Change in maternal cardiac output from preconception to mid-pregnancy is associated with birth weight in healthy pregnancies.

OBJECTIVE: Birth weight (BW) is thought to be determined by maternal health and genetic, nutritional and placental factors, the latter being influenced by anatomical development and perfusion. Maternal cardiovascular changes contribute to uteroplacental perfusion; however, they have not yet been investigated in relation to fetal growth or BW. Our aim was to explore the relationship between maternal cardiovascular adaptation, fetal growth and BW in healthy pregnancies. METHODS: This was a longitudinal prospective study of women planning to conceive a pregnancy. Maternal cardiac output (CO), cardiac index (CI), pulse-wave velocity, aortic augmentation index, central blood pressure and peripheral vascular resistance were assessed prior to pregnancy and at 6, 23 and 33 weeks' gestation. Fetal growth was assessed using serial ultrasound measurements of biometry. RESULTS: In total, 143 women volunteered to participate and were eligible for study inclusion. A total of 101 women conceived within 18 months and there were 64 live births with normal pregnancy outcome. There were positive correlations between BW and the pregnancy-induced changes in CO (ρ = 0.4, P = 0.004), CI (ρ = 0.3, P = 0.02) and peripheral vascular resistance (ρ = 0.3, P = 0.02). There were significant associations between second-to-third-trimester fetal weight gain and the prepregnancy-to-second-trimester increase in CO (Δ, 0.8 ± 1.2 L/min; ρ = 0.3, P = 0.02) and CI (Δ, 0.4 ± 0.6 L/min/m2 ; ρ = 0.3, P = 0.04) and reduction in aortic augmentation index (Δ, -10 ± 9%; ρ = -0.3, P = 0.04). CONCLUSIONS: In healthy pregnancy, incremental changes in maternal CO in early pregnancy are associated with third-trimester fetal growth and BW. It is plausible that this association is causative as the changes predate third-trimester fetal growth and eventual BW. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Impact of ovulation and implantation timing on first-trimester crown-rump length and gestational age.

OBJECTIVE: To determine the impact of ovulation and implantation timing on first-trimester crown-rump length (CRL) and the derived gestational age (GA). METHOD: One hundred and forty-three women who were trying to conceive were recruited prospectively. The timing of ovulation and implantation and the ovulation to implantation (O-I) interval were established in 101 pregnancies using home urinary tests for luteinizing hormone and human chorionic gonadotropin. In 71 ongoing pregnancies, GA determined by measurement of fetal CRL at 10-14 weeks' gestation was compared with GA based on ovulation and implantation day. First-trimester growth was determined by serial ultrasound scans at 6-7, 8-9 and 10-14 weeks. RESULTS: The median ovulation and implantation days were 16 and 27, respectively, with an O-I interval of 11 days. GA estimated from CRL at 10-14 weeks was on average 1.3 days greater than that derived from ovulation timing. CRL Z-score was inversely related to O-I interval (ρ= -0.431, P=0.0009). There was no significant relationship between CRL growth rate and the difference between observed CRL and expected CRL based on GA from last menstrual period (ρ=0.224, P=0.08). CONCLUSIONS: Early implantation leads to a larger CRL and late implantation to a smaller CRL at 10-14 weeks, independent of CRL growth rate. Implantation timing is a major determinant of fetal size at 10-14 weeks and largely explains the variation in estimates of GA in the first trimester derived from embryonic or fetal CRL.

Beyond the placental bed: placental and systemic determinants of the uterine artery Doppler waveform.

The uterine artery Doppler waveform has been extensively investigated, though its widespread clinical use as a predictor of adverse pregnancy outcome remains under debate. The determinants of the waveform have classically been ascribed to transformation of the spiral arteries and the development of a low resistance uteroplacental circulation, failure of which predisposes to pre-eclampsia, fetal growth restriction and other adverse outcomes. It has become increasingly evident that although spiral artery transformation determines in some part the characteristics of the Doppler waveform, factors pertaining to maternal vascular and endothelial function are also important.

Raised uterine artery impedance is associated with increased maternal arterial stiffness in the late second trimester.

OBJECTIVE: To assess the relationship between uterine artery Doppler pulsatility index (PI) and maternal global arterial stiffness and aortic stiffness in women at high a priori risk of preeclampsia in the late second trimester of pregnancy. METHODS: A prospective cohort study was performed. 99 women were recruited from the high-risk obstetric ultrasound clinic in the second trimester; median (±IQR) age and gestation were 33 (29-37) years and 23(+6) (23(+3)-24(+4)) weeks respectively. Transabdominal uterine artery Doppler was performed and mean values recorded. Women returned at a later date, median gestation (±IQR) 26(+5) (25(+6)-28(+0)) weeks, for measurement of blood pressure, augmentation index (AIx) and aortic pulse wave velocity (aPWV). RESULTS: Uterine artery PI is positively associated with both AIx (r = 0.4, P <0.0001, 95% CI: 0.22-0.55) and aPWV (r = 0.22, P = 0.03, 95% CI: 0.02-0.40). No relationship was found between uterine artery PI and mean arterial pressure or pulse pressure. AIx was significantly higher in women with uterine artery PI > 1.45 (P = 0.003, 95% CI: 3.1-14.9) but not aPWV (P = 0.45). AIx, but not aPWV, was significantly higher in women who developed preeclampsia (14% vs 9%, 95% CI: 2.0-8.6, P = 0.0018) or IUGR (11% vs 9%, 95% CI: 0.3-4.2, P = 0.027). AIx showed a negative correlation with birth weight z-score (r = -0.25, 95% CI: -0.43 to -0.06, P = 0.013). CONCLUSION: Increasing uterine artery Doppler PI reflects impaired placentation and increasing risk of preeclampsia. We show a positive association between uterine artery Doppler PI and both global arterial and aortic stiffness. We also show that increased maternal arterial stiffness is associated with a lower birth weight. These findings may represent evidence of an early effect of impaired placentation on the maternal vasculature. Alternatively, given the association between preeclampsia and later cardiovascular disease, ineffective placentation may result from impaired arterial function.

Laparoscopic assisted vaginal hysterectomy and bilateral salpingo-oophorectomy as a day surgery procedure: a promising option.

Laparoscopic surgical techniques are increasingly being used to treat gynaecological malignancies as studies confirm long-term results similar to open procedures. Within the UK National Health Service, there is a drive towards day of surgery admission and reducing inpatient stay. We audited the length of inpatient stay, acceptability to patients of day of surgery admission and timing of discharge and accessibility to early community follow-up, among women undergoing laparoscopic assisted vaginal hysterectomy and bilateral salpingo-oophorectomy in our unit over a 6-month period. We show that women find short inpatient stays acceptable and that many can be safely discharged, with no postoperative hospital follow-up, within 24 h. Adequate pre-admission procedures and easy access to advice, post-discharge must be ensured.