions. For 20% screen positive rate the modeling achieves sensitivities of about 55% for SGA and 48% for LGA neonates.

CONCLUSION

Prediction for birthweight deviations is feasible using data available at the routine 11-14 weeks' examination. Delta CRL and delta nuchal translucency were significant independent predictors for both SGA and LGA.

Does nuchal translucency thickness in the first trimester predict GDM onset during pregnancy?

BACKGROUND AND AIMS

This study was planned to evaluate whether increased nuchal translucency (NT) thickness in the first trimester of gestation can be related to onset of gestational diabetes mellitus (GDM) during pregnancy.

METHODS

From January 2006 to August 2008, a group of 678 singleton pregnancies who had developed GDM has been selected as a study group among a total of 3966 pregnant women who had undergone first trimester screening for aneuploidies at 11-14 weeks of gestation. A group of 420 single pregnant women with physiological pregnancy were enrolled as control group. Both fetal structural and karyotype's anomalies were excluded in the two groups. NT was mesured by a Fetal Medicine Foundation certificated operator; GDM was diagnosed at 24-28 weeks of gestation following Carpenter and Coustan criteria. In the analyses of continuos variables, study and control group were compared by Student's t-test and Anova test.

RESULTS

There was no significative difference (p = 0.585) between NT values in the study (mean = 1.56) and control group (mean = 1.54).

CONCLUSIONS

NT thickness does not show a significative increase in those women who subsequently develop GDM. Therefore, NT assessment does not prove to be an useful ultrasound parameter for predicting GDM onset during pregnancy.

Increased nuchal translucency is associated with large for gestational age neonates in singleton pregnancies

OBJECTIVE

To evaluate the correlation between sonographic measurements of nuchal translucency (NT) and neonatal birth weight in non-diabetic population.

METHODS

A retrospective analysis was performed on all singleton term pregnancies delivered at our hospital between 2004 and 2008. Data collected included maternal age, parity, NT measurement, results of glucose challenge test, birth weight, gestational age at delivery, and fetal gender.

RESULTS

The study population comprised of 1649 patients. The mean NT was 1.3 ± 0.5 mm. Male fetuses had a significantly thicker NT (1.3 ± 0.5 vs. 1.2 ± 0.4; P<0.001). NT significantly correlated to birth weight (P=0.002). This correlation was independent of neonatal gender. The median NT in the large for gestational age (LGA) neonates was significantly higher than in the non-LGA neonates (1.4 mm vs. 1.2 mm, P=0.001). Equations for the predicted probability for delivering LGA neonates were derived using either NT alone or in combination with parity. An increase in 0.1 mm in the NT has the odd ratio of 1.042 for delivering an LGA neonate (P=0.02).

CONCLUSIONS

NT correlated with LGA neonates in term non-diabetic patients. This correlation was independent of the neonatal gender. The predictive clinical impact of NT was limited to LGA neonates.

Sonographic evaluation and the pregnancy complicated by diabetes

Sonography is a fundamental tool in the management of pregnancies affected by maternal diabetes. Purposeful use of ultrasound in each trimester provides an invaluable amount of information about the developing fetus including gestational age and growth patterns, anatomical structure and function, assessment of fetal well-being, and prediction of adverse outcome. There are great ongoing research efforts in this field of prenatal diagnosis and management, yet even more are needed.

Fetal cardiac function between 11 and 35 weeks' gestation and nuchal translucency thickness

OBJECTIVES

The pathophysiological background of an increased nuchal translucency (NT) is still poorly understood. Cardiac dysfunction has been proposed as a cause. The aim of this study was to determine if, in fetuses with normal hearts, the NT thickness is related to cardiac function throughout gestation.

METHODS

The NT was measured in 191 karyotypically/phenotypically normal fetuses with structurally normal hearts and was increased (≥ 95(th) centile) in 104. All fetuses had been referred for fetal echocardiography and were prospectively included between October 1 2003 and April 1 2009. Three-hundred and ten echocardiograms were performed between 11 and 35 weeks' gestation. The E- and A-wave velocity, E/A velocity ratio, E/time velocity integral (TVI) ratio over the atrioventricular (AV) valves, myocardial performance index, acceleration time (AT) and peak velocity over the semilunar valves, stroke volume (SV) and cardiac output (CO) as well as the ductus venosus pulsatility index for veins at 11-14 weeks' gestation (DV-PIV), were measured. A multilevel analysis was performed using the NT multiples of the median (MoM) as a continuous variable.

RESULTS

AV-E- and A-wave velocities, E/A velocity ratios, semilunar valve peak velocity, SV, CO and aortic valve (AoV) AT increased significantly with advancing gestation. At 11-14 weeks' gestation, the AoV-AT, tricuspid valve (TV)-E/A, TV-E/TVI ratios and DV-PIV increased, and the pulmonary valve (PV) AT decreased, with increasing NT-MoMs. After midgestation, the PV-AT increased and the AoV-AT, TV-E/A and TV-E/TVI ratios decreased with increasing NT-MoMs.

CONCLUSIONS

NT thickness is related to right ventricular diastolic function and semilunar valve AT. Our findings suggest improved first-trimester, but later reduced, right ventricular relaxation and discordant ventricular afterload in fetuses with an increased NT.

First-trimester prediction of macrosomia

OBJECTIVE

To determine if combinations of maternal characteristics and measurements of parameters used in screening for aneuploidies at 11-13 weeks provide significant prediction of macrosomia.

METHOD

Maternal characteristics, fetal nuchal translucency (NT), free β-human chorionic gonadotrophin (β-hCG) and pregnancy-associated plasma protein-A (PAPP-A) were recorded at 11(+0)-13(+6) weeks in 36,743 singleton pregnancies. Regression analysis was used to determine if in predicting macrosomia significant contributions are provided by maternal factors, fetal NT, free β-hCG and PAPP-A.

RESULTS

The risk for macrosomia increased with maternal weight and height and was higher in parous women with previous delivery of a macrosomic baby and in those with diabetes mellitus; the risk was lower in women of African and South Asian racial origins, in cigarette smokers and in those with chronic hypertension. In the macrosomic group compared to the unaffected group there were higher Δ-NT (0.167 vs. 0.116 mm), free β-hCG (1.010 vs. 0.964 MoM) and PAPP-A (1.103 vs. 1.003 MoM). Prediction of macrosomia provided by maternal factors was significantly improved by fetal NT, free β-hCG and PAPP-A (34.4 vs. 33.1% at a false-positive rate of 10%).

CONCLUSION

Prediction of macrosomia is provided in the first trimester of pregnancy by a combination of maternal characteristics and measurements of parameters used in screening for aneuploidies.

Individualized norms of optimal fetal growth: fetal growth potential

OBJECTIVE

To demonstrate that individualized optimal fetal growth norms, accounting for physiologic and pathologic determinants of fetal growth, better identify normal and abnormal outcomes of pregnancy than existing methods.

METHODS

In a prospective cohort of 38,033 singleton pregnancies, we identified 9,818 women with a completely normal outcome of pregnancy and characterized the physiologic factors affecting birth weight using multivariable regression. We used those physiologic factors to individually predict optimal growth trajectory and its variation, growth potential, for each fetus in the entire cohort. By comparing actual birth weight with growth potential, population, ultrasound, and customized norms, we calculated for each fetus achieved percentiles, by each norm. We then compared proportions of pregnancies classified as normally grown, between 10th and 90th percentile, or aberrantly grown, outside this interval, by growth potential and traditional norms, in 14,229 complicated pregnancies, 1,518 pregnancies with diabetes or hypertensive disorders, and 1,347 pregnancies with neonatal complications.

RESULTS

Nineteen physiologic factors, associated with maternal characteristics and early placental function, were identified. Growth potential norms correctly classified significantly more pregnancies than population, ultrasound, or customized norms in complicated pregnancies (26.4% compared with 18.3%, 18.7%, 22.8%, respectively, all P<.05), pregnancies with diabetes or hypertensive disorders (37.3% compared with 23.0%, 28.0%, 34.0%, respectively, all P<.05) and neonatal complications (33.3% compared with 19.7%, 24.9%, 29.8%, respectively, all P<.05).

CONCLUSION

Growth potential norms based on the physiologic determinants of birth weight are a better discriminator of aberrations of fetal growth than traditional norms.

LEVEL OF EVIDENCE

II.

Nuchal Translucency and First Trimester Risk Assessment

First-trimester risk assessment for fetal aneuploidy using nuchal translucency (NT) measurement is rapidly gaining popularity in the United States. In combination with maternal serum markers in the first trimester, the screening performance is exceptionally good, with detection rates of more than 80% at a screen positive rate of 5%. Recently, the method has been validated for screening for Down syndrome and other aneuploidies in multicenter trials in the United States and elsewhere. Compliance with established criteria for measurement of the NT is essential to achieve uniform reliability and high screening test sensitivity. There is an international consensus about the importance of specific training in the NT examination, conformity to standards of NT measurement, and regular audit for quality assurance. In the United States, the Nuchal Translucency Quality Review program has been developed to administer credentialing and quality review for registered practitioners. The Nuchal Translucency Quality Review credentials signify the proficiency of the sonographer or sonologist in NT measurement and participation in a regular quality assurance audit. We encourage accreditation of clinical sites offering first-trimester risk assessment to ensure the highest quality care.