Doppler Finding, Cardiovascular Function Assessment, and Fetuses' Survival Following the Fetoscopic Laser in Twin-to-Twin Transfusion Syndrome

Introduction: This study aimed to evaluate the effectiveness of selective laser photocoagulation of communicating vessels (SLPCV) on cardiac function in twins with twin-to-twin transfusion syndrome (TTTS). Methods: This retrospective cohort study evaluated 178 women with twin pregnancies complicated with TTTS and scheduled for SLPCV between 16 and 26 weeks of gestation. The severity of TTTS was determined by Quintero staging and the severity of cardiovascular disorders by the CHOP (Children's Hospital of Philadelphia) score. Patient survival was evaluated through a one-month-after-birth follow-up of fetuses. Results: The study revealed significant improvements in Doppler indices in both donors and recipients after SLPCV. The CHOP score also significantly decreased after the intervention. One-month-after-birth survival rates were 55.1% in donors and 56.7% in recipients. Some Doppler indexes of fetuses before SLPCV could predict survival until one month after birth. Conclusion: The study suggests that SLPCV can improve cardiac function in fetuses with TTTS and that some Doppler indexes can predict survival outcomes. Additionally, the severity of TTTS can be a powerful indicator of the severity of cardiovascular complications.

Extreme βHCG levels in first trimester screening are risk factors for adverse maternal and fetal outcomes

Multiples of the normal median (MoM) of free βHCG is a valuable parameter in evaluation of risk of adverse pregnancy outcomes. In the current retrospective study, we assessed the maternal and fetal outcomes in pregnant women having free βHCG MoM levels < 0.2 or > 5 in their first trimester screening (FTS). Relative risk of trisomy 21 was significantly higher in patients having free βHCG MoM > 5. On the other hand, relative risk of trisomies 13 and 18 and Turner syndrome were higher in those having free βHCG MoM < 0.2. Other chromosomal abnormalities were nearly equally detected between those having free βHCG MoM < 0.2 or > 5. Relative risk of hydrocephaly and hydrops fetalis was higher when free βHCG MoM was below 0.2. On the other hand, relative risk of low birth weight was higher when free βHCG MoM was above 5. Moreover, frequency of gestational diabetes mellitus, preeclampsia, preterm delivery and vaginal bleeding increased with levels of free βHCG MoM. However, polyhydramnios had the opposite trend. Frequencies of premature rupture of membranes and pregnancy induced hypertension were highest among pregnant women having levels of free βHCG MoM < 0.2. The current study indicates importance of free βHCG MoM in identification of at-risk pregnancies in terms of both fetal and maternal outcomes. In fact, βHCG MoM < 0.2 or > 5 can be regarded as risk factors for adverse maternal or fetal outcomes irrespective of the presence of other abnormalities in the FTS results.

Angle of progression measured using transperineal ultrasound for prediction of uncomplicated operative vaginal delivery: systematic review and meta-analysis

OBJECTIVE

To determine whether intrapartum transperineal ultrasound measurement of the angle of progression (AoP) during the second stage of labor can predict uncomplicated operative vaginal delivery (OVD) using vacuum or forceps extraction.

METHODS

A systematic search in PubMed, EMBASE, Scopus, Web of Science and Google Scholar was performed from inception to February 2021. Studies assessing the predictive accuracy of AoP, measured using intrapartum transperineal ultrasound, for uncomplicated OVD, defined as successful vaginal delivery within three pulls using forceps or no more than two detachments of the vacuum extractor cup, were included. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Summary receiver-operating-characteristics (ROC) curves, pooled sensitivity and specificity, area under the ROC curve (AUC) and summary likelihood ratios (LRs) were calculated.

RESULTS

Seven studies reporting on a total of 782 patients undergoing OVD were included in this systematic review and meta-analysis. Second-stage AoP measured during maternal rest had a pooled sensitivity of 80% (95% CI, 59-92%) and specificity of 89% (95% CI, 76-95%), with a LR+ of 7.3 (95% CI, 3.1-15.8) for uncomplicated OVD. AoP measured during active pushing had a sensitivity of 91% (95% CI, 85-94%) and specificity of 83% (95% CI, 69-92%), with a LR+ of 5.4 (95% CI, 2.7-10.6) for uncomplicated OVD. The performance of AoP measured at rest was particularly high in nulliparous women, with a sensitivity of 87% (95% CI, 75-94%) and specificity of 90% (95% CI, 82-94%) for uncomplicated OVD.

CONCLUSION

AoP may be a reliable predictor for uncomplicated OVD when measured during the second stage of labor, especially in nulliparous women. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

The association between fetal renal artery indices in late pregnancy and birth weight in gestational diabetes mellitus: A cohort study

Background

Estimation of the fetal birth weight and diagnosis of small for gestational age in the fetuses of women with gestational diabetes mellitus (GDM) are currently imprecise.

Objective

We aimed to evaluate the association between fetal renal artery Doppler indices and neonatal birth weight in women with GDM in late pregnancy.

Materials and Methods

This cohort study recruited 246 pregnant women from Shariati Hospital in Tehran, Iran, in two GDM and healthy control groups. Participants underwent weekly Doppler ultrasounds in the late pregnancy period (37-40 wk) to determine the Doppler indices of the umbilical artery, middle cerebral, and renal arteries. Fetal growth indices including biparietal diameter, abdominal circumference, head circumference, and femur length were also recorded and compared between the two groups.

Results

Fetal growth indices and estimated fetal weight were not significantly different between the two groups. Neonatal birth weight was significantly higher in the GDM group (p < 0.01). The GDM group had significantly higher renal artery indices (resistance index: p = 0.01, pulsatility index [PI]: p = 0.03, and systolic/diastolic ratio [S/D]: p = 0.01) compared to the control group. Also, there was an inverse linear correlation between umbilical indices and birth weight (PI: p = 0.01, S/D: p < 0.01), and between renal artery indices and birth weight (resistance index: p = 0.02, PI: p = 0.01, and S/D: p = 0.03). In the control group, only umbilical artery PI had an inverse linear correlation with birth weight (p = 0.03) and there was no correlation between renal artery indices and birth weight.

Conclusion

Using Doppler hemodynamic indices of the renal artery in late pregnancy in women with GDM can be helpful for early detection of hypoxic fetuses, who are at risk of being small for gestational age or having intrauterine growth restriction, even when of normal weight.

Intrapartum ultrasound measurement of angle of progression at the onset of the second stage of labor for prediction of spontaneous vaginal delivery in term singleton pregnancies: a systematic review and meta-analysis

OBJECTIVE

This study aimed to investigate the diagnostic performance of transperineal ultrasound-measured angles of progression at the onset of the second stage of labor for the prediction of spontaneous vaginal delivery in singleton term pregnancies with cephalic presentation.

DATA SOURCES

We performed a predefined systematic search in PubMed, Embase, Scopus, Web of Science, and Google Scholar from inception to February 5, 2021.

STUDY ELIGIBILITY CRITERIA

Prospective cohort studies that evaluated the diagnostic performance of transperineal ultrasound-measured angles of progression (index test) at the onset of the second stage of labor (ie, when complete cervical dilation is diagnosed) for the prediction of spontaneous vaginal delivery (reference standard) were eligible for inclusion. Eligible studies were limited to those published as full-text articles in the English language and those that included only parturients with a singleton healthy fetus at term with cephalic presentation.

STUDY APPRAISAL AND SYNTHESIS METHODS

Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Summary receiver operating characteristic curves, pooled sensitivities and specificities, area under the curve, and summary likelihood ratios were calculated using the Stata software. Subgroup analyses were done based on angle of progression ranges of 108° to 119°, 120° to 140°, and 141° to 153°.

RESULTS

A total of 8 studies reporting on 887 pregnancies were included. Summary estimates of the sensitivity and specificity of transperineal ultrasound-measured angle of progression at the onset of the second stage of labor for predicting spontaneous vaginal delivery were 94% (95% confidence interval, 88%-97%) and 47% (95% confidence interval, 18%-78%), respectively, for an angle of progression of 108° to 119°, 81% (95% confidence interval, 70%-89%) and 73% (95% confidence interval, 57%-85%), respectively, for an angle of progression of 120° to 140°, and 66% (95% confidence interval, 56%-74%) and 82% (95% confidence interval, 66%-92%), respectively, for an angle of progression of 141° to 153°. Likelihood ratio syntheses gave overall positive likelihood ratios of 1.8 (95% confidence interval, 1-3.3), 3 (95% confidence interval, 2-4.7), and 3.7 (95% confidence interval, 1.7-8.1) and negative likelihood ratios of 0.13 (95% confidence interval, 0.07-0.22), 0.26 (95% confidence interval, 0.18-0.38), and 0.42 (95% confidence interval, 0.29-0.60) for angle of progression ranges of 108° to 119°, 120° to 140°, and 141° to 153°, respectively.

CONCLUSION

Angle of progression measured by transperineal ultrasound at the onset of the second stage of labor may predict spontaneous vaginal delivery in singleton, term, cephalic presenting pregnancies and has the potential to be used along with physical examinations and other clinical factors in the management of labor and delivery.

The correlation between the cerebroplacental ratio and fetal arterial blood gas in appropriate-for-gestational-age fetuses: A cross-sectional study

Background

The cerebroplacental ratio (CPR) is an important index for predicting adverse pregnancy outcomes in small-for-gestational-age and appropriate-for-gestational-age fetuses.

Objective

To find out whether there is an association between the CPR level and the blood cord gases analysis in appropriate for gestational age fetuses.

Materials and Methods

This cross-sectional study included 347 pregnant women at the gestational age of 37-40 wk. Patients had an appropriate-for-gestational-age fetus confirmed from their first ultrasonography results. Participants were divided into two groups based on their CPR, measured before delivery. Finally, after delivery, arterial blood gas level and the incidence of emergency cesarean section, intrapartum fetal distress and neonatal intensive care unit admissions were compared between the two groups.

Results

Fifty-four (15.6%) cases had a CPR below the detection limit of the assay. The incidence of fetal distress, emergency cesarean section, neonatal hospitalization in the neonatal intensive care unit, and pH < 7.2 were significantly lower in women with CPR ≥ 0.67 multiples than in women with a CPR < 0.67 multiples of the median.

Conclusion

The third-trimester CPR is an independent predictor of stillbirth and perinatal mortality and morbidity. The role of UA/MCA Doppler and the CPR in assessing the risk of adverse pregnancy outcomes should be evaluated prospectively.

Development of a scoring system for prediction of placenta accreta and determine the accuracy of its results

Background: Optimal management of women with placenta accreta requires accurate preoperative diagnosis. Therefore, this study was conducted with the aim to evaluate a new prediction scoring items for risk assessment on placenta accreta and determine its accuracy ratio.Methods: This prospective cohort study was carried out on 159 suspected pregnant women morbidly adherent placenta (MAP) in Shariati, Imam Khomeini, and Yas Hospitals in Tehran from October 2016 to May 2018. The number of previous cesarean deliveries; lacunae stage, location of placenta; Doppler assessment; and loss of clear zone were used for review and scoring of ultrasound images. Ultimately after collecting scores, subjects fall into one of the following three categories: low (≤5 points), moderate (6-7 points), or high (8-10 points) probability for placenta accreta. Ultimately, diagnosis of accreta was based on hysterectomy during surgery or reports of pathology. A logistic regression model was used to calculate the probability of placenta accreta on univariable analysis, to assess the discriminant power of all explanatory variables assessed by the receiver operating characteristic (ROC) curve.Results: The area-under-the-ROC curve of the composite scores was 98% and the overall sensitivity, specificity, and positive and negative predictive values of our developed scoring system were 91.84%, 87.27%, 86.54%, and 92.31%, respectively.Conclusion: Combination of several simple ultrasound and clinical characteristics in a scoring system may be highly effective for prenatal risk assessment and prediction of placenta accreta. Output of scoring system helps medical staff to prepare appropriately before surgery and avoid perinatal mortality and morbidity.

Adverse perinatal outcomes in borderline amniotic fluid index

BACKGROUND

Normal amniotic fluid predicts normal placental function, fetal growth and fetal well-being.

OBJECTIVE

To determine adverse pregnancy outcomes in borderline amniotic fluid index (AFI).

MATERIALS AND METHODS

Pregnant women (37-40 wks) with diagnosis of borderline AFI between December 2012 and August 2014 were identified. Antepartum, intrapartum and neonatal data were collected and compared with those of pregnant women with normal AFI. An AFI less than 8 and more than 5 cm was defined for borderline AFI. Pregnancy outcomes included Cesarean section for non-reassuring fetal heart rate, meconium stained amniotic fluid, 5-min Apgar score <7, low birth weight, umbilical cord blood pH at term and NICU admission.

RESULTS

Gestational age at delivery in pregnancies with borderline AFI was significantly lower than normal AFI. Cesarean section rate for non-reassuring fetal heart rate in women of borderline AFI was significantly higher and there was an increased incidence of birth weight less than 10^th percentile for gestation age in borderline AFI group. Incidence of low Apgar score and low umbilical artery pH in pregnancies with borderline AFI was significantly higher than women with normal AFI. There were no significant difference in the rate of NICU admission and meconium staining in both groups.

CONCLUSION

There are significant differences for adverse pregnancy outcomes , such as Cesarean section due to non-reassuring fetal heart rate, birth weight less than 10^th percentile for gestation age, low 5 min Apgar score and low umbilical artery pH between pregnancies with borderline and normal AFI.

Multicenter screening for adverse pregnancy outcomes by uterine artery Doppler in the second and third trimester of pregnancy

AIMS

Increased uterine artery pulsatility index (PI) is associated with adverse pregnancy outcomes. The aim of the study was to determine the role of uterine artery PI at 18-24 and 30-34 weeks, gestation in predicting adverse pregnancy outcomes.

MATERIAL AND METHODS

Color Doppler assessment of the uterine arteries was carried out in 435 consecutive women attending an antenatal clinic at 18-24 weeks and in 134 women at 30-34 weeks. The 95th percentiles of the mean uterine PI and the presence or the absence of bilateral notches was recorded. Using the reference range, performance characteristics in the prediction of pregnancy outcomes were calculated. Association of mean PI at 30-34 weeks with pregnancy outcomes also was studied. The adverse pregnancy outcomes were defined as any or the combination of pre-eclampsia, fetal growth restriction, intrauterine fetal death, preterm delivery and placental abruption.

RESULTS

The women with adverse pregnancy outcomes had significant higher mean PI (1.27 +/- 0.55 vs. 0.99+/-0.32; p=0.003) and higher prevalence of bilateral notch (20% vs. 4.6%, p=0.001) than those with normal outcomes. The mean (+/-SD) PI in women with severe adverse outcome was 1.66+/-0.66 vs. 1.0+/-0.32 in women with normal pregnancy outcome (p=0.002). For a screen positive rate of 10.6% (mean PI>95th percentile for gestational age and/or bilateral notches), the sensitivity for predicting an adverse outcome was 33.3%. The sensitivity increased to 60% for predicting a severe adverse outcome. Increased resistance in the third trimester was also associated with an adverse pregnancy outcome.

CONCLUSION

Increased uterine artery PI in second and third trimester of pregnancy is associated with an increased risk of adverse pregnancy outcomes.

Association between fetal overgrowth and metabolic parameters in cord blood of newborns of women with GDM

AIM

There is evidence that arthrosclerosis may originate at birth, so assessment of serum lipid levels in cord blood might be important. The aim of this study was to investigate the association between fetal overgrowth and metabolic parameters in cord blood of newborns of women with gestational diabetes mellitus (GDM) and to compare these parameters with those in newborns of non-diabetic.

METHODS

The study group included 112 women (singleton pregnancy, and GDM diagnosed following WHO criteria), and as controlled subjects, 159 matched healthy pregnant women and their newborn babies were selected. A sample of cord blood was obtained at delivery. The cord blood's insulin, glucose, and lipids (total cholesterol, high-density cholesterol, low- density cholesterol, and triglyceride) were determined. The relationships between these metabolic parameters and large for gestational age (LGA) were also assessed.

RESULTS

There were no significant differences between total cholesterol (TC), HDL cholesterol (HDL -C), triglyceride (TG) and glucose levels between two groups but the LDL-C level, LDL/HDL ratio and insulin level were significantly higher in newborns of mother with GDM. LGA newborns of diabetic mothers, show the HDL-C level were significantly lower and LDL-C level were significantly higher than AGA (Appropriate for Gestational Age).

CONCLUSION

These results show that GDM altered neonatal plasma lipids metabolism and so newborns of diabetic mothers may be predisposed early in life to LDL hypercholesterolemia and thus may be at a greater risk of developing coronary heart disease later in life.

First-trimester screening for chromosomal abnormalities by integrated application of nuchal translucency, nasal bone, tricuspid regurgitation and ductus venosus flow combined with maternal serum free β-hCG and PAPP-A: a 5-year prospective study

OBJECTIVE

To investigate the performance of first-trimester screening for chromosomal abnormalities by integrated application of nuchal translucency thickness (NT), nasal bone (NB), tricuspid regurgitation (TR) and ductus venosus (DV) flow combined with maternal serum free β-human chorionic gonadotropin (fβ-hCG) and pregnancy-associated plasma protein-A (PAPP-A) at a one-stop clinic for assessment of risk (OSCAR).

METHODS

In total, 13,706 fetuses in 13,437 pregnancies were screened for chromosomal abnormalities during a period of 5 years. Maternal serum biochemical markers and maternal age were evaluated in combination with NT, NT + NB, NT + NB + TR, and NT + NB + TR + DV flow data in 8581, 242, 236 and 4647 fetuses, respectively.

RESULTS

In total, 51 chromosomal abnormalities were identified in the study population, including 33 cases of trisomy 21, eight of trisomy 18, six of sex chromosome abnormality, one of triploidy and three of other unbalanced abnormalities. The detection rate and false-positive rate (FPR) for trisomy 21 were 93.8% and 4.84%, respectively, using biochemical markers and NT, and 100% and 3.4%, respectively, using biochemical markers, NT, NB, TR and DV flow.

CONCLUSION

While risk assessment using combined biochemical markers and NT measurement has an acceptable screening performance, it can be improved by the integrated evaluation of secondary ultrasound markers of NB, TR and DV flow. This enhanced approach would decrease the FPR from 4.8 % to 3.4 %, leading to a lower number of unnecessary invasive diagnostic tests and subsequent complications, while maintaining the maximum level of detection rate. Pre- and post-test genetic counseling is of paramount importance in either approach.

Random urine protein creatinine ratio as a preadmission test in hypertensive pregnancies with urinary protein creatinine ratio

To evaluate the value of random urinary protein creatinine ratio in prediction of 24h proteinuria in hypertensive pregnancies.

METHOD

Random urine samples and routine 24h urine collections were collected from hypertensive pregnant women (n=100). Reliability of random urinary protein-creatinine ratio was assessed by receiver operator characteristic (ROC) curve to detect significant proteinuria (≥300mg/day) using 24h. Urine protein as a gold standard. Forty six patients (46%) had significant proteinuria. The random protein creatinine ratio was correlated to 24h urine protein excretion (r(2)=0.777, P<0.001) Area under ROC curve to predict proteinuria was 0.926 (95% CI: 0.854-0.995, P<0.001). A cut off value of 0.22mg/mg for protein creatinine ratio best predicted significant proteinuria with sensitivity, specificity, positive and negative predictive values of 87%, 92.6%, 90.6% and 89.3% respectively. Random urinary protein creatinine ratio is a simple inexpensive and excellent alternative to 24h urine collection. It's helpful in diagnosis of preeclampsia and can be used as a pre admission test in PIH cases.

Increased intravenous fluid intake and the course of labor in nulliparous women

OBJECTIVE

To compare the effect of 2 regimens of intravenous fluid therapy on the course of labor.

METHODS

In a prospective, randomized, double-blind study of 300 nulliparous pregnant women at term conducted at a teaching hospital, 153 women received 125 mL and 147 received 250 mL of intravenous fluid per hour. The groups were matched and analysis was done using the t, chi(2), and Fisher exact tests. P<0.05 was considered statistically significant.

RESULTS

In the group that received intravenous fluid at a rate of 250 mL per hour the mean+/-S.D. duration of labor was significantly shorter (253+/-97 vs. 386+/-110 min; P = 0.0001), the frequency of labor lasting both more than 10h and more than 15 h was statistically lower (4.8% vs. 13.8%; P=0.001 and 0% vs. 4.5%; P=0.02, respectively), and the frequency of oxytocin administration was significantly lower (8.1% vs. 20.4%; P=0.001). There was a trend toward a lower frequency of cesarean deliveries in the 250-mL group (16% vs. 22.8%; P=0.1).

CONCLUSION

A greater volume per hour of intravenous fluid than is commonly administered to nulliparous women in active labor is associated with significantly shorter duration of labor and lower frequency of both prolonged labor and oxytocin administration.

Thyroid hormone alteration in pre-eclamptic women

This study sought a possible relationship between pre-eclampsia and thyroid profile. In a case-control setting, total thyroxine (T4), total tri-iodothyronine (T3), free T4, free T3, thyroxine binding globulin (TBG) and thyrotropin (TSH) levels in 39 pre-eclamptic patients were measured and compared with the levels in 42 healthy controls. We examined possible variations with regard to the severity of pre-eclampsia by dividing cases into mild (n = 17) and severe (n = 22) subgroups. Patients with mild pre-eclampsia showed significantly increased free T4 and TSH levels compared to healthy controls. In severe cases, TSH level was higher, but free T3 and free T4 levels were significantly lower than in controls. Other tests returned non-significant differences between the groups. Our findings suggest that primary hypofunctioning of the thyroid can accompany mild pre-eclampsia and possibly contribute to the pathogenesis. Elevated levels of free thyroid hormones in severe cases, however, may have reflected a preceding thyroid disorder.