Cerebroplacental ratio assessment in early labor in uncomplicated term pregnancy and prediction of adverse perinatal outcome: prospective multicenter study.

OBJECTIVE: It has been suggested that the use of Doppler ultrasound in term pregnancies with normal-sized fetuses is able to identify those at high risk of subclinical placental function impairment. The objective of this study was to evaluate the relationship between cerebroplacental ratio (CPR) measured in early labor and perinatal and delivery outcomes in a cohort of uncomplicated singleton term pregnancies. METHODS: This was a prospective multicenter observational study conducted at three tertiary centers between January 2016 and July 2017. Low-risk term pregnancies, defined by the absence of maternal morbidity or pregnancy complication, accompanied by normal ultrasound and clinical screening of fetal growth in the third trimester, with spontaneous onset of labor were included. Umbilical artery (UA) and fetal middle cerebral artery (MCA) Doppler was assessed on admission for early labor. All measurements were performed in between uterine contractions and according to international standards. CPR was computed by dividing MCA pulsatility index by UA pulsatility index and converted into multiples of the median (MoM) in order to adjust for gestational age. Doctors and midwives involved in the clinical management of the women were blinded to the results of the Doppler evaluation. Mode of delivery and perinatal outcome were compared between pregnancies with reduced CPR MoM, defined as CPR MoM within the lowest decile of the study population, and those with normal CPR MoM. Receiver-operating characteristics curve analysis was used to assess the predictive performance of CPR for obstetric intervention due to fetal distress and composite adverse perinatal outcome. RESULTS: Overall, 562 women were included. The rate of obstetric intervention for suspected fetal distress in labor was more than three times higher among cases with reduced CPR MoM compared to those with normal CPR MoM (9/54 (16.7%) vs 28/508 (5.5%); P = 0.004). Furthermore, a significantly higher rate of composite adverse perinatal outcome was found in fetuses with CPR MoM < 10th percentile compared to those with CPR MoM ≥ 10th percentile (6/54 (11.1%) vs 19/508 (3.7%); P = 0.012). CPR had low sensitivity and low positive predictive value for prediction of obstetric intervention due to fetal distress (24.3% and 18.0%, respectively) and composite adverse perinatal outcome (24.0% and 11.1%, respectively). CONCLUSIONS: Data on a wide cohort of low-risk term pregnancies in early labor showed that, while reduced CPR is associated with a higher risk of obstetric intervention due to fetal distress and composite adverse perinatal outcome, it is a poor predictor of adverse perinatal outcome. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Placental volume and uterine artery Doppler evaluation at 11 + 0 to 13 + 6 weeks' gestation in pregnancies conceived with in-vitro fertilization: comparison between autologous and donor oocyte recipients.

OBJECTIVE: To compare first-trimester uterine artery pulsatility index (UtA-PI) and three-dimensional (3D) placental volume in pregnancies conceived through in-vitro fertilization (IVF) using autologous or donor oocytes and pregnancies conceived naturally, and to relate these measurements to the development of pre-eclampsia (PE). METHODS: UtA-PI and placental volume were measured at 11 + 0 to 13 + 6 weeks of gestation in 416 IVF pregnancies (307 with autologous and 109 with donor oocytes) and in 498 spontaneously conceived pregnancies. We recruited nulliparous women with singleton pregnancy. The measured mean UtA-PI and placental volume values were converted to multiples of the expected normal median (MoM), adjusted for gestational age. MoM values of IVF pregnancies were compared with MoM values of the naturally conceived pregnancies and related to PE development. RESULTS: Placental volume was significantly reduced in IVF pregnancies (K = 169.3; P < 0.0001) compared with natural pregnancies. No difference was found in UtA-PI MoM between the two groups. Among IVF pregnancies, significantly lower placental volumes were seen in those that received donor oocytes when compared with those with autologous oocytes (z = 3.89; P < 0.001). In IVF pregnancies that developed PE, lower values of placental volume were demonstrated with respect to normotensive pregnancies (donor: U = 6.8; P = 0.009; autologous: U = 5.1; P = 0.023), whereas no difference was found in UtA-PI. Multivariate logistic regression analysis demonstrated that placental volume (odds ratio (OR), 1.97 (95% CI, 1.33-2.27)) and donor oocytes in IVF pregnancy (OR, 2.24 (95% CI, 1.5-2.83)) were independent predictors of PE, whereas autologous oocytes in IVF pregnancy were not found to be significant in the model. CONCLUSIONS: First-trimester placental volume, as assessed by 3D ultrasound, is reduced in IVF pregnancies and this reduction is more marked in those involving donor oocyte recipients. The relative decrease in placental volume in IVF pregnancies that developed PE suggests an etiological mechanism different from uterine perfusion in such patients. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Narrow subpubic arch angle is associated with higher risk of persistent occiput posterior position at delivery.

OBJECTIVE: To determine whether the subpubic arch angle (SPA) measured by three-dimensional ultrasound is associated with the fetal occiput position at delivery and the mode of delivery. METHODS: Nulliparous women with an uncomplicated singleton pregnancy at ≥ 37 weeks' gestation were recruited from two tertiary centers between September 2013 and August 2015. All women underwent a three-dimensional transperineal ultrasound examination and the SPA was measured using the previously validated Oblique View Extended Imaging software. Data on the outcome of labor were obtained prospectively in all cases and the correlations between SPA and the fetal occiput position at delivery and the incidence of operative delivery were investigated. RESULTS: Overall, 368 women were included in the study. Fetal position at delivery was occiput anterior in 339 (92.1%) cases and occiput posterior (OP) in 29 (7.9%) cases. A significantly narrower SPA was found in the OP group compared with the occiput anterior group (104.4 ± 16.8° vs 116.4 ± 11.9°; P < 0.0001). The SPA was significantly narrower in women requiring obstetric intervention compared with in women with a spontaneous vaginal delivery. From multivariable logistic regression analysis, SPA and maternal height appeared to be significant predictors of both the fetal occiput position at delivery and the risk of operative delivery. The best cut-off value of SPA for predicting an OP position at delivery was 90.5°. CONCLUSION: A narrow SPA is associated with a higher risk of persistent OP position at delivery and of operative delivery. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Uterine artery Doppler evaluation in twin pregnancies at 11 + 0 to 13 + 6 weeks of gestation.

OBJECTIVES: To compare uterine artery pulsatility index (PI) obtained at 11 + 0 to 13 + 6 weeks of gestation in singleton and twin pregnancies and to evaluate changes in PI values of twin pregnancies developing pre-eclampsia (PE) or small-for-gestational age (SGA) of either one or both fetuses. METHODS: Uterine artery PI was measured in 421 twin pregnancies (384 dichorionic and 37 monochorionic) and in 500 singleton pregnancies. The measured mean and lowest uterine artery PI values were converted to multiples of the expected normal median (MoM) after correction for maternal body mass index, ethnicity and gestational age. The median PI-MoM values of twins were compared with those of singleton pregnancies. In twin pregnancies, PI-MoM values were analyzed according to chorionicity, development of early-onset (< 34 weeks) or late-onset (≥ 34 weeks) PE and SGA of one or both twins. RESULTS: Uterine artery PI-MoM was significantly lower in twin compared with singleton pregnancies (mean K = 174.31, P < 0.0001, lowest K = 139.27, P < 0.0001). However, there were no significant differences in the uterine artery PI-MoM values between monochorionic and dichorionic twins. The uterine artery PI in twin pregnancies that developed early-onset PE (P < 0.001) and SGA of both twins (P < 0.05) was higher than the uterine artery PI in uncomplicated twin pregnancies, whereas no differences were found for late PE or SGA of one twin. CONCLUSIONS: First-trimester placental impedance to flow, as assessed by uterine artery Doppler examination, is reduced in twin pregnancies, with no differences related to chorionicity. The relative increase of uterine artery PI found in twin pregnancies that developed early PE and SGA of both twins suggests that first-trimester uterine artery assessment may be useful in identifying such complications.

Automated three-dimensional coded contrast imaging hysterosalpingo-contrast sonography: feasibility in office tubal patency testing.

OBJECTIVE: To evaluate the feasibility of transvaginal hysterosalpingo-contrast sonography (HyCoSy) with new automated three-dimensional coded contrast imaging (3D-CCI) software in the evaluation of tubal patency and visualization of tubal course. METHODS: Patients undergoing HyCoSy with automated 3D-CCI software were evaluated prospectively. First, to evaluate the feasibility of 3D visualization of tubal course, we performed consecutive volume acquisitions while injecting SonoVue contrast agent. We then performed conventional two-dimensional (2D) real-time HyCoSy to confirm tubal patency status by detection of saline and air bubbles moving through the Fallopian tubes and around the ovaries. We also evaluated visualization with CCI of the contrast agent around the ovaries, side effects and pain during and after the procedure, by visual analog scale (VAS) (ranging from 0 to 10, with 0 corresponding to no pain and 10 corresponding to maximum pain). RESULTS: A total of 126 patients (252 tubes) underwent 3D-CCI HyCoSy followed by 2D real-time HyCoSy. According to the final 2D real-time evaluation, bilateral tubal patency was observed in 111 patients, bilateral tubal occlusion in four patients and unilateral tubal patency in 11 patients. The concordance rate for tubal patency status between the first 3D volume acquisition and the final 2D real-time evaluation was 84% and that between the second 3D volume acquisition and the final 2D real-time evaluation was 97%. A pain score >5 on VAS was recorded in 58% of patients during the procedure, but a pain score ≤ 5 was recorded in 85.7% of patients immediately after the procedure. CONCLUSIONS: HyCoSy with automated 3D-CCI technology retains the advantages of conventional 2D HyCoSy while overcoming the disadvantages. 2D HyCoSy is highly observer-dependent and is only accurate in the hands of experienced investigators; by obtaining a volume of the uterus and tubes, automated 3D volume acquisition permits visualization of the tubes in the coronal view and of the tubal course in 3D space, and should allow less experienced operators to evaluate tubal patency status relatively easily.

An algorithm based on OmniView technology to reconstruct sagittal and coronal planes of the fetal brain from volume datasets acquired by three-dimensional ultrasound.

OBJECTIVE: To describe a novel algorithm, based on the new display technology 'OmniView', developed to visualize diagnostic sagittal and coronal planes of the fetal brain from volumes obtained by three-dimensional (3D) ultrasonography. METHODS: We developed an algorithm to image standard neurosonographic planes by drawing dissecting lines through the axial transventricular view of 3D volume datasets acquired transabdominally. The algorithm was tested on 106 normal fetuses at 18-24 weeks of gestation and the visualization rates of brain diagnostic planes were evaluated by two independent reviewers. The algorithm was also applied to nine cases with proven brain defects. RESULTS: The two reviewers, using the algorithm on normal fetuses, found satisfactory images with visualization rates ranging between 71.7% and 96.2% for sagittal planes and between 76.4% and 90.6% for coronal planes. The agreement rate between the two reviewers, as expressed by Cohen's kappa coefficient, was > 0.93 for sagittal planes and > 0.89 for coronal planes. All nine abnormal volumes were identified by a single observer from among a series including normal brains, and eight of these nine cases were diagnosed correctly. CONCLUSIONS: This novel algorithm can be used to visualize standard sagittal and coronal planes in the fetal brain. This approach may simplify the examination of the fetal brain and reduce dependency of success on operator skill.

Adenomyosis: three-dimensional sonographic findings of the junctional zone and correlation with histology.

OBJECTIVE: To correlate with histopathological features the adenomyosis-induced morphological alterations of the outer myometrium and the inner myometrium ('junctional zone', JZ) detectable on two- (2D) and three-dimensional (3D) transvaginal ultrasound imaging (TVS), and to evaluate their diagnostic accuracy for adenomyosis. METHODS: Premenopausal patients scheduled for hysterectomy for benign pathology were enrolled in this prospective study. Before hysterectomy all patients underwent detailed 2D-TVS and 3D volume acquisition of the entire uterus. The major sonographic signs of adenomyosis were noted. On the multiplanar coronal and longitudinal views obtained by 3D-TVS we measured the maximum and minimum JZ thickness from the basal endometrium to the internal layer of the outer myometrium (JZmax, JZmin), the difference between them (JZdif = JZmax - JZmin) and the ratio JZmax/total maximum myometrial thickness. Results of these examinations were correlated blindly to the presence of adenomyosis on histological specimens. RESULTS: A total of 72 premenopausal patients underwent 2D- and 3D-TVS before hysterectomy. The histological prevalence of adenomyosis was 44.4% (32/72 patients). In diagnosing adenomyosis, the presence of myometrial cysts was the most specific 2D-TVS feature (specificity, 98%; accuracy, 78%) and heterogeneous myometrium was the most sensitive (sensitivity, 88%; accuracy, 75%). The 3D-TVS markers JZdif ≥ 4 mm and JZ infiltration and distortion had high sensitivity (88%) and the best accuracy (85% and 82%, respectively). For 2D-TVS and 3D-TVS, respectively, the overall accuracy for diagnosis of adenomyosis was 83% and 89%, the sensitivity was 75% and 91%, the specificity was 90% and 88%, the positive predictive value was 86% and 85% and the negative predictive value was 82% and 92%. CONCLUSIONS: The coronal section of the uterus obtained by 3D-TVS permits accurate evaluation and measurement of the JZ, and its alteration has good diagnostic accuracy for adenomyosis.

The role of three-dimensional ultrasound in the diagnosis of fetal congenital anomalies: a review.

The objective of this review was to establish whether three-dimensional (3D) and four dimensional (4D) ultrasonography adds diagnostic information to what is currently provided by two-dimensional (2D) ultrasound in the diagnosis of the most frequent fetal structural defects: congenital heart disease and central nervous system congenital anomalies. There are evidences suggesting that 3D ultrasound allows to reduce the operator dependency in the visualization of standard diagnostic planes, thus reducing the examination time require for the obstetric ultrasound examination, with minimal impact on the visualization quality of the anatomic landmarks. Furthermore, operators with minimal experience may record cardiac or brain volumes that can be successfully analyzed off-line locally or sent by internet to experts for remote review. As a consequence 3D ultrasonography promises to become the method of choice for diagnosis congenital structural defects.

First-trimester umbilical vein blood flow in pregnancies with low serum pregnancy-associated plasma protein-A levels: an early predictor of fetal growth restriction.

OBJECTIVE: To investigate umbilical vein blood flow (UVBF) during the first trimester in pregnancies with low serum pregnancy-associated plasma protein-A (PAPP-A) levels and to relate umbilical vein (UV) diameter, time-averaged maximum velocity (TAMXV) and UVBF values to the subsequent development of fetal intrauterine growth restriction (IUGR). METHODS: UVBF assessment was performed at 11 + 0 to 13 + 6 weeks' gestation in 102 singleton pregnancies with PAPP-A concentrations of < 0.3 multiples of the median. UV diameter, UV-TAMXV and UVBF were calculated and analyzed in relation to pregnancy outcome. RESULTS: Pregnancy outcomes were: 51 pregnancies with birth weight ≥ 10(th) centile (Group A), 30 pregnancies with birth weight < 10(th) centile with normal Doppler in the umbilical artery throughout gestation (Group B) and 21 pregnancies with birth weight < 10(th) centile and abnormal umbilical artery Doppler later in gestation (Group C). No differences were found in PAPP-A levels between groups. Group C fetuses exhibited significantly lower values of UV-TAMXV (z-score - 1.99 SDs, t = 8.527, P ≤ 0.0001) and UVBF (z-score - 0.97 SDs, t = 7.420, P ≤ 0.0001) in comparison with normal reference ranges, while no differences were found in Groups A or B. CONCLUSIONS: Decreased UV-TAMXV and UVBF at 11 + 0 to 13 + 6 weeks' gestation identify fetuses at risk of developing IUGR among pregnancies with low levels of PAPP-A.

Intrauterine growth restriction: diagnosis and management. A review.

Intrauterine growth restriction (IUGR) is the failure to achieve the genetically predetermined growth potential and may be caused by maternal, fetal, placental, and external factors. IUGR is associated not only with a marked increased risk in perinatal mortality and morbidity but also with long-term outcome risks. IUGR is clinically suspected when ultrasonographic estimates of fetal size, simmetry or weight result abnormal. Exclusion of structural and/or chromosomal anomalies and Doppler studies of maternal and fetal circulations is the most effective method to differentiate IUGR fetuses secondary to placental dysfunction from those secondary to aneuploidy, genetic syndromes, and intrauterine infections. This review summarizes the current knowledge about fetal hemodynamics in IUGR pregnancies and its relationship with the severity of the disease. A better understanding of fetal hemodynamic changes occurring in IUGR will likely lead to targeted monitoring intervals in such fetuses leading to an appropriate timing of delivery only when fetal risks exceed neonatal risks.

Low cardiac output to the placenta: an early hemodynamic adaptive mechanism in intrauterine growth restriction.

OBJECTIVE: A low combined cardiac output (CCO) to the placenta (placenta/CCO fraction) has been reported in growth-restricted (IUGR) fetuses, but the temporal sequence of these modifications in relation to other changes in the fetal circulation is unknown. The aim of this study was to evaluate the placenta/CCO fraction in relation to other hemodynamic changes in fetuses at risk of developing IUGR. METHODS: We studied 340 singleton nulliparous pregnancies characterized at 20-24 weeks by abnormal uterine artery pulsatility index (PI) values (> 95(th) centile). At this gestational age we measured fetal biometry and Doppler waveforms from the umbilical artery (UA), middle cerebral artery (MCA), ductus venosus (DV), umbilical vein (UV) and outflow tracts of both ventricles. The diameters of the semilunar valves and UV were measured and CCO (left cardiac + right cardiac outputs) and UV blood flow were calculated. The placenta/CCO fraction was calculated as UV flow as a percentage of CCO. RESULTS: There were 283 pregnancies with birth weight >or= 10(th) centile and normal UA-PI throughout gestation (Group A), 34 with birth weight < 10(th) centile and normal UA-PI throughout gestation (Group B) and 23 with birth weight < 10(th) centile and abnormal UA-PI developing later in gestation (Group C). At 20-24 weeks there were no differences among the three groups in fetal biometric parameters, PI values from the UA, MCA and DV, and CCO. UV flow and placenta/CCO fraction were significantly lower in Group C compared with Group A (UV flow delta value = - 1.439, P < 0.0001; placenta/CCO fraction delta value = - 1.74, P < 0.0001) but not in Group B. CONCLUSIONS: Our data suggest that, in fetuses developing IUGR secondary to placental compromise, UV flow and placental/CCO fraction are already reduced by 20-24 weeks, and that this reduction occurs earlier than do modifications in fetal size and arterial and venous PI values.

Fetal renal artery velocity waveforms and amniotic fluid volume in growth-retarded and post-term fetuses.

Renal blood flow velocity waveforms were recorded by Doppler ultrasonography in 114 growth-retarded fetuses and in 97 post-term fetuses. The pulsatility index (PI) values were compared with our reference limits for gestational age and related to the amount of amniotic fluid. Growth-retarded fetuses showed significantly increased PI values compared with normally grown fetuses, and this difference was particularly evident in cases of oligohydramnios. Furthermore, there was a significant negative correlation between the increase in PI and the amniotic fluid volume. Post-term fetuses showed no significant differences in PI values compared with term fetuses and no significant correlation between the amount of amniotic fluid and PI values.

Changes of pulsatility index from fetal vessels preceding the onset of late decelerations in growth-retarded fetuses.

Thirty-six growth-retarded fetuses selected from a population of 214 cases were studied by Doppler ultrasonography at weekly intervals for at least 4 weeks between the diagnosis of Doppler abnormalities suggestive of the existence of the brain-sparing effect (ie, ratio between umbilical artery and middle cerebral artery pulsatility indexes [PIs] above the 95th percentile of our reference limits) to the onset of antepartum late fetal heart rate (FHR) decelerations. Recordings were made from the umbilical artery, descending aorta, renal artery, internal carotid artery, and middle cerebral artery and the PIs were calculated. Statistically significant changes in PI occurred in all the vessels studied. However, different trends were found when the modifications in cerebral vessels were compared with those in fetal peripheral vascular beds and in the umbilical artery. In cerebral arteries, a nadir of vasodilatation was reached 2 weeks before the onset of antepartum late FHR decelerations, whereas significant changes in the peripheral and umbilical vessels occurred close to the onset of abnormal FHR patterns. This study demonstrates that despite a brain-sparing effect, there are further Doppler-detectable modifications in fetal circulation that differ between the cerebral and peripheral vascular beds.

Uterine artery Doppler velocity waveforms in twin pregnancies.

OBJECTIVE: To compare uterine artery resistance index values in twin and singleton pregnancies, to examine eventual modifications of these values in twin pregnancies complicated by gestational hypertension and preeclampsia, and to determine whether resistance index values in twin pregnancies could predict the development of gestational hypertension and preeclampsia. METHODS: In a cross-sectional study, reference limits for gestation were constructed for the uterine artery resistance index (higher, lower, and mean values) in 96 uncomplicated twin pregnancies and compared to the reference limits constructed from 315 normal singleton pregnancies. Uterine artery resistance indexes obtained in 53 twin pregnancies complicated by either gestational hypertension or preeclampsia were compared with the newly established nomograms. The clinical efficacy of the uterine artery resistance index to predict hypertensive complications was evaluated prospectively in 64 twin pregnancies studied at 20-24 weeks' gestation. RESULTS: In both singleton and twin pregnancies, uterine artery resistance indexes decreased linearly with advancing gestation. However, twin pregnancies showed significantly different slopes and constant values, resulting in lower resistance indexes at all gestational ages examined. No significant differences were found when comparing resistance indexes in all patients with gestational hypertension or preeclampsia to the reference limits. Statistically significant differences were obtained for the higher (P < or = .05) and mean (P < or = .01) resistance indexes when the comparison was restricted to preeclamptic patients. In the twin pregnancies studied at 20-24 weeks' gestation, the diagnostic efficacy of the uterine artery resistance index for predicting the development of gestational hypertension and/or preeclampsia was disappointingly low (k < 0.10). CONCLUSIONS: Resistance index values in the uterine artery are lower in twin pregnancies than in singleton pregnancies. Gestational hypertension and preeclampsia may occur in twin pregnancies despite normal uterine artery velocity waveforms, suggesting a limited role of this measurement in the management and prediction of hypertensive complications in twin pregnancies.

Accelerated cardiac growth and abnormal cardiac flow in fetuses of type I diabetic mothers.

OBJECTIVES: To determine the growth patterns of the fetal heart and the development of cardiac function during gestation in fetuses of diabetic mothers, and to compare these findings with those of normal fetuses. METHODS: Serial M-mode and Doppler echocardiographic recordings were made at 4-week intervals in 14 fetuses of well-controlled type I insulin-dependent diabetic mothers and in ten control fetuses at 20-36 weeks' gestation. The following variables were measured: interventricular septal thickness, left ventricular wall thickness, right ventricular wall thickness, ratio between the peak velocities during early passive ventricular filling and active atrial filling at the level of the atrioventricular valves, peak velocities, and time to peak velocity at the level of the ascending aorta and pulmonary artery. RESULTS: In both groups of fetuses, all of the indices increased linearly with gestation. However, fetuses of diabetic mothers showed significant differences in the slope and intercept values for the function describing the growth of the interventricular septum (P less than or equal to .001) and the right and left ventricular wall thicknesses (P less than or equal to .01), resulting in accelerated cardiac growth. The function describing the development of the ratios between early and active ventricular filling showed differences in slope and intercept values at the level of both the mitral (P less than or equal to .001) and tricuspid valves (P less than or equal to .001), resulting in a lower rate of increase during diabetic pregnancy when compared with control fetuses. Significantly higher intercept values were found in the functions describing the increase of peak velocities in the aorta and pulmonary artery in fetuses of diabetic mothers (P less than or equal to .01), whereas the slopes were similar to those of control fetuses. No differences were found in the time to peak values between the groups of fetuses. No relationships were found between the echocardiographic results and the metabolic control of pregnancy or fetal characteristics. CONCLUSIONS: This study suggests that strict maternal diabetes control does not exclude accelerated fetal cardiac growth and abnormal development of cardiac function.

Fetal blood flow velocity waveforms as predictors of growth retardation.

Seventy-five high-risk pregnancies were studied in order to define the clinical value of the analysis of fetal blood flow velocity waveforms in early screening for growth retardation. Recordings were obtained at 26-28 weeks' gestation, in the absence of ultrasonographic signs of growth retardation, using a pulsed duplex Doppler system. The pulsatility index was evaluated at the level of the umbilical artery, descending aorta, and internal carotid artery. Fetuses (N = 23) who developed growth retardation showed higher values of pulsatility index in the umbilical artery (P less than .001) and descending aorta (P less than .05) than fetuses of normal growth. In the internal carotid artery, the pulsatility index was lower (P less than .001) in the fetuses who developed growth retardation than in those with normal growth. The ratio between the pulsatility indexes of the umbilical and internal carotid arteries proved an accurate predictor of growth retardation (specificity 92.3%; sensitivity 78.2%; positive predictive value 81.8%; negative predictive value 90.5%; accuracy 88%).

Atrial natriuretic peptide levels in fetal blood in relation to inferior vena cava velocity waveforms.

OBJECTIVE: To determine whether blood levels of atrial natriuretic peptide in small for gestational age (SGA) fetuses are related to Doppler indices measured in arterial and venous vessels. METHODS: Atrial natriuretic peptide was assayed in fetal blood obtained at funipuncture in 42 third-trimester fetuses, of whom 11 were appropriate for gestational age (AGA) and 31 were SGA. Small for gestational age fetuses were divided into three groups according to Doppler findings in the umbilical artery and inferior vena cava: 1) normal in both vessels (n = 10); 2) abnormal in the umbilical artery but normal in the inferior vena cava (n = 10); and 3) abnormal in both vessels (n = 11). Atrial natriuretic peptide levels were related to Doppler indices and acid-base status of the fetal blood. RESULTS: Small for gestational age fetuses with abnormal waveforms in both vessels had higher atrial natriuretic peptide blood levels (median 544.8 pg/mL, range 404.2-1112.3) compared with AGA fetuses (median 316.8 pg/mL, range 159.3-470.1; P < or = .001), SGA fetuses with normal waveforms only in both vessels (median 299.8 pg/mL, range 242.6-480.5; P < or = .001), and SGA fetuses with abnormal waveforms only in the umbilical artery (median 367.6 pg/mL, range 192.7-748.9; P = .002). Blood levels of atrial natriuretic peptide were significantly related to the preload index in the inferior vena cava (p = 0.554, P < or = .001). This relation remained significant when the analysis was restricted to the SGA fetuses with abnormal waveforms in the umbilical artery and the inferior vena cava (p = 0.673, P = .03). CONCLUSIONS: Small for gestational age fetuses with abnormal velocity waveforms in the inferior vena cava have significantly higher concentrations of atrial natriuretic peptide. This may represent a compensatory mechanism in the SGA fetus for regulation of an abnormal hemodynamic condition.

Monitoring of hormone replacement therapy in postmenopausal women by transvaginal sonography and color flow doppler: study in different phases of sequential therapy.

OBJECTIVE: To assess uterine artery blood flow and endometrial thickness in postmenopausal patients receiving sequential hormone replacement therapy (HRT) at different phases of the treatment. DESIGN: Prospective controlled study. SETTING: Ultrasound and menopause units of the obstetrics and gynecology department of the University of Tor Vergata, Rome, Italy. PATIENT(S): Forty postmenopausal women were treated with cyclic sequential HRT (transdermal E2, 50 microg/d, days 1-21; and dydrogesterone, 10 mg/d, days 12-24). INTERVENTION(S): All patients underwent transvaginal color Doppler sonography in the estrogen (phase E) and progestogen (phase E/P) phases and after uterine bleeding when no hormone was administered (phase 0). MAIN OUTCOME MEASURE(S): Endometrial thickness; systolic, diastolic, and mean velocities; and pulsatility and resistance indices of the uterine arteries. RESULT(S): No statistically significant difference in endometrial thickness between phase E (6.5+/-1.6 mm) and phase E/P (6.0+/-1.7 mm) was observed. In phase 0, compared with phases E and E/P, a statistically significant decrease in endometrial thickness was found (4.1+/-1.2 mm). Doppler flow impedance parameters of uterine arteries during the different phases of the HRT cycle showed no differences between the phases considered. CONCLUSION(S): The decrease in endometrial thickness in phase 0 suggests a protective effect of our cyclic sequential regimen on the endometrium. Dydrogesterone does not interfere markedly with the vasodilatory effect of estrogen on uterine arteries.