Longitudinal Doppler Assessments in Late Preterm Fetal Growth Restriction.

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+ 0-36+ 6, at risk of FGR (estimated fetal weight [EFW] or abdominal circumference [AC] < 10th percentile, abnormal arterial Doppler or fall in AC from 20-week scan of > 40 percentile points). The primary outcome was a composite of abnormal condition at birth or major neonatal morbidity. UCR was categorized as normal (< 0.9) or abnormal (≥ 0.9). 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 (81 %) had more than one measurement (median 3 (IQR 2-4). At inclusion, 63 (7 %) a UCR ≥ 0.9. These delivered earlier and had a lower birth weight and higher incidence of adverse outcome (30 % vs. 9 %, relative risk 3.2; 95 %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 67 % (95 %CI 55-80), but after a normal UCR the chance of finding an abnormal UCR was 6 % (95 %CI 5-7 %). 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 5-7 % 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.

Fetal cerebral Doppler changes and outcome in late preterm fetal growth restriction: prospective cohort study.

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.

Fetal and neonatal alloimmune thrombocytopenia.

OBJECTIVE: This article shows our experience with fetal and neonatal alloimmune thrombocytopenia (FNAIT) on a particular patient and the difficulties we faced during the hospitalization. DESIGN: Case report. SETTING: Department of Obsterics and Gynecology 1st Faculty of Medicine, Charles University and General Faculty Hospital in Prague. METHODS: Our experience with FNAIT therapy. RESULTS: According to literature is recommended to use IVIG for FNAIT treatment. Women, who were treated by IVIG have better results, in comparison with women, who had no treatment at all. Our case is not confirming this statement, because first pregnancy of our patient terminated by IUFD, on the other hand second pregnancy was successful and she delivered healthy child. CONCLUSION: FNAIT is relatively rare disease, but if it appears, it can be dangerous for a fetus or for a new-born baby. In the worst case FNAIT can result in intracranial bleeding or prenatal death. There are limited preventive steps and available therapy produces uncertain results. The only partially accepted treatment substance is IVIG (intravenous immunoglobulins). Unfortunately, this therapy is very expensive and not accepted by some experts. This article shows our experience with FNAIT on a particular patient and the difficulties we faced during the hospitalization.

Effect of systemic enzymotherapy on Cesarean section scar healing.

OBJECTIVES: The aim of our study was to monitor changes in the healing of Caesarean section scars in patients using systemic enzymotherapy in comparison with patients not treated with systemic enzymotherapy (Wobenzym). METHODS: A prospective cohort study was conducted in 60 primiparous women delivered by CS. We compared the following outcomes: scar thickness after the Caesarean section, dehiscence risk coefficient (DRC), severity of the Caesarean section scar defect, uterine cavity dilation, post-operative pain, C-reactive protein level and febrility. RESULTS: The scar thickness 6 weeks after CS was significantly greater in the group of patients taking Wobenzym (7.1±0.9 mm; mean ± SD) than in the patients without Wobenzym (5.3±0.7 mm) (p = 0.01). Severe Caesarean section scar defects were observed in 1/30 (3.3%) Wobenzym users and in 5/30 (16.7%) patients who did not use Wobenzym, with no statistically significant difference (p = 0.195). CONCLUSION: Despite the percentage of patients with a severe CS scar defect being apparently lower in the group treated with Wobenzym, the difference did not reach statistical significance due to the small size of the study population.

[Preeclampsia in pregnancy - prediction, prevention and further management]. / Preeklampsie v tehotenství - predikce, prevence a dalsí management.

UNLABELLED: Review article about preeclampsia (PE), analysis and summarization of cutting-edge knowledge about this adverse pregnancy outcome based on the study of existing literature. A relatively new trend is the prediction possibility of the development of PE in early gestation and appropriate management of high risk pregnancies. In this paper we accord special attention to this important aspect. On the other hand possibilities and efficiency of prevention of PE are discussed. Prediction, prevention, early diagnosis and appropriate treatment of PE are important goals of the modern obstetrics. KEYWORDS: preeclampsia, screening, prediction, PlGF, sFlt-1, prevention, Aspirin.

[Prenatal growth curves of the Czech population]. / Prenatální rustové krivky ceské populace.

OBJECTIVE: Determination of ultrasound biometric parameters of fetuses in the Czech population during pregnancy. METHODS: We retrospectively analyzed a data set of 20,566 pregnant women from the years 2008 to 2012 who met the following inclusion criteria: Caucasian ethnicity; measured biometric parameters biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femur length (FL); body mass index (BMI) of the pregnant women < 35 kg/m2.We excluded pregnant women with multiple fibroids distorting the uterine cavity; pathologically developing fetuses; and pregnancies where we were not able to verify the correct dating. We did not carry out selection as to the method of getting pregnant. The pregnancy age was from 19+0 to 42+6 gestation weeks. As in all studies, the age of pregnancy refers to the completed gestation weeks (for instance 23+0 to 23+6 = 23rd gestation week). We then compared our newly derived growth curves with the curves currently used, for BPD, HC, AC, FL and EFW, in the 3rd or 5th percentile, 50th percentile and 95th or 97th percentile (according to data obtained from reference studies). RESULTS: The study included 40,806 observations. The number of observations exceeded 500 in all weeks except in the 42nd week. The median age of the pregnant patients was 31.9 years (min 14.9, max 52.54). In the studied group we found a lower degree of variability in all parameters. The biometric parameters had higher values for the gestation week than the reference parameters. The estimated weight of the fetuses in our group on the level of the 3rd percentile was significantly higher than the reference value. DISCUSSION: The study was based exclusively on sonographic measurements. Although we excluded from our group intrauterine pathologies that could affect the physiological growth of the fetus, we did not carry out an additional selection using information on the pathologies of fetuses obtained postnatally. However, as the study contains more than 40,000 measurements, we can assume that such additional selection would have had only a minimum effect on the resulting curve. A section of the fetuses that would have been considered eutrophic according to present reference studies could be considered hypotrophic or small for gestational age (SGA) according to our observations. CONCLUSION: We have obtained new prenatal ultrasound growth curves for the Czech population of healthy developing fetuses. In early gestation weeks, we have found statistically significant deviations from the reference studies. Fetuses in our study have significantly higher weight estimate and show a lower degree of variability compared to the reference studies. KEYWORDS: prenatal, ultrasound diagnosis, fetal biometry, percentile curves, biparietal diameter, head circumference, abdominal circumference, femur length, estimated fetal weight, Czech population.

[Extracellular chromosome 21--derived microRNAs in maternal circulation: evaluation of their diagnostic potential for screening of Down syndrome]. / Chromozom 21 - specifické mikroRNA v materské cirkulaci: zhodnocení jejich významu pro screening Downova syndromu u plodu.

OBJECTIVE: Initially, we focused on the detection of extracellular microRNAs in maternal circulation, whose genes are located on human chromosome 21 (miR-99a, let-7c, miR-125b-2, miR-155 and miR-802). Subsequently, we studied if plasmatic concentrations and/or expression profile of extracellular chromosome 21-derived microRNAs would distinguish between pregnancies bearing euploid foetuses and those affected with Down syndrome. DESIGN: Pilot study. SETTING: Division of Molecular Biology and Cell Pathology, Department of Gynaecology and Obstetrics, Third Faculty of Medicine, Charles University, Prague. METHODS: 12 women with normal course of gestation (mean 16.4 weeks, median 16.0 weeks), 12 pregnancies bearing Down syndrome foetus (mean 18.2 weeks, median 18.5 weeks) and 6 non-pregnant individuals were involved in the retrospective study. RNA enriched for small RNAs (including microRNAs) was isolated from 1ml of plasma sample. Consequently relevant microRNA was transcribed into cDNA using specific stem-loop primer and detected by specific real-time PCR assay. RESULTS: Commercial systems enabled reliable detection of 4 out of 5 extracellular chromosome 21-derived microRNAs (miR-99a, let-7c, miR-125b-2 and miR-155). Expression profile of extracellular miR-99a, miR-125b-2 and miR-155 was significantly higher in the cohort of pregnant women than in non-pregnant individuals. Also plasmatic levels of miR-99a and miR-125b-2 were significantly increased in pregnant women. Unfortunately, the concentrations and gene expression of extracellular chromosome 21-derived microRNAs (miR-99a, let-7c, miR-125b-2 and miR-155) did not differ between the cohorts of pregnancies bearing euploid foetuses and those affected with Down syndrome. CONCLUSION: Analysis of extracellular chromosome 21-derived microRNAs does not distinguish between pregnancies with euploid and aneuploid foetuses and has no benefit for screening programmes.

Detection of fetal major structural anomalies at the 11-14 ultrasound scan in an unselected population.

OBJECTIVE: The aim of the study was to determine the efficacy of the 11-14 week scan in detecting fetuses with structural anomalies. STUDY DESIGN AND METHODS: Prospective interventional study in an unselected population of pregnant women in a 5-year period (2003-2008) in a single ultrasound unit. 8889 fetuses with median CRL 65mm (45-84mm) were examined. Continuing pregnancies were rescanned at 20-22 weeks. Actual structural anomalies among newborns from the studied group were obtained from our computerized database. RESULTS: The median maternal age was 30 years (14-50 years). The incidence of anomalies was 16.08 per 1000 (143/8889). Of these, 99 of the 143 were detected with prenatal sonography. 46.9% (67/143) of all anomalies were detected at the 11-14 week scan. Later in pregnancy, another 22.3% (32/143) of structural anomalies were detected. CONCLUSIONS: 67.7% of all antenatally detected malformations by ultrasound were recognized in the 11 14 week scan. Obviously, the second trimester scan cannot be abandoned, as it provides effective detection of other anomalies.

[Accuracy of placenta accreta ultrasound prediction in clinical work]. / Moznosti ultrazvukové predikce placenta accreta v klinické praxi.

OBJECTIVE: To evaluate accuracy of placenta accreta ultrasound prediction in own group of patients. DESIGN: Retrospective analysis. SETTING: Department of Obstetrics and Gynaecology, 1st Faculty of Medicine, Charles University and General Faculty Hospital, Prague. METHODS: We retrospectively evaluated a group of 12 patients, that had undergone ultrasound examination during pregnancy at our department and afterwards had been diagnosed during caesarean section (CS) with placenta accreta (years 2010-2011). RESULTS: 11 out of 12 women in our group had at least one of the risk factors (placenta praevia, previous SC, history of uterine surgery). During US examination, suspicion of placenta accreta was raised at 7 out of 12 women. In 5 cases we have performed elective CS and in 7 cases CS was done after onset of the labour (in 4 cases the reason was severe bleeding). The peripartal blood loss ranged from 500 ml to 7000 ml. Due to life threatening bleeding in 5 cases (42%), abdominal hysterectomy was performed. Placenta accreta was successfully diagnosed in cases with hysterectomy by US in 80 percent (4/5). Histological examination of the uterus confirmed in 2 cases placenta accreta, in 2 cases placenta increta and in 1 case placenta percreta. CONCLUSION: US diagnosis of placenta accreta is possible, with success rate of 58 percent (7/12). Early diagnosis helps to properly set up CS and consult the patient about the risk of unavoidable hysterectomy.

Monitoring and treatment of anti-D in pregnancy.

Prophylactic anti-D is a very safe and effective therapy for the suppression of anti-D immunization and thus prevention of haemolytic disease of the foetus and newborn. However, migration from countries with low health standards and substantial cuts in public health expenses have increased the incidence of anti-D immunization in many "developed" countries. Therefore, this forum focuses on prenatal monitoring standards and treatment strategies in pregnancies with anti-D alloimmunization. The following questions were addressed, and a response was obtained from 12 centres, mainly from Europe.

Prenatal diagnosis and neonatal management of anorectal malformation--a case report.

Intestinal dilatation and hyperechogenic bowel, some typical ultrasonographic features of anorectal malformation, were found in the 21st week of a singleton pregnancy. These findings were associated with unilateral renal agenesis and a single umbilical artery. All prenatally diagnosed anomalies were confirmed postpartum. Development of the sonographic appearance of the anorectal malformation, prenatal and neonatal management are described and discussed.

[Comparison of prenatal ultrasound examination, post-mortem magnetic resonance imaging and autopsy (a case report--schizencephaly)]. / Komparace prenatáního ultrazvukového vysetrení, post mortem magnetické rezonance a patologicko-anatomické pitvy (kazuistika--schizencefalie).

OBJECTIVE: To improve prenatal diagnostic with a feedback of autopsy, complemented by post mortem magnetic resonance imaging (MRI). MRI is important for malformations of CNS, where autopsy can be insufficient. SUBJECT: Case report. SETTING: MR unit of the Department of radiology, Department of obstetrics and gynaecology and Department of pathology, 1st medical school, Charles University in Prague, General Teaching Hospital. SUBJECT AND METHOD: To compare prenatal ultrasound, post mortem MRI and autopsy. CONCLUSION: Case report documented complementarity of all three method; full agreement in brain malformation type was found.

Prenatal diagnosis of pentalogy of Cantrell in the third trimester.

We report about the prenatal diagnosis of pentalogy of Cantrell in the third trimester. In this case sonographic evaluation revealed mild form of ectopia cordis, severe omphalocele, small meningomyelocele, mild hydrocephalus, severe polyhydramnios and allantoic cyst of the umbilical cord. The pregnancy was terminated by a caesarean section at 35 weeks of pregnancy because of severe polyhydramnios. The neonate died shortly after delivery and the obduction confirmed the diagnosis of pentalogy of Cantrell. We discuss the reason of the late prenatal diagnosis in this case, the importance of early prenatal diagnosis and the options of pregnancy management.

[Prenatal diagnostics of chromosomal aberrations Czech Republic: 1994-2007]. / Prenatální diagnostika chromozomálních aberací Ceská republika: 1994-2007.

AIM OF STUDY: An analysis of prenatal diagnostics efficiency of selected types of chromosomal aberrations in the Czech Republic in 2007. Update of 1994-2007 data according to particular selected diagnoses. TYPE OF STUDY: Retrospective epidemiological analysis of pre- and postnatal chromosomal aberrations diagnostics and its efficiency. MATERIAL AND METHODS: Data on pre- and postnatally diagnosed birth defects in the Czech Republic during 1994-2007 were used. Data on prenatally diagnosed birth defects (and for terminated pregnancies) were collected from particular departments of prenatal diagnostics, medical genetics and ultrasound diagnostics in the Czech Republic, data on birth defects in births from the National Birth Defects Register (Institute for Health Information and Statistics). Total numbers over the period under the study, mean incidences of selected types of chromosomal aberrations and mean prenatal diagnostics efficiencies were analyzed. Following chromosomal aberrations were studied: Down, Edwards, Patau, Turner and Klinefelter syndromes and syndromes 47,XXX and 47,XYY. RESULTS: A relative proportion of Down, Edwards and Patau syndromes as well as other autosomal and gonosomal aberration is presented in figures. Recently, trisomies 13, 18 and 21 present around 70% of all chromosomal aberrations in selectively aborted fetuses, in other pregnancies, "other chromosomal aberrations" category (mostly balanced reciprocal translocations and inversions) present more than 2/3 of all diagnoses. During the period under the study, following total numbers, mean relative incidences (per 10,000 live births, in brackets) and mean prenatal diagnostics efficiency (in %) were found in following chromosomal syndromes: Down syndrome 2,244 (16.58) and 63.37%, Edwards syndrome 521 (3.85) and 79.93%, Patau syndrome 201 (1.49) and 68.87%, Turner syndrome 380 (2.81) and 79.89%, 47,XXX syndrome 61 (0.45) and 59.74%, Klinefelter syndrome 163 (1.20) and 73.65% and 47,XYY syndrome 22 (0.16) and 54.76%. CONCLUSIONS: The study gives updated results of incidences analysis of both pre- and postnatally diagnosed chromosomal birth defects in the Czech Republic during the 1994-2007 period. Incidences found in our study correspond (in case of trisomies 13, 18 and 21) with those published widely in literature as well as with those found in large-scale international studies (ICBDSR, EUROCAT). In case of gonosomal aberrations, incidences found in this study are lower that those published, most probably due to a later registration (over 15 years of age of the child) of these diagnoses.

[Prenatal intracranial hemorrhagie--diagnosis and follow-up]. / Prenatálne vzniklé intrakraniální krváicení--diagnostika a sledování.

AIM: We present a case of difficult prenatal diagnosis and follow-up of severe fetal intracranial hemorrhage. With an analysis of the available literature that is related to this topic, we would like to bring attention to the necessity of accurate evaluation of fetal brain morphology even during routine ultrasound examination in the late third trimester. TYPE OF STUDY: Case report. SETTING: Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University, Prague. METHODS AND RESULTS: Four cases of prenatal intracranial hemorrhage are presented. All cases were diagnosed during ultrasound examination during the third trimester of pregnancy and the findings were clarified using nuclear magnetic resonance imaging. The etiology of the hemorrhage was determined in only two cases. Postnatal follow-up of the affected children over a range of one to two years of age shows a very severe prognosis of the described hemorrhagic conditions. CONCLUSION: Prenatally diagnosed fetal intracranial hemorrhage is a rare but severe complication in pregnancy associated with fetal and neonatal morbidity and mortality. A detailed description and precise image documentation of the damaged fetal structures have a fundamental forensic significance. Postnatal estimation of the time of hemorrhage using analysis of the cerebrospinal fluid and ultrasound findings (echogenicity of the lesions) is not always unified.