Comparing the cerebro-placental to umbilico-cerebral Doppler ratios for the prediction of adverse neonatal outcomes in pregnancies complicated by fetal growth restriction.

OBJECTIVE: The cerebroplacental ratio (CPR) has shown utility as a surrogate marker for fetal growth restriction and can be used to stratify the risk for adverse perinatal outcomes in affected pregnancies. However, recent studies suggest that its inverse, the umbilico-cerebral ratio (UCR), may be a better predictor of such outcomes. The aim of this study was to compare the prognostic accuracy of CPR to that of UCR Doppler in predicting short-term adverse perinatal outcomes in growth-restricted fetuses. METHODS: We conducted a secondary analysis using data from a prospective study on women referred for fetal growth ultrasounds between 26 and 36 weeks of gestation and with an EFW < 10th percentile by Hadlock standard. The CPR and UCR were converted into Z-scores adjusted for gestational age at ultrasound. Abnormal CPR was defined as Z-score below the 10th percentile for the gestational age and abnormal UCR as Z-score above the 90th percentile. We calculated sensitivity and specificity of the two Doppler parameters for predicting composite adverse perinatal outcome (APO) defined as the presence of any one of the following: umbilical cord arterial pH <7.10, Apgars at 5 min <7, NICU admission,grade III/IV intraventricular hemorrhage (IVH), neonatal seizure and death. Logistic regression analysis was performed, ROC curves plotted and the area under the ROC curve (AUC) were compared between CPR and UCR. RESULTS: Over the study period, there were 197 women meeting inclusion criteria, of which 27 (13.7%) had a composite adverse neonatal outcome. The sensitivity using CPR Z-score for predicting the composite APO was higher thanwas similar to using UCR Z-score (39.3% compared with 37%) for a similar specificity (94.7 versus 94.1), respectively. However, the positive predictive value (PPV) was higher for CPR (55% vs UCR 50%) and the negative predictive values (NPV) were similar. For a fixed false positive rate of 10%, the detection rates for adverse neonatal outcomes were 40% using either CPR or UCR. The AUC for CPR and UCR were 0.70 and 0.68, respectively. CONCLUSION: This study did not find any advantage in utilizing the UCR over the CPR.

Detection of small for gestational age in preterm prelabor rupture of membranes by Hadlock versus the Fetal Medicine Foundation growth charts.

OBJECTIVE: The primary outcome was to compare the diagnostic accuracy of neonatal small for gestational age (SGA) by the Hadlock and Fetal Medicine Foundation (FMF) charts in our cohort, followed by the ability to predict composite severe neonatal outcomes (SNO) in pregnancies with preterm prelabor rupture of membranes (PPROM). METHODS: This study was a secondary analysis of a prospective cohort of pregnancies with PPROM from 2015 to 2018, from 23 to 36 completed weeks of gestation. Sensitivity, specificity, and positive and negative predictive values for the primary and secondary outcomes of the Hadlock and FMF fetal charts were calculated. The discriminatory ability of each chart was compared using the area under the receiver's operating curves of clinical characteristics. RESULTS: Of the 106 women who met the inclusion criteria, 48 (45%) were screened positive using the FMF fetal growth chart and 22 (21%) were screened positive using the Hadlock chart. SGA was diagnosed in 12 infants (11%). Both fetal growth charts had comparable diagnostic accuracies and were statistically significant predictors of SGA (Hadlock: area under the receiver operating characteristic curves [AUC], 0.76, risk ratio [RR], 7.6, 95% confidence interval [CI], 2.5-23; and FMF: AUC, 0.76 RR, 13.3 95%CI 1.8-99.3). Both growth standards were poor predictors of SNO. CONCLUSION: The Hadlock and FMF fetal growth charts have a similar accuracy to predict SGA in pregnancies complicated by PPROM. The FMF fetal growth chart may result in a 2-fold increase in positive screens, potentially increasing fetal surveillance.

The value of introducing cerebroplacental ratio (CPR) versus umbilical artery (UA) Doppler alone for the prediction of neonatal small for gestational age (SGA) and short-term adverse outcomes.

OBJECTIVE: To compare the role of umbilical artery (UA) Doppler versus CPR in the prediction of neonatal SGA and short-term adverse neonatal outcome in a high-risk population. STUDY DESIGN: We conducted a prospective study on women referred for fetal growth ultrasounds between 26 and 36 weeks of gestation and with an EFW <20th percentile by Hadlock standard. UA and middle cerebral artery (MCA) Doppler assessments were performed. Abnormal UA Doppler was defined as: pulsatility index (PI) above the 95th percentile and absent or reverse end-diastolic flow. The CPR, calculated as a ratio of the MCA PI by the UA PI, was defined as low if <1.08. The primary outcome was the sensitivity and specificity of the two Doppler assessments to predict neonatal SGA, defined as birthweight <10th percentile by using Alexander curves. The secondary outcomes included umbilical cord arterial pH <7.10, Apgars at 5 minutes <7, NICU admission, respiratory distress syndrome (RDS), hypoglycemia or a composite including any of these secondary outcomes. Chi-square was performed for statistical analysis. RESULTS: Of the 199 women meeting inclusion criteria, 94 (47.2%) had SGA and 68 (34.2%) had a composite adverse outcome. A total of seven pregnancies with FGR had a low CPR. Abnormal UA Doppler showed a better sensitivity for predicting SGA and adverse neonatal outcomes with comparable specificity to low CPR. The area under the ROC curve (AUC) using abnormal UA Doppler for predicting SGA was 0.54, 95% CI 0.50-0.58; and 0.51, 95% CI 0.48-0.53 for low CPR. The AUC for predicting a composite adverse neonatal outcome are: 0.60, 95% CI 0.51-0.68 for abnormal UA Doppler; and 0.54, 95% CI 0.47-0.84 for low CPR. CONCLUSION: The CPR did not improve our ability to predict neonatal SGA or other short-term adverse outcomes.

Comparing INTERGROWTH-21st Century and Hadlock growth standards to predict small for gestational age and short-term neonatal outcomes.

Objective: To compare the INTERGROWTH-21st Century growth standard to the Hadlock standard in predicting small for gestational age (SGA) and adverse neonatal outcomes.Method: This is a prospective cohort study on women with singleton gestations referred for fetal growth ultrasound between 26.0 and 36.6 weeks gestational age (GA). The primary outcome is prediction of neonatal SGA. Neonatal SGA was defined as birthweight <10th percentile for GA by Alexander chart. The discriminatory ability of the growth standards was compared using area under receiver operating characteristic curves (AUC).Results: Among 1054 patients who met inclusion criteria, 139 (13.2%) had neonatal SGA. The mean interval between estimated fetal weight and birthweight was 6.7 ± 3.1 weeks. Composite adverse neonatal outcome was seen in 300 (28.4%) patients. The sensitivity for identifying SGA neonates was higher for Hadlock compared with INTERGROWTH-21st standard (41.7 vs. 24.5%); AUC (95% CI) were 0.69 (0.65-0.73) and 0.62 (0.58-0.65), respectively. Both standards were comparable in predicting the composite adverse neonatal outcomes; AUC (95% CI) were 0.52 (0.50-0.53) and 0.52 (0.50-0.54), respectively; p = .28.Conclusions: The Hadlock standard had a moderate but higher discriminatory ability for predicting neonatal SGA compared to the INTERGROWTH-21st project standard. However, the two standards were poor predictors of early adverse neonatal outcomes.Rationale: The Intergrowth-21st project was recently introduced with the goal of providing a universal benchmark for comparing growth across different ethnicity. We performed a prospective cohort study to compare the Intergrowth-21st standard with the commonly used Hadlock standard for predicting pregnancies at risk for neonatal SGA and adverse outcomes. Hadlock fetal growth standard is moderately superior at predicting neonatal SGA compared to the Intergrowth-21st standard. Both standards are poor at predicting adverse neonatal outcomes. These findings, however, need further validation.

Treatment and Prevention of Hypertensive Disorders During Pregnancy.

This article reviews the pharmacology of the most commonly used antihypertensive medications during pregnancy; their mechanism of action; and the effects on the mother, the fetus, and lactation. Each class of antihypertensive pharmacologic agents have specific mechanisms of action by which they exert their antihypertensive effect. ß-Adrenoreceptor antagonists block these receptors in the peripheral circulation. Calcium channel blockers result in arterial vasodilation. α-Agonists inhibit vasoconstriction. Methyldopa is a centrally acting adrenoreceptor antagonist. Vasodilators have a direct effect on vascular smooth muscle. Diuretics decrease intravascular volume. Medications acting on the angiotensin pathway are avoided during pregnancy because of fetotoxic effects.

Customized fetal growth standard compared with the INTERGROWTH-21st century standard at predicting small-for-gestational-age neonates.

INTRODUCTION: The INTERGROWTH-21st project (IG-21) was recently performed aiming to provide a universal benchmark for comparing fetal growth across different ethnicities. Our aim was to compare the IG-21 with a customized standard for predicting pregnancies at risk for neonatal small-for-gestational age (SGA) and adverse outcomes. MATERIAL AND METHODS: This was a prospective cohort study including singleton pregnancies presenting for fetal growth assessment between 26 and 36 weeks of gestation. Fetal growth restriction was defined as estimated fetal weight <10th centile for gestational age using IG-21 and a customized standard. Neonatal SGA was defined as birthweight <10th centile for gestational age by the Alexander chart. Primary outcome was the prediction of neonatal SGA. Secondary outcomes included a composite of adverse neonatal outcomes. The discriminatory ability of each growth standard was compared using area under receiver operating characteristic curves (AUC). RESULTS: Of 1054 pregnancies meeting the inclusion criteria, the incidence of neonatal SGA was 139 (13.2%), and a composite adverse neonatal outcome occurred in 300 (28.4%). The sensitivity of the customized standard (38.8%) was higher than that of IG-21 (24.5%) for predicting neonatal SGA, with AUC (95% CI) of 0.67 (0.63-0.71) for customized vs 0.62 (0.58-0.65) for IG-21; P = .003. Both standards were comparable in predicting the composite adverse neonatal outcomes: AUC (95% CI) 0.52 (0.50-0.55) for customized vs 0.51 (0.50-0.53) for IG-21; P = 0.25. CONCLUSIONS: Both growth standards had modest performance in detecting neonatal SGA and were poor at predicting short-term adverse neonatal outcome.

Chromosomal microarray in prenatal diagnosis: case studies and clinical challenges.

Chromosomal microarray analysis (CMA) is a diagnostic tool used in the evaluation of pediatric patients with congenital anomalies or developmental and intellectual disability. In both the pediatric and prenatal patient population, CMA has been shown to have a higher detection rate of chromosomal abnormalities than conventional karyotype alone. Currently, the diagnostic yield of prenatal CMA is highest when applied to the evaluation of a fetus with multiple ultrasound anomalies. Challenges arise when CMA yields isolated findings not associated with a phenotype on ultrasound or variants of uncertain significance, which warrants evaluation of the risks, benefits, limitations and optimal incorporation of CMA into prenatal care. The clinical cases presented here will be used to illustrate these issues.

The Prevalence Of Sexually Transmitted Infections On Teen Pregnancies And Their Association To Adverse Pregnancy Outcomes.

INTRODUCTION: Based on our population data, the teen pregnancy rate and the prevalence of sexually transmitted infections (STIs) reported during pregnancy are worrisome. STIs appear to pose a threat to pregnancy outcomes including preterm birth (PTB), neonatal low birth weight (NLBW) and premature rupture of membranes (PROM). The objective of this study is to determine the prevalence of STIs in pregnant teens and the association of this variable to adverse pregnancy outcomes. METHODS: We performed a cross sectional study to assess the prevalence of STIs among pregnant teens during a 4-year period at our institution. Birth outcomes such as gestational age at delivery, PROM and NLBW were analyzed and compared with adults. RESULTS: In the four years of our study, teen pregnancy rate fluctuated from 21.7% in 2010 to 16.8% in 2013. The rate of STIs for adult and teen pregnancies was similar, 21% and 23%, respectively. Chlamydia was the most common STI (67.3%) for both groups. PTB was more prevalent among adults affected with STIs than teens, 13.8% and 11.5%, respectively. NLBW was similar among teens and adults with STIs. PROM complicated 9.1% of teen pregnancies with STIs, compared to 6.7% in adults. CONCLUSION: There was no significant correlation between the STIs and adverse pregnancy outcomes on teen pregnancies for our population, except for PROM. This age group is associated with a high-risk sexual behavior and poor adherence to treatment. They would benefit from efforts to prevent unintended pregnancies and infectious diseases.

Antenatal screening for Down syndrome with special considerations in the Puerto Rican population.

Down syndrome is the most studied chromosomal abnormality, and the risk of having a child with Down syndrome increases as maternal age increases. The prevalence of Down syndrome has been increasing in the last decade because more women older than 35 years of age are having children. In recent decades, the rate of identification of fetal anomalies in the uterus has substantially increased. Diagnostically speaking, serious concerns yet remain within the obstetrical community regarding who should be recommended for invasive procedures. The FASTER, SURUSS, and BUN studies have attempted to address this issue. In the United States, the quadruple screen for Down syndrome (hcG, AFP, estriol, and inhibin-A) is the most commonly used test today. During the first trimester, the nuchal translucency measurement combined with serum markers hcG and PAPP-A (pregnancy-associated plasma protein-A) results in high detection rates and low false-positive rates. For Down syndrome screening, new methods of evaluation have been proposed; among these are integrated, sequential, and contingent modalities. Different trials have demonstrated that first-trimester screening for Down syndrome is very effective, but all conclude that combining screening during both trimesters allows for lower false-positive values and higher detection rates. In Puerto Rico, in spite of the fact that a large proportion of the population undergoes serum screening, the rate of Down syndrome live births remains steady. One important aspect that appears to limit prenatal diagnosis of Down syndrome in our population is a poor acceptance rate of diagnostic testing techniques such as amniocentesis. Also, a limited efficiency in the implementation of these screening methods as well as their diagnostic success has been observed for our patient population.