Comparison between Protocols for Management of Fetal Growth Restriction / Comparação entre protocolos de acompanhamento da restrição de crescimento fetal

Abstract This comprehensive review compares clinical protocols of important entities regarding the management of fetal growth restriction (FGR), published since 2015. Five protocols were chosen for data extraction. There were no relevant differences regarding the diagnosis and classification of FGR between the protocols. In general, all protocols suggest that the assessment of fetal vitality must be performed in a multimodally, associating biophysical parameters (such as cardiotocography and fetal biophysical profile) with the Doppler velocimetry parameters of the umbilical artery, middle cerebral artery, and ductus venosus. All protocols reinforce that the more severe the fetal condition, the more frequent this assessment should be made. The timely gestational age and mode of delivery to terminate the pregnancy in these cases can vary much between the protocols. Therefore, this paper presents, in a didactic way, the particularities of different protocols for monitoring FGR, in order to help obstetricians to better manage the cases.

Resumo Esta revisão compreensiva compara protocolos clínicos de entidades importantes em relação ao manejo da restrição de crescimento fetal (RCF), publicados desde 2015. Cinco protocolos foram escolhidos para a extração de dados. Não houve diferenças relevantes quanto ao diagnóstico e classificação da RCF entre os protocolos. Em geral, todos os protocolos sugerem que a avaliação da vitalidade fetal deve ser realizada de forma multimodal, associando parâmetros biofísicos (como cardiotocografia e perfil biofísico fetal) aos parâmetros dopplervelocimétricos da artéria umbilical, artéria cerebral média e ducto venoso. Todos os protocolos reforçam que quanto mais grave a condição fetal, mais frequente essa avaliação deve ser feita. A idade gestacional oportuna e o modo de parto para interromper a gravidez nesses casos podem variar muito entre os protocolos. Portanto, este trabalho apresenta, de forma didática, as particularidades de diferentes protocolos de acompanhamento de RCF, a fim de auxiliar os obstetras no melhor manejo dos casos.

Uterine Artery Doppler Screening in 2nd Trimester of Pregnancy for Prediction of Pre-eclampsia and Fetal Growth Restriction

Background: Pre-eclampsia is a pregnancy specific disorder characterized by hypertension and proteinuria after 20 weeks of gestation. Uterine artery Doppler velocimetry analysis has been extensively studied in the second trimester of pregnancy as a predictive investigation for the future development of pre-eclampsia and Fetal Growth Restriction.Aims: To predict the probability of developing pre-eclampsia of pregnant women and Fetal Growth Restriction in relation with normal and abnormal Doppler velocimetry of uterine artery at 2nd trimester of pregnancy.Methods:A total of 97 pregnant women of 2nd trimester of pregnancy were included in this study After taking informed written consent of the participants, all they underwent uterine artery Doppler velocimetry at 22ndand 24thweek of pregnancy. They again examined clinically during delivery at different gestational age. Pre-eclampsia (PE) was diagnosed on the basis of measurement of blood pressure as well as urine routine and microscopic examination. Fetal Growth Restriction (FGR) was determined by measuring birth weight and gestational age at the time of delivery. Development of PE and FGR was observed in relation to severity of Uterine Artery Doppler Velocimetry findings. A pre-structured data collection sheet was used as a research tool for data collection. Statistical analyses of the results were obtained by using windows-based computer software devised with Statistical Packages for Social Sciences (SPSS-23).Results: More than half (52.6%) of the subjects belonged to age 21-25 years and 52(53.6%) subjects were nulliparous. More than half (56.7%) of the subjects came from low income group family. Pre-eclampsia developed 11(11.3%) of the patients, 15(15.5%) had FGR and 12(12.4%) had notching in 2ndUADV at 24thweek. Presence of Pre-diastolic notch in 2ndUADV study at 24thweek to predict pre-eclampsia has sensitivity 72.7%, specificity 95.4%, accuracy 92.8% and positive predictive values 66.7% and negative predictive value 96.5%. Presence of Pre-diastolic notch in 2ndUADV study at 24thweek to predict FGR has sensitivity 20.0%, specificity 89.0%, accuracy 78.4% and positive predictive values 25.0% and negative predictive value 85.9%. The mean age was 28.69±7.81 years who had per-diastolic notch in 2ndUADV at 24thweek and 24.13±6.11 years who had normal UADV and the p value is 0.022 which is significant. The mean para was 1.29±0.33 who had per-diastolic notch in 2ndUADV at 24thweek and 1.77±0.29 who had normal UADV together with remarkable p value which is 0.001. The mean BMI was 23.59±1.09 Kg/m2who had per-diastolic notch in 2ndUADV at 24thweek and 21.57±0.47 Kg/m2who had normal UADV with notable p value 0.001 in this study.Conclusion:Uterine artery Doppler velocimetry in early pregnancy can be a good investigating tool for prediction of subsequent development of pre-eclampsia and Fetal Growth Restriction

Aortic isthmus doppler velocimetry in fetuses with intrauterine growth restriction: A literature review / Dopplervelocimetria do istmo aórtico em fetos com crescimento intrauterino restrito: Uma revisão da literatura

Abstract Intrauterine growth restriction (IUGR) is associated with poor perinatal prognosis and a higher risk of stillbirth, neonatal death, and cerebral palsy. Its detection and the evaluation of its severity by new Doppler velocimetric parameters, such as aortic isthmus (AoI), are of great relevance for obstetrical practice. The AoI is a vascular segment that represents a point of communication between the right and left fetal circulations. It is considered to be a functional arterial shunt that reflects the relationship between the systemic and cerebral impedances, and has recently been proposed as a tool to detect the status of hemodynamic balance and prognosis of IUGR in fetuses. In the present review, we noticed that in healthy fetuses, the AoI net flow is always antegrade, but in fetuses with IUGR the deterioration of placental function leads to progressive reduction in its flow until it becomes mostly retrograde; this point is associated with a drastic reduction in oxygen delivery to the brain. The more impaired the AoI flow is, the greater is the risk of impairment in the Doppler velocimetry of other vessels; and the alterations of the AoI Doppler seem to precede other indicators of severe hypoxemia. Although there seems to be an association between the presence of retrograde flow in the AoI and the risk of long-term neurologic disability, its role in the prediction of perinatal morbi-mortality remains unclear. The AoI Doppler seems to be a promising tool in the management of fetuses with IUGR, but more studies are needed to investigate its employment in clinical practice.

Resumo O crescimento intrauterino restrito (CIUR) está associado a um prognóstico perinatal adverso, com maior risco de óbito intrauterino e neonatal, bem como de paralisia cerebral. Assim, sua detecção e a determinação de sua gravidade por novos parâmetros Dopplervelocimétricos, como o istmo aórtico (IAo), são de fundamental importância na prática obstétrica. O IAo é um segmento vascular que representa um ponto de comunicação entre os sistemas circulatórios fetais esquerdo e direito. É considerado um shunt arterial funcional, capaz de refletir a relação entre as impedâncias dos circuitos cerebral e sistêmico, e foi proposto como uma ferramenta para detecção do status do equilíbrio hemodinâmico e do prognóstico de fetos com CIUR. Na presente revisão, observou-se que, em fetos saudáveis, o fluxo predominante no IAo é sempre anterógrado; mas em fetos com CIUR a deterioração do estágio de insuficiência placentária acarreta reduções progressivas no fluxo ístmico até este apresentar sentido predominantemente retrógrado e levar a uma drástica redução no aporte de oxigênio ao sistema nervoso central. Quanto mais alterado estiver o fluxo no IAo, maior a chance de haver alteração na Dopplervelocimetria de outros vasos; e as alterações no Doppler do IAo parecem preceder outros indicadores de hipoxemia severa. Embora o fluxo retrógrado no IAo pareça se correlacionar com maior risco de alteração no desenvolvimento neurológico a longo prazo, ainda não está claro o seu papel na predição de morbimortalidade perinatal. O Doppler do IAo parece ser um parâmetro promissor no manejo do CIUR; entretanto, mais estudos são necessários para avaliar seu emprego na prática clínica.

Study of fetal doppler velocimetry versus non stress test as predictors of adverse perinatal outcome in high risk pregnancies

Background: Pregnancy is a unique, physiologically normal event in a women’s life. Objective of this study was to compare the efficacy of the doppler velocimetry versus non stress test in relation to perinatal outcome in high risk pregnancies.Methods: This is a prospective study conducted in the department of obstetrics and gynaecology, Narayana Medical College and Hospital. 100 women with high risk pregnancy were recruited. All were examined systematically, and Doppler velocimetry and non-stress test were done.Results: All cases were divided into four groups based on NST and doppler velocimetry of umbilical artery and middle cerebral artery. 10% of women had abnormal doppler. Middle cerebral artery doppler abnormality was noted in 3% and CPR abnormality in 3% of women in the study group. 15% had abnormal NST. In Group A, out of 88 patients 9 had fetal compromise. In Group B, out of 5 patients all had fetal compromise. In Group C, out of 4 patients none had fetal compromise. In Group D, all 3 patients had fetal compromise. In Group D, all 3 had neonatal deaths. Average birth weights in Group A was 2.7 kg, in Group B was 2 kg, in Group C was 2.5 kg, in Group D was 1.4 kg. Two (2.2%) newborn in Group A, 4 (80%) newborns in Group B, 3 (100%) in Group had Apgar < 7 at 5 minutes. 4 (4.5%) babies in Group A, 5 (100%) babies in Group B, 3 (100%) babies in Group D were admitted in NICU. Umbilical artery doppler was found to have sensitivity 46.6%, specificity - 94%, PPV - 93%, NPV - 54%. Middle cerebral artery doppler was found to have sensitivity 73.3%, specificity - 90%, PPV - 91.6%, NPV- 69.3%.Conclusions: In present study, highest percentage of perinatal complications and perinatal deaths were seen in groups with abnormal tests of NST and velocimetry. Group D had the worst perinatal outcome.

Modelo predictivo de restricción del crecimiento intrauterino usando doppler de arterias uterinas y edad materna / Predictive model of intrauterine growth restriction using uterine artery doppler and maternal age

INTRODUCCIÓN: La restricción del crecimiento intrauterino representa una importante morbimortalidad perinatal y cuya detección es variable según modelos clínicos y características propias en cada población. OBJETIVO: Evaluar si el Doppler de arterias uterinas y la edad materna conforman un modelo clínico con capacidad predictiva de restricción del crecimiento intrauterino en una amplia muestra de población peruana. MATERIALES Y MÉTODOS: Estudio observacional, analítico, de prueba diagnóstica. Participaron 1344 gestantes atendidas en un centro de referencia nacional materno perinatal Nivel III en Perú entre 2010-2018. La muestra fue seleccionada aleatoriamente y dividida en: muestra de entrenamiento y muestra para validación del mejor modelo clínico obtenido. Se usó análisis multivariado, medición de la capacidad diagnóstica y predictiva. RESULTADOS: El modelo clínico formado por el índice de pulsatilidad promedio mayor al percentil 95 de la arteria uterina y la edad materna mayor a 35 años conformo el modelo con el menor indicador de penalidad de Akaike en comparación con los otros modelos clínicos elaborados en el presente estudio, el índice de Youden fue 0.53. El área bajo la curva ROC fue de 0.75. Se obtuvo una sensibilidad de 71.5%, especificidad 72.1%, valor predictivo positivo 65.8%, valor predictivo negativo 91.2%. CONCLUSIONES: El uso del índice de pulsatilidad promedio de la arteria uterina asociado a la edad materna contribuyen a la formación de un modelo para discriminar RCIU; sin embargo, requiere de otros factores que permitan ajustar el modelo para una mayor tasa de detección.

INTRODUCTION: Intrauterine growth restriction represents an important perinatal morbimortality and its detection varies according to clinical models and characteristics of each population. OBJECTIVES: To evaluate if uterine artery Doppler and maternal age conform a clinical model with predictive capacity of intrauterine growth restriction in a wide sample of Peruvian population. MATERIALS AND METHOD: Observational, analytical, diagnostic test study. A total of 1344 pregnant women attended a national maternal perinatal reference center Level III in Peru between 2010-2018. The sample was randomly selected and divided: training sample and validation sample. In the analysis, multivariate analysis and measurement of diagnostic and predictive capabilities were applied. RESULTS: The clinical model formed by the average pulsatility index greater than the 95th percentile of the uterine artery and maternal age greater than 35 years made up the model with the lowest Akaike's penalty indicator compared to the other clinical models developed in the present study, Youden's index was 0.53. The area under the ROC curve 0.75. Sensitivity 71.5%, specificity 72.1%, positive predictive value 65.8%, negative predictive value 91.2%. CONCLUSIONS: The use of the average pulsatility index of the uterine artery associated with maternal age contributes to the formation of a model to discriminate IUGR; however, it requires other factors to adjust the model for a higher detection rate.

Comparative performance of Cerebral Perfusion Ratio as compared to MCA PI and UA PI in prediction of adverse perinatal outcomes in intra uterine growth restricted fetuses

Background: Intra uterine growth restriction (IUGR) is a common clinical sign seen due to chronic foetal hypoxemia and is considered a major contributor of perinatal morbidity and mortality. The aim of the present study was to determine and compare the sensitivity and specificity of umbilical artery pulsatility index (UA PI), middle cerebral artery (MCA) PI and cerebral perfusion ratio (CPR) in predicting adverse and poor perinatal outcomes in fetuses with IUGR.Methods: The study included 100 pregnant women with post 24 weeks of gestation with clinical history of IUGR.  Doppler examination parameters, including waveforms and measurements, of the umbilical artery, middle cerebral artery were recorded. The Cerebral Perfusion Ratio (CPR) was calculated from MCA PI and UA PI and a final comparison of accuracy of Doppler indices was done with perinatal outcome.Results: The sensitivity of the UA PI was higher (49.3%) than that of the MCA PI (43.6%) and the CPR (37.7%). The specificity of the CPR was higher (87.1%) than that of the MCA PI (83.9%) and the UA PI (74.2%).Conclusions: From the findings of the study, it can be concluded that UA PI is the most sensitive and CPR is the most specific parameter in predicting adverse perinatal outcomes in IUGR fetuses. Thus, in addition to pulsatility indices, CPR should be used as a tool for surveillance and included in the routine reporting formats of obstetric Doppler studies.

Efficacy of doppler velocimetry of the umbilical artery in the defined high-risk groups to determine the fetal outcome

Background: Doppler ultrasound provides a non-invasive method of studying the status of various blood vessels. It provides a spectrum analysis of the velocities of moving red blood cells. Doppler sonography can provide useful information in a variety of gynecological and obstetric conditions. In obstetrics, Doppler velocimetry of the uteroplacental and fetoplacental circulation can be used to further investigate complications of pregnancy such as fetal growth restriction, other forms of fetal distress that result from fetal hypoxemia or asphyxia.Methods: In a prospective observational study, 93 pregnancies fitting in the criteria for high risk were evaluated by doppler velocimetry between 28-40 weeks of gestation. The flow velocity time wave forms were examined and quantitated by use of systolic/diastolic (S/D) ratio, resistance index (RI), pulsatility index (PI) values. The outcome of pregnancy was noted.Results: Fetuses with abnormal velocimetry are at higher risk with regard to birth weight, Apgar score, fetal distress, need of cesarean section, need of NICU admission. The patients with absent end-diastolic flow (AEDF)/reversal of end-diastolic flow (REDF) had poor perinatal outcome. Positive predictive value for small for gestational age (SGA) and fetal distress was 75% and 60% respectively. 23.8% babies needed to be kept in neonatal intensive care unit (NICU).Conclusions: Doppler velocimetry can be useful prenatal test for the patients of hypertensive disorder of pregnancy and IUGR. Abnormal doppler waveform changes indicate adverse perinatal outcome. Appropriate and timely interventions guided by doppler study help to reduce perinatal morbidity and mortality.

Biometric, B-mode and color Doppler ultrasound assessment of eyes in healthy dogs / Avaliação biométrica, ultrassonográfica em modo-B e por Doppler colorido ocular de cães hígidos

B-scan ultrasonography is an important diagnostic tool that allows characterization of internal organ anatomy and, when complemented by Doppler ultrasound, allows vascular hemodynamic assessment, increasing the diagnostic accuracy. Thus, the aim of the present study was the B-scan ultrasound characterization and measurement of the eyeball segments and assessment of the external ophthalmic artery by color and pulsed Doppler. Sixty eyeballs were assessed from 30 dogs of different breeds using an 8.5MHz microconvex transductor. First, biometry was performed by B-scan of the following segments: axial length (M1), anterior chamber depth (M2), lens thickness (M3), lens length (M4), vitreous chamber depth (M5), optical disc length (M6) and optic nerve diameter (M7). Colored Doppler identified the external ophthalmic article and pulsed Doppler assessed its flow, and the following were measured: systolic peak velocity (VPS), final diastolic velocity (VDF), resistivity index (IR) and pulse index (IP). No statistical difference was observed for the biometric values of the eye segments between the right and left eyes (p>0.05). The vitreous chamber depth (M5) was shown to be the biometric variable with greatest bilateral symmetry, varying from 0.79 to 0.87cm and 0.78 to 0.86cm for the right and left eye, respectively. The ophthalmic artery was visualized over the optic nerve towards the eyeball, with flow stained red. There was no significant statistical difference between the Doppler velocimetric values for the ophthalmic artery between the right and left eye of the animals assessed (p>0.05). The mean resistivity index (RI) showed average values equal to 0.63±0.03, bilaterally. The mean base velocity was 17.50cm/s and 18.18cm/s at the systolic peak and 6.21cm/s and 6.68cm/s at the end of the diastole, for the right and left eyes respectively. The anatomic, biometric and hemodynamic characterization using the ultrasound B-scan and the Doppler modalities permitted the ultrasonographic and Doppler velocimetric assessment of the eyeball components in dogs of different breeds, and it can be used in ophthalmic clinical routine to identify eye pathologies.

O exame ultrassonográfico modo-B é uma importante ferramenta diagnóstica que permite caracterizar a anatomia interna dos órgãos e, complementada pelo exame modo Doppler, possibilita realizar a avaliação hemodinâmica vascular, aumentando a acurácia diagnóstica. Desta forma, este trabalho teve como objetivo a caracterização ultrassonográfica e mensuração dos segmentos do bulbo ocular modo-B, assim como a avaliação da artéria oftálmica externa pelo Doppler colorido e pulsado. Foram avaliados 60 bulbos oculares de 30 cães de diferentes raças utilizando transdutor microconvexo de 8,5MHz. Inicialmente foi realizada biometria por meio do exame em modo-B dos seguintes seguimentos: comprimento axial (M1), profundidade da câmara anterior (M2), espessura da lente (M3), comprimento da lente (M4), profundidade da câmara vítrea (M5), comprimento do disco óptico (M6) e diâmetro do nervo óptico (M7). A artéria oftálmica externa foi identificada pelo Doppler colorido e seu fluxo foi avaliado por meio do Doppler pulsado, sendo mensurados: velocidade do pico sistólico (VPS), velocidade diastólica final (VDF), índice de resistividade (IR) e índice de pulsatilidade (IP). Não foi verificada diferença estatística para os valores biométricos dos seguimentos oculares entre os olhos direito e esquerdo (p>0,05). A profundidade da câmera vítrea (M5), mostrou-se a variável biométrica com maior simetria bilateral, variando entre 0,79 a 0,87cm e 0,78 a 0,86cm para o olho direito e esquerdo, respectivamente. A artéria oftálmica foi visibilizada sobre o nervo óptico em direção ao bulbo ocular, com fluxo marcado em vermelho. Não houve diferença estatística significativa entre os valores Dopplervelocimétricos da artéria oftálmica entre do olho direito e esquerdo dos animais avaliados (p>0.05). O índice de resistividade (IR) médio evidenciou valores médios sendo igual a 0,63±0,03, bilateralmente. A velocidade basal média foi 17,50cm/s e 18,18cm/s no pico sistólico e 6,21cm/s e 6,68cm/s no final da diástole, para os olhos direito e esquerdo, respectivamente. A caracterização anatômica, biométrica e hemodinâmica utilizando o exame ultrassonográfico modo-B e as modalidades do Doppler permitiram a avaliação ultrassonográfica e Dopplervelocimétrica dos componentes do bulbo ocular nos cães de diferentes raças, podendo ser utilizados na rotina clínica oftalmológica para identificação de patologias oculares.

The Influence of Incudostapedial Joint Separation on the Middle Ear Transfer Function

OBJECTIVES: One of the risks in middle ear surgery is high frequency hearing loss. It is believed that manipulations on the middle ear ossicles with the instruments may cause overstimulation of the inner ear and damage of the hear cells. Controversy arises whether temporary separation of the ossicles has any impact on middle ear transfer function and hearing threshold after surgery. The aim of the study is to evaluate the influence of incudostapedial joint (ISJ) separation on middle ear function in an experimental model. METHODS: With the use of single point laser Doppler vibrometer (LDV) stapes velocity in the intact chain and after ISJ separation was measured in 5 fresh human cadaver temporal bones. RESULTS: In all cases there was a decrease in stapes velocity after ISJ separation. Mead stapes velocity was reduced for 1 dB in 800 Hz to 9 dB in frequencies above 1,000 Hz. The decrease of velocity was greater in higher frequencies. CONCLUSION: Separation of the ISJ does not reduce significantly the middle ear function.

Modificaciones en el flujo sanguíneo del tronco de la arteria pulmonar en fetos prematuros que recibieron corticoides

Objetivos: Evaluar las modificaciones de la velocimetría Doppler en el flujo sanguíneo del tronco de la arteria pulmonar en fetos prematuros expuestos a corticoesteroides. Diseño: Estudio prospectivo. Institución: Instituto Latinoamericano de Salud reproductiva (ILSAR), Lima, Perú. Participantes: Madres con 29 a 36 semanas de edad gestacional y sus fetos. Intervenciones: En gestantes con 29 a 36 semanas de gestación que habían recibido corticoides para madurez pulmonar fetal, se hizo velocimetría Doppler del flujo sanguíneo del tronco de la arteria pulmonar de sus fetos. Principales medidas de resultados: Correlación de los cambios de la velocimetría Doppler con la madurez pulmonar en el neonato. Resultados: Los fetos prematuros que recibieron corticoides no tuvieron complicaciones respiratorias neonatales cuando el índice tiempo de aceleración/tiempo de desaceleración sistólico (TA/TD) fue igual o mayor a 0,57, cuyo valor se alcanzó en fetos con 33 semanas o más y con peso desde 2 000 g. Los valores de TA/TD luego de corticoides tuvieron una correlación estadística alta con las complicaciones respiratorias del RN (p<0,0001). Conclusiones: Después de aplicar corticoides para madurar el pulmón en fetos prematuros, se observó modificaciones en el flujo del tronco de la arteria pulmonar medidos con el índice TA/TD, con valores superiores a los observados para la misma edad gestacional en fetos sin corticoides. La diferencia fue altamente significativa desde la semana 33. El índice TA/TD del tronco de la arteria pulmonar es una herramienta útil para determinar madurez pulmonar.

Objectives: To determine changes in pulmonary artery blood flow Doppler velocimetry in preterm fetuses exposed to corticosteroids. Design: Prospective study. Setting: Instituto Latinoamericano de Salud Reproductiva (ILSAR), Lima, Peru. Participants: Mothers 29-36 weeks of gestation and their fetuses. Interventions: In fetuses of mothers 29-36 weeks of gestation who had received corticosteroids for maturation pulmonary artery blood flow Doppler velocimetry was performed. Main outcome measures: Correlation of Doppler velocimetry changes and neonate lung maturity. Results: Preterm fetuses that received corticosteroids did not present neonatal respiratory complications when systolic acceleration time/deceleration time (AT/DT) index was equal or over 0,57, value obtained in fetuses 33 weeks or more and weight over 2 000 g. AT/DT values following corticosteroids showed high statistical correlation with newborn respiratory complications (p<0,0001). Conclusions: Pulmonary artery blood flow measured with AT/DT index was modified after corticosteroids administration for preterm fetal lung maturation; values were superior to those observed for same gestational age fetuses without corticosteroids. Difference was highly significant starting at week 33. AT/DT index of the pulmonary artery stem is a useful tool to determine pulmonary maturity.

Repercussões da cicatriz uterina resultante de cesariana prévia na dopplervelocimetria das artérias uterinas entre 26 e 32 semanas / Repercussions of previous cesarean uterine scar at uterine arteries Doppler velocimetry between the 26th and 32nd gestational weeks

OBJETIVO: Avaliar as repercussões da cicatriz uterina na dopplervelocimetria das artérias uterinas, entre 26 e 32 semanas, em gestantes primíparas com uma cesariana prévia, considerando quando esta foi realizada fora (cesárea eletiva) ou durante o trabalho de parto. MATERIAIS E MÉTODOS: Estudo prospectivo transversal em 45 gestantes, divididas em três grupos: 17 gestantes com cicatriz prévia resultante de cesariana eletiva (grupo A); 14 gestantes com uma cicatriz prévia oriunda de cesariana executada em trabalho de parto (grupo B); 14 gestantes cujo único parto anterior foi realizado por via vaginal (grupo C). A dopplervelocimetria das artérias uterinas foi realizada pela via abdominal. Foram calculados as médias, medianas e desvios-padrão (DP) para cada grupo em estudo. Em relação ao índice de pulsatilidade, a comparação dos grupos foi conduzida pelo teste não paramétrico de Kruskal-Wallis. RESULTADOS: Os valores médios do índice de pulsatilidade no grupo A variaram de 0,60 a 1,60 (média: 0,90; DP: 0,29), no grupo B, de 0,53 a 1,43 (média: 0,87; DP: 0,24), e no grupo C, de 0,65 a 1,65 (média: 1,01; DP: 0,37); p = 0,6329. CONCLUSÃO: Não houve repercussões da cicatriz de cesariana prévia na dopplervelocimetria das artérias uterinas avaliadas de 26 a 32 semanas de gestação.

OBJECTIVE: To evaluate the possible repercussions of the previous cesarean scar at uterine arteries Doppler velocimetry between the 26th and 32nd gestational weeks. MATERIALS AND METHODS: Prospective cross-sectional study including 45 women between 11 and 14 weeks of gestation, divided into three groups: 17 pregnant women with uterine scar resulting from a previous elective cesarean section (group A); 14 with uterine scar resulting from a previous cesarean section performed during labor (group B); and 14 pregnant women with a single previous vaginal delivery (group C). Uterine arteries Doppler velocimetry was performed with transabdominal approach. Means, medians and standard deviation (SD) were calculated for each group in the study. The groups comparison regarding pulsatility index was performed with the non-parametric Kruskal-Wallis test. RESULTS: In group A, the pulsatility index ranged from 0.60 to 1.60 (mean: 0.90; SD: 0.29), in group B, from 0.53 to 1.43 (mean: 0.87; SD: 0.24), and in group C, from 0.65 to 1.65 (mean: 1.01; SD: 0.37); with p = 0.6329. CONCLUSION: No repercussion of previous cesarean scar was observed at uterine arteries Doppler velocimetry performed in the period between the 26th and 32nd gestational weeks.

Flujometría Doppler patológica y su correlación con el pronóstico perinatal a corto plazo

Objetivos: Determinar la morbilidad y mortalidad de fetos con flujometría Doppler patológico y evaluar discapacidades en el corto plazo. Diseño: Estudio tipo retrospectivo, observacional, analítico, correlacional. Lugar: Unidad de vigilancia fetal, Hospital Nacional Edgardo Rebagliati Martins, Red Asistencial Rebagliati, EsSalud, Lima, Perú. Participantes: Gestantes con flujometría Doppler patológicos y sus perinatos. Intervenciones: Se estudió todos los casos de gestantes con flujometría Doppler alterado, entre febrero de 2008 y febrero de 2010. Se agrupó por tipos de flujometría Doppler y se describió la frecuencia de patología y morbimortalidad perinatal, correlacionándolas con la edad gestacional. El análisis se realizó con el paquete estadístico SPSS 11,0, la prueba chi cuadrado para las variables discretas y la de Kruskal-Wallis, para las variables continuas. Se asumió un valor de significancia de p < ,005. Principales medidas de resultados: Morbilidad y mortalidad perinatal, discapacidades motoras, auditivas y psicomotoras a las 6 meses de edad. Resultados: Sesentaitrés gestantes cumplieron con el criterio de inclusión. El peso medio al nacer de sus fetos fue 1 593 g; 24 casos (40%) presentaron peso al nacer menor al percentil 10 para la edad gestacional. La mayor parte mostró flujometría Doppler tipo III, 46 casos con signos de redistribución hemodinámica. La mortalidad global fue 8%. Cuatro fetos murieron intraútero; 59 fetos (94%) llegaron a nacer vivos; de ellos solo un caso falleció durante el periodo de estudio. La tasa global de mortalidad fue significativamente mayor y el peso al nacer más bajo en el grupo de fetos con flujometría Doppler tipo IV, con una media de 937 g. La mortalidad fue significativamente más alta en el grupo de 24 a 27,6 semanas. La estancia en UCI, la necesidad de ventilación asistida (VM) y presión positiva continua, el riesgo de desarrollar retinopatía y hemorragia interventricular y las discapacidades auditivas y trastorno del desarrollo psicomotor estuvieron correlacionados con la prematuridad. Conclusiones: Los casos de flujometría Doppler con compromiso hemodinámico severo presentaron acidemia y tasa alta de mortalidad, independiente del percentil de crecimiento al nacer. La mortalidad intraútero se asoció significativamente a la severidad mostrada por el estudio Doppler, por lo que no se recomienda continuar el embarazo en los tipos III y IV, si hay madurez pulmonar fetal.

Objectives: To determine both morbidity and mortality in fetuses with pathological Doppler velocimetry and short term handicap. Design: Retrospective, observational, analytical, correlation study. Setting: Fetal surveillance unit, Hospital Nacional Edgardo Rebagliati Martins, Red Asistencial Rebagliati, EsSalud, Lima, Peru. Participants: Pregnant women with pathological Doppler velocimetry and their perinates. Interventions: All pregnant women with altered Doppler velocimetry between February 2008 and February 2010 were studied. They were grouped by Doppler velocimetry types, and frequency of pathology; perinatal morbidity and mortality were determined and correlated with gestational age. SPSS 11,0 was used for statistical analysis, chi square test for discrete variables and Kruskal-Wallis test for continued variables. Significant value was p < ,005. Main outcome measures: Perinatal morbidity and mortality, motor, hearing and psychomotor discapacities at 6 months after birth. Results: Sixty-three pregnant women fulfilled inclusion criteria. Their mean newborns weight was 1 593 g; 24 cases (40%) presented weight at birth less than 10th percentile for gestational age. Most of them showed type III Doppler velocimetry, 46 with signs of hemodynamic redistribution. Global mortality was 8%. Four fetuses died in utero; 59 fetuses (94%) were born alive and only one case died during the study period. Mortality rate was significantly higher and birth weight less in type IV Doppler velocimetry fetuses, mean weight 937 g. Mortality was significatively higher at 24-27,6 weeks. ICU stay, need of assisted ventilation and continuous positive pressure, risk to develop retinopathy and interventricular hemorrhage, and hearing and psychomotor discapacities correlated with prematurity. Conclusions: Doppler velocimetry fetuses with severe hemodynamic compromise presented acidemia and high mortality rate, independent of growth percentile. Intrauterine mortality was significantly associated with Doppler velocimetry severity changes. To continue pregnancy with type III or IV Doppler velocimetry is not recommended in fetuses with lung maturity.

Pathologic Differences between Placentas from Intrauterine Growth Restriction Pregnancies with and without Absent or Reversed End Diastolic Velocity of Umbilical Arteries

BACKGROUND: Abnormal umbilical artery Doppler velocimetry is one of the important findings of intrauterine growth restriction (IUGR) and IUGR is associated with high perinatal morbidity and mortality. In addition, this abnormal Doppler velocimetry is correlated with placental insufficiency. The aim of this study was to determine the pathologic differences in the placentas from IUGR pregnancies with and without the absent or reversed end diastolic velocity (AREDV). METHODS: Among the cases that had undergone prenatal follow-up in our institute, a retrospective slide review was conducted for 18 cases of IUGR with AREDV and 17 cases with IUGR that had normal end-diastolic flow of the umbilical artery. RESULTS: The birth weight and the other clinical parameters were not different among the two groups. Grossly, the placental weight percentiles were significantly smaller in AREDV group when they were adjusted according to gestational age. Histologically, chronic deciduitis, mural hypertrophy of the decidual arteries, an intimal fibrin cushion of the large fetal vessels, increased syncytial knots, villous agglutinations, avascular villi, villous stromal-vascular karyorrhexis, and acute atherosis were more frequently found in the AREDV group and their presence showed statistical significance. CONCLUSIONS: These findings suggest that pathologic abnormalities due to fetal and maternal vasculopathies in the placenta may be the cornerstone for inducing AREDV in the umbilical artery.

Repercusión de la anemia materna sobre el pico de velocidad sistólica de la arteria cerebral media fetal / Impact of maternal anemia on the systolic velocity peak in fetal middle cerebral artery

Determinar la relación entre el grado de afectación fetal y anemia materna mediante la velocimetría Doppler de la arteria cerebral media, en hijos de madres anémicas. Estudio prospectivo, observacional y analítico, de 35 pacientes entre 26 y 28 semanas de gestación de las cuales 15 con diagnóstico de anemia (hemoglobina menor de 11 g por ciento y hematocrito menor de 33 por ciento) constituyeron el grupo de estudio y 20 el grupo control. Previo consentimiento informado, se estableció el índice cerebro-placentario. Se excluyeron pacientes que presentaran patologías que generan hipoxia severa crónica. En la Unidad de perinatología del Hospital Universitario de Caracas. La edad promedio fue de 28 años para el grupo de estudio y de 27,39 años para el grupo control, la edad gestacional de 27,02 semanas para ambos grupos. En los antecedentes familiares predominó la diabetes en ambos grupos, seguidos de hipertensión arterial. El promedio de hemoglobina y hematocrito fue de 10,21 g por ciento y 31,23 por ciento para el grupo de estudio y de 12,05 g por ciento y 36,21 por ciento para el grupo control. El pico de velocidad sistólica de la arteria cerebral media fetal fue de 34,47 cm/seg para el grupo de estudio y de 34,43 cm/seg para el grupo control; los valores promedio de sístole-diástole de arteria cerebral media, S/D: 4,84 y S/D: 5,62, arteria umbilical S/D: 2,87 y S/D:2,96 e índices cerebro- placentarios de 1,71 y 1,91, para grupos de estudio y control respectivamente, no arrojaron diferencias estadísticamente significativas. Tampoco hubo diferencia estadística cuando se compararon los grupos según el número de gestas, peso y sexo fetales. En el estudio realizado la anemia materna no afectó directamente la circulación fetal. No existe afectación fetal, ni elementos de hipoxia en pacientes hijos de madres anémicas

To determine the relationship between the degree of fetal affectation and maternal anemia by Doppler velocimetry middle cerebral artery in anemic mothers. Prospective, observational and analytical study, of 35 patients between 26 and 28 weeks of gestation, including 15 diagnosed with anemia (hemoglobin less than 11 g percent and hematocrit <33 percent) constituted the study group and 20 the control group. After informed consent cerebro-placental index was established. We excluded patients who had severe pathologies leading to chronic hypoxia. Unidad de perinatologia del Hospital Universitario de Caracas. The mean age was 28 years for the study group and 27.39 years for the control group, the gestational age of 27.02 weeks for both groups. The predominant family history was diabetes in both groups, followed by hypertension. The average hemoglobin and hematocrit was 10.21 g percent and 31.23 percent for the study group and 12.05 g percent and 36.21 percent for the control group. The peak systolic velocity of the fetal middle cerebral artery was 34.47 cm / sec for the study group and 34.43 cm / sec for the control group, the average values of systole-diastole of middle cerebral artery, S / D: 4.84 and S / D: 5.62, umbilical artery S / D: 2.87 and S / D: 2.96 and cerebro-placental indices of 1.71 and 1.91, for study groups and control respectively, yielded no statistically significant differences. There was also no statistical difference when comparing the groups according to the number of pregnancies, fetal weight and sex. The maternal anemia study did not directly affect the fetal circulation. There fetal impairment, or elements of hypoxia in patients anemic mothers

Dopplervelocimetria fetoplacentária em gestantes hipertensas e resultados perinatais segundo a idade gestacional / Fetal and placental Doppler velocimetry in hypertensive pregnant women and perinatal outcomes according to gestational age

OBJETIVO: Avaliar índices de pulsatilidade das artérias umbilical (IPAU) e cerebral média (IPACM) e relação do índice de pulsatilidade umbilico-cerebral (IPAU/IPACM) em fetos de gestantes hipertensas e presença de resultados perinatais adversos. MATERIAIS E MÉTODOS: Analisamos IPAU, IPACM e IPAU/IPACM de 289 fetos de gestantes hipertensas quanto à previsão dos resultados perinatais adversos. Os resultados foram comparados sem e com ajuste pela idade gestacional. RESULTADOS: O índice de Apgar < 7 no 5º minuto foi associado com resultados alterados após o ajuste por idade gestacional. O risco para recém-nascidos pequenos para a idade gestacional aumentou em três vezes após o ajuste, com significância estatística em todos os parâmetros do Doppler. Na síndrome da hipóxia neonatal o aumento do risco ajustado pela idade gestacional foi estatisticamente significante no IPAU e IPAU/IPACM. Não houve aumento no risco de síndrome do desconforto respiratório na análise ajustada. A mortalidade perinatal e o IPAU alterado apresentaram um risco três vezes maior e foram estatisticamente significantes após o ajuste. CONCLUSÃO: Em gestantes hipertensas, o IPAU apresentou melhor correlação com os resultados perinatais do que o IPACM ou relação IPAU/IPACM. O risco de resultados adversos deve considerar a idade gestacional.

OBJECTIVE: To evaluate the pulsatility index of umbilical artery (UAPI) and middle cerebral artery (MCAPI), as well as the umbilical-cerebral pulsatility (UAPI/MCAPI) ratio in fetuses of hypertensive pregnant women and associated adverse perinatal outcomes. MATERIALS AND METHODS: The authors have analyzed UAPI, MCAPI and UAPI/MCAPI ratio in 289 fetuses of hypertensive women, correlating the results with the presence of adverse perinatal outcomes. Results were compared with and without adjustment for gestational age. RESULTS: Apgar score < 7 at the 5th minute was associated with altered outcomes after adjustment for gestational age. The risk for small-for-gestational-age infant increased three times after such adjustment, with statistical significance for all the Doppler parameters. The increase in risk for neonatal hypoxia after adjustment for gestational age was statistically significant for UAPI and UAPI/MCAPI ratio. No increase was observed in the risk for respiratory distress syndrome in the adjusted analysis. A three-time higher risk for perinatal mortality and altered UAPI with statistical significance was observed after adjustment. CONCLUSION: In fetuses of hypertensive pregnant women, UAPI demonstrated better correlations with perinatal outcomes than MCAPI and UAPI/MCAPI ratio. The risk for adverse gestational outcome should be evaluated taking the gestational age into consideration.

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.

Recent advances in obstetrical ultrasound / 대한산부인과학회지

An obstetrical ultrasound examination provides invaluable information regarding the fetus. Many publications from the last years have advanced the use of ultrasound in obstetrics. With the advent of high-resolution ultrasound and transvaginal scanning, a significant amount of information about the fetus have been gained, and provided to the patient. It must be emphasized to evaluate the fetus for structural malformations, and searches for the sonographic markers of fetal aneuploidy in first trimester because it allows the early diagnosis of many conditions. The presence of sonographic markers including the nuchal fold, short femur and humerus, pyelectasis, hyperechoic bowel, echogenic intracardiac focus, and any major abnormality, either singly or in combination, will raise the baseline risk of aneuploidy using likelihood ratios calculated for each individual marker. Fetuses with abnormal Doppler velocimetry in the uteroplacental, umbilical, and fetal circulations but normal chromosomes are at higher risk for adverse pregnancy outcome, including preeclampsia and growth restriction. Improved technology has lowered the gestational age at which fetal cardiac anatomy scanning can be reliably performed by properly trained and experienced examiners. Early fetal echocardiography can be offered as a screening examination to at-risk and low-risk patients, with the condition that it be repeated following screen-negative scans at mid-gestation to exclude later developing lesions. This review describes the recent advances in the role of first trimester ultrasound in screening and diagnosis of fetal anomalies, a number of new ultrasound markers for fetal aneuploidy, Doppler ultrasonography, and fetal echocardiography.

A Study on Correlation of Vascular Endothelial Growth Factor in Preeclampsia / 대한주산의학회잡지

OBJECTIVE: The purpose of this study was to assess the impact of vascular endothelial growth factor (VEGF) in pregnancies with mild and severe preeclampsia. METHODS: From January 1999 to June 2001, we studied the severity for pregnant women with pregnancy induced hypertension between 28 and 40 weeks gestation. In the mild (n=46) and severe preeclamptic women (n=28), the laboratory evaluation included liver function test, platelet counts, and serum creatinine. The systolic/diastolic (S/D) ratio of the fetal umbilical artery flow for placental resistance was measured by ultrasonographic doppler velocimetry. To detect the damage of vascular endothelial cells in all preeclamptic women, serum concentrations of VEGF were measured. RESULTS: Severe preeclampsia had more elevated liver enzymes, thrombocytopenia, high creatinine than mild preeclampsia. HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) was encountered in 8/28 (28.6%) of severe preeclampsia. Fifteen out of twenty-eight cases (53.6%) in severe preeclampsia had elevated S/D ratio from 3.0 to 4.5 including 6 cases with absent end diastolic velocity, whereas 4/46 (8.7%) was elevated SD ratio (>3.0) in mild preeclampsia. Serum concentrations of VEGF were elevated in both mild (7.5+/-4.9 ng/mL, p<0.05) and severe preeclampsia (19.3+/-8.8 ng/mL, p<0.05) compared to normal pregnancy (0.5~2.1 ng/mL). CONCLUSION: The higher serum concentration of VEGF and elevated S/D ratio of umbilical artery were responsible for the changes of the resistance of placental blood flow in severe preeclampsia. Furthermore, elevated S/D ratio of umbilical artery velocity was essential as a surveillance method of fetal health status with IUGR (Intrauterine growth restriction) by vascular declination of placenta.

Transabdominal cervicoisthmic cerclage during pregnancy: The strength of cerclage band and the pregnancy outcomes / 대한산부인과학회잡지

BACKGROUND/OBJECTIVE: After introducing transabdominal approach of cervical cerclage since 1965, several authors have reported significant increases in fetal survival rate. However, this procedure has not been widely used because its complexity of procedure and serious complications. Furthermore, there is a dilemma on the strength of the cerclage bands knots. Yet, there is no standard guidance in this approach. The purpose of this study was to suggest degree of adequate tension on the knot when tying the cerclage band on the cervico-isthmic junction during post-conceptional transabdominal cerclage and to assess whether the strength of the band is associated with uterine blood flow or pregnancy outcomes. STUDY DESIGN: Sixty-five transabdominal cervico-isthmic cerclages during pregnancy were performed for 7 years since 1989 in patients of incompetent cervix who could not be taken transvaginal cerclage. The procedures were performed with our own technique, modified technique from original Novys procedure. The cerclage used a 5mm-Mersilene band and knot was placed on the anterior side. Pre- and post-operative uterine blood flow were evaluated with Doppler velocimetry. After cesarean section at term, cerclage bands were removed and collected for measurement of bands length if they do not want further pregnancies. The relationships between strength of cerclage, length of band and pregnancy outcomes were evaluated. The effects of the bands length on the uterine blood flow were also analyzed. RESULTS: To date there have been 56 completed pregnancies in 50 patients. Among these, 21 cerclage bands were removed and collected for measurement of bands length. All pregnancies (27 pregnancies from 21 patients) were successful; the average gestational age at delivery was 38.4 weeks (range: 37-43) and mean birth weight was 3178gm (range:2670-4370). Average length of cerclage bands was 7.01cm(range:5.0-9.4), thus diameter of cerclage bands was calculated as 2.2cm. Statistically, significant positive correlation was found between the bands' length and birth weights (r=0.614, p=0.002). There were no differences between pre- and post-operative uterine blood flow regardless of cerclage bands length. CONCLUSIONS: We suggest 7cm is adequate bands length when performing transabdominal cerclage during pregnancy. Uterine blood flow was not influenced by operation. It was interesting that bands length was correlated with birth weight. It seems that tightened cerclage might preclude the adequate formation of lower uterine segment during pregnancy. Recently we use the specific Mersilene bands after marking of each centimeter interval on it, and bands are tied with 7cm in length for adequate strength of the cerclage. We propose this result also could be used when performing the pre-conceptional transabdominal cerclage.

Uterine artery Doppler velocimetry in the prediction of adverse obstetric outcomes in unexplained MSAFP elevations

Unexplained maternal serum-fetoprotein (MSAFP) elevation has been known to be associated with adverse obstetric outcomes, however it is not sufficiently useful as a screening test. This study was undertaken to determine whether uterine artery Doppler velocimetry could define a subset of patients with an elevated MSAFP level in whom complications of pregnancy might develop. The subjects included 179 women between 26 and 28 weeks' gestation with MSAFP > or = 2.5 multiples of the median, in whom either the presence of an early diastolic notch or a resistance index 0.6 was considered as an abnormal Doppler velocimetry finding. Those subjects who displayed abnormal Doppler velocimetry findings showed an increased incidence of preeclampsia, preterm birth, IUGR, and IUFD compared to those subjects with only elevated MSAFP (p < 0.05). No differences were observed in the incidence of LBW. Positive predictive values of adverse obstetric outcomes were significantly higher in the group having both elevated MSAFP and abnormal Doppler velocimetry compared to the group with only elevated MSAFP (p < 0.05). Uterine artery Doppler velocimetry in the second trimester can improve the value of unexplained MSAFP elevation in the prediction of adverse obstetric outcomes.