Effect of absent end diastolic flow velocity in the fetal umbilical artery on subsequent outcome

A systematic review and meta-analysis of the role of Doppler ultrasonography of the superior mesenteric artery in detecting neonates at risk of necrotizing enterocolitis

The role of postnatal Doppler measurements of the superior mesenteric artery (SMA) in detecting neonates at risk of necrotizing enterocolitis (NEC) remains uncertain; therefore, we systematically reviewed and meta-analyzed the existing evidence regarding the usefulness of SMA Doppler measurements in detecting neonates at risk for NEC. We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, and we included studies which reported the following Doppler ultrasonography indices: peak systolic velocity, end-diastolic velocity, time average mean velocity, differential velocity, pulsatility index (PI) and resistive index. Eight studies were eligible for inclusion in the meta-analysis. Evidence suggested that, during the first postnatal day, neonates who developed NEC had a significantly higher peak systolic velocity (mean difference of 2.65 cm/s (95% confidence interval [CI] 1.23, 4.06, overall effect Z=3.66, P<0.001)), higher PI (mean difference of 1.52 (95% CI 0.00, 3.04, Z=1.96, P=0.05)) and higher resistive index (mean difference of 1.09 (95% CI 0.59, 1.60, Z=4.24, P<0.001)), compared to neonates who did not develop NEC. However, our findings do not support a strong association between the Doppler ultrasound indices and development of NEC at the time of disease onset. This meta-analysis suggests that first postnatal day SMA Doppler parameters, namely peak systolic velocity, PI and resistive index, are higher in neonates who develop NEC. On the other hand, the aforementioned indices are of uncertain significance once the diagnosis of NEC has been established.

Maternal Steroids on Fetal Doppler Indices, in Growth-Restricted Fetuses with Abnormal Umbilical Flow from Pregnancies Complicated with Early-Onset Severe Preeclampsia

Corticoids are largely used for fetal interest in expected preterm deliveries. This study went further, evaluating the effect of maternal administration of dexamethasone (Dex) on the umbilical artery (UA), middle cerebral artery (MCA), and ductus venous (DV) spectrum, in growth-restricted fetuses, with the absent end-diastolic flow (AEDF) in UA, from singleton early-onset severe preeclamptic pregnancies. Supplementary, the impact on both uterine arteries (UTAs) flow was also evaluated. In 68.7% of cases, the EDF was transiently restored (trAEDF group), in the rest of 31.2% remained persistent absent (prAEDF group). UA-PI significantly decreased in the first day after Dex (day 1/0; p < 0.05), reaching its minimum during day 2 (day 2/1; p > 0.05), revealing a significant recovery to day 4 (day 4/2; p < 0.05), in both groups. The MCA-PI decreased from day 1 until day 3 in both groups, but significantly only in the trAEDF group (p = 0.030 vs. p = 0.227. The DV-PI's decrease (during day 1) and the CPR's increase (between days 0 and 2) were not significant in both groups. UTAs-PIs did not vary. The prAEDF group had a significantly increased rate of antenatal worsening Doppler and a poorer perinatal outcome compared with the trAEDF group. In conclusion, Dex transiently restored the AEDF in UA in the majority of cases, a "positive" effect being a useful marker for better perinatal prognosis. UA-PI significantly decreased in all cases. The improvement in umbilical circulation probably was responsible for the short but not significant DV-PI reduction. MCA-PI decreased only in sensitive cases, probably due to an already cerebral "full" vasodilation in the prAEDF group. Furthermore, the CPR's nonsignificant improvement was the result of a stronger effect of Dex on UA-PI than on MCA-PI. Finally, despite the same etiology, it was only a weak correlation between the severity of the umbilical and uterine abnormal spectrum.

Dexamethasone on absent end-diastolic flow in umbilical artery, in growth restricted fetuses from early-onset preeclamptic pregnancies and the perinatal outcome

BACKGROUND

Absent end-diastolic flow (AEDF) in the umbilical artery (UA) worsens the already poor prognosis of growth-restricted fetuses (GRFs) in pregnancies complicated by early-onset preeclampsia with severe features (ESP).

METHOD

We assessed the correlation between the effect of maternal dexamethasone (Dex) on AEDF in the UA and perinatal outcomes, in 59 GRFs from EPS-complicated pregnancies. The maternal outcome was also evaluated.

RESULTS

The mean maternal age at inclusion was 22.4 ± 5.9 years. Dex transiently restored EDF in the UA in 38 (64.4%) cases (trAEDF group), but in 21 (35.6%) patients, the flow was persistently absent (prAEDF group). The effect lasted up to the 4th day.The gestational age at diagnosis, number of days from admission until delivery, and fetal weight were significantly lower in the prAEDF group than in the trAEDF group (p < .05). The same group had a significantly increased rate of fetal proximal deterioration, low APGAR scores, neonatal hypoxia, assisted ventilation, mild intraventricular haemorrhage (I/II), and respiratory distress syndrome, as well as maternal deterioration, especially in cases of resistant hypertension (p < .05). Although the rates of fetal acidemia and perinatal mortality in the prAEDF group were respectively three times and two times higher, the differences were not significant (p > .05).

CONCLUSIONS

The Dex no-effect on UA Doppler in GRFs with AEDF in the UA, in EPS-complicated pregnancies, can be a useful marker for a higher risk of proximal fetal deterioration, poor state at delivery, neonatal hypoxic complications, and worsening maternal condition, but not for perinatal mortality. The findings also highlight the alarmingly younger age of patients with EPS. Finally, all these pregnancies should be monitored in a complex multidisciplinary manner in tertiary referral units.Key messageThe effect of dexamethasone on absent end-diastolic flow in the umbilical artery in growth-restricted fetuses from pregnancies complicated by early-onset preeclampsia with severe features can be a useful prognostic factor for perinatal outcomes.

Abnormal Umblical Artery Doppler is Utilized for Fetuses with Intrauterine Growth Restriction Birth at 280/7-336/7 Gestational Weeks

Purpose: To compare short-term perinatal outcomes in preterm infants with intrauterine growth restriction (IUGR) in those with absent or reversed end-diastolic umbilical artery blood flow (AREDF) to those with normal end-diastolic umbilical artery blood flow (NEDF). Methods: This study included preterm births (28^0/7-33^6/7 gestational weeks) with IUGR with AREDF (n = 86) or NEDF (n = 27). Results: There were lower mean gestational weeks, birth weights, and a higher ratio of corticosteroid application in the AREDF group (p < 0.05). The mean length of neonatal intensive care unit stay of the AREDF group was significantly longer (p < 0.001). Sepsis and feeding intolerance ratios in the AREDF group were also significantly higher (p = 0.041 and p < 0.001 respectively). Conclusions: Patients with IUGR and umbilical Doppler abnormalities have longer neonatal intensive care unit stays.

ROS promote epigenetic remodeling and cardiac dysfunction in offspring following maternal engineered nanomaterial (ENM) exposure

BACKGROUND

Nano-titanium dioxide (nano-TiO2) is amongst the most widely utilized engineered nanomaterials (ENMs). However, little is known regarding the consequences maternal ENM inhalation exposure has on growing progeny during gestation. ENM inhalation exposure has been reported to decrease mitochondrial bioenergetics and cardiac function, though the mechanisms responsible are poorly understood. Reactive oxygen species (ROS) are increased as a result of ENM inhalation exposure, but it is unclear whether they impact fetal reprogramming. The purpose of this study was to determine whether maternal ENM inhalation exposure influences progeny cardiac development and epigenomic remodeling.

RESULTS

Pregnant FVB dams were exposed to nano-TiO2 aerosols with a mass concentration of 12.09 ± 0.26 mg/m3 starting at gestational day five (GD 5), for 6 h over 6 non-consecutive days. Aerosol size distribution measurements indicated an aerodynamic count median diameter (CMD) of 156 nm with a geometric standard deviation (GSD) of 1.70. Echocardiographic imaging was used to assess cardiac function in maternal, fetal (GD 15), and young adult (11 weeks) animals. Electron transport chain (ETC) complex activities, mitochondrial size, complexity, and respiration were evaluated, along with 5-methylcytosine, Dnmt1 protein expression, and Hif1α activity. Cardiac functional analyses revealed a 43% increase in left ventricular mass and 25% decrease in cardiac output (fetal), with an 18% decrease in fractional shortening (young adult). In fetal pups, hydrogen peroxide (H2O2) levels were significantly increased (~ 10 fold) with a subsequent decrease in expression of the antioxidant enzyme, phospholipid hydroperoxide glutathione peroxidase (GPx4). ETC complex activity IV was decreased by 68 and 46% in fetal and young adult cardiac mitochondria, respectively. DNA methylation was significantly increased in fetal pups following exposure, along with increased Hif1α activity and Dnmt1 protein expression. Mitochondrial ultrastructure, including increased size, was observed at both fetal and young adult stages following maternal exposure.

CONCLUSIONS

Maternal inhalation exposure to nano-TiO2 results in adverse effects on cardiac function that are associated with increased H2O2 levels and dysregulation of the Hif1α/Dnmt1 regulatory axis in fetal offspring. Our findings suggest a distinct interplay between ROS and epigenetic remodeling that leads to sustained cardiac contractile dysfunction in growing and young adult offspring following maternal ENM inhalation exposure.

Slow versus rapid enteral feed in preterm neonates with antenatal absent end diastolic flow

OBJECTIVE

Incidence of feed intolerance (FI) and necrotizing enterocolitis (NEC) in preterm neonates with Doppler evidence of absent end diastolic flow (AEDF) velocities in the fetal umbilical artery when enteral feed volumes were started by 6-72 h and advanced either slowly or rapidly.

METHODS

Stable inborn neonates, 30-36 weeks gestation, weighing ≥1000 g and with antenatal evidence of AEDF were included in this pilot study. Infants (stratified in <1250 g and ≥1250 g birth weight categories) were allocated under randomized controlled trial, to receive either slow or rapid advancement of enteral feeding, while initiating the feeds after 6 h of birth if bowel sounds were present. Primary outcome measure was, FI and NEC till day 7 after reaching full feeds.

RESULTS

Of 159 eligible infants, 83 were randomized: 53 infants in the ≥1250 g category (28 in rapid and 25 in slow group) and 30 in the <1250 g category (15 in each group). FI was present in 11% versus 16% in ≥1250 g (p = 0.570) and 27% versus 33% in <1250 g (p = 0.690), NEC developed in 8.4% (3 versus 1) in ≥1250 g and (1 versus 2) in <1250 g, in slow versus rapid feeding.

CONCLUSION

This trial did not find increase in incidence of feed intolerance with very early introduction and rapid advancement of enteral feeds in stable preterm neonates with AEDF and birth weight ≥1250 g.

Foetal Doppler abnormality is associated with increased risk of sepsis and necrotising enterocolitis in preterm infants

AIM

Fetoplacental Doppler abnormalities have been associated with increased neonatal mortality and morbidity. This study evaluated the associations between prenatal Doppler assessments and neonatal mortality and morbidity in premature infants born small for gestational age or after pre-eclampsia.

METHODS

This was a population-based study of infants born alive at 22(0) -33(6) weeks of gestation, a birthweight <10th percentile for gestational age and/or maternal pre-eclampsia. Doppler assessments of the umbilical artery, middle cerebral artery and ductus venosus were evaluated in 127, 125 and 95 cases, respectively. Circulatory compromise was defined as absent or reversed end-diastolic velocity in the umbilical artery (AREDF), middle cerebral artery pulsatility index <2.5 percentile for gestational age and ductus venosus pulsatility index for veins >97.5 percentile.

RESULTS

AREDF was present in 28% of the infants. This was associated with increased frequencies of neonatal sepsis and necrotising enterocolitis after adjusting for gestational age. Abnormal ductus venosus pulsatility index for veins was associated with increased risk of neonatal sepsis, but only in combination with AREDF. These associations were only present when gestational age was <28 weeks.

CONCLUSION

AREDF was associated with increased neonatal morbidity in premature infants born small for gestational age or after pre-eclampsia.

Feeding infants below 29 weeks' gestation with abnormal antenatal Doppler: analysis from a randomised trial

OBJECTIVE

To describe feeding and gastrointestinal outcomes in growth-restricted infants <29 weeks' gestation and to determine the rate of feed advancement which they tolerate.

DESIGN

Analysis of prospectively collected data from a randomised feeding trial, the Abnormal Doppler Enteral Prescription Trial (ADEPT).

SETTING

54 neonatal units in the UK and Ireland.

PARTICIPANTS

404 preterm, growth-restricted infants with abnormal antenatal Doppler studies from ADEPT. 83 infants <29 weeks and 312 infants ≥ 29 weeks' gestation were included in this analysis.

INTERVENTIONS

In ADEPT, infants were randomised to start milk 'early' on day 2 after birth, or 'late' on day 6. Subsequent feed advancement followed a regimen, which should have achieved full feeds by day 16 in the early and day 20 in the late group.

MAIN OUTCOME MEASURES

Full feeds were achieved later in infants <29 weeks; median age 28 days {IQR 22-40} compared with 19 days {IQR 17-23} in infants ≥ 29 weeks (HR 0.35, 95% CI 0.3 to 0.5). The incidence of necrotising enterocolitis was also higher in this group; 32/83 (39%) compared to 32/312 (10%) in those ≥ 29 weeks (RR 3.7, 95% CI 2.4 to 5.7). Infants <29 weeks tolerated very little milk for the first 10 days of life and reached full feeds 9 days later than predicted from the trial regimen.

CONCLUSIONS

Growth-restricted infants born <29 weeks' gestation with abnormal antenatal Doppler failed to tolerate even the careful feeding regimen of ADEPT. A slower advancement of feeds may be required for these infants.

TRIAL REGISTRATION NUMBER

ISRCTN87351483.

How to feed small for gestational age newborns

Feeding small for gestational age (SGA) newborns is extremely challenging and the neonatologist should be brave and cautious at the same time. Although these babies have a high risk of milk intolerance and necrotising enterocolitis, enteral feeding guidelines are not well established and practice varies widely among different neonatal units. Currently available studies on this topic include extremely and very low birth weight neonates, but are not focused specifically on small for gestational age infants. This review analyzes papers focused on feeding interventions in order to provide the best available evidences about the optimum timing for introduction of enteral feeding, how fast feed volume can be advanced, which milk and which feeding method is more appropriate in SGA infants.

Postnatal neuro-development of fetuses with absent end-diastolic flow in the umbilical artery and/or fetal descending aorta

OBJECTIVE

To determine whether absence of end-diastolic flow in the umbilical artery and/or fetal aorta impacts postnatal neuro-development in preterm-born children.

METHODS

The study group, consisting of 43 fetuses with absent end-diastolic flow in the umbilical artery and/or fetal aorta, was compared with a control group, consisting of 30 fetuses, matching for gestational age but with normal doppler-flow results. The children's neuro-developmental status was assessed using the 'Munich functional developmental diagnostics' (MFDD), between the 2nd and 3rd year of life.

RESULTS

Gestational age at birth was 33 + 6 weeks in the study group and 34 + 4 weeks in the control group. A brain-sparing effect was observed in 37.3% of fetuses in the study group compared with 10.0% in the control group (p = 0.014). For all seven MFDD domains, the number of children with deficiencies was higher in the study group. For the domains perception, active speech and comprehension this effect was statistically significant (p < 0.05). Overall, 30.2% of children in the study group and 16.7% of the control group had pathologic test results (p < 0.013).

CONCLUSION

Pathological doppler-flow in the umbilical artery and/or fetal descending aorta in preterm born children is associated with neuro-developmental deficiencies. Intensive pediatric care is recommended to mitigate these deficiencies during early childhood.

Prediction of feed intolerance and necrotizing enterocolitis in neonates with absent end diastolic flow in umbilical artery and the correlation of feed intolerance with postnatal superior mesenteric artery flow

OBJECTIVES

To evaluate the role of postnatal superior mesenteric artery (SMA) flow in predicting feed intolerance and NEC in the babies who had AEDF in comparison with gestation matched SGA and AGA with normal flow.

DESIGN

This was a prospective cohort study conducted in 62 eligible babies admitted in NICU. Babies were enrolled in 3 groups. Group 1 (n = 23) was SGA and AEDF, group 2 (n = 20) was SGA and group 3 (n = 19) was AGA and both with normal UA flow. In all babies baseline SMA flow was measured before test feed (0.5 ml) and repeated every 15 minutes for 1 hour after the feed.

RESULTS

Feed intolerance was seen in 69.5% of babies in group1 (p = <0.001) as compared to 20% and 17.5% in group 2 and 3. Four (17.3%) babies developed NEC in group1 (p = 0.02) but none in other 2 groups. Baseline peak systolic velocity (PSV) and time average mean velocity (TAMV) at 60 min post feed were significantly (p = 0.01 and 0.028 respectively) lower in group1 than group3. TAMV and PSV at 60 min post feed were significantly lower (p = 0.028 and 0.03) in babies with feed intolerance as compared to no feed intolerance group. Absent end diastolic flow and hypoglycemia were independent risk factors for feed intolerance.

CONCLUSION

SGA babies with AEDF had higher incidence of feed intolerance and NEC. Serial SMA flow studies specially the 60 min post feed study may help in differentiating which babies are likely to develop feed intolerance.

ADEPT - Abnormal Doppler Enteral Prescription Trial

BACKGROUND

Pregnancies complicated by abnormal umbilical artery Doppler blood flow patterns often result in the baby being born both preterm and growth-restricted. These babies are at high risk of milk intolerance and necrotising enterocolitis, as well as post-natal growth failure, and there is no clinical consensus about how best to feed them. Policies of both early milk feeding and late milk feeding are widely used. This randomised controlled trial aims to determine whether a policy of early initiation of milk feeds is beneficial compared with late initiation. Optimising neonatal feeding for this group of babies may have long-term health implications and if either of these policies is shown to be beneficial it can be immediately adopted into clinical practice.

METHODS AND DESIGN

Babies with gestational age below 35 weeks, and with birth weight below 10th centile for gestational age, will be randomly allocated to an "early" or "late" enteral feeding regimen, commencing milk feeds on day 2 and day 6 after birth, respectively. Feeds will be gradually increased over 9-13 days (depending on gestational age) using a schedule derived from those used in hospitals in the Eastern and South Western Regions of England, based on surveys of feeding practice. Primary outcome measures are time to establish full enteral feeding and necrotising enterocolitis; secondary outcomes include sepsis and growth. The target sample size is 400 babies. This sample size is large enough to detect a clinically meaningful difference of 3 days in time to establish full enteral feeds between the two feeding policies, with 90% power and a 5% 2-sided significance level. Initial recruitment period was 24 months, subsequently extended to 38 months.

DISCUSSION

There is limited evidence from randomised controlled trials on which to base decisions regarding feeding policy in high risk preterm infants. This multicentre trial will help to guide clinical practice and may also provide pointers for future research.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN: 87351483.

Antenatal umbilical Doppler abnormalities: an independent risk factor for early onset neonatal necrotizing enterocolitis in premature infants

BACKGROUND

Necrotizing enterocolitis (NEC) is the most common gastrointestinal (GI) emergency seen in neonatal units. Many factors have been considered as potentially important aetiologically, including gut ischaemia, sepsis and feeding. However, evidence remains equivocal.

OBJECTIVE

This study investigated whether preterm babies born to mothers with abnormal antenatal umbilical Dopplers (absent or reversed end diastolic flow--AREDF), that is exposed to antenatal gut ischaemia, are at an identical risk of developing NEC early in life, compared to babies born to mothers with normal Dopplers.

METHODS

All preterm (<or=32+6 week gestation) babies with no congenital anomaly, born to mothers resident in the county of Leicestershire in United Kingdom in 2001 and 2002 were identified using the Trent Neonatal Survey (TNS). Clinical data including the presence and severity of any NEC were extracted from the notes.

RESULTS

Two hundred forty-three preterm babies who met the criteria were identified during the period. Babies in whom umbilical Dopplers were not available and babies that died in the first 48 h were excluded. Complete data was thus available for 206 of these babies. A strong relation between AREDF and subsequent development of NEC was noted in these babies (OR: 5.88, 95% CI: 2.41 to 14.34, p<0.0001). This association still held after adjustment for gestational age at birth (OR: 7.64, 95% CI: 2.96 to 19.70, p<0.0001) and after adjustment for birthweight for gestational age z-score (OR: 6.72, 95% CI: 2.23 to 20.25, p=0.0007).

CONCLUSIONS

This study, based on a neonatal cohort, indicates that AREDF is an important independent risk factor for the production of NEC.

Management of preterm infants with intrauterine growth restriction

Preterm intrauterine growth restriction (IUGR) is strongly associated with increased mortality and morbidity. In the management of these infants, complications of preterm birth can be amplified by the effect of suboptimal fetal growth. It is important that pregnancies with IUGR are detected before birth, so that delivery can be arranged in a high-risk maternity unit with the appropriate neonatal staff in attendance. The provision of full support for resuscitation and stabilisation of these infants is crucial to the short-term and long-term health of these infants, who have suffered chronic hypoxia and malnutrition in utero. The long term outcome studies of these infants are retrospective and they include SGA infants. The effects of prematurity affect the outcome of IUGR infants. IUGR is associated with cerebral palsy in those delivered more than 32 weeks gestation. Infants less than 32 weeks of gestation may have poor developmental outcome if the head growth is affected, these infants may have associated cognitive and behavioural problems. Children who fail to grow by 2-4 years are at risk of long term growth problems. This paper outlines the acute and long-term management of these infants.

Feeding growth restricted preterm infants with abnormal antenatal Doppler results

Absence or reversal of end diastolic flow (AREDF) in the umbilical artery is associated with poor outcome, and elective premature delivery is common. Feeding these infants is a challenge. They often have poor tolerance of enteral feeding, and necrotising enterocolitis may develop. This review explores current practice to see if there is evidence on which to base guidelines. The incidence of necrotising enterocolitis is increased in infants with fetal AREDF, especially when complicated by fetal growth restriction. Abnormalities of splanchnic blood flow persist postnatally, with some recovery during the first week of life, providing justification for a delayed and careful introduction of enteral feeding. Such a policy exposes babies to the risks of parenteral nutrition, with no trials to date showing any benefit of delayed enteral nutrition. Trials are required to determine the optimum timing for introduction of enteral feeds in growth restricted infants with fetal AREDF.

The management of large and small for gestational age fetuses

The major influence on birth weight is gestational age. At any given week of gestation, however, size varies enormously. There is no specific cut-off that separates abnormally large or small babies for gestational age from normal. Instead, function alters as a continuum across the weight distribution. Small babies are prone to hypoxia, acidosis, and stillbirth. Large babies on the other hand are associated with prolonged labor and mechanical problems. The optimum size for fetal survival is 1 to 1.5 standard deviations above the mean, whereas cesarean section rates are lowest when the fetal weight is 0.5 to 1.5 standard deviations below the mean. Antenatal detection of both very small and very large babies is difficult and imprecise. Expectant management is therefore preferable unless there are very specific indications for emergency or operative delivery.

Absent or reversed end-diastolic blood flow in the umbilical artery and abnormal Doppler cerebroplacental ratio--cognitive, neurological and somatic development at 3 to 6 years

The objective of this study was to examine the cognitive, neurological and somatic developments of children who had in utero an absent or reversed end-diastolic blood flow (ARED) in the umbilical artery or an abnormal cerebroplacental ratio (ABF).

METHODS

16 children with ARED blood flow and 15 children with ABF were each matched to children with the same gestational age, appropriate for gestational age, the same sex and born within 4 months. Data were assessed at the age of 3-6 years. Children with asphyxia, neonatal infection, malformation or major surgical interventions in the neonatal period were excluded. Each child underwent a neuropediatrical examination; furthermore, a Kaufman Assessment Battery for Children, a Snijders-Oomen Intelligence Scale for Children and a Man-Drawing Test were used to evaluate cognitive development. The socioeconomic status was also assessed.

RESULTS

Children in the ARED group remained lighter and had a higher frequency of microcephaly. In the Kaufman Assessment Battery for Children and the Snijders-Oomen Intelligence Scale for Young Children, cognitive development was impaired in the ARED and the ABF groups compared to the control group. The ARED and the ABF groups, however, showed no differences. The Man-Drawing Test and the Denver Development Test did not show any differences.

DISCUSSION

ARED blood flow and ABF showed impaired cognitive development. The degree of impairment was the same in the ARED and the ABF groups. Long-term follow-up studies until adulthood are necessary to see if impaired cognitive development remains significant in these groups of patients.

Early feeding advancement in very low-birth-weight infants with intrauterine growth retardation and increased umbilical artery resistance

BACKGROUND

To investigate whether intrauterine growth retardation (birth weight <10th percentile), increased umbilical artery resistance (resistance index >90th percentile measured by Doppler velocimetry), or brain sparing (increased umbilical artery resistance and decreased middle cerebral artery resistance index <5th percentile) were associated with early feeding intolerance in very low-birth-weight (VLBW, <1,500 g) infants.

METHODS

From July 1999 to December 2000, 124 inborn VLBW infants were enrolled in a prospective trial evaluating early enteral nutrition after a standardized feeding protocol (daily feeding advancement, 16 mL/kg birth weight). Feeding tolerance was assessed as the age at which full enteral feeds (150 mL/kg daily) were achieved. Data are shown as median, 25th, and 75th percentiles.

RESULTS

Full enteral feeds were achieved at 15 days (range, 12-21 days) of age for all infants. Intrauterine growth retardation (full enteral feeding achieved at 14 days; range, 12-21 days), increased umbilical artery resistance (full enteral feeding achieved at 14 days; range, 11-16 days), and brain sparing (full enteral feeding achieved at 15 days; range, 14-20 days) were not associated with early feeding intolerance.

CONCLUSION

Very low-birth-weight infants with intrauterine growth retardation, increased umbilical artery resistance, and brain sparing tolerated enteral feeding as well as appropriate-for-gestational-age VLBW infants.

Outcome of 88 pregnancies with absent or reversed end-diastolic blood flow (ARED flow) in the umbilical arteries

OBJECTIVES

To investigate both perinatal and postneonatal morbidity and mortality in fetuses with absent or reversed end-diastolic flow (ARED flow) in the umbilical artery.

STUDY DESIGN

A 5 year prospective follow-up of 88 fetuses with ARED flow.

RESULTS

Sixteen stillbirths, 16 neonatal deaths, six postneonatal deaths and one death at 2 years of age were noted. Out of the 42 fetuses born alive, 36 showed a normal neurological development whereas six were mentally handicapped. Adverse prognosis was more frequently found in the group with absent end-diastolic flow at first examination and then reversed flow until delivery, compared to the groups of always absent or always reversed end-diastolic flows.

CONCLUSIONS

Prompt delivery is recommended in these high-risk pregnancies in order to prevent long-term sequelae, obviously depending on the local limits of viability. Further studies appropriately designed for assessing long-term neurodevelopment of fetuses with ARED flow, although demanding, are mandatory.