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PURPOSE: To assess the longitudinal variation of the ratio of umbilical and cerebral artery pulsatility index (UCR) in late preterm fetal growth restriction (FGR). MATERIALS AND METHODS: A prospective European multicenter observational study included women with a singleton pregnancy, 32+â0-36+â6, at risk of FGR (estimated fetal weight [EFW] or abdominal circumference [AC] <â10th percentile, abnormal arterial Doppler or fall in AC from 20-week scan of >â40 percentile points). The primary outcome was a composite of abnormal condition at birth or major neonatal morbidity. UCR was categorized as normal (<â0.9) or abnormal (≥â0.9). UCR was assessed by gestational age at measurement interval to delivery, and by individual linear regression coefficient in women with two or more measurements. RESULTS: 856 women had 2770 measurements; 696 (81â%) had more than one measurement (median 3 (IQR 2-4). At inclusion, 63 (7â%) a UCR ≥â0.9. These delivered earlier and had a lower birth weight and higher incidence of adverse outcome (30â% vs. 9â%, relative risk 3.2; 95â%CI 2.1-5.0) than women with a normal UCR at inclusion. Repeated measurements after an abnormal UCR at inclusion were abnormal again in 67â% (95â%CI 55-80), but after a normal UCR the chance of finding an abnormal UCR was 6â% (95â%CI 5-7â%). The risk of composite adverse outcome was similar using the first or subsequent UCR values. CONCLUSION: An abnormal UCR is likely to be abnormal again at a later measurement, while after a normal UCR the chance of an abnormal UCR is 5-7â% when repeated weekly. Repeated measurements do not predict outcome better than the first measurement, most likely due to the most compromised fetuses being delivered after an abnormal UCR.
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Retardo del Crecimiento Fetal , Nacimiento Prematuro , Embarazo , Recién Nacido , Femenino , Humanos , Estudios Prospectivos , Ultrasonografía Prenatal , Recién Nacido Pequeño para la Edad Gestacional , Ultrasonografía Doppler , Peso Fetal , Edad Gestacional , Arterias Umbilicales/diagnóstico por imagenRESUMEN
OBJECTIVES: Little is known regarding fetal growth patterns in monochorionic twin pregnancy complicated by Type-III selective fetal growth restriction (sFGR). We aimed to assess fetal growth and umbilical artery Doppler pattern in Type-III sFGR across gestation and evaluate the effect of changing Doppler flow pattern on growth and intertwin growth discordance. METHODS: This was a retrospective cohort study of all Type-III sFGR pregnancies managed at nine fetal centers over a 12-year time period. Higher-order multiple pregnancy and cases with major fetal anomaly or other monochorionicity-related complications at presentation were excluded. Estimated fetal weight (EFW) was assessed on ultrasound for each twin pair at five timepoints (16-20, 21-24, 25-28, 29-32 and > 32 weeks' gestation) and compared with singleton and uncomplicated monochorionic twin EFW. EFW and intertwin EFW discordance were compared between pregnancies with normalization of umbilical artery Doppler of the smaller twin later in pregnancy and those with persistently abnormal Doppler. RESULTS: Overall, 328 pregnancies (656 fetuses) met the study criteria. In Type-III sFGR, the smaller twin had a lower EFW than an average singleton fetus (EFW Z-score ranging from -1.52 at 16 weeks to -2.69 at 36 weeks) and an average monochorionic twin in uncomplicated pregnancy (Z-score ranging from -1.73 at 16 weeks to -1.49 at 36 weeks) throughout the entire gestation, while the larger twin had a higher EFW than an average singleton fetus until 22 weeks' gestation and was similar in EFW to an average uncomplicated monochorionic twin throughout gestation. As pregnancy advanced, growth velocity of both twins decreased, with the larger twin remaining appropriately grown and the smaller twin becoming more growth restricted. Intertwin EFW discordance remained stable throughout gestation. On multivariable longitudinal modeling, normalization of fetal umbilical artery Doppler was associated with better growth of the smaller twin (P = 0.002) but not the larger twin (P = 0.1), without affecting the intertwin growth discordance (P = 0.09). CONCLUSIONS: Abnormal fetal growth of the smaller twin in Type-III sFGR was evident early in pregnancy, while EFW of the larger twin remained normal throughout gestation. Normalization of umbilical artery Doppler was associated with improved fetal growth of the smaller twin. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Retardo del Crecimiento Fetal , Embarazo Gemelar , Femenino , Retardo del Crecimiento Fetal/diagnóstico por imagen , Peso Fetal , Humanos , Embarazo , Estudios Retrospectivos , Gemelos Monocigóticos , Ultrasonografía Prenatal , Arterias Umbilicales/diagnóstico por imagenRESUMEN
OBJECTIVE: Monochorionic diamniotic twin pregnancies complicated by Type-III selective fetal growth restriction (sFGR) are at high risk of fetal death. The aim of this study was to identify predictors of fetal death in these pregnancies. METHODS: This was an international multicenter retrospective cohort study. Type-III sFGR was defined as fetal estimated fetal weight (EFW) of one twin below the 10th percentile and intertwin EFW discordance of ≥ 25% in combination with intermittent absent or reversed end-diastolic flow in the umbilical artery of the smaller fetus. Predictors of fetal death were recorded longitudinally throughout gestation and assessed in univariable and multivariable logistic regression models. The classification and regression trees (CART) method was used to construct a prediction model of fetal death using significant predictors derived from the univariable analysis. RESULTS: A total of 308 twin pregnancies (616 fetuses) were included in the analysis. In 273 (88.6%) pregnancies, both twins were liveborn, whereas 35 pregnancies had single (n = 19 (6.2%)) or double (n = 16 (5.2%)) fetal death. On univariable analysis, earlier gestational age at diagnosis of Type-III sFGR, oligohydramnios in the smaller twin and deterioration in umbilical artery Doppler flow were associated with an increased risk of fetal death, as was larger fetal EFW discordance, particularly between 24 and 32 weeks' gestation. None of the parameters identified on univariable analysis maintained statistical significance on multivariable analysis. The CART model allowed us to identify three risk groups: a low-risk group (6.8% risk of fetal death), in which umbilical artery Doppler did not deteriorate; an intermediate-risk group (16.3% risk of fetal death), in which umbilical artery Doppler deteriorated but the diagnosis of sFGR was made at or after 16 + 5 weeks' gestation; and a high-risk group (58.3% risk of fetal death), in which umbilical artery Doppler deteriorated and gestational age at diagnosis was < 16 + 5 weeks' gestation. CONCLUSIONS: Type-III sFGR is associated with a high risk of fetal death. A prediction algorithm can help to identify the highest-risk group, which is characterized by Doppler deterioration and early referral. Further studies should investigate the potential benefit of fetal surveillance and intervention in this cohort. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Retardo del Crecimiento Fetal , Embarazo Gemelar , Femenino , Muerte Fetal/etiología , Retardo del Crecimiento Fetal/diagnóstico por imagen , Peso Fetal , Edad Gestacional , Humanos , Lactante , Embarazo , Resultado del Embarazo/epidemiología , Estudios Retrospectivos , Gemelos Monocigóticos , Ultrasonografía Prenatal/métodos , Arterias Umbilicales/diagnóstico por imagenRESUMEN
OBJECTIVE: Type-III selective intrauterine growth restriction (sIUGR) is associated with a high and unpredictable risk of fetal death and fetal brain injury. The objective of this study was to describe the prospective risk of fetal death and the risk of adverse neonatal outcome in a cohort of twin pregnancies complicated by Type-III sIUGR and treated according to up-to-date guidelines. METHODS: We reviewed retrospectively all monochorionic diamniotic twin pregnancies complicated by Type-III sIUGR managed at nine fetal centers over a 12-year period. Higher-order multiple gestations and pregnancies with major fetal anomalies or other monochorionicity-related complications at initial presentation were excluded. Data on fetal and neonatal outcomes were collected and management strategies reviewed. Composite adverse neonatal outcome was defined as neonatal death, invasive ventilation beyond the resuscitation period, culture-proven sepsis, necrotizing enterocolitis requiring treatment, intraventricular hemorrhage Grade > I, retinopathy of prematurity Stage > II or cystic periventricular leukomalacia. The prospective risk of intrauterine death (IUD) and the risk of neonatal complications according to gestational age were evaluated. RESULTS: We collected data on 328 pregnancies (656 fetuses). After exclusion of pregnancies that underwent selective reduction (n = 18 (5.5%)), there were 51/620 (8.2%) non-iatrogenic IUDs in 35/310 (11.3%) pregnancies. Single IUD occurred in 19/328 (5.8%) pregnancies and double IUD in 16/328 (4.9%). The prospective risk of non-iatrogenic IUD per fetus declined from 8.1% (95% CI, 5.95-10.26%) at 16 weeks, to less than 2% (95% CI, 0.59-2.79%) after 28.4 weeks and to less than 1% (95% CI, -0.30 to 1.89%) beyond 32.6 weeks. In otherwise uncomplicated pregnancies with Type-III sIUGR, delivery was generally planned at 32 weeks, at which time the risk of composite adverse neonatal outcome was 29.0% (31/107 neonates). In twin pregnancies that continued to 34 weeks, there was a very low risk of IUD (0.7%) and a low risk of composite adverse neonatal outcome (11%). CONCLUSIONS: In this cohort of twin pregnancies complicated by Type-III sIUGR and treated at several tertiary fetal centers, the risk of fetal death was lower than that reported previously. Further efforts should be directed at identifying predictors of fetal death and optimal antenatal surveillance strategies to select a cohort of pregnancies that can continue safely beyond 33 weeks' gestation. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Retardo del Crecimiento Fetal/mortalidad , Resultado del Embarazo/epidemiología , Embarazo Gemelar , Adulto , Femenino , Muerte Fetal , Retardo del Crecimiento Fetal/terapia , Edad Gestacional , Humanos , Recién Nacido , Estudios Longitudinales , Embarazo , Estudios Retrospectivos , Ultrasonografía Prenatal , Arterias Umbilicales/diagnóstico por imagenRESUMEN
OBJECTIVES: To explore the association between fetal umbilical and middle cerebral artery (MCA) Doppler abnormalities and outcome in late preterm pregnancies at risk of fetal growth restriction. METHODS: This was a prospective cohort study of singleton pregnancies at risk of fetal growth restriction at 32 + 0 to 36 + 6 weeks of gestation, enrolled in 33 European centers between 2017 and 2018, in which umbilical and fetal MCA Doppler velocimetry was performed. Pregnancies were considered at risk of fetal growth restriction if they had estimated fetal weight and/or abdominal circumference (AC) < 10th percentile, abnormal arterial Doppler and/or a fall in AC growth velocity of more than 40 percentile points from the 20-week scan. Composite adverse outcome comprised both immediate adverse birth outcome and major neonatal morbidity. Using a range of cut-off values, the association of MCA pulsatility index and umbilicocerebral ratio (UCR) with composite adverse outcome was explored. RESULTS: The study population comprised 856 women. There were two (0.2%) intrauterine deaths. Median gestational age at delivery was 38 (interquartile range (IQR), 37-39) weeks and birth weight was 2478 (IQR, 2140-2790) g. Compared with infants with normal outcome, those with composite adverse outcome (n = 93; 11%) were delivered at an earlier gestational age (36 vs 38 weeks) and had a lower birth weight (1900 vs 2540 g). The first Doppler observation of MCA pulsatility index < 5th percentile and UCR Z-score above gestational-age-specific thresholds (1.5 at 32-33 weeks and 1.0 at 34-36 weeks) had the highest relative risks (RR) for composite adverse outcome (RR 2.2 (95% CI, 1.5-3.2) and RR 2.0 (95% CI, 1.4-3.0), respectively). After adjustment for confounders, the association between UCR Z-score and composite adverse outcome remained significant, although gestational age at delivery and birth-weight Z-score had a stronger association. CONCLUSION: In this prospective multicenter study, signs of cerebral blood flow redistribution were found to be associated with adverse outcome in late preterm singleton pregnancies at risk of fetal growth restriction. Whether cerebral redistribution is a marker describing the severity of fetal growth restriction or an independent risk factor for adverse outcome remains unclear, and whether it is useful for clinical management can be answered only in a randomized trial. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Desarrollo Fetal , Retardo del Crecimiento Fetal/diagnóstico por imagen , Reología , Ultrasonografía Doppler , Ultrasonografía Prenatal , Adulto , Peso al Nacer , Europa (Continente) , Femenino , Retardo del Crecimiento Fetal/fisiopatología , Peso Fetal , Feto/irrigación sanguínea , Feto/diagnóstico por imagen , Feto/fisiopatología , Edad Gestacional , Humanos , Recién Nacido , Recién Nacido Pequeño para la Edad Gestacional , Nacimiento Vivo , Arteria Cerebral Media/diagnóstico por imagen , Arteria Cerebral Media/embriología , Embarazo , Estudios Prospectivos , Flujo Pulsátil , Valores de Referencia , Mortinato , Arterias Umbilicales/diagnóstico por imagen , Arterias Umbilicales/embriología , Circunferencia de la CinturaRESUMEN
AIM: To test a new parameter to assess the position of the fetal cerebellar vermis in the posterior fossa (PF) using intrauterine magnetic resonance imaging (MRI). MATERIALS AND METHODS: The angle between the cerebellar vermis and the internal occipital crest (vermian-crest angle, VCA) was assessed retrospectively using MRI in fetuses with and without PF anomalies. Spearman's rank test was used to investigate correlation of the VCA with gestational age (GA). Groups were compared using Student's t-test and the one-way analysis of variance (ANOVA) with the Bonferroni adjustment. Box-and-whisker plots were also used. RESULTS: One hundred and two normal cases were identified. Mean±SD GA at MRI was 26.5±2.8 weeks (range: 22-32 weeks). The VCA was 64.49±11.5° independently of GA (r=0.19; p=0.12). In addition, 30 fetuses at 19-28 weeks were identified with Blake's pouch cyst (BPC; n=5), Dandy-Walker malformation (DWM; n=12), mega cisterna magna (MCM; n=10), and vermian hypoplasia (VH; n=3). The VCA was significantly different in the DWM (p<0.001) and BPC (p<0.001) subgroups, but was not significantly different in cases of VH (p=0.84) and MCM (p=0.95) in comparison with controls. CONCLUSIONS: A new method to assess vermian position within the PF using intrauterine MRI was assessed. In combination with the other existing parameters, it may be helpful for addressing the categorisation of upward rotation of the fetal cerebellar vermis; however, further studies are necessary to strengthen the present findings.
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Vermis Cerebeloso/diagnóstico por imagen , Vermis Cerebeloso/embriología , Imagen por Resonancia Magnética/métodos , Adulto , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Diagnóstico Prenatal/métodos , Reproducibilidad de los Resultados , Estudios Retrospectivos , Rotación , Adulto JovenRESUMEN
OBJECTIVES: Develop recommendations for women's health issues and family planning in systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS). METHODS: Systematic review of evidence followed by modified Delphi method to compile questions, elicit expert opinions and reach consensus. RESULTS: Family planning should be discussed as early as possible after diagnosis. Most women can have successful pregnancies and measures can be taken to reduce the risks of adverse maternal or fetal outcomes. Risk stratification includes disease activity, autoantibody profile, previous vascular and pregnancy morbidity, hypertension and the use of drugs (emphasis on benefits from hydroxychloroquine and antiplatelets/anticoagulants). Hormonal contraception and menopause replacement therapy can be used in patients with stable/inactive disease and low risk of thrombosis. Fertility preservation with gonadotropin-releasing hormone analogues should be considered prior to the use of alkylating agents. Assisted reproduction techniques can be safely used in patients with stable/inactive disease; patients with positive antiphospholipid antibodies/APS should receive anticoagulation and/or low-dose aspirin. Assessment of disease activity, renal function and serological markers is important for diagnosing disease flares and monitoring for obstetrical adverse outcomes. Fetal monitoring includes Doppler ultrasonography and fetal biometry, particularly in the third trimester, to screen for placental insufficiency and small for gestational age fetuses. Screening for gynaecological malignancies is similar to the general population, with increased vigilance for cervical premalignant lesions if exposed to immunosuppressive drugs. Human papillomavirus immunisation can be used in women with stable/inactive disease. CONCLUSIONS: Recommendations for women's health issues in SLE and/or APS were developed using an evidence-based approach followed by expert consensus.
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Síndrome Antifosfolípido/tratamiento farmacológico , Neoplasias de los Genitales Femeninos/diagnóstico , Lupus Eritematoso Sistémico/tratamiento farmacológico , Complicaciones del Embarazo/tratamiento farmacológico , Anticonceptivos Hormonales Orales/uso terapéutico , Técnica Delphi , Detección Precoz del Cáncer , Terapia de Reemplazo de Estrógeno , Servicios de Planificación Familiar , Femenino , Preservación de la Fertilidad , Monitoreo Fetal , Humanos , Menopausia , Atención Preconceptiva , Embarazo , Técnicas Reproductivas Asistidas , Medición de RiesgoAsunto(s)
Aorta Torácica , Venas Braquiocefálicas , Corazón Fetal , Humanos , Ultrasonografía Doppler de PulsoRESUMEN
PURPOSE: Congenital uterine anomalies often remain asymptomatic until they cause problems, for example during pregnancy. We studied the diagnostic aspects of two- and three-dimensional ultrasound and MRI. MATERIALS AND METHODS: 63 women referred for suspected uterine anomalies were studied: In the first group (until July 2008) with 2âD-US and MRI, in the second group (from August 2008) additionally with 3âD-US; these women also had diagnostic or therapeutic operative confirmation. In the third group, only 3D-US was used. RESULTS: In all women 3D-US was possible and successful. The most common anomaly was a subseptate uterus, while a septate uterus was less frequent, and uterus bicornis (unicollis) and uterus didelphys (bicornis bicollis) were rare. The women in the first two groups all underwent at least diagnostic hysteroscopy, and some (subseptate or septate uterus) underwent operative hysteroscopy. After preoperative volume imaging, laparoscopies were required less often. 3D-US diagnoses as judged by intraoperative findings were correct in 100â% of cases, while the MRI diagnoses in the same group were correct in only 7/13 cases. CONCLUSION: Since the introduction of volume imaging (MRI, later 3âD-US), laparoscopy during hysteroscopic septum resection was not necessary in the majority of cases. 3D-US brings the diagnostics of uterine anomalies back into the hands of the gynecologist and can provide the gynecological surgeon with a higher subjective degree of certainty during operative hysteroscopy.
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Imagenología Tridimensional , Imagen por Resonancia Magnética , Complicaciones del Embarazo/diagnóstico , Ultrasonografía Prenatal , Útero/anomalías , Adulto , Conducta Cooperativa , Femenino , Humanos , Histeroscopía , Comunicación Interdisciplinaria , Laparoscopía , Embarazo , Complicaciones del Embarazo/cirugía , Sensibilidad y Especificidad , Útero/patología , Útero/cirugíaRESUMEN
BACKGROUND: Numerous studies have shown that the preconceptional use of folic acid prevents neural tube defects. We created a study to find out whether the preconceptional use of folic acid has improved in the past 10 years, in the area of Münsterlingen, Switzerland. MATERIAL AND METHODS: We interviewed 2 groups of patients who delivered at our Institution, namely between 2000 and 2002 (period A) involving 287 women and from 2009 to 2010 (period B) involving 305 pregnant women. We asked them whether they used folic acid by means of a standardised questionnaire. RESULTS: In period B significantly more women have taken folic acid preconceptionally (period A: 27.5% vs. period B: 40.7%; p=0.001). A significant increase in folic acid intake was seen in the German speaking group from period A to B (30.3% vs. 52.7%; p=0.0005), while this was not the case in the non-German speaking group (21.4% in both periods). More multiparaé women were taking folic acid compared to nulliparae. A significant increase from period A to B was noted only in the German speaking group. Unexpectedly, in nulliparae non-German speaking women, folic acid supplementation decreased from 14% to 6.1%. DISCUSSION: We have found a significant increase in preconceptional folic acid supplementation from 2001 to 2010. The percentage of women taking folic acid is disappointingly low in all groups, particularly in nulliparae women of non-German ethnicity.
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Ácido Fólico/uso terapéutico , Adhesión a Directriz/estadística & datos numéricos , Cumplimiento de la Medicación/estadística & datos numéricos , Defectos del Tubo Neural/epidemiología , Defectos del Tubo Neural/prevención & control , Atención Prenatal/estadística & datos numéricos , Atención Prenatal/normas , Suplementos Dietéticos/normas , Suplementos Dietéticos/estadística & datos numéricos , Femenino , Humanos , Estudios Longitudinales , Masculino , Guías de Práctica Clínica como Asunto , Embarazo , Factores de Riesgo , Autoadministración/normas , Autoadministración/estadística & datos numéricos , Suiza/epidemiologíaRESUMEN
OBJECTIVE: Our purpose was to evaluate the antenatal incidence of single umbilical artery (SUA) in twin pregnancies according to chorionicity and to assess its relationship with outcome. METHODS: Consecutive twin pregnancies undergoing ultrasound evaluation at our institutions were included. A targeted sonographic evaluation of the umbilical cord and vessels was performed in all cases. Chorionicity was determined according to standard ultrasound criteria. RESULTS: A total of 174 twin pregnancies, 100 dichorionic (DC) and 74 monochorionic (MC), were included in the study. An SUA was identified in 17 (9.8%) pregnancies, and in 18 (5.2%) fetuses. No difference was found in the incidence of SUA in DC and MC twins. Among affected pregnancies, all but one DC twin pregnancy were discordant for SUA. Structural and/or chromosomal abnormalities were present in 27.8% of fetuses with SUA. The prevalence of small-for-gestational-age fetuses and of discordant birth weight (> 20% discordance) was higher in the SUA group than in the rest of the population, although these differences were not statistically significant. Twin pairs discordant for SUA had significantly higher weight discordance than those with normal umbilical cords. The sonographic cross-sectional area of the SUA did not appear to show the typical adaptive dilatation usually seen in singleton pregnancies with SUA. CONCLUSIONS: The incidence of SUA in twins is higher than in singletons, with no difference between MC and DC twins. Intrapair discordance for SUA in identical twins provides evidence against an exclusively genetic origin of this anomaly. The apparent failure of compensatory dilatation of the umbilical artery in twins with SUA may explain in part the higher risk for fetal growth restriction in these cases.
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Corion/patología , Enfermedades en Gemelos/diagnóstico por imagen , Retardo del Crecimiento Fetal/diagnóstico por imagen , Insuficiencia Placentaria/diagnóstico por imagen , Arteria Umbilical Única/diagnóstico por imagen , Ultrasonografía Prenatal , Adulto , Enfermedades en Gemelos/epidemiología , Enfermedades en Gemelos/fisiopatología , Femenino , Retardo del Crecimiento Fetal/epidemiología , Retardo del Crecimiento Fetal/fisiopatología , Edad Gestacional , Humanos , Incidencia , Recién Nacido , Masculino , Insuficiencia Placentaria/epidemiología , Insuficiencia Placentaria/fisiopatología , Valor Predictivo de las Pruebas , Embarazo , Resultado del Embarazo , Arteria Umbilical Única/epidemiología , Arteria Umbilical Única/fisiopatologíaRESUMEN
PURPOSE: Umbilical vein pulsations (UV-P) are due to various etiologies. The aim of the present study was to investigate the incidence and type of UV-P in monochorionic twins with twin-twin transfusion syndrome (TTTS). MATERIALS AND METHODS: TTTS cases diagnosed between 1999 and 2009 were examined retrospectively. The UV flow pattern taken from a free floating loop of the umbilical cord was classified as "non-pulsatile" (NP), "monophasic" (MP) and "complex" (CP). Only Doppler flow analyses prior to intervention were examined. RESULTS: Of 106 cases seen during the study period, 56 cases met the inclusion criteria. Of those, 62.5% were classified as stage III TTTS, and fetoscopic laser therapy was performed in 45 cases. NP flow patterns were more likely found in the donor twin (80.4 vs. 28.6%; p < 0.0001), while the incidence of MP (50 vs. 17.9%; p < 0.0006) and CP flow patterns (21.4 vs. 1.7%; p < 0.01) was higher in the recipient twin. Moreover, the perinatal mortality was highest in cases with CP (CP: 76.9 vs. MP 42.1 vs. NP: 26.2%; p < 0.01) as well as the rate of cases with double death. CONCLUSION: CP patterns are more frequently found in the recipient twin and are associated with a considerably high mortality rate. Studying the umbilical vein flow pattern in TTTS may provide additional information for counseling and prognosis similar to that obtained by expensive fetal echocardiography.
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Transfusión Feto-Fetal/diagnóstico por imagen , Interpretación de Imagen Asistida por Computador , Embarazo de Alto Riesgo , Flujo Pulsátil/fisiología , Ultrasonografía Doppler en Color , Ultrasonografía Prenatal , Venas Umbilicales/diagnóstico por imagen , Aborto Eugénico , Femenino , Muerte Fetal , Transfusión Feto-Fetal/mortalidad , Transfusión Feto-Fetal/cirugía , Fetoscopía , Humanos , Recién Nacido , Coagulación con Láser , Trabajo de Parto Prematuro/diagnóstico por imagen , Trabajo de Parto Prematuro/mortalidad , Embarazo , Pronóstico , Estudios Retrospectivos , Sensibilidad y EspecificidadRESUMEN
OBJECTIVE: The primary aim of this study was to determine the desires and wishes of pregnant patients vis-à-vis their external genital anatomy after female genital mutilation (FGM) in the context of antenatal care and delivery in a teaching hospital setting in Switzerland. Our secondary aim was to determine whether women with FGM and non-mutilated women have different fetal and maternal outcomes. DESIGN: A retrospective case-control study. SETTING: A teaching hospital. POPULATION: One hundred and twenty-two patients after FGM who gave consent to participate in this study and who delivered in the Department of Obstetrics and Gynaecology in the University Hospital of Berne and 110 controls. METHODS: Data for patients' wishes concerning their FGM management, their satisfaction with the postpartum outcome and intrapartum and postpartum maternal and fetal data. As a control group, we used a group of pregnant women without FGM who delivered at the same time and who were matched for maternal age. MAIN OUTCOME MEASURES: Patients' satisfaction after delivery and defibulation after FGM, maternal and fetal delivery data and postpartum outcome measures. RESULTS: Six percent of patients wished to have their FGM defibulated antenatally, 43% requested a defibulation during labour, 34% desired a defibulation during labour only if considered necessary by the medical staff and 17% were unable to express their expectations. There were no differences for FGM patients and controls regarding fetal outcome, maternal blood loss or duration of delivery. FGM patients had significantly more often an emergency Caesarean section and third-degree vaginal tears, and significantly less first-degree and second-degree tears. CONCLUSION: An interdisciplinary approach may support optimal antenatal and intrapartum management and also the prevention of FGM in newborn daughters.
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Circuncisión Femenina/efectos adversos , Complicaciones del Trabajo de Parto/etiología , Satisfacción del Paciente , Adolescente , Adulto , Estudios de Casos y Controles , Cesárea/estadística & datos numéricos , Circuncisión Femenina/psicología , Tratamiento de Urgencia , Femenino , Humanos , Embarazo , Resultado del Embarazo , Estudios Retrospectivos , Suiza , Adulto JovenRESUMEN
PURPOSE: In this study we examined the arterial-adaptive dilatation and Doppler velocimetry, especially RI values, in normal fetuses with a single umbilical artery (SUA). MATERIALS AND METHODS: We studied 195 fetuses from 18 to 39 weeks of gestational age with a prenatally identified SUA retrospectively. They were enrolled in this study if the following information applied: > 18 weeks of gestational age, no structural or chromosomal abnormalities, and histopathological confirmation of SUA. Sonographic examination included evaluation of the umbilical artery resistance and the cross-sectional area of the umbilical cord, and its vessels were measured in all cases. Small for gestational age (SGA) was diagnosed when the birth weight was below the 10th percentile for gestational age. Fetuses with intrauterine growth restriction were defined as those with biometric data below the 5th percentile. RESULTS: There were 119 cases of prenatally identified SUA which met the inclusion criteria. RI values were below the 10th percentile in 33/119 (27.33) and below the 50th percentile in 73/119 (61.33). RI values below the 10th percentile were significantly more likely to be in the normal collective than in the growth restricted collective [31/87 (35.63%) vs. 2/32 (6.25%); p = 0.001]. Even more significant differences became apparent when comparing the RI values below the 50th percentile of both groups. An umbilical artery diameter over the 90th percentile was found in 49 (41.9%) of cases and was significantly more likely to be present in normal growing fetuses than in the growth restricted group. CONCLUSION: Normal fetuses with SUA are at higher risk to be born as SGA. With our study results we can confirm the hypothesis that Doppler flow measurements and arterial diameter in SUA are different from those found in normal fetal umbilical arteries. RI values over the 50th percentile or a cross-sectional area of the artery below 95th percentile after 26th week of gestation significantly increases the risk of SGA.
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Arterias Umbilicales/diagnóstico por imagen , Femenino , Retardo del Crecimiento Fetal/diagnóstico por imagen , Retardo del Crecimiento Fetal/epidemiología , Monitoreo Fetal , Edad Gestacional , Humanos , Recién Nacido , Selección de Paciente , Embarazo , Tercer Trimestre del Embarazo , Estudios Retrospectivos , Medición de Riesgo , Ultrasonografía Doppler/métodos , Arterias Umbilicales/fisiología , VasodilataciónRESUMEN
OBJECTIVE: C-reactive protein (CRP) is a marker of systemic inflammation. Recently, it has been shown that CRP is present in amniotic fluid and fetal urine, and that elevated levels are associated with adverse pregnancy outcome. However, the precise source of amniotic fluid CRP, its regulation, and function during pregnancy is still a matter of debate. The present in vivo and in vitro studies were designed to investigate the production of CRP in human placental tissues. MATERIAL AND METHODS: Ten paired blood samples from peripheral maternal vein (MV), umbilical cord artery (UA) and umbilical vein (UV) were collected from women with elective caesarean sections at term. The placental protein accumulation capacity of hCG, hPL, leptin and CRP was compared with the dual in vitro perfusion method of an isolated cotyledon of human term placentae and quantified by ELISA. Values for accumulation (release) were calculated as total accumulation of maternal and fetal circuits normalized for tissue weight and duration of perfusion. For gene expression, RNA was extracted from placental tissue and reverse transcribed. RT-PCR and real-time PCR were performed using specific primers. RESULTS: The median (range) CRP level was significantly different between UA and UV [50.1 ng/ml (12.1-684.6) vs. 61 ng/ml (16.9-708.1)]. The median (range) difference between UV and UA was 9.3 ng/ml (2.2-31.6). A significant correlation was found between MV CRP and both UA and UV CRP levels. Median (range) MV CRP levels [2649 ng/ml (260.1-8299)] were 61.2 (6.5-96.8) fold higher than in the fetus. In vitro, the total accumulation rates (mean+/-SD) were 31+/-13 (mU/g/min, hCG), 1.16+/-0.19 (microg/g/min, hPL), 4.71+/-1.91 (ng/g/min, CRP), and 259+/-118 (pg/g/min, leptin). mRNA for hCG, hPL and leptin was detectable using conventional RT-PCR, while CRP mRNA could only be demonstrated by applying real-time RT-PCR. In the perfused tissue the transcript levels for the four proteins were comparable to those detected in the native control tissue. CONCLUSIONS: Our results demonstrate that the human placenta produces and releases CRP mainly into the maternal circulation similarly to other analyzed placental proteins under in vitro conditions. Further studies are needed to explore the exact role of placental CRP during pregnancy.
Asunto(s)
Proteína C-Reactiva/metabolismo , Placenta/metabolismo , Nacimiento a Término/metabolismo , Adulto , Biomarcadores/metabolismo , Proteína C-Reactiva/genética , Gonadotropina Coriónica/metabolismo , Femenino , Sangre Fetal/metabolismo , Expresión Génica , Humanos , Técnicas In Vitro , Leptina/metabolismo , Placenta/irrigación sanguínea , Placenta/citología , Lactógeno Placentario/metabolismo , Embarazo/sangre , ARN Mensajero/metabolismo , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Arterias Umbilicales , Venas UmbilicalesRESUMEN
Purpose: To provide 2-dimensional ultrasonographic (2D-US) normograms of cerebellar vermis biometry, as well as to evaluate the feasibility and the reproducibility of these measurements in clinical practice. Materials and Methods: A prospective cross-sectional study of 328 normal singleton pregnancies between 18 and 33 weeks of gestation. Measurements of the fetal cerebellar vermis circumference (VC) in the mid-sagittal plane were performed by both a senior and a junior operator using 2D-US. VC as a function of gestational age (GA) was expressed by regression equations. In 24 fetuses 3-dimensional (3D) reconstructed planes were obtained in order to allow comparisons with 2D-US measurements. The agreement between 2D and 3D measurements and the interobserver variability were assessed by interclass correlation coefficients (ICC). Results: Satisfactory vermis measurements could be obtained in 89.9% of cases. The VC (constant= - 12.21; slope=2.447; r=0.887, p<0.0001) correlated linearly with GA. A high degree of consistency was observed between 2D and 3D ultrasound measurements (ICC=0.846 95% CI 679-0.930) as well as between measurements obtained by different examiners (ICC=0.890 95% CI 989-0.945). Conclusion: 2-dimensional ultrasonographic measurements of cerebellar vermis throughout gestation in the mid-sagittal view seem to be feasible and reproducible enough to be potentially used in clinical practice. Such measurements may supply a tool for accurate identification of posterior fossa anomalies, providing the basis for proper counseling and management and of these conditions.
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Background: The traditional surgical treatment for cervical insufficiency is vaginal placement of a cervical cerclage. However, in a small number of cases a vaginal approach is not possible. A transabdominal approach can become an option for these patients. Laparoscopic cervical cerclage is associated with good pregnancy outcomes but comes at the cost of a higher risk of serious surgical complications. The aim of the present study was to evaluate intraoperative and long-term pregnancy outcomes after laparoscopic cervical cerclage, performed either as an interval procedure or during early pregnancy, using a new device with a blunt grasper and a flexible tip. Methods: All women who underwent laparoscopic cervical cerclage for cervical insufficiency in our institution using the Goldfinger® device (Ethicon Endo Surgery, Somerville, NJ, USA) between January 2008 and March 2014 were included in the study. Data were collected from the patients' medical records and included complications during and after the above-described procedure. Results: Eighteen women were included in the study. Of these, six were pregnant at the time of laparoscopic cervical cerclage. Mean duration of surgery was 55 ± 10 minutes. No serious intraoperative or postoperative complications occurred. All patients were discharged at 2.6 ± 0.9 days after surgery. One pregnancy ended in a miscarriage at 12 weeks of gestation. All other pregnancies ended at term (> 37 weeks of gestation) with good perinatal and maternal outcomes. Summary: Performing a laparoscopic cervical cerclage using a blunt grasper device with a flexible tip does not increase intraoperative complications, particularly in early pregnancy. We believe that use of this device, which is characterized by increased maneuverability, could be an important option to avoid intraoperative complications if surgical access is limited due to the anatomical situation. However, because of the small sample size, further studies are needed to confirm our findings.
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An anastomosis between the two umbilical arteries, located approximately within 3 cm from the placental insertion, has been previously described at delivery and in utero. However, the prenatal investigation of the Hyrtl anastomosis is limited to case reports. We report a series of antenatal functional evaluations of this vessel. Forty-one women underwent a target ultrasonography to evaluate the blood flow characteristics of the Hyrtl anastomosis. The resistance index of the anastomosis and the umbilical arteries resistance indices before and after the anastomosis were obtained. The direction of the blood flow in the anastomosis was determined by color Doppler evaluation. An anastomosis between the two stems of the umbilical arteries was present in 36 cases while a fusion of the two umbilical arteries was found in the remaining five cases. The median (range) gestational age at diagnosis was 33.1 weeks (25.5-40.1). The median diameter of the anastomosis was 2.3 mm (1.3-7.1). The blood flow in the anastomosis was pulsatile with a median resistance index of 0.62 (0.45-0.85) and unidirectional toward the umbilical artery with lower resistance index. The difference between the resistance indices of the two umbilical arteries was higher after than before the anastomosis [0.07 (0-0.3) versus 0.04 (0-0.17), P=0.05]. The median diameter of the Hyrtl anastomosis was significantly higher when the anastomosis was oblique (n=8) than when it was transverse (n=28) (4.8 mm [2-7.1] versus 2.3 mm [1.3-5.3], P< 0.05). In three out of the five cases with fusion of the two umbilical arteries the placental insertion was marginal or velamentous. We conclude that the Hyrtl anastomosis may act as a pressure-equalizing system between umbilical arteries. This supports the hypothesis that the Hyrtl anastomosis plays an important role when the placental territories supplied by the umbilical arteries are different in size.