Perinatal and 2-year neurodevelopmental outcome in late preterm fetal compromise: the TRUFFLE 2 randomised trial protocol

INTRODUCTION

Following the detection of fetal growth restriction, there is no consensus about the criteria that should trigger delivery in the late preterm period. The consequences of inappropriate early or late delivery are potentially important yet practice varies widely around the world, with abnormal findings from fetal heart rate monitoring invariably leading to delivery. Indices derived from fetal cerebral Doppler examination may guide such decisions although there are few studies in this area. We propose a randomised, controlled trial to establish the optimum method of timing delivery between 32 weeks and 36 weeks 6 days of gestation. We hypothesise that delivery on evidence of cerebral blood flow redistribution reduces a composite of perinatal poor outcome, death and short-term hypoxia-related morbidity, with no worsening of neurodevelopmental outcome at 2 years.

METHODS AND ANALYSIS

Women with non-anomalous singleton pregnancies 32+0 to 36+6 weeks of gestation in whom the estimated fetal weight or abdominal circumference is <10th percentile or has decreased by 50 percentiles since 18-32 weeks will be included for observational data collection. Participants will be randomised if cerebral blood flow redistribution is identified, based on umbilical to middle cerebral artery pulsatility index ratio values. Computerised cardiotocography (cCTG) must show normal fetal heart rate short term variation (≥4.5 msec) and absence of decelerations at randomisation. Randomisation will be 1:1 to immediate delivery or delayed delivery (based on cCTG abnormalities or other worsening fetal condition). The primary outcome is poor condition at birth and/or fetal or neonatal death and/or major neonatal morbidity, the secondary non-inferiority outcome is 2-year infant general health and neurodevelopmental outcome based on the Parent Report of Children's Abilities-Revised questionnaire.

ETHICS AND DISSEMINATION

The Study Coordination Centre has obtained approval from London-Riverside Research Ethics Committee (REC) and Health Regulatory Authority (HRA). Publication will be in line with NIHR Open Access policy.

TRIAL REGISTRATION NUMBER

Main sponsor: Imperial College London, Reference: 19QC5491. Funders: NIHR HTA, Reference: 127 976. Study coordination centre: Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS with Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University. IRAS Project ID: 266 400. REC reference: 20/LO/0031. ISRCTN registry: 76 016 200.

Is there still a role for nuchal translucency measurement in the changing paradigm of first trimester screening?

Objectives

To give an overview of the genetic and structural abnormalities occurring in fetuses with nuchal translucency (NT) measurement exceeding the 95th percentile at first‐trimester screening and to investigate which of these abnormalities would be missed if cell‐free fetal DNA (cfDNA) were used as a first‐tier screening test for chromosomal abnormalities.

Methods

This is a national study including 1901 pregnancies with NT≥95th percentile referred to seven university hospitals in the Netherlands between 1 January 2010 and 1 January 2016. All cases with unknown pregnancy outcome were excluded. Results of detailed ultrasound examinations, karyotyping, genotyping, pregnancy and neonatal outcomes, investigation by a clinical geneticist and post‐mortem investigations were collected.

Results

In total, 821 (43%) pregnancies had at least one abnormality. The rate of abnormalities was 21% for fetuses with NT between 95^th and 99^th percentile and 62% for fetuses with NT≥99^th percentile. Prevalence of single‐gene disorders, submicroscopic, chromosomal and structural abnormalities was 2%, 2%, 30% and 9%, respectively.

Conclusion

Although cfDNA is superior to the combined test, especially for the detection of trisomy 21, 34% of the congenital abnormalities occurring in fetuses with increased NT may remain undetected in the first trimester of pregnancy, unless cfDNA is used in combination with fetal sonographic assessment, including NT measurement.

What's already known about this topic?

Nuchal translucency is associated with a wide range of chromosomal and structural abnormalities.

What does this study add?

If cell‐free DNA were used as the only first trimester screening test, 34% of fetal congenital abnormalities would be missed in the first trimester of pregnancy.

In high‐risk pregnancies with increased nuchal translucency (NT≥95^th percentile), 23% of abnormalities are found in fetuses with NT between 95^th and 99^th percentile.

Facial shape; height and width in the second and third trimester of pregnancy

OBJECTIVES

The objective of this study is to calculate on 3D volumes obtained from 16 weeks' gestation normative data of facial height (FH), facial width (FW) and their ratio and to test these parameters in pathological cases.

METHODS

In total, 228 volumes were analyzed: 207 from normal and 21 from pathological cases. After multiplanar correction to the exact midsagittal plane FH was measured from the nasion to the gnathion and FW between the most lateral points on the zygomatic arch.

RESULTS

For both FH and FW the intra- and inter-observer intraclass correlation coefficient variability was 0.99 and the difference between paired measurements was less than 0.3 cm in 95% of the cases. FH increased from 1.48 to 5.08 cm (FH = -16.10 + 3.78 × log(GA), R²: 0.93) and FW from 2.20 to 6.42 cm (FW: 4.19-17.18 × log(GA), R²: 0.85). The ratio increased steadily until about 25 weeks and less thereafter (ratio: (1/GA) × 26.44 + 0.92, R²: 0.23). In pathological cases 16.6% of measurements were outside the normal range.

CONCLUSIONS

This study provides normative data for FH and FW measurements and insight in normal facial growth after 16 weeks' gestation. FH exceeds FW growth especially before 25 weeks.

3-Phenyl-4H-furo[3,2-C]chromen-4-one

The crystal structure of the title compound, C(17)H(10)O(3), is the first example of a furocoumarin containing three fused rings. The tricyclic furocoumarin fragment is perfectly planar. The phenyl substituent forms a dihedral angle of 39.52 (8) degrees with the plane of the tricyclic system. The crystal packing involves centrosymmetric dimers interconnected by strong pi-interactions between their furo[3,2-c]coumarin fragments [at distances of 3.42 (4) A].

Second trimester ultrasound markers for fetal aneuploidy

Most fetuses with major chromosomal abnormalities have either external or internal defects that can be recognized by detailed ultrasonographic examination. These are defined as ultrasound markers for fetal chromosomal defects. In case of trisomy 13, 18, Turner's syndrome and triploidy, what we would consider as ultrasound markers are often major defects. In contrast, in Down's syndrome fetuses the structural defects are subtle and often isolated. Ultrasound screening programs for this trisomy are based on a systematic search for specific markers. Chromosomal anomalies are more common in fetuses with multisystem malformation. In fact the risk of a fetal aneuploidy increases with the number of detected defects. Other important prognostic factors are maternal age and gestational age. For every single structural abnormality it is possible to estimate the specific risk of this being a phenotypic expression of a chromosomal defect according to whether it is isolated or associated to more structural defects. This risk will also be influenced by the maternal age and the gestational age.