The use of cardiac ultrasound imaging in first-trimester prenatal diagnosis of congenital heart diseases.

This study aims to explore ultrasound (US) cardiac and echocardiographic features that may enable the early diagnosis of various major congenital heart diseases (CHDs). Focusing on providing useful US tools for this assessment, high resolution of US cardiac images of various CHDs, such as hypoplastic left heart syndrome, conotruncal anomalies, and univentricular heart, were evaluated. Results show that early US detection of most major CHDs is feasible during first-trimester ultrasonography cardiac evaluation. Concerns about safety issues, findings on early fetal cardiovascular hemodynamics, and cardiac lesions that can progress during the course of pregnancy were also discussed.

References Values of Fetal Heart Myocardial Volume by Three-Dimensional Ultrasound using Spatiotemporal Image Correlation and Virtual Organ Computer-Aided Analysis Methods and Their Applicability in Pregestational Diabetic Women.

OBJECTIVE: To determine reference values for myocardial volume of the fetal heart using three-dimensional ultrasound with spatiotemporal image correlation (STIC) and virtual organ computer-aided analysis (VOCAL) and to assess their applicability in women with pregestational diabetes. STUDY DESIGN: This retrospective cross-sectional study included 177 normal pregnant women with fetuses between 200/7 and 336/7 weeks of age. Fetal cardiac volumes were collected using the STIC method, and myocardial volume was obtained by subtraction of the intracavitary volumes using the VOCAL 30-degree method. Intra- and interobserver reproducibility values were determined using the concordance correlation coefficient (CCC). Sixteen women with pregestational diabetes mellitus were evaluated for validation. RESULTS: There was a strong correlation between fetal myocardial volume and gestational age (R 2 = 0.82). Intra- and interobserver reproducibility values were excellent and moderate, respectively, with CCCs of 0.99 and 0.83, respectively. There was no significant difference in mean fetal myocardial volume between normal pregnant women and those with pregestational diabetes (p = 0.64). CONCLUSION: Reference values for myocardial volume of the fetal heart were determined in normal pregnant women and were not statistically different from those in women with pregestational diabetes mellitus.

Predictive values of clinical parameters and biophysical and biochemical markers in the first trimester for the detection of small-for-gestational age fetuses.

OBJECTIVES: To evaluate the predictive values of maternal characteristics, biophysical parameters (mean arterial pressure [MAP] and Doppler uterine artery measurements), and biochemical parameters (pregnancy-associated plasma protein A [PAPP-A] and placental growth factor [PlGF]) alone and in association for small-for-gestational age (SGA) fetuses. METHODS: We performed a retrospective analysis of a prospective observational study that evaluated 615 pregnant women in the first trimester using ultrasonography. For all the women, information regarding clinical and obstetric histories, MAP, and uterine artery mean pulsatility index (UtA-PI), and blood samples for analysis of biochemical markers (PAPP-A and PlGF) were obtained. The patients were grouped according to birth weight as follows: group I (n=571), >10th percentile (control); group II (n=44), <10th percentile; and group III (n=34), <5th percentile. The predictive values of the variables for the detection of SGA fetuses were calculated using a logistic regression model and an analysis of the area under the receiver-operating characteristic curve (AUC). RESULTS: The sensitivity rates of the maternal characteristics, biophysical markers (MAP and UtA-PI), biochemical markers (PAPP-A and PlGF), and the association between them were: 23.3, 32.5, 25, and 30% respectively, at a false-positive (FP) rate of 10%, in group II and 26.5, 26.5, 23.5, and 23.5%, respectively, at a FP rate of 10% in group III. CONCLUSIONS: The predictive performances of the combination of maternal characteristics and biophysical and biochemical parameters were unsatisfactory, with a slight improvement in the predictive capacity for SGA fetuses <10th percentile.

Reference ranges for the fetal mitral, tricuspid, and interventricular septum annular plane systolic excursions (mitral annular plane systolic excursion, tricuspid annular plane systolic excursion, and septum annular plane systolic excursion) between 20 and 36 + 6 weeks of gestation.

Objectives This study aimed to establish reference ranges for fetal mitral, tricuspid, and interventricular septum annular plane systolic excursions (MAPSE, TAPSE, and SAPSE) in normal pregnant women between 20 and 36 + 6 weeks of gestation. Methods This prospective and cross-sectional study included 360 low-risk singleton pregnancies between 20 and 36 + 6 weeks of gestation. MAPSE, TAPSE, and SAPSE were measured by M-mode in real time in an apical or basal four-chamber view through placing the cursor at the atrioventricular junction, marked by the valve rings at the tricuspid, mitral, and basal septum, respectively. A regression analysis was done to determine the appropriate polynomial equation model for both measurements and standard deviation (SD) values in relation to gestational age (GA). The intra- and inter-observer reproducibility was evaluated using the concordance correlation coefficient (CCC) and limits of agreement (LoA). Results There was a significant positive correlation between MAPSE (r=0.705, p<0.0001), TAPSE (r=0.804, p<0.0001), and SAPSE (r=0.690, p<0.0001) and GA. The mean of each parameter ranged as follows: 2.87-5.56 mm, MAPSE; 3.98-8.07 mm, TAPSE; and 2.34-4.21 mm, SAPSE. Poor/moderate intra- and inter-observer reliability (CCC between 0.70 and 0.90) and poor/moderate agreement of all the tested parameters were evaluated (LoA between 10 and 50%). Conclusions Reference values were established for the fetal MAPSE, TAPSE, and SAPSE between 20 and 36 + 6 weeks of gestation in low-risk pregnant women. These parameters showed poor/moderate reproducibility.

Fetal Cardiac Function and Ventricular Volumes Determined by Three-Dimensional Ultrasound Using STIC and VOCAL Methods in Fetuses from Pre-gestational Diabetic Women.

To assess the fetal cardiac function and ventricular volumes by three-dimensional (3D) ultrasound using spatio-temporal image correlation (STIC) and virtual organ computer-aided analysis (VOCAL) methods in fetuses from pre-gestational diabetic women. This was a prospective and cross-sectional study that evaluated 53 fetuses from pre-gestational diabetic women and 53 fetuses from healthy mothers between 20 and 34 weeks of gestation. Only fetuses with no structural or genetic abnormalities and singleton pregnant women were included in this study. The fetal cardiac volumes were assessed by STIC and VOCAL methods. The ejection fraction, stroke volume, and cardiac output were calculated from these measurements to evaluate fetal cardiac function. The Mann-Whitney U test was performed to compare the two groups. For calculation of intra- and interobserver reproducibility's, we used concordance correlation coefficients. The mean differences in the right atrial volumes between the diabetic and normal groups ranged from 0.05 mL to 0.1 mL (p = 0.917 and 0.355, respectively). The median of left atrium (LA) volume measurement in pre-gestational diabetic group was significantly lower than healthy mothers (LA: 0.62 vs. 0.68 mL; p < 0.001). The fetal right and left ventricular volumes were similar in both groups. No significant differences in ejection fraction, stroke volume and cardiac output were observed (p value range 0.086-0.815). The majority of fetal atrial/ventricular volumes showed good intra- and interobserver reliabilities. Conversely, the majority cardiac function parameters showed poor intra- and interobserver agreements. STIC and VOCAL methods gave reproducible quantitative results for fetal atrial and ventricular volumes. Significant differences in fetal left atrial volumes were observed between the two groups, which be related to LA atrial dysfunction and /or left ventricle (LV) compliance, reflecting earlier stages of cardiac dysfunction.

Evaluation of fetal heart geometry during pregnancy by three-dimensional ultrasound using the STIC rendering mode.

OBJECTIVE: To determine fetal heart geometry during pregnancy using three-dimensional (3D) ultrasound and the spatiotemporal image correlation (STIC) rendering mode. METHODS: This prospective, cross-sectional study evaluated 250 normal singleton pregnancies from 20 to 33 weeks and 6 days of gestation. STIC rendering was used to calculate the eight angles of the fetal heart: apex, base, mitral valve, tricuspid valve, left ventricle, right ventricle, left atrium, and right atrium angles. The concordance correlation coefficient (CCC) was used for intra- and inter-observer tests. RESULTS: The average ± SD maternal age was 31.7 ± 4.9 years, and the average gestational age was 26.3 ± 4.2 weeks. There was little variation in fetal heart angles using STIC rendering according to the gestational age, with determination coefficient (R2 ) values of 0.01 for the apex and mitral valve angles and <0.01 for the base, tricuspid valve, left ventricle, right ventricle, left atrium, and right atrium angles. Moderate/good intra- and inter-observer concordance was observed for the measurement of fetal heart angles using STIC rendering, and the obtained CCC varied from 0.74 to 0.93. CONCLUSION: The fetal heart geometry did not present significant variations during pregnancy using 3D ultrasound and the STIC rendering mode.

Reference range for amniotic fluid index measurements in a Brazilian population.

OBJECTIVE: The aim of this study was to determine the reference range for amniotic fluid index (AFI) measurements in a large sample of the Brazilian population. METHODS: This was a retrospective cross-sectional study on 3837 normal singleton pregnancies between 18+0 and 38+6 weeks of pregnancy. The AFI was measured from the largest vertical pockets of amniotic fluid in the four quadrants of the uterine cavity. To assess the correlation between AFI and gestational age (GA), polynomial equations were calculated, with adjustments using the determination coefficient (R2). RESULTS: The mean maternal age and gestational age were 27.01±6.57 years and 30.43±5.29 weeks, respectively. The mean AFI ranged from 12.2±2.6 cm at 18 weeks to 11.6±6.0 cm at 38 weeks of pregnancy. The correlation between AFI and GA was best represented by a linear equation: AFI=17.78-0.153*GA (R2=0.027). CONCLUSION: We established the reference range for the AFI in a large sample of the Brazilian population. This reference range can be used to monitor deviations in the volume of amniotic fluid in fetuses at high risk for intrauterine growth disturbances.

Intrauterine Transfusion for Rhesus Alloimmunization: A Historical Retrospective Cohort from A Single Reference Center in Brazil.

Objective: This study aimed to describe the historical experience of a single reference center in Brazil with intrauterine transfusion (IUT) for Rhesus (Rh) alloimmunization, evaluating the major complications and the perinatal outcomes of this procedure. Methods: This retrospective cohort study evaluated data from medical records of pregnant women between 20 and 34 weeks of gestation whose fetuses underwent IUT by cordocentesis between January 1991 and June 2021. The same experienced examiner performed all procedures. Univariate and multivariate logistic regression was used to assess the effect of fetal hydrops, duration of IUT, post-transfusion cord bleeding time, and bradycardia on death (fetal or neonatal). Results: We analyzed data from 388 IUTs in 169 fetuses of alloimmunized pregnant women with a mean age of 29.3 ± 5.1 years. Death and fetal hydrops were significantly associated at first IUT (p < 0.001). We had two cases of emergency cesarean section (mean of 0.51% per IUT) and three cases of premature rupture of the ovular membranes (mean of 0.77% per procedure). Thirty-six deaths were recorded, including 14 intrauterine and 22 neonatal. A higher percentage of neonatal deaths was observed in the group with post-transfusion cord bleeding time > 120 s (45.8%). The odds of neonatal death were 17.6 and 12.9 times higher in cases with hydrops and bradycardia than in cases without hydrops and bradycardia, respectively. The odds of death (fetal and neonatal) were 79.9 and 92.3 times higher in cases with hydrops and bradycardia than in cases without hydrops and bradycardia, respectively. Conclusions: The most common complications of IUT for Rh alloimmunization were post-transfusion cord bleeding, fetal bradycardia, premature rupture of ovular membranes, and emergency cesarean section. The IUT complication most associated with death (fetal and neonatal) was bradycardia, and the perinatal outcomes were worse in fetuses with hydrops.

Assessment of the fetal heart at 12-14 weeks of pregnancy using B-mode, color Doppler, and spatiotemporal image correlation via abdominal and vaginal ultrasonography.

This study aimed to evaluate the effect that combining multiple ultrasonographic imaging methods has on the proportion of tests with a satisfactory fetal heart assessment at 12-14 weeks of pregnancy using B-mode, color Doppler, and spatiotemporal image correlation software (STIC) via both the abdominal and vaginal routes. This cross-sectional prospective study involved healthy pregnant women at 12-14 weeks of pregnancy with a crown-rump length (CRL) of 84 mm or shorter. The following four cardiac views were assessed: four-chamber, left and right ventricular outflow tract, and aortic arch views. The same examiner sought to identify these four views using B-mode, color Doppler, and STIC via both the vaginal and abdominal routes. The study determined the proportion of cases and the respective 95 % confidence intervals (CIs) in which all four views were identified. The presence of significant differences in comparisons between methods was analyzed using McNemar's test. Although 57 pregnant women at 12-14 weeks of pregnancy agreed to participate in the study, 4 were not included because they presented with a CRL longer than 84 mm. Thus, 53 pregnant women were thoroughly assessed and included in the analysis. The combination of B-mode, color Doppler, and STIC via both the abdominal and vaginal routes enabled the highest proportion of identification of the four views (90.6 %; 95 % CI, 79.8-95.9 %). The lowest proportions were observed when B-mode was used alone via both the vaginal route (30.2 %; 95 % CI, 19.5-43.5 %) and the abdominal route (37.7 %; 95 % CI, 25.9-51.2 %). The abdominal route showed results slightly better than those of the vaginal route with all the methods, but the differences were not statistically significant. In the vast majority of the cases, the fetal hearts were properly assessed at 12-14 weeks of pregnancy when several methods were combined using both the abdominal and vaginal routes. However, only one-third of them would have had adequate heart assessment if the B-mode via either the abdominal or the vaginal route had been used alone.

A new model based on artificial intelligence to screening preterm birth.

OBJECTIVE: The objective of this study is to create a new screening for spontaneous preterm birth (sPTB) based on artificial intelligence (AI). METHODS: This study included 524 singleton pregnancies from 18th to 24th-week gestation after transvaginal ultrasound cervical length (CL) analyzes for screening sPTB < 35 weeks. AI model was created based on the stacking-based ensemble learning method (SBELM) by the neural network, gathering CL < 25 mm, multivariate unadjusted logistic regression (LR), and the best AI algorithm. Receiver Operating Characteristics (ROC) curve to predict sPTB < 35 weeks and area under the curve (AUC), sensitivity, specificity, accuracy, predictive positive and negative values were performed to evaluate CL < 25 mm, LR, the best algorithms of AI and SBELM. RESULTS: The most relevant variables presented by LR were cervical funneling, index straight CL/internal angle inside the cervix (≤ 0.200), previous PTB < 37 weeks, previous curettage, no antibiotic treatment during pregnancy, and weight (≤ 58 kg), no smoking, and CL < 30.9 mm. Fixing 10% of false positive rate, CL < 25 mm and SBELM present, respectively: AUC of 0.318 and 0.808; sensitivity of 33.3% and 47,3%; specificity of 91.8 and 92.8%; positive predictive value of 23.1 and 32.7%; negative predictive value of 94.9 and 96.0%. This machine learning presented high statistical significance when compared to CL < 25 mm after T-test (p < .00001). CONCLUSION: AI applied to clinical and ultrasonographic variables could be a viable option for screening of sPTB < 35 weeks, improving the performance of short cervix, with a low false-positive rate.

Cervical pessary plus vaginal progesterone in a singleton pregnancy with a short cervix: an experience-based analysis of cervical pessary's efficacy.

BACKGROUND: Several studies were published about cervical pessary, with controversial results. These studies demonstrated that the patient follow-up after pessary insertion is very different between the study centers and the number of pessary insertions per center was often <30 cases. This study aims to determine cervical pessary performance in singleton pregnancies with a short cervix based on a single center learning curve. METHODS: Between 2011 and 2018, 128 singleton pregnancies between 18 and 24 gestational weeks with a short cervix (<25 mm) were referred to our clinic. All cases were treated with progesterone, and when available in our supplies (due to low resources) cervical pessary was also offered. Three groups were created for statistical analysis: Group 1 (n = 33), treated with progesterone-only; Groups 2 and 3, treated with cervical pessary plus progesterone. Group 2 included the first cases (n = 30) of pessary, defined by a learning curve and cumulative sum analysis, while Group 3 included the subsequent 65 cases. The primary outcome was preterm birth (PTB) < 34 gestational weeks. RESULTS: The learning curve was performed with all cases of pessary plus progesterone, and 30 patients were obtained as the number needed for learning, in our study with two operators. The PTB rate < 34 weeks was 27.3, 20, and 4.6% in groups 1, 2, and 3, respectively. There was no significant difference between Group 1 and 2 (OR 1.1; 95% CI 0.066 - 18.45; p = .945). When comparing Groups 1 and 3 there was a significant difference in PTB rates (OR 0.08; CI95% 0.01-0.42; p = .003). Considering Kaplan-Meyer Survival analysis, we can observe that the performance of progesterone alone (Group 1) was similar to Group 2 (progesterone + first 30 cases of pessary) (p = .432), but the performance of Group 3 (progesterone + subsequent 65 cases of pessary) and Group 1 shows a statistically significant difference (p = .011). CONCLUSION: Learning curve and cumulative sum analysis determined that the application and surveillance of at least 30 patients is required to see significant improvements in the primary outcome of PTB < 34 weeks.

Reference values for left and right ventricular systolic-to-diastolic duration ratio (SDR) found using both spectral and tissue Doppler of fetal heart between 20 and 36+6 weeks of gestation.

PURPOSE: To establish reference values for the systolic-to-diastolic duration ratio (SDR) of the left ventricle (LV) using spectral Doppler, as well as for the SDR' of the interventricular septum (SEP), LV, and right ventricles (RV) using tissue Doppler of the fetal heart. METHOD: This prospective and cross-sectional study evaluated 374 low-risk singleton pregnancies from 20 to 36 + 6 weeks of gestation. The ventricular filling time (FT) was obtained from LV inflow using spectral Doppler. Tissue Doppler was used to assess the FT of each ventricle by placing the cursor at the atrioventricular junction marked by the mitral and tricuspid valves, respectively. SDR was calculated as the sum of the isovolumic contraction time (ICT) and the ejection time (ET) divided by the sum of the isovolumic relaxation time (IRT) and the ventricular FT. We used regression analysis to obtain the best-fit model polynomial equation for the parameters. The concordance correlation coefficient (CCC) was used to assess intra- and inter-observer reproducibility. RESULTS: SDR and SDR' LV showed a progressive decrease with gestational age (GA); the SDR' RV and SDR' SEP did not show a significant decrease with advancing GA. The SDR LV (r = 0.29, p < 0.0001), SDR' RV (r = 0.21, p < 0.0001), SDR' LV (r = 0.20, p = 0.0001), and SDR' SEP (r = 0.25, p < 0.0001) showed a significant weak positive correlation with fetal heart rate. The inter-observer SDR' SEP measurements demonstrated poor reproducibility (CCC: 0.50), whereas intra-observer SRD LV measurements demonstrated moderate reproducibility (CCC: 0.78). CONCLUSIONS: Reference values for SDR SEP, LV, and RV using spectral and tissue Doppler of fetal heart were established between 20 and 36+6 weeks of gestation.

Noninvasive determination of fetal rh blood group, D antigen status by cell-free DNA analysis in maternal plasma: experience in a Brazilian population.

We evaluated the diagnostic accuracy of Rh blood group, D antigen (RHD) fetal genotyping, using real-time polymerase chain reaction in maternal blood samples, in a racially mixed population. We performed a prospective study conducted between January 2006 and December 2007, analyzing fetal RHD genotype in the plasma of 102 D- pregnant women by real-time polymerase chain reaction, targeting exons 7 and 10 of the RHD gene. Genotype results were compared with cord blood phenotype obtained after delivery or before the first intrauterine transfusion when necessary. Most of the participants (75.5%) were under 28 weeks of pregnancy, and 87.5% had at least one relative of black ancestry. By combining amplification of two exons, the accuracy of genotyping was 98%, sensitivity was 100%, and specificity was 92%. The positive likelihood ratio was 12.5, and the negative likelihood ratio was 0. The two false-positive cases were confirmed to be pseudogene RHD by real-time polymerase chain reaction. There were no differences between the patients with positive or negative Coombs test ( P = 0.479). Determination of fetal RHD status in maternal peripheral blood was highly sensitive in this racially mixed population and was not influenced by the presence of antierythrocyte antibodies.

Reference ranges of filling time and systolic-to-diastolic time index of the left ventricle, right ventricle, and interventricular septum using both spectral and tissue Doppler of fetal heart between 20 and 36 + 6 weeks of gestation.

OBJECTIVE: The objective of this study is to determine the reference ranges for filling time (FT) and systolic-to-diastolic time index (SDI) of the left ventricle (LV) by using spectral Doppler, and FT' and SDI' of the LV, right ventricle, and interventricular septum (IVS) by using tissue Doppler of the fetal heart. STUDY DESIGN: This prospective and cross-sectional study included 360 low-risk singleton pregnancies between 20 and 36 + 6 weeks of gestation. The SDI/SDI' is the sum of the ejection time, isovolumic contraction time, and isovolumic relaxation time (IRT) divided by the FT. We measured FT/FT' from the beginning of the opening click of the E wave of the mitral valve to the closing click of the A wave of the mitral valve. We used regression analysis to obtain the best-fit model polynomial equation for the parameters. Additionally, we assessed intra- and inter-observer reproducibility by using concordance correlation coefficient (CCC). RESULTS: There was a weak correlation among FT LV (r = 0.31, p < 0.0001), SDI LV (r = -0.23, p < 0.0001), and gestational age (GA). Additionally, there was a very weak positive correlation among FT' RV (r = 0.09, p = 0.0001), FT' LV (r = 0.07, p < 0.0001), FT' IVS (r = 0,08, p < 0.0001), and GA. In contrast, there was a very weak negative correlation among SDI' LV (r=-0.09, p < 0.0001), SDI' IVS (r=-0.05, p < 0.0021), and GA. There was no significative correlation between SDI' RV (r=-0.06, p < 0.081) and GA. Poor/very poor intra- and inter-observer reliability was observed for all the parameters (CCC = 0.19-0.79), whereas moderate intra- and inter-observer agreement was observed for all parameters (CCC = 0.37-0.72). CONCLUSIONS: The reference ranges for FT and SDI were determined by using spectral and tissue Doppler of the fetal heart and showed a poor reproducibility.

Cervical Pessary Plus Progesterone for Twin Pregnancy with Short Cervix Compared to Unselected and Non-Treated Twin Pregnancy: A Historical Equivalence Cohort Study (EPM Twin Pessary Study).

OBJECTIVE: The present study aims to determine if the use of cervical pessary plus progesterone in short-cervix (≤ 25 mm) dichorionic-diamniotic (DC-DA) twin pregnancies is equivalent to the rate of preterm births (PBs) with no intervention in unselected DC-DA twin pregnancies. METHODS: A historical cohort study was performed between 2010 and 2018, including a total of 57 pregnant women with DC-DA twin pregnancies. The women admitted from 2010 to 2012 (n = 32) received no treatment, and were not selected by cervical length (Non-Treated group, NTG), whereas those admitted from 2013 to 2018 (n = 25), were routinely submitted to cervical pessary plus progesterone after the diagnosis of short cervix from the 18th to the 27th weeks of gestation (Pessary-Progesterone group, PPG). The primary outcome analyzed was the rate of PBs before 34 weeks. RESULTS: There were no statistical differences between the NTG and the PPG regarding PB < 34 weeks (18.8% versus 40.0% respectively; p = 0.07) and the mean birthweight of the smallest twin (2,037 ± 425 g versus 2,195 ± 665 g; p = 0.327). The Kaplan-Meyer Survival analysis was performed, and there were no differences between the groups before 31.5 weeks. Logistic regression showed that a previous PB (< 37 weeks) presented an odds ratio (OR) of 15.951 (95% confidence interval [95%CI]: 1.294-196.557; p = 0.031*) for PB < 34 weeks in the PPG. CONCLUSION: In DC-DA twin pregnancies with a short cervix, (which means a higher risk of PB), the treatment with cervical pessary plus progesterone could be considered equivalent in several aspects related to PB in the NTG, despite the big difference between these groups.

OBJETIVO: Este estudo tem como objetivo determinar se o uso de pessário cervical associado a progesterona em gestações de gêmeos dicoriônicos-diamnióticos (DC-DAs) com colo do útero curto (≤ 25 mm) apresenta taxa de parto prematuro (PP) equivalente à de gestações gemelares DC-DA sem nenhuma intervenção/não selecionadas. MéTODOS: Um estudo de coorte histórica foi realizado entre 2010 e 2018, incluindo um total de 57 mulheres grávidas com gestações gemelares DC-DA. As mulheres admitidas de 2010 a 2012 (n = 32) não receberam tratamento, e não foram selecionadas pelo comprimento cervical (grupo Não Tratado, GNT), enquanto as admitidas de 2013 a 2018 (n = 25) receberam pessário cervical rotineiramente associado a progesterona após o diagnóstico de colo curto entre a 18a e a 27ª semanas de gestação (grupo Pessário-Progesterona, GPP). O desfecho primário analisado foi a taxa de PP antes de 34 semanas. RESULTADOS: Não houve diferenças estatísticas entre o GNT e o GPP em relação ao PP < 34 semanas (respectivamente, 18,8% versus 40,0%; p = 0,07) e ao peso médio ao nascer do gêmeo menor (2.037 ± 425 g versus 2.195 ± 665 g; p = 0,327). A análise de Kaplan-Meyer foi realizada, e não houve diferenças entre os grupos antes de 31,5 semanas. A regressão logística demonstrou que o nascimento prematuro anterior (< 37 semanas) apresentou razão de probabilidades (odds ratio, OR) de 15,951 (intervalo de confiança de 95% [IC95%]: 1,294­196,557; p = 0,031*) para o nascimento prematuro < 34 semanas no GPP. CONCLUSãO: Em gêmeos DC-DA com colo uterino curto (o que significa maior risco de nascimento prematuro), o tratamento com pessário cervical associado a progesterona pode ser considerado equivalente em diversos aspectos relacionados à prematuridade no GNT, apesar da grande diferença entre os grupos.

Prediction of preeclampsia in the first trimester of pregnancy using maternal characteristics, mean arterial pressure, and uterine artery Doppler data in a Brazilian population.

OBJECTIVE: To evaluate the performance of the preeclampsia (PE) screening algorithm of the Fetal Medicine Foundation (FMF) during the first trimester in a Brazilian population using maternal characteristics, mean arterial pressure (MAP), and uterine artery Doppler data. METHODS: This is a prospective cohort study that evaluated 701 pregnant women during the first trimester ultrasound screening for chromosomal abnormalities (11-13+6 weeks). All patients provided information regarding clinical and obstetric history, MAP, and mean uterine artery pulsatility index (mean PI). Patients were assigned to four groups based on the presence of PE and gestational age at delivery: group 1 (control), patients without hypertensive disorders (n=571); group 2, PE and delivery before 34 weeks of gestation (n=7); group 3, PE and delivery before 37 weeks of gestation, including patients from group 2 and patients that presented PE with delivery between 34 and 37 weeks (n=17); and group 4, PE and delivery before 42 weeks of gestation, including patients from both groups 2 and 3 and patients that presented PE with delivery between 37 and 42 weeks of gestation (n=34). RESULTS: After the exclusion of 96 patients, we evaluated the data of 605 patients. By combining maternal characteristics, MAP, and the mean uterine artery PI for the detection of PE, we found a sensitivity of 71.4% in group 2, 50% in group 3, and 41.2% in group 4 (false positive rate=10%). CONCLUSION: Using maternal characteristics, MAP, and uterine artery Doppler data, we were able to identify a significant proportion of patients who developed preterm PE.

Validation of Fetal Medicine Foundation algorithm for prediction of pre-eclampsia in the first trimester in an unselected Brazilian population.

OBJECTIVE: The objective of this study is to evaluate the predictive performance of the Fetal Medicine Foundation (FMF) algorithm for prediction of preeclampsia (PE) between 11 and 14 weeks of gestation in an unselected Brazilian population. METHODS: We conducted a prospective cohort study with 617 singleton pregnancies of unselected risk. Biophysical markers (mean pulsatility index, mean arterial pressure) and biochemical markers (placental growth factor (PLGF) and PAPP-A) were inserted into the FMF software and converted into multiples of the median (MoM). The subjects were divided into five groups: early-onset PE, parturition <34 weeks' gestation; preterm PE, parturition <37 weeks; PE, parturition at any gestational age; gestational hypertension (GH); and control group. Areas under the receiver operating characteristics curve (AUC) were calculated for the outcomes. RESULTS: Among 617 patients, seven developed early-onset PE, 18 developed preterm PE (seven early PE plus 11 delivered between 34 and 36 + 6 weeks gestation), 34 developed PE (18 preterm PE plus 16 delivered after 37-week gestation), 12 pregnant women developed GH, and 517 women comprised the control group. The best predictive performance using the FMF algorithm occurred in the early-onset PE group, with AUC = 0.946 (95% CI 0.919-0.973) and the detection rate of 28.6% and 85.7% for 5% and 10% false-positive (FP), respectively. CONCLUSIONS: The FMF algorithm to predict PE was effective in a Brazilian population, mainly in the early-onset form of the disease at 10% FP.

Reference range for the fetal intracranial translucency measurement between 11 and 14 + 2 weeks of gestation in a Brazilian population.

OBJECTIVE: To establish a reference range for the fetal intracranial translucency (IT) measurement between 11 and 14 + 2 weeks in a Brazilian population. METHODS: A retrospective cross-sectional study was performed with 199 low-risk singleton pregnancies during the first trimester ultrasound exam. The IT (fourth ventricle width) measurement was performed in a mid-sagittal view of fetal profile defined by two echogenic borders - the dorsal part of the brain stem anteriorly and the choroid plexus of the fourth ventricle posteriorly. Polynomial regression was used to obtain the best fit using fetal IT measurements and crown-rump length (CRL). Percentiles 5th, 50th and 95th were determined for each gestational age. RESULTS: The mean of fetal IT ranged from 1.6 mm at CRL 45 to 2.0 mm at CRL 84 mm. A best fit curve was a first-degree polynomial regression: IT measurement = 1.001 + 0.0124 × CRL (R(2)=0.09). CONCLUSION: Reference range for the fetal IT measurement between 11 and 14 + 2 weeks of gestation in a Brazilian population was established.

Neonatal neuronal apoptosis after betamethasone administration in pregnant Wistar rats.

OBJECTIVE: To analyze the apoptosis of cortical and hippocampal neurons in newborn following the intramuscular administration of betamethasone in pregnant Wistar rats. METHODS: Betamethasone or placebo was administered to 10 pregnant rats. Subsequently, 98 newborns were analyzed in three different groups: therapeutic dose (TD, 20 mg/kg), triple therapeutic dose (3TD, 60 mg/kg), and nine times TD (9TD, 180 mg/kg). Forty-four newborns were injected with placebo (control subjects--CTR). Neuronal apoptosis was measured by immunofluorescence using the TUNEL assay. The one-way analysis of variance, Tukey-Kramer (parametric) test and Kruskal-Wallis (non-parametric) test were used for statistical analysis. RESULTS: The CA1 area of the hippocampus of TD and 3TD groups showed significant differences from that of the CTR group (p < 0.001). Compared to the CTR group, there was increased neuronal apoptosis in the dentate gyrus (DG) of animals in TD and 3TD groups (p < 0.0001). There were no significant differences in CA2 and CA3 regions as well as in amygdala and cortex. CONCLUSION: Prenatal administration of betamethasone leads to significant changes in neuronal apoptosis in CA1 and DG regions.

Fetal frontomaxillary facial angle between 11 and 13 + 6 weeks of gestation in a Brazilian population: influence of different races.

OBJECTIVE: To evaluate the influence of different races over the measurement of the frontomaxillary facial angle between 11 and 13 + 6 weeks of pregnancy in a Brazilian population. METHODS: A cross-sectional study was conducted with 332 healthy pregnant women, with a crown-rump length (CRL) between 47 and 84 mm. Such measurements were taken abdominally, using the mid-sagittal plane, and the angle was measured by tracing a line over the palate and a line from the anterosuperior maxillary angle all the way to the external part of the forehead. As for the reference intervals, a simple linear regression between the frontomaxillary facial angle and the CRL was used, as well as Pearson's correlation coefficient (r). To evaluate the difference between races, a variance analysis was used (ANOVA). To calculate reproducibility, the intraclass correlation coefficient (ICC) was used. RESULTS: The means for the fetal frontomaxillary facial angle in white, black and mixed races were 81.8 ± 6.6; 82.2 ± 6.1 and 81.4 ± 6.2 mm, respectively. There was no statistical difference between races (p = 0.713). A decreasing correlation between the frontomaxillary facial angle and the CRL was observed for the black (r = -0.450) and mixed (r = -0.212) races. Excellent intraobserver reproducibility was observed, as well as a satisfactory interobserver reproducibility, with ICC of 0.858 and 0.605, respectively. CONCLUSION: There were no significative statistical differences in the measurement of the fetal frontomaxillary facial angle between 11 and 13 + 6 weeks of pregnancy in the different races in a Brazilian population.