Ocular ultrasonography for diagnosing increased intracranial pressure in patients with severe preeclampsia.

BACKGROUND: Ultrasound measurements of optic nerve sheath diameter (ONSD) and optic disc height (ODH) measured outside pregnancy correlate with intracranial hypertension. Data on the usefulness of ocular ultrasonography in preeclampsia are limited. OBJECTIVE: To determine whether ONSD and ODH are greater in patients with features of severe preeclampsia compared to healthy controls. METHODS: Consecutively admitted patients with severe preeclampsia (according to the ACOG Task Force on Hypertension in Pregnancy) and healthy term control pregnant women were included in this prospective observational study. Optic nerve sheath diameter measured 3 mm behind the globe and ODH were assessed using ocular ultrasonography. Patients with severe preeclampsia were compared to controls before delivery, and at one and four days post-delivery. RESULTS: We included 30 patients with severe preeclampsia and 30 controls. Optic nerve sheath diameter was significantly higher in patients with severe preeclampsia compared to controls before delivery, and one day and four days post-delivery (P <0.001). Optic disc height was significantly greater in patients with severe preeclampsia compared to controls before delivery (P <0.001), and one day (P <0.001) but not four days, post-delivery (P=0.66). Before delivery, 43% of patients with severe preeclampsia had an ONSD >5.8 mm and 77% an ODH ≥1 mm: compatible with intracranial hypertension. None of the control patients had an ONSD of >5.8 mm or an optic disc height of ≥1 mm before or after delivery. CONCLUSIONS: Severe preeclampsia was associated with a significantly higher ONSD and increased ODH, which could be ultrasonographic evidence of papilledema.

Lung and cardiac ultrasound for hemodynamic monitoring of patients with severe pre-eclampsia.

OBJECTIVE: To evaluate lung and cardiac ultrasound for the assessment of fluid tolerance and fluid responsiveness before and after delivery in pregnant women with severe pre-eclampsia (PE). METHODS: This was a prospective observational study of singleton pregnant women with severe PE and healthy term controls. Lung ultrasound echo comet score (ECS), which denotes the amount of extravascular lung water, was obtained using the 28-rib interspaces technique. The echocardiographic E/e' ratio, measured by pulsed-wave and tissue Doppler, was used as a marker of diastolic left ventricular function. Fluid responsiveness was assessed by measuring changes in stroke volume (SV) with passive leg raising (PLR). SV was calculated from the left ventricular flow velocity-time integral measured by pulsed-wave Doppler at baseline and after PLR. Change in SV ≥ 12% was considered to indicate fluid responsiveness. Measurements obtained 1 day before delivery and 1 and 4 days after delivery were compared in the two groups (PE vs controls). RESULTS: We included 21 women with severe PE and 12 healthy controls. ECS and E/e' ratio were higher in women with PE than in controls, both before delivery (P = 0.002 and P = 0.02) and 1 day postdelivery (P = 0.02 and P = 0.03); however there was no difference at 4 days postdelivery (P = 0.63 and P = 0.90). The change in SV with PLR before (P = 0.26) and after (P = 0.71) delivery did not differ between groups. An increase in SV ≥ 12% was observed in three (14%) women with PE and four (33%) controls before delivery and in four (19%) women with PE and two (17%) controls 1 day after delivery. CONCLUSIONS: Severe PE is associated with an increase in extravascular lung water, which could in part be caused by disturbed diastolic left ventricular function. Excess lung water can be identified by lung ultrasound assessment in women with severe PE before the appearance of clinical signs. Only a small proportion of these women are fluid responsive. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Perinatal outcomes in singleton and twin pregnancies following first-trimester bleeding.

OBJECTIVE: To investigate associations between first-trimester bleeding and perinatal outcomes. STUDY DESIGN: Registry-based survey of the period 2002 through 2010. Pregnancies with versus without first-trimester bleeding were compared using Student's t- and χ(2)-test. Multivariable logistic regression was used to control for potential confounders. RESULT: 9924 singleton and 275 twin pregnancies with first-trimester bleeding, and 160 099 singleton and 2710 twin pregnancies without bleeding were included. Bleeding increased the risk of preterm birth in singletons (odds ratio 1.48; 95% confidence interval 1.38-1.60). Risks were also increased for preterm premature rupture of membranes, abruption, previa, stillbirth and congenital anomalies, with a reduced risk of preeclampsia. The differences remained significant after adjustment for confounders. In twin pregnancies, bleeding was not significantly associated with prematurity (odds ratio 1.04; 95% confidence interval 0.81-1.34), nor with other outcomes. CONCLUSION: In singletons, but not in twins, the risk of perinatal complications is significantly increased after first-trimester bleeding.

Maternal serum free beta-hCG and PAPP-A in fetal sex chromosome defects in the first trimester.

We have studied maternal serum free beta-hCG and PAPP-A, and fetal nuchal translucency (NT) in a series of 46 cases of fetal Turner's syndrome, 13 cases of other sex chromosomal anomalies and compared these with 947 control pregnancies in the first trimester. In cases of Turner's syndrome (45,X) the median fetal NT was significantly higher than in controls (4.76 MoM), the median PAPP-A was significantly lower (0.49 MoM), whilst the free beta-hCG was not significantly different (1.11 MoM). For NT, 93% (43/46) of cases were equal to or greater than the 95th centile of controls, for PAPP-A 35% (16/46) of cases were less than or equal to the 5th centile of controls and for free beta-hCG 15% (7/46) of cases were equal to or greater than the 95th centile of controls. For other sex chromosomal anomalies (47XXX, XXY, XYY) the median NT was increased (2.07 MoM) whilst PAPP-A was not significantly decreased (0.88 MoM) and free beta-hCG was not significantly different (1.07 MoM) from controls. Using a previously derived multivariate risk algorithm for trisomy 21, incorporating NT, PAPP-A, free beta-hCG and maternal age, 96% of the Turner's cases and 62% of the other sex chromosomal anomalies would have been identified.

Screening for trisomy 18 by fetal nuchal translucency and maternal serum free beta-hCG and PAPP-A at 10-14 weeks of gestation.

In a study of 50 cases of trisomy 18 compared with 947 controls we have found the median multiple of the median (MoM) of maternal serum free beta human chorionic gonadotrophin to be significantly decreased (0.281 MoM) in samples collected between the 10th and 14th week of gestation. Similarly, maternal serum pregnancy associated plasma protein A (PAPP-A) levels are also decreased (0.177 MoM), whilst the median nuchal translucency is significantly higher (3.272 MoM). Free beta-hCG MoM was less than the 5th centile of normal in 64 per cent of cases of trisomy 18 and for PAPP-A was less than the 5th centile in 78 per cent of cases. Also, in 78 per cent of cases the nuchal translucency was above the 95th centile. When combined together in a multivariate algorithm with maternal age, we predict that 89 per cent of cases of trisomy 18 could be detected at a 1 per cent false-positive rate. We conclude that specific trisomy 18 risks should be part of developing risk algorithms combining maternal serum biochemistry and nuchal translucency for use in first trimester screening alongside those for trisomy 21.

A screening program for trisomy 21 at 10-14 weeks using fetal nuchal translucency, maternal serum free beta-human chorionic gonadotropin and pregnancy-associated plasma protein-A.

OBJECTIVE: To examine the potential impact of combining maternal age with fetal nuchal translucency thickness and maternal serum free beta-human chorionic gonadotropin (beta-hCG) and pregnancy-associated plasma protein-A (PAPP-A) in screening for trisomy 21 at 10-14 weeks of gestation. METHODS: Maternal serum free beta-hCG and PAPP-A were measured by Kryptor, a random access immunoassay analyzer using time-resolved amplified cryptate emission, in 210 singleton pregnancies with trisomy 21 and 946 chromosomally normal controls, matched for maternal age, gestation and sample storage time. In all cases the fetal crown-rump length and nuchal translucency thickness had been measured by ultrasonography at 10-14 weeks of gestation and maternal blood had been obtained at the time of the scan. The distributions (in multiples of the median; MoM) of free beta-hCG and PAPP-A (corrected for maternal weight) and fetal nuchal translucency (NT) were determined in the trisomy 21 group and the controls. Likelihood ratios for the various marker combinations were calculated and these were used together with the age-related risk for trisomy 21 in the first trimester to calculate the expected detection rate of affected pregnancies, at a fixed false-positive rate, in a population with the maternal age distribution of pregnancies in England and Wales. RESULTS: In a population with the maternal age distribution of pregnancies in England and Wales, it was estimated that, using the combination of maternal age, fetal nuchal translucency thickness and maternal serum free beta-hCG and PAPP-A, the detection of trisomy 21 pregnancies would be 89% at a fixed false-positive rate of 5%. Alternatively, at a fixed detection rate of 70%, the false-positive rate would be 1%. The inclusion of biochemical parameters added an additional 16% to the detection rate obtained using NT and maternal age alone. CONCLUSIONS: Rapid diagnostic technology like Kryptor, which can provide automated reproducible biochemical measurements within 30 min of obtaining a blood sample, will allow the development of interdisciplinary one-stop clinics for early fetal assessment. Such clinics will be able to deliver improved screening sensitivity, rapidly and more efficiently, leading to reduced patient anxiety and stress.