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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 do Crescimento Fetal , Nascimento Prematuro , Gravidez , Recém-Nascido , Feminino , Humanos , Estudos Prospectivos , Ultrassonografia Pré-Natal , Recém-Nascido Pequeno para a Idade Gestacional , Ultrassonografia Doppler , Peso Fetal , Idade Gestacional , Artérias Umbilicais/diagnóstico por imagemRESUMO
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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Desenvolvimento Fetal , Retardo do Crescimento Fetal/diagnóstico por imagem , Reologia , Ultrassonografia Doppler , Ultrassonografia Pré-Natal , Adulto , Peso ao Nascer , Europa (Continente) , Feminino , Retardo do Crescimento Fetal/fisiopatologia , Peso Fetal , Feto/irrigação sanguínea , Feto/diagnóstico por imagem , Feto/fisiopatologia , Idade Gestacional , Humanos , Recém-Nascido , Recém-Nascido Pequeno para a Idade Gestacional , Nascido Vivo , Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/embriologia , Gravidez , Estudos Prospectivos , Fluxo Pulsátil , Valores de Referência , Natimorto , Artérias Umbilicais/diagnóstico por imagem , Artérias Umbilicais/embriologia , Circunferência da CinturaRESUMO
OBJECTIVES: Maternal gestational diabetes mellitus (GDM) is known to influence fetal physiology. Phase-rectified signal averaging (PRSA) is an innovative signal-processing technique that can be used to investigate fetal heart signals. The PRSA-calculated variables average acceleration capacity (AAC) and average deceleration capacity (ADC) are established indices of autonomic nervous system (ANS) function. The aim of this study was to evaluate the influence of GDM on the fetal cardiovascular and ANS function in human pregnancy using PRSA. METHODS: This was a prospective clinical case-control study of 58 mothers with diagnosed GDM and 58 gestational-age matched healthy controls in the third trimester of pregnancy. Fetal cardiotocography (CTG) recordings were performed in all cases at entry to the study, and a follow-up recording was performed in 19 GDM cases close to delivery. The AAC and ADC indices were calculated by the PRSA method and fetal heart rate short-term variation (STV) by CTG software according to Dawes-Redman criteria. RESULTS: Mean gestational age of both groups at study entry was 35.7 weeks. There was a significant difference in mean AAC (1.97 ± 0.33 bpm vs 2.42 ± 0.57 bpm; P < 0.001) and ADC (1.94 ± 0.32 bpm vs 2.28 ± 0.46 bpm; P < 0.001) between controls and fetuses of diabetic mothers. This difference could not be demonstrated using standard computerized fetal CTG analysis of STV (controls, 10.8 ± 3.0 ms vs GDM group, 11.3 ± 2.5 ms; P = 0.32). Longitudinal fetal heart rate measurements in a subgroup of women with diabetes were not significantly different from those at study entry. CONCLUSIONS: Our findings show increased ANS activity in fetuses of diabetic mothers in late gestation. Analysis of human fetal cardiovascular and ANS function by PRSA may offer improved surveillance over conventional techniques linking GDM pregnancy to future cardiovascular dysfunction in the offspring. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Sistema Nervoso Autônomo , Diabetes Gestacional/fisiopatologia , Frequência Cardíaca Fetal , Processamento de Sinais Assistido por Computador , Adulto , Peso ao Nascer , Cardiotocografia/métodos , Estudos de Casos e Controles , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Masculino , Gravidez , Terceiro Trimestre da Gravidez , Estudos Prospectivos , Ultrassonografia Pré-NatalRESUMO
OBJECTIVE: To evaluate the incidence of chorioamniotic membrane separation (CMS) after fetoscopy in monochorionic diamniotic (MCDA) twins and its impact on pregnancy outcome. METHODS: The study group comprised a consecutive series of 338 women with an MCDA pregnancy complicated by twin-twin transfusion syndrome (TTTS) or selective intrauterine growth restriction (sIUGR) treated with selective laser photocoagulation of communicating vessels (SLPCV) or cord occlusion (CO). Data obtained included cervical length, gestational age at procedure, type and duration of surgery and placental location. The incidence of CMS, the rates of miscarriage and preterm prelabor rupture of membranes (PPROM), gestational age at delivery and neonatal survival were recorded. RESULTS: Of the study population of MCDA pregnancies, 270 (79.9%) had TTTS and 68 (20.1%) had sIUGR. SLPCV was performed in 252 (74.6%) cases and CO in 86 (25.4%). Postoperative CMS was observed in 70 (20.7%) cases. Patients with CMS had higher rates of miscarriage (14.3% vs 7.1%; P = 0.049), PPROM before 32 weeks (43.3% vs 13.7%; P < 0.001) and preterm delivery before 32 weeks (53.3% vs 26.1%; P < 0.001) and a lower rate of neonatal survival of at least one twin (81.7% vs 93.6%; P = 0.003). Multivariate analysis showed that gestational age at surgery was the only independent predictor, with the highest proportion of CMS occurring in cases that underwent surgery before 18 weeks' gestation (odds ratio, 2.941 (95% CI, 1.640-5.275); P < 0.001). There was no influence of cervical length, placental location, duration of surgery or type of surgery on the risk of CMS. CONCLUSIONS: CMS complicated one-fifth of all MCDA pregnancies that underwent fetoscopy. It appeared to be more common in those who underwent surgery before 18 weeks' gestation and was associated with poorer outcomes. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Ruptura Prematura de Membranas Fetais/epidemiologia , Transfusão Feto-Fetal/epidemiologia , Fetoscopia/efeitos adversos , Gêmeos Monozigóticos , Feminino , Retardo do Crescimento Fetal/epidemiologia , Ruptura Prematura de Membranas Fetais/etiologia , Transfusão Feto-Fetal/etiologia , Transfusão Feto-Fetal/cirurgia , Idade Gestacional , Humanos , Incidência , Recém-Nascido , Fotocoagulação a Laser/métodos , Gravidez , Complicações na Gravidez/epidemiologia , Resultado da Gravidez , Espanha/epidemiologiaRESUMO
OBJECTIVES: To compare the value of Doppler surveillance with maternal blood angiogenic factors at diagnosis for the prediction of adverse outcome in late-pregnancy small-for-gestational-age (SGA) fetuses. METHODS: In a cohort of 198 SGA fetuses we evaluated the association of Doppler indices (mean uterine artery pulsatility index (UtA-PI) and cerebroplacental ratio (CPR)) and angiogenic factors (maternal serum levels of soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF)) with the development of pre-eclampsia and adverse perinatal outcome (operative delivery for non-reassuring fetal status or neonatal metabolic acidosis). RESULTS: In SGA fetuses subsequently developing pre-eclampsia, mean UtA-PI (P < 0.001), sFlt-1 MoM (P < 0.001) and sFlt-1/PlGF MoM ratio (P < 0.001) were higher, while PlGF MoM was lower (P = 0.004). In SGA fetuses with adverse perinatal outcome, CPR (P < 0.002) and PlGF MoM (P < 0.001) were lower, and sFlt-1/PlGF MoM ratio was higher (P = 0.001). For predicting pre-eclampsia, the areas under the receiver-operating characteristics (ROC) curves for mean UtA-PI, sFlt-1 MoM and the combination of both were 0.852, 0.839 and 0.860, respectively. For adverse perinatal outcome, the areas under the ROC curves for CPR, PlGF MoM and the combination of both were 0.652, 0.656 and 0.684, respectively. The combination of Doppler indices and angiogenic factors did not significantly improve prediction of either pre-eclampsia (P = 0.851) or adverse outcome (P = 0.579). CONCLUSIONS: In SGA fetuses, angiogenic factors at diagnosis and follow-up with Doppler ultrasound both predict adverse outcome with a similar performance.
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Indutores da Angiogênese/sangue , Retardo do Crescimento Fetal/sangue , Retardo do Crescimento Fetal/diagnóstico por imagem , Ultrassonografia Doppler , Artérias Umbilicais/diagnóstico por imagem , Artéria Uterina/diagnóstico por imagem , Biomarcadores/sangue , Feminino , Sangue Fetal , Seguimentos , Humanos , Recém-Nascido Pequeno para a Idade Gestacional , Masculino , Valor Preditivo dos Testes , Gravidez , Resultado da Gravidez , Terceiro Trimestre da Gravidez , Estudos Prospectivos , Fluxo Pulsátil , Curva ROC , Ultrassonografia Pré-NatalRESUMO
OBJECTIVE: To compare left myocardial performance index (MPI) values and reproducibility using different settings and ultrasound equipment in order to standardize optimal machine settings. METHODS: Left MPI was prospectively evaluated by one observer performing conventional Doppler in 62 fetuses (28-36 weeks of gestational age) using different settings (changing sweep speed, gain and wall motion filter (WMF)) and two different ultrasound devices (Siemens Antares, Siemens; Voluson 730 Expert, GE Medical Systems). Intraclass coefficients of agreement (ICCs) were calculated using Bland-Altman analysis. RESULTS: Using baseline settings on the Siemens, mean (SD) MPI was 0.44 (0.05) with an ICC of 0.81. Decreasing the sweep speed resulted in decreasing average MPI values (0.43) and decreasing ICC (0.61). Lowering gain also influenced average MPI values (0.46) and ICC (0.76). Raising gain resulted in similar MPI values (0.45) with better ICC (0.90) compared with baseline settings. Raising wall motion filter (WMF) provided the best ICC (0.94) compared with the other settings. Changing the ultrasound equipment resulted in an ICC of 0.64. The optimal settings to achieve the highest reproducibility in measurement of MPI were sweep speed 8, gain 60 dB and WMF 281 Hz for Siemens Antares and sweep speed 5, gain -10 dB and WMF 210 Hz for Voluson 730 Expert. CONCLUSION: Changing ultrasound settings or equipment may affect the calculation and repeatability of measurement of MPI values. Strict standardization of methods decreases the variability of this parameter for fetal cardiac function assessment.
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Coração Fetal/fisiologia , Adulto , Ecocardiografia Doppler/métodos , Ecocardiografia Doppler/normas , Feminino , Coração Fetal/diagnóstico por imagem , Idade Gestacional , Humanos , Masculino , Gravidez , Resultado da Gravidez , Estudos Prospectivos , Fluxo Pulsátil/fisiologia , Valores de Referência , Reprodutibilidade dos Testes , Ultrassonografia Pré-Natal/métodos , Ultrassonografia Pré-Natal/normas , Artérias Umbilicais/fisiologiaRESUMO
Prenatal diagnosis of a huge coronary artery fistula between the left coronary artery and the right ventricle was made by Doppler echocardiography at 22 weeks of gestation. Progression of the dilated fistula was monitored throughout pregnancy. The size of the fistula increased enormously up to 11 mm. Death occurred at birth. Monitoring of these fetuses is essential as severe complications can occur during pregnancy or at birth.
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Extracorporeal membrane oxygenation (ECMO) is increasingly used for the management of acute severe cardiac and respiratory failure. One of the indications is acute respiratory distress syndrome (ARDS) for which, in some severe cases, ECMO represents the only possibility to save lives. We report on the successful long-term use of ECMO in a postpartum patient with recurrent pulmonary decompensation after peripartum uterine rupture with extensive blood loss.
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OBJECTIVE: This study aims to compare average acceleration capacity (AAC), a new parameter to assess the dynamic capacity of the fetal autonomous nervous system, and short term variation (STV) in fetuses affected by intrauterine growth restriction (IUGR) and healthy fetuses. METHODS: A prospective observational study was performed, including 39 women with IUGR singleton pregnancies (estimated fetal weight <10th percentile and umbilical artery resistance index >95th percentile) and 43 healthy control pregnancies matched according to gestational age at recording. Ultrasound biometries and Doppler examination were performed for identification of IUGR and control fetuses, with subsequent analysis of fetal heart rate, resulting in STV and AAC. Follow-up for IUGR and control pregnancies was done, with perinatal outcome variables recorded. RESULTS: AAC [IUGR mean value 2.0 bpm (interquartile range = 1.6-2.1), control 2.7 bpm (2.6-3.0)] differentiates better than STV [IUGR 7.4 ms (5.3-8.9), control 10.9 ms (9.2-12.7)] between IUGR and control. The area under the curve for AAC is 97 % [95% CI = (0.95-1.0)], for STV 85 % (CI = 0.76-0.93; p < 0.01). Positive predictive value for STV is 77% and negative predictive value is 81%. For AAC both positive and negative predictive values are 90%. CONCLUSIONS: AAC shows an improvement to discriminate between normal and compromised fetuses at a single moment in time, in comparison with STV.
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Retardo do Crescimento Fetal/fisiopatologia , Monitorização Fetal/métodos , Processamento de Sinais Assistido por Computador , Adulto , Velocidade do Fluxo Sanguíneo , Estudos de Casos e Controles , Feminino , Retardo do Crescimento Fetal/diagnóstico por imagem , Feto/irrigação sanguínea , Feto/fisiopatologia , Frequência Cardíaca Fetal/fisiologia , Humanos , Estudos Longitudinais , Gravidez , Estatística como Assunto/métodos , Ultrassonografia Doppler , Ultrassonografia Pré-Natal , Artérias Umbilicais/diagnóstico por imagem , Artérias Umbilicais/fisiopatologia , Adulto JovemRESUMO
OBJECTIVE: To study fetal heart rate (FHR), its short term variability (STV), average acceleration capacity (AAC), and average deceleration capacity (ADC) throughout uncomplicated gestation, and to perform a preliminary comparison of these FHR parameters between small-for dates (SFD) and control fetuses. METHODS: Prospective observational study of 7 h FHR-recordings obtained with a fetal-ECG monitor in the second half of uncomplicated pregnancies (n = 90) and pregnancies complicated by fetal SFD (n = 30). FHR and STV were calculated according to established analysis. True beat-to-beat FHR, recorded at 1 ms accuracy, was used to calculate AAC and ADC using Phase Rectified Signal Averaging (PRSA). Mean values of FHR, STV, AAC, and ADC derived from recordings in SFD fetuses were compared with the reference curves. RESULTS: Compared with the control group the mean z-scores for STV, AAC, and ADC in SFD fetuses were lower by 1.0 SD, 1.5 SD, and 1.7 SD, respectively (p < 0.0001 for all comparisons). In SFD fetuses, both the AAC and ADC z-scores were lower than the STV z-scores (p < 0.02 and p < 0.002, respectively). CONCLUSIONS: Analysis of the AAC and ADC as recorded with a high resolution fECG recorder may differentiate better between normal and SFD fetuses than STV.