Comparison of modified biophysical profile and Doppler ultrasound in prediction of perinatal outcome in high-risk pregnancies

Background: The objective of this present study was to compare MBPP and umbilical artery Doppler flow in high-risk pregnant women in prediction of perinatal outcome.Methods: A cohort study was done on 150 high-risk pregnant women over 16 months. Antenatal women with singleton pregnancy who delivered within 48 hours of performing MBPP and Doppler USG, with presence of ≥1 high-risk factor like pre-eclampsia/gestational HTN, BOH, post-dated pregnancy, FGR, GDM, maternal heart disease, anaemia, hypothyroidism and IHCP were included in the study. MBPP (NST and AFI) and umbilical artery Doppler was performed. Perinatal outcome was measured in terms of stillbirth/IUD, LBW, Apgar <7 at 5 minutes, admission to NICU, neonatal death within 48 hours of delivery, MSL and neonatal seizures within 24-48 hours. Quantitative variables were compared using independent t-test/Mann Whitney test. Qualitative variables were correlated using Chi square test/Fisher exact test. Sensitivity, specificity, NPV, PPV were calculated and p-value <0.05 was considered statistically significant. Data analysis was done using social sciences (SPSS) licensed version 21.0.Results: Majority belonged to the age group 21-25 years and were between 37-40 weeks of gestation. It was found that highest perinatal complications occurred in those with both abnormal MBPP and Doppler followed by those with only abnormal MBPP (p-value<0.0001).Conclusions: MBPP is a better predictor of perinatal outcome compared to umbilical artery Doppler USG in high-risk pregnant women. MBPP should be done in all high-risk pregnancies even if Doppler is normal. Both the tests must be performed in all high-risk pregnancies to improve perinatal outcome.

The role of sildenafil citrate in the treatment of fetal growth restriction: a randomized controlled trial

Background: This study was aimed to evaluate the effect of sildenafil citrate on Doppler velocity indices in patients with fetal growth restriction (FGR) associated with impaired placental circulation.Methods: A double-blinded, parallel group randomized clinical trial (clinicaltrials.gov NCT02590536) was conducted in Ain Shams Maternity Hospital, in the period between October 2015 and June 2017. Ninety pregnant women with documented intrauterine growth retardation at 24-37 weeks of gestation were randomized to either sildenafil citrate 25 mg orally every 8 hours or placebo visually-identical placebo tablets with the same regimen. The primary outcome of the study was the change in umbilical artery and fetal middle cerebral artery indices.Results: There was a significant improvement in umbilical and middle cerebral artery indices after sildenafil administration p<0.001. Present study observed that, sildenafil group, in comparison to placebo, has a significantly higher mean neonatal birth weight. 1783±241g vs 1570±455g (p<0.001). There was a significantly higher mean gestational age at delivery in women in sildenafil group 35.3±1.67 weeks, whereas it was lower in the placebo group 33.5±1.7 weeks. The side effects as headache, palpitation and facial flushing were significantly higher in sildenafil group compared to placebo group.Conclusions: The use sildenafil citrate in pregnancies with fetal growth restriction (FGR) improved the feto-placental Doppler indices (pulsatility index of umbilical artery and middle cerebral artery) and improved neonatal outcomes.

Doppler patterns in growth restricted foetuses: determinants and outcome in a tertiary hospital in South Kerala, India

Background: Foetal growth restriction refers to a condition in which the foetus is unable to achieve its genetically determined growth potential. Doppler velocimetry in FGR not only decides the optimum time of delivery but also the optimum mode of delivery and so authors evaluated the Doppler patterns in growth restricted fetuses.Methods: Nested case-control study conducted among normal and abnormal Doppler groups at a tertiary care teaching hospital in the year 2017.Results: Among 82 growth restricted foetuses, 54 of them had normal Doppler patterns (65.85%) and 28 had abnormal Doppler patterns (34.15%).13(46.5%) had umbilical S/D elevation,2 (7.14%) had AEDV,1(3.57%) with REDV and 12 (42.8%) with CPR<1. Mean maternal age was slightly higher in the abnormal Doppler group. FGR babies with abnormal velocity waveforms had shorter diagnosis to delivery interval than those with normal Doppler and decision for delivery was taken at a lower gestational age. (p value-0.001). Mothers of FGR babies with abnormal Doppler studies underwent emergency caesarean section for non-reassuring foetal heart patterns. (p value-0.001) The mean birth weight was higher (2201.80gm) in Doppler normal FGR and it was 1929.46grams in abnormal umbilical Doppler group and 1363.33gm in AREDV (pvalue-0.001). Growth restricted with normal Doppler had shorter NICU stays than with abnormalities (p value-0.003). Term FGR went home early than early preterm. (p value-0.001).Conclusions: Growth restricted foetuses with normal umbilical velocimetry are at a lower risk than those with abnormal velocimetry in terms of prolonged diagnosis-delivery interval and shorter NICU days. The need for neonatal resuscitation at birth was more in babies with abnormal Doppler velocimetry and absent diastole /reversed diastolic flow of umbilical artery velocimetry.

Predictive value of fetal umbilical artery Doppler in preterm birth in patients with Systemic Lupus Erythe-matosus / 实用医学杂志

Objective To examine the predictive value of fetal umbilical artery Doppler in preterm birth in pregnant women with systemic lupus erythematosus(SLE).Methods The clinical data from 160 live births of SLE patients were analyzed retrospectively.Results The mean age of SLE patients at pregnancy was(29.7 ± 3.7) years(20 ~ 37 years). Totally,56 patients(32.5%)were preterm births and 76(47.5%)were full-term births without any other adverse pregnancy outcomes. The rate of preterm birth before 34 weeks was 26.9% and that was 73.1% for those preterm deliveries after 34 weeks. Iatrogenic preterm birth was the most common cause of preterm birth(32 cases),followed by spontaneous preterm birth(12 cases)and preterm premature rupture of membranes (10 cases).The pulsatility index(PI),resistance index(RI)as well as S/D value of SLE patients with pre-term delivery was higher than those of patients with full-term delivery(P<0.05).The area below the ROC curve for PI, RI and S/D was 0.6(95% CI 0.5~0.7),0.7(95% CI 0.6~0.8)and 0.6(95% CI 0.5~0.7),respectively.PI with cut-off value of 1.0 indicated the highest risk of preterm birth,with sensitivities of 34.6% and 84.2.The optimal cut-off value for RI and S/D was 0.7 and 2.8 respectivly,at which sensitivity and specificity had the best combination. Conclusions Pregnancies in lupus still have an increased risk of preterm birth. Umbilical artery Doppler was a useful monitoring tool for preterm birth in lupus pregnancies.

Predictive Value of Fetal Umbilical Artery Doppler on Adverse Pregnancy Outcomes in Women with Systemic Lupus Erythematosus / 中山大学学报(医学科学版)

[Objective]To explore the adverse pregnancy outcomes(APO)and examine the predictive value of umbil-ical artery Doppler in systemic lupus erythematosus(SLE)pregnancies.[Methods]Data of 273 pregnancies from 2010 to 2016 were analyzed retrospectively. Pulsatility index(PI),resistance index(RI),and systolic/diastolic ratio(S/D)of the umbilical artery flow velocity data were monitored by Doppler ultrasound.[Results]One or more APO occurred in 61.9% of patients with SLE,among which pregnancy loss occurred in 60 cases;preterm birth in 56 cases;intrauterine growth retardation occurred in 20 cases;and fetal distress occurred in 21 cases.Twelve of pregnancies resulted in neona-tal Lupus. In total,118 patients underwent fetal umbilical artery Doppler during 28~34 gestational weeks. Doppler PI, RI,and S/D were significantly higher in the APO groups than in the patients without APO.[Conclusion]Pregnancies in lupus still had an increased risk of APO.Umbilical artery Doppler was useful in predicting APO in lupus pregnancies.

Restricción selectiva del crecimiento intrauterino (RCIUs)

La restricción de crecimiento intrauterino selectivo es una complicación de la gestación monocorial poco frecuente, caracterizada por el déficit de crecimiento de uno de los fetos, fenómeno que se explica principalmente por la distribución asimétrica del territorio placentario. La influencia de las anastomosis vasculares determina el tipo de evolución de cada caso. El estudio Doppler de la arteria umbilical del feto con restricción es la mejor maneja de valorar el comportamiento clínico y la posible evolución, con la finalidad de minimizar el riesgo de muerte intraútero y el daño cerebral que podrían sufrir ambos fetos.

Selective intrauterine growth restriction is arare complication of monochorionic gestation characterized by growth deficiency of one fetus, phenomenon due to asymmetric distribution of the placental territory; the influence of the vascular anastomosis determines the type of evolution in each case. Umbilical artery Doppler study ofthe restricted fetus determines the clinical status and possible outcome in order to minimize risk of intrauterine death and brain da mage in both fetuses.

Resultados perinatales en fetos con flujo umbilical diastólico ausente / Perinatal outcome in fetuses with absent end diastolic umbilical flow

Objetivo: Estudiar los resultados perinatales de fetos diagnosticados con flujo umbilical ausente en diástole en el Hospital Universitario de Canarias, España. Métodos: Estudio retrospectivo de gestantes con Doppler fetal umbilical con flujo diastólico ausente entre 2004 y 2011, excluyendo embarazos gemelares. Las variables estudiadas fueron: edad y enfermedades maternas, edad gestacional al diagnóstico y parto, vía de parto, Apgar y estado del recién nacido. Resultados: Se recogieron 57 casos. Hubo un 43 por ciento de gestantes hipertensas y 19 por ciento de diabéticas. La edad gestacional media al diagnóstico fue de 30+4 semanas. En el 89% de los casos se observó redistribución del flujo y en el 21 por ciento el Doppler umbilical fue reverso. El 28 por ciento se acompañó de oligoamnios y en el 26 por ciento el peso fetal estimado inferior al percentil 3. Hubo 3 muertes fetales. En el 80 por ciento de los casos la vía de parto fue por cesárea. La supervivencia fue del 83 por ciento con una tasa de mortalidad perinatal del 17 por ciento. En el seguimiento entre 1 y 6 años encontramos un 35 por ciento de niños sin secuelas. Conclusiones: En nuestra serie, el Doppler con flujo umbilical ausente en diástole se relaciona con alto riesgo de morbimortalidad perinatal. El 65 por ciento de los niños tendrán secuelas de algún tipo en el seguimiento entre 1 a 6 años. El momento óptimo para la extracción fetal debe ser individualizado y resuelto junto con el consejo pediátrico y participación de los padres.

Objective: To determine the perinatal outcome in fetal growth restriction were umbilical artery Doppler end diastolic flow was absent. Methods: A retrospective study performed at the Canary Islands University Hospital. All consecutive cases between 2004 and 2011 were included. We excluded twin pregnancies. Data was abstracted for maternal age, gestational age at diagnosis and delivery, mode of delivery, Apgar and perinatal adverse outcomes. Results: Fifty seven patients were included. Forty three percent had a pregnancy complicated by hypertension and 19 percent diabetes. Mean gestational age at diagnosis was 30+4 weeks. We found 89 percent and 21 percent absent umbilical artery end diastolic flow and reverse flow respectively. Oligohydramnios was seen in 28 percent of the cases. Fetal weight was below the third percentile in 26 percent of the cases. Fetal demise occurred in 3 cases. Mode of delivery was cesarean section in 80 percent of the cases. We found a rate of 17 percent perinatal mortality. At 1 to 6 years follow up 35 percent of the children had no sequelae. Conclusion: Absent end diastolic umbilical flow is associated with a high risk of perinatal mortality. Up to 65 percent of the children will show some type of sequelae. The optimal gestational date for fetal extraction should be individualized after multidisciplinary counseling.

Umbilical Artery Doppler Study as a Predictive Marker of Perinatal Outcome in Preterm Small for Gestational Age Infants

PURPOSE: To evaluate the merit of umbilical artery Doppler study as a predictive marker of perinatal outcome in preterm small for gestational age (SGA) infants. MATERIALS AND METHODS: A total of 218 patients at 27 - 36 weeks of gestational age (GA) who received antenatal umbilical artery Doppler velocimetry and delivered singleton infants with SGA. The ratio of peak-systolic to end-diastolic blood flow velocities (S/D) in the umbilical artery was measured in each patient. The patients were divided into 3 groups: the normal group with S/D ratios of less than 95th percentile (n = 134), elevated S/D ratio group of 95th or more percentile (n = 41), and those with absent/reversed end diastolic flow (n = 43). Maternal characteristics and neonatal outcomes of these groups were comparatively analyzed. RESULTS: The gestational age (GA) at the time of diagnosis of SGA, the mean GA at delivery, and the mean birth weight showed statistically significant difference among three groups (p < 0.001). Also, poor perinatal outcome was significantly increased in infants with abnormal S/D ratio (13.4% vs. 31.7% vs. 67.4%, p < 0.001). Multivariate logistic regression analysis revealed umbilical artery Doppler study as a significant independent factor for prediction of poor perinatal outcome (odds ratio: 3.7, 95% confidence interval 1.4 - 9.5, p = 0.007). CONCLUSION: Antenatal umbilical artery Doppler velocimetry is shown as a significantly efficient marker in predicting perinatal outcome in preterm SGA infants.

En embarazos con restricción del crecimiento intrauterino la velocimetría Doppler refleja las arteriopatías del lecho placentario / The correlation of the histomorphology of the placenta and the placental bed with the doppler velocimetries of the uterine and umbilical arteries

We correlated the histomorphology of the placenta and the placental bed with the Doppler velocimetries of the uterine and umbilical arteries of intrauterine growth restricted pregnancies. The study group consisted of 47 women with intrauterine growth restricted fetuses. Twenty-five uneventful pregnancies with appropriate for gestational age fetuses were selected as controls. Doppler studies of umbilical and uterine arteries were performed within the last week before delivery. Placental bed biopsies were obtained at Caesarean section with direct visualization of the placental site. The incidence of pathologic bed biopsies in control, IUGR with normal uterine artery Doppler velocimetry and IUGR with abnormal uterine artery Doppler velocimetry was 0, 16.6% and 79.3% respectively (p < 0.001). Abnormal placental bed biopsy pathology was significantly associated with abnormal uterine artery velocimetry (OR 33.7, 6.5-173.6; p < 0.001). Abnormal placental pathology was significantly associated with abnormal umbilical artery Doppler velocimetry (OR 21.04, 3.8- 115.9; p < 0.001). Women with both abnormal uterine and umbilical artery Doppler velocimetries were delivered earlier and their babies had lower mean birth and placental weight (p < 0.001). As a conclusion, placental bed biopsy and placental pathologies are best reflected by abnormal uterine and umbilical artery velocity waveforms, respectively. The most severe clinical outcomes and perinatal mortality are present when both uterine and umbilical districts are altered

Correlacionamos la histomorfología de la placenta y del lecho placentario con la velocimetría Doppler de las arterias uterinas y umbilical en embarazos con restricción del crecimiento intrauterino (RCIU). El grupo estudiado consistió en 47 mujeres con fetos que presentaban restricción del crecimiento intrauterino. Veinticinco embarazos normales con fetos adecuados para la edad gestacional fueron seleccionados como control. Los estudios Doppler de las arterias uterinas y umbilical fueron realizados dentro de la última semana antes del parto. Se obtuvieron biopsias del lecho placentario al momento de la cesárea con visualización directa del sitio de inserción. La incidencia de biopsias patológicas del lecho placentario en el grupo control, en el grupo que presentó RCIU con Doppler de la arteria uterina normal y en el de los RCIU con velocimetría Doppler anormal de la arteria uterina fue de 0, 16.6% y 79.3%, respectivamente (p < 0.001). La biopsia anormal del lecho placentario estuvo significativamente asociada con velocimetría anormal tanto de la arteria uterina (OR 33.7, 6.5-173.6; p < 0.001) como de la arteria umbilical (OR 21.04, 3.8-115.9; p < 0.001). En las mujeres que presentaron velocimetría Doppler anormal de las arterias uterinas y umbilical los nacimientos se produjeron más precozmente y sus hijos tuvieron un peso de nacimiento y placentario promedio más bajo (p < 0.001). Como conclusión, la biopsia del lecho placentario y las patologías de la placenta son reflejadas mejor por las formas de onda anormales en la velocimetría de las arterias uterinas y umbilical, respectivamente. Los resultados clínicos más graves y la mortalidad perinatal están presentes cuando ambos territorios, uterino y umbilical, se encuentran alterados.

The Clinical Significance of Absence of Umbilical Artery End-Diastolic Flow in Severe Pre-Eclampsia and Eclampsia / 대한산부인과학회잡지

To determine the perinatal mortality and morbidity of fetuses with absent end-diastolic velocities (AEDV) of the umbilical artery in severe pre-eclampsia and eclampsia, the outcome of 5 fetuses with AEDV was compared with that of 35 fetuses with positive end-diastolic velocities (PEDV). The study population comprised 38 cases of severe pre-eclampsia and 2 cases of eclampsia with structurally normal singletons, who had had umbilical artery Doppler velocimetry weekly from admission to delivery. The Doppler velocimetry result was not used for the clinical management. Perinatal death and neonatal morbidity from both groups were further examined in gestational age category to control the influence of preterm births. The incidence of AEDV of the umbilical artery Doppler velocimetry in severe pre-eclampsia and eclampsia was 12.5% (5/40). The AEDV group had a significantly higher incidence than the PEDV group in terms of ceasarean section due to fetal distress (60% : 17%), Apgar score < 7 at 5 minutes (60% : 14%), perinatal death (25% : 0%) and assisted mechanical ventilation (67% : 9%) both at 32-36 weeks. Time intervals from the detection of AEDV to delivery of live neonates varied from the day to 15 days. In conclusion, AEDV in the umbilical artery might be of clinical value in routine surveillance of pregnancies complicated by severe pre-eclampsia and eclampsia, and predict hypoxic fetal condition which needs operative interventions before or during labor and mechanical ventilation after birth.