Do knowledge of uterine artery resistance in the second trimester and targeted surveillance improve maternal and perinatal outcome? UTOPIA study: a randomized controlled trial.

OBJECTIVES: To ascertain whether screening for pre-eclampsia (PE) and intrauterine growth restriction (IUGR) by uterine artery (UtA) Doppler in the second trimester of pregnancy and targeted surveillance improve maternal and perinatal outcomes in an unselected population. METHODS: This was a multicenter randomized open-label controlled trial. At the routine second-trimester anomaly scan, women were assigned randomly to UtA Doppler or non-Doppler groups. Women with abnormal UtA Doppler were offered intensive surveillance at high-risk clinics of the participating centers with visits every 4 weeks that included measurement of maternal blood pressure, dipstick proteinuria, fetal growth and Doppler examination. The primary outcome was a composite score for perinatal complications, defined as the presence of any of the following: PE, IUGR, spontaneous labor < 37 weeks' gestation, placental abruption, stillbirth, gestational hypertension, admission to neonatal intensive care unit and neonatal complications. Secondary outcomes were a composite score for maternal complications (disseminated intravascular coagulation, maternal mortality, postpartum hemorrhage, pulmonary edema, pulmonary embolism, sepsis), and medical interventions (for example, corticosteroid administration and induction of labor) in patients developing placenta-related complications. RESULTS: In total, 11 667 women were included in the study. Overall, PE occurred in 348 (3.0%) cases, early-onset PE in 48 (0.4%), IUGR in 722 (6.2%), early-onset IUGR in 93 (0.8%) and early-onset PE with IUGR in 32 (0.3%). UtA mean pulsatility index > 90(th) percentile was able to detect 59% of early-onset PE and 60% of early-onset IUGR with a false-positive rate of 11.1%. When perinatal and maternal data according to assigned group (UtA Doppler vs non-Doppler) were compared, no differences were found in perinatal or maternal complications. However, screened patients had more medical interventions, such as corticosteroid administration (relative risk (RR), 1.79 (95% CI, 1.4-2.3)) and induction of labor for IUGR (RR, 1.36 (95% CI, 1.07-1.72)). In women developing PE or IUGR, there was a trend towards fewer maternal complications (RR, 0.46 (95% CI, 0.19-1.11)). CONCLUSIONS: Routine second-trimester UtA Doppler ultrasound in an unselected population identifies approximately 60% of women at risk for placental complications; however, application of this screening test failed to improve short-term maternal and neonatal morbidity and mortality. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Doppler study of uterine artery blood flow: comparison of findings in the first and second trimesters of pregnancy.

In 55 women with singleton pregnancies, colour flow mapping and pulsed wave velocimetry were used to measure impedance to flow in the uterine arteries at 10-13 weeks gestation and again at 19-22 weeks. In the first trimester, examinations were performed both transabdominally and transvaginally and in the second trimester transabdominally only. There were significant associations between the first- and second-trimester measurements obtained with both Doppler techniques. These associations were higher when transvaginal than transabdominal Doppler was used and when the measurement of impedance was the pulsatility index (PI) rather than the resistance index. These data suggest that impedance to flow in the uteroplacental circulation in the second trimester is dependent on impedance in the first trimester. In any prospective, first-trimester, uterine artery Doppler screening study for pregnancy complications, it may be preferable to use transvaginal Doppler and measure PI.

Effect of centrifugation on amniotic fluid phospholipid composition.

The first step in the determination of phospholipid in amniotic fluid is generally the removal of cells and debris from the fluid by centrifugation. Low-speed centrifugation of the supernatant is reported to have the same phospholipidic profile and L/S, PG/S and PI/S ratios similar to those of the uncentrifuged amniotic fluid sample. With high-speed centrifugation almost all the pulmonary surfactant seems to be recovered in pellet with the same characteristics as the uncentrifuged amniotic fluid.

Amniotic fluid phospholipids. New predictive values of L/S and PG/S ratios.

The lecithin/sphingomyelin (L/S) ratio after cold acetone precipitation is widely used to predict fetal lung maturity. The separation of saturated lecithin, the main component of surfactant, is the basis for using the precipitation procedure but there is still a controversy as to whether cold acetone precipitable lecithin can be equated with saturated lecithin. Following up a previous paper in which the effect of cold acetone precipitation on phospholipids of amniotic fluid was studied, the present work reports that non-precipitated L/S and phosphatidylglycerol/sphingomyelin (PG/S) ratios correlate well with the precipitated L/S ratio (r = 0.93, r = 0.84, n = 92). The predictive value of both non-precipitated L/S and PG/S ratios has been studied when a "positive" result predicts a precipitated L/S ratio > or = 2.0, and proposes a L/S ratio > or = 4.7 and a PG/S ratio > or = 0.8 to predict fetal lung maturity, when cold acetone precipitation step is omitted.

Maternal peripheral blood lymphocyte subpopulations in normal and pathological pregnancies.

Flow cytometry was used to determine lymphocyte subpopulations in maternal blood from 143 pathological pregnancies: 50 with fetal aneuploidy; 32 with missed abortions; 12 with ectopic pregnancies; 20 with multi-fetal pregnancies, and 29 with pregnancies complicated by intrauterine growth retardation (IUGR). The values were compared to those of 240 women with normal singleton pregnancies at 8-40 weeks of gestation and 20 non-pregnant controls. In early pregnancy (8-10 weeks), compared to non-pregnant values, there was a decrease in the percentage of CD4+ cells and CD4+ to CD8+ ratio and an increase in the percentage of CD8+ cells. In later pregnancy, the CD4+ cell percentage and CD4+ to CD8+ ratio increased and the CD8+ cell percentage decreased to reach non-pregnant values at term. The percentage of natural killer (CD3- and CD16/56+) cells decreased with gestation, while the percentage of B (CD19+) cells did not change significantly. In IUGR, the percentage of CD4+ cells and CD4+ to CD8+ ratio were decreased, while the percentage of CD8+ cells was increased. In contrast, in the groups of missed abortions and ectopic pregnancies, the CD4+ to CD8+ ratio was increased. In multifetal pregnancies and those with fetal aneuploidies there were no significant differences in maternal lymphocyte subpopulations from normals.

Doppler velocimetry and fetal heart rate studies in nephropathic diabetics.

OBJECTIVES: Our objectives were to determine in pregnancies complicated by diabetic nephropathy (1) if impedance to flow in the uterine and umbilical arteries is normal and (2) if these fetuses are hypoxemic and acidemic and if they have decreased fetal heart rate variation and Doppler blood flow redistribution. STUDY DESIGN: In a cross-sectional study at the Harris Birthright Research Centre for Fetal Medicine, London, serial assessment of fetal heart rate variation and Doppler velocimetry of the placental and fetal circulations was undertaken in six pregnancies complicated by diabetic nephropathy. In all cases cordocentesis was performed within 24 hours before delivery for the measurement of umbilical venous blood gases. RESULTS: Cordocentesis demonstrated these fetuses to be hypoxemic and acidemic. The fetal heart rate variation was decreased; however, impedance to flow in the uterine artery was normal, and increased impedance to flow in the umbilical artery with evidence of blood flow redistribution was observed in only one case. CONCLUSIONS: Fetal hypoxemia and acidemia in pregnancies complicated by diabetic nephropathy is not a consequence of impaired placental perfusion, and the degree of metabolic derangement may be obscured by the apparent normal growth and failure of these fetuses to demonstrate blood flow redistribution.

Placental and fetal Doppler velocimetry in pregnancies complicated by maternal diabetes mellitus.

OBJECTIVE: Our purpose was to investigate placental and fetal circulation in pregnancies complicated by maternal diabetes mellitus and to relate any changes to fetal blood pH, Po2, and hematocrit. STUDY DESIGN: Doppler measurements of both uterine arteries, one umbilical artery, the fetal descending thoracic aorta, and one fetal middle cerebral artery were performed in 65 well-controlled diabetic pregnancies in a cross-sectional study at the Harris Birthright Research Centre for Fetal Medicine, London. In 41 cases cordocentesis was also performed for the measurement of umbilical venous blood pH, Po2, and hematocrit. RESULTS: The mean umbilical venous blood pH was significantly lower and the hematocrit significantly higher than the appropriate normal mean for gestation. However, the Doppler indices of the placental and fetal circulations were essentially normal, except in some of the cases complicated by preeclampsia or intrauterine growth retardation. CONCLUSIONS: Maternal diabetes mellitus is not associated with abnormalities in Doppler indexes of the placental or fetal circulations.