Alteration of vascularization in preeclamptic placentas measured by three-dimensional power Doppler ultrasound

Effects of different PCOS phenotypes on placental three-dimensional power Doppler indices and placental volume during the first trimester

INTRODUCTION

The aim of the present study was to evaluate the effects of different polycystic ovary syndrome (PCOS) phenotypes using first-trimester placental three-dimensional power Doppler indices and placental volume.

METHODS

In this prospective case-control study, 170 pregnant women who met the inclusion criteria were divided into five groups according to PCOS phenotype: non-PCOS control (n = 34), PCOS phenotype A (n = 34), PCOS phenotype B (n = 34), PCOS phenotype C (n = 34), and PCOS phenotype D (n = 34). The primary outcomes determined in the present study were the differences in placental volume and placental flow index (FI), vascularization flow index (VFI), vascularization index (VI), and uterine artery pulsatility index (PI) betweenthe PCOS groups and control group.

RESULTS

The mean placental volume and VI were significantly decreased in the phenotype A, B, and C groups compared to the control group and PCOS phenotype D group. The mean FI and VFI were significantly decreased in the phenotype A and B groups compared to the control group and PCOS phenotype C and D groups. The mean testosterone, dehydroepiandrostenedione, sex-hormone binding globulin, free androgen index, and insulin resistance levels were significantly increased in the phenotype A, B, and C groups compared to the control group and PCOS phenotype D group.

DISCUSION

The results indicated that placental volume and placental vascular Doppler indices in the first trimester were more adversely affected in the PCOS A and B phenotypes than other PCOS phenotypes.

Effect of maternal hypertensive disorders during pregnancy on offspring's early childhood body weight: A population-based cohort study

OBJECTIVE

The prevalence of hypertensive disorder during pregnancy (HDP) and childhood obesity is increasing worldwide. HDP or obesity in mothers can increase the risk of overweight/obesity (OWOB) in their children. Few longitudinal studies have examined the associations of maternal body weight with the growth and risk factors for overweight in infants born to mothers with HDP. This study examined the risk factors for childhood OWOB through the age of 66 months in children born to mothers with HDP.

MATERIALS AND METHODS

In total, 24,200 pairs of mothers and their children were selected from the Taiwan Birth Cohort Study. The children's body weights were classified and analyzed to determine infant growth at birth and at the ages of 12, 24, 36, and 66 months. Multiple logistic regression analyses with different model settings were performed to identify the factors affecting growth and childhood OWOB in the children of mothers with HDP.

RESULTS

The average birth weight of children was lower in the HDP group than in the non-HDP group. The catch-up phenomenon began at the age of 18 months. The incidence of OWOB was higher in the children in the HDP group than in those in the non-HDP group from the age of 24 months and increased with the children's age. At every age point, maternal overweight before pregnancy was the main risk factor for childhood OWOB, and this effect increased with the children's age (odds ratio [OR]: 1.83 at 66 months). The effect of excessive maternal gestational weight gain on childhood OWOB was significant (OR: 1.26-1.44 for various age points).

CONCLUSION

Maternal overweight is the main risk factor for OWOB in children born to mothers with HDP. After adjusting for related confounders, we determined that HDP did not exert a significant effect on the risk of childhood OWOB.

PLACENTAL HEMODYNAMIC ASSESSMENT IN WOMEN WITH SEVERE PREECLAMPSIA IN SECOND- AND THIRD-TRIMESTER PREGNANCY BY 3D POWER QUANTITATIVE DOPPLER ULTRASOUND

Objective: The present study analyzed the fetal–placental hemodynamic parameters in women with severe preeclampsia in second- and third-trimester pregnancy with a view to developing effective predictive indicators for preeclampsia and providing support for the prenatal clinical treatment of preeclampsia. Materials and Methods: From January 2015 to January 2019, 160 pregnant women diagnosed with severe preeclampsia at Xiangyang First People’s Hospital were recruited as the study group. The diagnostic criteria for preeclampsia were in accordance with the guidelines of the International Society for the Study of Hypertension in Pregnancy (ISSHP). A sample of 160 healthy pregnant women with normal blood pressure were selected as the control group. The GE Voluson E8 and E10 four-dimensional (4D) ultrasonic diagnostic instruments and the three-dimensional (3D) power Doppler in angio-quantitative mode were used to measure the hemodynamic parameters of the placenta, left uterine artery (LUA), right uterine artery (RUA), middle cerebral artery (MCA), umbilical artery (UA), and ductus venosus (DV) in the two groups. The above parameters were analyzed statistically using SPSS 22.0. Results: The systolic/diastolic velocity ratio (S/D), pulsatility index (PI), and resistance index (RI) of the MCA in the study group were lower than those of normal subjects of the same gestational age (P < 0.05). These parameters in the UA were higher in the study group than those in normal subjects (P < 0.05). The ratios between the peak ventricular systolic velocity and the peak atrial systolic velocity (S/A), pulsatility index for the vein (PIV), pre-load index (PLI), and peak velocity index for the vein (PVIV) in the DV were significantly different between the study and normal groups (P < 0.05). The placental vascularization index (VI), flow index (FI), and vascularization flow index (VFI) were lower in the study group than those in normal subjects of the same gestational age (P < 0.05). There were good correlations between VI, VFI and RUA, PI, with correlation coefficients of −0.697 and −0.702, respectively. FI was the indicator that had the highest diagnostic efficacy for severe preeclampsia. The predictive sensitivity of the FI with a cut-off value of 34.92 was 96.3%, and the corresponding specificity was 86.9%. Conclusions: Placental FI had the highest predictive efficacy for severe preeclampsia and provides a reliable quantitative indicator and data support for preeclampsia management. 3D power quantitative Doppler ultrasound provides a novel avenue for the study of severe preeclampsia.

First-trimester screening for early preeclampsia risk using maternal characteristics and estimated placental volume

OBJECTIVE

The purpose of this study was to evaluate the strategy of screening for preeclampsia (PE) in the first trimester based on maternal characteristics, and estimated placental volume (EPV).

METHODS

A prospective cohort study was performed with 351 women enrolled, of which 13 women developed PE. This study analyzed the risk of PE according to ultrasonography findings of the placenta, maternal characteristics, and serum markers. The placental ultrasound exam and maternal serum pregnancy-associated plasma protein A (PAPP-A) was determined at 11⁺⁰ to 13⁺⁶weeks and the serum alpha-fetoprotein (MSAFP), human chorionic gonadotropin (hCG), unconjugated estriol (uE₃), and inhibin A were assayed at 14⁺⁰ to 22⁺⁰weeks. We reviewed all antenatal medical screening records and assessed the relationships of EPV of ultrasound examination, maternal characteristics, and serum markers by using multiple logistic regression analysis.

RESULTS

Thirteen of the 351 women (3.7%) developed PE in singleton pregnancy. The gestational age at delivery was significantly different between the normal and PE group (p < .001). In the PE group, the placental weight at delivery was not statistically different between the normal and the PE group. The EPV at the first trimester was significantly lower in women with PE compared to those without PE (p = .002). In addition, we predicted PE using combined maternal age, BMI, and EPV, which were achieving an area under the curve of 0.83 overall.

CONCLUSION

A risk prediction model of PE, which combined maternal age, BMI, and EPV can be adopted for the screening of PE at the first trimester in singleton pregnancy.

Placental Pulsatility: Quantitative Assessment of Placental Bed Vasculature by 2-Dimensional Doppler Cine Imaging

OBJECTIVES

Vascular resistance is known to be one of the determinants of pulsatile flow. This study aimed to investigate whether quantitative 2-dimensional Doppler ultrasound can capture and evaluate the pulsatility within the placental bed vasculature.

METHODS

The placental bed vasculature was imaged by directional power Doppler ultrasound. Ten-second cine clips were recorded by using standardized machine settings. A region of interest with a prominent Doppler signal in the uteroplacental interface was analyzed for the percentage of vascularity to generate a time-vascularity waveform. A vascular pulsatility index representing variation over the cardiac cycle was calculated by the ratio of the systolic-diastolic difference in vascularity to the mean vascularity. The acquisitions were repeated with 6 different pulse repetition frequencies (PRFs) and 3 wall motion filter (WMF) settings to evaluate their impact on the Doppler measurements.

RESULTS

Ten sets of cine clips were analyzed for this study. The pulsatile nature of the vascularity was readily apparent in each cine clip. The measured time-vascularity waveforms showed uniform cyclic variation in vascularity over the cardiac cycle, with systolic vascularity significantly higher than diastolic vascularity at each combination of PRF and WMF (P < .05). A gradual increase in the vascular pulsatility index was observed with an increasing PRF or WMF. Normalization of systolic-to-diastolic measurement provided a stable vascular assessment across the range of PRFs.

CONCLUSIONS

Doppler cine clips provide a dynamic representation of the placental bed vasculature and a novel analytic approach to quantitatively evaluating the pulsatility of this critical vascular network. Further work is warranted to explore the reproducibility and clinical potential of this approach.

Placental vascularization indices and prediction of pre-eclampsia in high-risk women

OBJECTIVE

To assess ability of first and second trimester Placental Vascularization Indices (PVIs) to predict pre-eclampsia (PE) in high-risk pregnancies.

METHOD

PVIs derived from 3-Dimensional power Doppler imaging were measured at 11+0-13 + 6 (n = 194) and 19+0-21 + 6 weeks (n = 195). Logistic regression (LR) models used PE as the outcome. To quantify added value of PVIs to baseline characteristics in predicting PE, integrated discrimination improvement (IDI) and net reclassification improvement (NRI) indices were calculated.

RESULTS

Overall rate of PE was 12% (n = 26). Lower first trimester PVIs were seen in women with PE (mean, SD); Vascularization Index (VI,%): 10.0 (6.2) v 14.7 (7.6), P = 0.005, Flow Index (FI): 37.7 (9.1) v 42.9 (10.4), P = 0.03, Vascularization Flow Index (VFI): 3.8 (2.5) v 6.6 (4.0), P < 0.001). All first trimester PVIs predicted PE in LR models adjusted for covariates. IDI and NRI analyses confirmed added clinical utility of VI (IDI 0.05, P = 0.004; NRI 0.66, P < 0.001) and VFI (IDI 0.06, P = 0.004; NRI 0.53, P = 0.91). In the second trimester, FI was lower in women with PE (39.6 (9.1) v 44.4 (8.6), P = 0.01) and predicted PE in adjusted LR models (standardised OR 0.53, 95% CI 0.29-0.97, P = 0.04). FI discriminated between cases and non-cases of PE (IDI 0.04, P = 0.04).

CONCLUSION

First trimester placental vascularization indices (VI, FI and VFI) have the potential to predict PE in high-risk pregnancies, with FI remaining predictive in the second trimester.

Comparison of placental three-dimensional power Doppler indices and volume in the first and the second trimesters of pregnancy complicated by gestational diabetes mellitus

Objective: To compare the changes of placental three-dimensional power Doppler indices and volume in the first and the second trimesters of pregnancy with gestational diabetes mellitus (GDM). Methods: This was a prospective case-control study of singleton pregnancies with risk factors for GDM. Data on placental vascular indices including vascularization index (VI), flow index (FI), and vascularization flow index (VFI), as well as placental volume were obtained and analyzed during the first and the second trimesters between pregnant women with and without GDM. Results: Of the 155 pregnant women enrolled, 31 developed GDM and 124 did not. VI and VFI were significantly lower in the GDM group during the first and second trimesters (VI: p = .023, and VFI: p = .014 in the first trimester; VI: p = .049, and VFI: p = .031 in the second trimester). However, the placental volume was similar in both the groups during the first trimester, while it was significantly increased in the GDM group during the second trimester (p = .022). There were no significant differences in FI and uterine artery pulsatility index between the two groups. After adjustments in multivariate logistic regression analysis, significant differences were observed in the first trimester VFI (adjusted odds ratio (OR) 0.76, 95% confidence interval (CI) 0.61-0.93), second trimester VFI (adjusted or 0.83, 95%CI 0.71-0.96), and second trimester placental volume (adjusted or 1.03, 95%CI 1.01-1.05). Conclusions: Placental vascular indices can provide an insight into placental vascularization in GDM during early pregnancy. VFI rather than placental volume may be a sensitive sonographic marker in the first trimester of GDM placentas.

Three dimensional power Doppler of the placenta and its clinical applications

The aim of this review is to discuss three dimensional (3D) power Doppler of the placenta and its clinical applications. There is a strong clinical need to develop noninvasive, simple and widely available methods of evaluating in vivo placental function to assess fetal wellbeing. While conventional ultrasound is a proven tool in the evaluation of fetal structural anomalies and health, its ability to assess placental function, especially prior to the onset of fetal compromise, is the subject of ongoing investigation. Three dimensional power Doppler has the ability to detect vascularity and blood flow with greater detail than conventional ultrasound, which has led to its investigation in preeclampsia, fetal growth restriction, and other placental vascular abnormalities. While more data are needed on the optimal imaging protocol and its predictive ability for clinical outcomes, 3D power Doppler is emerging as a promising new technology that will improve the evaluation of placental function.

First trimester placental volume and vascular indices in pregnancies complicated by preeclampsia

OBJECTIVE

To analyze placental volume and vascularization at first trimester in women with pre-eclampsia, and secondarily, the effect of maternal characteristics on placental development and perinatal outcomes.

METHODS

This was a prospective cohort study including women seen between 11 and 14 weeks of pregnancy. Biophysical and biochemical markers included in the screening program for aneuploidy were recorded. Placental volume and vascularization indices were obtained using three-dimensional power-Doppler imaging and Virtual Organ Computer-aided Analysis (VOCAL) techniques.

RESULTS

We compared 84 women with pre-eclampsia versus 904 non-affected. Placental volume and all vascular indices were lower in those with pre-eclampsia. Multivariate analysis showed that parity and maternal weight had a significant effect on placental volume and vascularization indices (p = 0.004 and p = 0.011). In women with pre-eclampsia, multiparity showed a negative effect on placental volume, gestational age, birth weight and Apgar test score. By contrast, in the non-affected group, multiparity had a protective effect. Low maternal weight had a significantly worse effect on placental vascularization and perinatal outcomes in women with pre-eclampsia.

CONCLUSIONS

Women with pre-eclampsia showed significantly lower placental volume and vascularization indices at first trimester. Multiparity and low maternal weight independently exacerbated the negative effects of pre-eclampsia on placental characteristics and perinatal outcomes. © 2015 John Wiley & Sons, Ltd.

Placental vascularization alterations in hypertensive disorders complicating pregnancy (HDCP) and small for gestational age with HDCP using three-dimensional power doppler in a prospective case control study

Background

Hypertensive disorders complicating pregnancy (HDCP) continues to be a leading cause of maternal and neonatal mortality and morbidity. The clinical value of placental three-dimensional power Doppler (3DPD) in assessing HDCP requires further confirmation. The research was developed to assess changes of placental vascularity in HDCP using 3DPD and to investigate the placental vascularity in small for gestational age (SGA) compared with not-SGA in patients with HDCP.

Methods

There were 126 normotensive and 128 hypertensive pregnant women included in this prospective case–control study from March 2011 to March 2013. Pregnant women underwent 3DPD. Vascularization index (VI), flow index (FI) and vascularization flow index (VFI) were obtained. The placental 3DPD indices, umbilical artery systolic and diastolic ratio (S/D) and pregnancy outcomes were compared between the groups.

Results

The placental VI and VFI were significantly lower in hypertensive women compared with normotensive women (P < 0.001 and P = 0.014, respectively), and these parameters were significantly reduced in severe preeclampsia (P < 0.001 and P = 0.003, respectively). A weak correlation was found between VI and umbilical artery S/D in HDCP group (r = -0.277, P = 0.001). In HDCP population, neonates who were postnatally diagnosed with SGA had lower VI (P = 0.041) and higher S/D (P < 0.001).

Discussion

The placental vascularity indices decreased in hypertensive women and the reduction inplacental perfusion was consistent with the severity of the hypertensive disorder. The associations betweenplacental vascularization and umbilical artery impedance may be valuable for further researches and arerequired confirmation. The significant differences in the 3DPD placental vascularization between SGA andnot-SGA in hypertensive pregnancy population may show some clinical importance that we could use tobetter assess or predict the progression and adverse outcomes in the future. Although 3DPD quantificationhas been widely used in multiple publications, we have to acknowledge its limitations.

Conclusions

The intraplacental vascularization was poor in HDCP, and especially in severe preeclampsia. Neonates with SGA had poor placental vascularization and higher umbilical artery S/D. Further studies should focus on the clinical assessment of placental 3DPD as well as a combination of placental 3DPD and other fetal Doppler indices to better predict the development and outcomes of preeclampsia.

First-trimester 3-dimensional power Doppler placental vascularization indices from the whole placenta versus the placental bed to predict preeclampsia: does pregnancy-associated plasma protein a or uterine artery Doppler sonography help?

OBJECTIVES

The purpose of this study was to compare the use of vascular indices derived from the whole placenta to those from the placental bed only for predicting preeclampsia and to determine whether the addition of pregnancy-associated plasma protein A (PAPP-A) and mean uterine artery Doppler values improves prediction.

METHODS

We conducted a secondary analysis of a prospective cohort of women with singletons between 11 and 14 weeks' gestation undergoing sonography for aneuploidy screening. Placental vascularization indices from the whole placenta versus the placental bed were combined with first-trimester maternal serum PAPP-A levels, mean uterine artery Doppler values, or the combination of both to predict the development of preeclampsia or early preeclampsia (delivery <34 weeks). The predictive ability of each vascular index was calculated by using areas under receiver operating characteristic curves. The sensitivity of the model for predicting preeclampsia and early preeclampsia at fixed false-positive rates of 10% and 20% was calculated.

RESULTS

Of 570 women, 48 (8.4%) had preeclampsia, and 10 (1.7%) had early preeclampsia. The area under the curve and sensitivity values for the prediction of preeclampsia or early preeclampsia were not different when evaluating the whole placenta versus the placental bed. Additionally, there was no significant improvement when adding PAPP-A, uterine artery Doppler values, or both. The variables in the model were more sensitive for the prediction of early preeclampsia than preeclampsia.

CONCLUSIONS

Although placental bed vascular indices are modestly predictive of preeclampsia, the addition of PAPP-A and uterine artery Doppler values to vascularization indices in the whole placenta or the placental bed did not significantly improve their predictive ability.

Three-dimensional ultrasonographic placental volume in gestational diabetes mellitus

OBJECTIVES

We aimed to evaluate the placental volume and placental mean gray value in gestational diabetes mellitus (GDM) and healthy placentas using three-dimensional (3D) ultrasound and Virtual Organ Computer-aided AnaLysis (VOCAL).

METHODS

This case-control prospective study consisted of 39 singleton pregnancies complicated by GDM and 42 healthy singleton pregnancies matched for gestational age, maternal age and parity. Placental volume and placental volumetric mean gray values were evaluated. The placental volume (cm(3)) was analyzed using the VOCAL imaging analysis program and 3D histogram was used to calculate the volumetric mean gray value (%).

RESULTS

Placental volume was significantly larger in GDM (411.59 ± 170.82 versus 343.86 ± 128.94 cm(3); p = 0.046). There was no significant difference in mean gray value between GDM and healthy placentas (36.65 ± 7.02 versus 38.71 ± 7.91, respectively; p = 0.277). Placental volume was significantly correlated with gestational week (r = 0.219, p = 0.035) and parity (r = 0.228, p = 0.048). There was negative significant relation between placental volume and umbilical artery systolic/diastolic ratio, pulsatility index and resistance index (r = -0.278, p = 0.007; r = -0.315, p = 0.002; r = -0.322, p = 0.001, respectively).

CONCLUSIONS

Placental volume increases significantly in GDM, whereas mean gray values do not alter significantly. These data may reflect the placental changes in GDM placentas that may help to understand the pathophysiology better.

[Placental 3D Doppler angiography: current and upcoming applications]

The placental dysfunction, which seems to be caused by a defect of trophoblastic invasion and impaired uterine vascular remodeling since the first trimester, is responsible in a non-exclusive way for the chronic placental hypoxia, resulting secondarily in the intra-uterine growth restriction (IUGR) and/or pre-eclampsia (PE). The quality of utero-placental vasculature is essential for a proper fetal development and a successful progress of pregnancy. However, the in vivo assessment of placental vascularization with non-invasive methods is complicated by the small size of placental terminal vessel and its complex architecture. Moreover, imaging with contrast agent is not recommended to pregnant women. Until recently, the fetal and maternal vascularization could only be evaluated through pulse Doppler of uterine arteries during pregnancy, which has little clinical value for utero-placental vascularization defects assessment. Recently, a non-invasive study, without use of contrast agent for vasculature evaluation of an organ of interest has become possible by the development of 3D Doppler angiography technique. The objective of this review was to make an inventory of its current and future applications for utero-placental vasculature quantification. The main findings of the literature on the assessment of utero-placental vascularization in physiological situation and major placental vascular dysfunction pathologies such as PE and IUGR were widely discussed.