Placental differences between severe fetal growth restriction and hypertensive disorders of pregnancy requiring early preterm delivery: morphometric analysis of the villous tree supported by artificial intelligence.

BACKGROUND: The great obstetrical syndromes of fetal growth restriction and hypertensive disorders of pregnancy can occur individually or be interrelated. Placental pathologic findings often overlap between these conditions, regardless of whether 1 or both diagnoses are present. Quantification of placental villous structures in each of these settings may identify distinct differences in developmental pathways. OBJECTIVE: This study aimed to determine how the quantity and surface area of placental villi and vessels differ between severe, early-onset fetal growth restriction with absent or reversed umbilical artery Doppler indices and hypertensive disorders of pregnancy or the 2 conditions combined among subjects with disease severity that warrant early preterm delivery. We hypothesized that the trajectories of placental morphogenesis diverge after a common initiating insult of deep defective placentation. Specifically, we postulated that only villi are affected in pregnancy-related hypertension, whereas both villous and vascular structures are proportionally diminished in severe fetal growth restriction with no additional effect when hypertension is concomitantly present. STUDY DESIGN: In this retrospective cohort study, paraffin-embedded placental tissue was obtained from 4 groups, namely (1) patients with severe fetal growth restriction with absent or reversed umbilical artery end-diastolic velocities and hypertensive disorders of pregnancy, (2) patients with severe fetal growth restriction with absent or reversed umbilical artery Doppler indices and no hypertension, (3) gestational age-matched, appropriately grown pregnancies with hypertensive disease, and (4) gestational age-matched, appropriately grown pregnancies without hypertension. Dual immunohistochemistry for cytokeratin-7 (trophoblast) and CD34 (endothelial cells) was performed, followed by artificial intelligence-driven morphometric analyses. The number of villi, total villous area, number of fetoplacental vessels, and total vascular area across villi within a uniform region of interest were quantified. Quantitative analyses of placental structures were modeled using linear regression. RESULTS: Placentas from pregnancies complicated by hypertensive disorders of pregnancy exhibited significantly fewer stem villi (-282 stem villi; 95% confidence interval, -467 to -98; P<.01), a smaller stem villous area (-4.3 mm2; 95% confidence interval, -7.3 to -1.2; P<.01), and fewer stem villous vessels (-4967 stem villous vessels; 95% confidence interval, -8501 to -1433; P<.01) with no difference in the total vascular area. In contrast, placental abnormalities in cases with severe growth restriction were limited to terminal villi with global decreases in the number of villi (-873 terminal villi; 95% confidence interval, -1501 to -246; P<.01), the villous area (-1.5 mm2; 95% confidence interval, -2.7 to -0.4; P<.01), the number of blood vessels (-5165 terminal villous vessels; 95% confidence interval, -8201 to -2128; P<.01), and the vascular area (-0.6 mm2; 95% confidence interval, -1.1 to -0.1; P=.02). The combination of hypertension and growth restriction had no additional effect beyond the individual impact of each state. CONCLUSION: Pregnancies complicated by hypertensive disorders of pregnancy exhibited defects in the stem villi only, whereas placental abnormalities in severely growth restricted pregnancies with absent or reversed umbilical artery end-diastolic velocities were limited to the terminal villi. There were no significant statistical interactions in the combination of growth restriction and hypertension, suggesting that distinct pathophysiological pathways downstream of the initial insult of defective placentation are involved in each entity and do not synergize to lead to more severe pathologic consequences. Delineating mechanisms that underly the divergence in placental development after a common inciting event of defective deep placentation may shed light on new targets for prevention or treatment.

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.

Umbilical artery pulsatility index and half-peak systolic velocity in second- and third-trimester fetuses with trisomy 18 and 13.

OBJECTIVES: To analyze umbilical artery (UA) Doppler velocimetry and its possible role in placenta-mediated fetal growth restriction (FGR) in second- and third-trimester fetuses with trisomy 18 and 13. METHODS: UA pulsatility index (PI) and half-peak systolic velocity deceleration time (hPSV-DT) were measured in fetuses with trisomy 18 and 13. Correlation with gestational age, birthweight, and perinatal outcome was analyzed. RESULTS: A total of 80 measurements were taken from 33 fetuses with trisomy 18 and 19 with trisomy 13. Overall, there was a high prevalence of abnormal UA Doppler velocimetry. In fetuses with trisomy 18, 54% (27/50) of the UA PI values and 58% (29/50) of the UA hPSV-DT values were abnormal. In fetuses with trisomy 13, 80% (24/30) of the UA PI values and 87% (26/30) of the UA hPSV-DT values were abnormal. The prevalence of abnormal UA Doppler velocimetry increased with gestational age in both types of aneuploidy. However, this trend was only significant for trisomy 13 (p<0.05). All fetuses with trisomy 18 and 86% of fetuses with trisomy 13 were classified at birth as FGR. There were no perinatal survivors in this series. CONCLUSIONS: A high prevalence of abnormal UA Doppler velocimetry was found in second- and third-trimester fetuses with trisomy 18 and 13, which further increased with gestational age. These results may well correlate with alterations described previously in the placenta, suggesting placental insufficiency has an important role in the development of FGR in these autosomal aneuploid fetuses.

Ultrassonografia em modo B e Doppler para avaliação reprodutiva de cães e gatos / B-mode and Doppler ultrasound for reproductive assessment of dogs and cats

A ultrassonografia do sistema reprodutivo é uma importante ferramenta utilizada em associação ao exame andrológico para avaliação de machos reprodutores. Novas modalidades de análise ultrassonográfica foram descritas na última década, como a análise Doppler da artéria testicular. O objetivo deste texto é apresentar estas modalidades com o intuito de acrescentar informações importantes ao exame andrológico de cães e gatos.

The ultrasound of the reproductive system is an important tool used in association with the andrological examination to evaluate reproductive males. New modalities of ultrasound analysis have been described in the last decade, such as the Doppler analysis of the testicular artery. The objective of this text is to present these tools in order to add important information to the andrological examination of dogs and cats.

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.

B-Mode and Doppler ocular ultrasound evaluation in healthy and positive dogs for visceral canine leishmaniasis

Background: The use of ultrasound examination in the evaluation of ophthalmopathies has been gaining more and more space within the ophthalmologic clinical routine. The hemodynamic study of ocular vascularization may anticipate future changes, aiding in the adequate establishment of therapeutic conduits. The objective of this study was to evaluate the structures of the ocular bulb and to perform the hemodynamic evaluation of the flow of the external ophthalmic artery of dogs with canine visceral leishmaniasis (CVL) correlating with healthy animals. Materials, Methods & Results: For this purpose, 100 animals were used, of these 70 positive for CVL and 30 healthy animals, submitted to B-mode and Doppler ultrasound examination. Two-dimensional evaluation included identification of ocular changes and biometry of the following segments: axial length (M1), anterior chamber depth (M2), lens thickness (M3), lens length (M4), glass chamber depth (M5), optical disc length (M6) and optic nerve length (M7). The Doppler velocimetric evaluation included the identification and hemodynamic evaluation of the external ophthalmic artery, being measured: systolic peak velocity (SPV), final diastolic velocity (FDV), resistivity index (RI) and pulsatility index (PI). Ophthalmopathies were frequent in animals with leishmaniasis in both right (91.42%) and left (29.14%) eyes, with identification of capsular cataract, lens dislocation, retinal detachment and lens rupture. No significant statistical difference (P > 0.05) was observed when comparing the biometric values between the right and left eyes of the animals with CVL, as well as for the measurements between healthy and CVL animals. Hemodynamic indexes of the flow of the external ophthalmic artery presented narrow limits for the right and left eyes of the positive animals, not statistically...

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.

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...(AU)

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...(AU)

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 effect of prenatally administered vaginal progesterone on uterine artery Doppler in asymptomatic twin pregnancies.

OBJECTIVES: This study investigated the influence of vaginal progesterone on uterine circulation in asymptomatic twin gestations. STUDY DESIGN: This study was a secondary analysis of a randomized, double-blind, placebo-controlled trial of twin pregnancies exposed to vaginal progesterone or placebo. We included all trial participants who had undergone uterine artery pulsatility index evaluation at the time of randomization. During each ultrasound examination, the uterine artery pulsatility index was evaluated transabdominally. The mean uterine artery pulsatility index between the progesterone and placebo groups were compared for each gestational age, starting between 18 to 34 weeks and 6days and were analyzed at three (Time 1), six (Time 2) and nine (Time 3) weeks after randomization. RESULTS: The final analysis included 128 women in the progesterone group and 122 women in the placebo group. The baseline characteristics were similar in both groups. No difference in the mean uterine artery pulsatility index was observed between the progesterone and placebo groups at each week of gestation or throughout gestation. CONCLUSIONS: In twin pregnancies, the use of vaginal progesterone in the second half of pregnancy does not influence uterine circulation.

Blood flow indices in single and multiple bearing does

The aim of present study was to examine the changes in blood flow indices throughout pregnancy in singleton and multiple pregnant does. Doppler scanning was done to assess resistance index (RI), pulsatility index (PI), time-averaged maximum velocity (TAMV) and blood flow volume (Vol). The placentomes were investigated for blood indices on day 45 as an echogenic structure on the surface of the endometrium. Transrectal ultrasonography was performed every 30 days during the overage of the pregnancy. Diameters of largest six placentomes from each doe were measured using an ultrasonography device, and the mean values of placentome diameters were calculated. Values of RI and PI exhibited a steady decrease toward term and declined more rapidly and earlier in multiple than in single pregnancies. Values of RI and PI were negatively correlated with placetome size; however, values of TAMV and Vol were positively correlated with placentome size. In singleton and multiple pregnancies, the placentome size showed an increase toward term, but there is no difference in placentome size between single and multiple bearing does. In conclusion, the values of TAMV and Vol for multiple pregnancies were significantly higher than for singleton at any gestational month to satisfy the high foetal demand of nutrients and dissolved oxygen for foetal progression. Knowing the relationship between the foetal number and blood flow parameters could be used in the clinical management of such pregnancies and the early detection or prediction adverse pregnancy outcome.

Blood flow indices in single and multiple bearing does

The aim of present study was to examine the changes in blood flow indices throughout pregnancy in singleton and multiple pregnant does. Doppler scanning was done to assess resistance index (RI), pulsatility index (PI), time-averaged maximum velocity (TAMV) and blood flow volume (Vol). The placentomes were investigated for blood indices on day 45 as an echogenic structure on the surface of the endometrium. Transrectal ultrasonography was performed every 30 days during the overage of the pregnancy. Diameters of largest six placentomes from each doe were measured using an ultrasonography device, and the mean values of placentome diameters were calculated. Values of RI and PI exhibited a steady decrease toward term and declined more rapidly and earlier in multiple than in single pregnancies. Values of RI and PI were negatively correlated with placetome size; however, values of TAMV and Vol were positively correlated with placentome size. In singleton and multiple pregnancies, the placentome size showed an increase toward term, but there is no difference in placentome size between single and multiple bearing does. In conclusion, the values of TAMV and Vol for multiple pregnancies were significantly higher than for singleton at any gestational month to satisfy the high foetal demand of nutrients and dissolved oxygen for foetal progression. Knowing the relationship between the foetal number and blood flow parameters could be used in the clinical management of such pregnancies and the early detection or prediction adverse pregnancy outcome.(AU)

Longitudinal reference intervals for Doppler velocimetric parameters of the fetal renal artery correlated with amniotic fluid index among low-risk pregnancies.

OBJECTIVE: To establish longitudinal reference intervals for pulsatility index (PI) and systolic velocity (SV) of the fetal renal artery, and to evaluate their correlation with the amniotic fluid index (AFI). METHODS: A prospective longitudinal study was conducted among women with low-risk pregnancies who attended outpatient clinics at the University of Campinas Medical School, Brazil, at 16-19 weeks of pregnancy between April 1, 2008, and March 31, 2010. Doppler velocimetric measurements of the fetal renal artery and assessments of the AFI were undertaken at 4-week intervals to 36 weeks, and every 2 weeks thereafter until delivery. RESULTS: A total of 63 women were enrolled. The PI of the fetal renal artery showed little variation during pregnancy, whereas SV values increased to 36-37 weeks of pregnancy and decreased thereafter. No correlations were found between the AFI and the fetal renal artery Doppler velocimetric parameters (P>0.05 for all). The intraclass correlation coefficients for intra-observer and inter-observer variability indicated good reproducibility of SV, but the reproducibility of PI was lower. CONCLUSIONS: The AFI did not correlate with fetal renal artery Doppler velocimetric measures among low-risk pregnancies. However, investigations are needed among high-risk pregnancies.

Predictive value of ophthalmic artery Doppler velocimetry in relation to development of pre-eclampsia.

OBJECTIVE: To test the hypothesis that ophthalmic artery Doppler velocimetry is predictive of the development of pre-eclampsia (PE). METHODS: This was a prospective cohort study that included pregnant women in the second trimester who had risk factors for PE. Seven ophthalmic artery Doppler parameters, in addition to uterine artery (UtA) Doppler and clinical variables, were investigated for their prognostic value with respect to PE. RESULTS: A total of 347 women were recruited, of whom 40 developed PE. A comparison of the mean ophthalmic artery Doppler parameter values between women with and those without PE showed statistically significant differences in several parameters: peak systolic velocity, end-diastolic velocity, mean velocity, peak mesodiastolic velocity (PMDV) and peak ratio. After adjusting for confounding variables, only PMDV remained statistically significant (P < 0.001), with an area under the receiver-operating characteristics curve (AUC) of 0.73. The best cut-off for predicting PE was a PMDV of > 22.11 cm/s, with sensitivity of 70%, specificity of 75%, positive likelihood ratio of 2.8, negative likelihood ratio of 0.4, positive predictive value of 28% and negative predictive value of 95%. The AUC increased from 0.72 to 0.78 when the PMDV was incorporated into a prediction model based on clinical variables, demonstrating that this marker increased the discriminatory capability of the model. The performance of ophthalmic artery Doppler was similar to that of UtA Doppler for predicting PE. Additionally, the AUC increased significantly from 0.82 to 0.88 when the PMDV was incorporated into the model containing clinical variables and UtA Doppler indices. CONCLUSION: A high ophthalmic artery PMDV in the second trimester of pregnancy is an independent predictor of PE that increases the discriminatory ability of clinical markers, as well as of models that include clinical variables and UtA Doppler indices.

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.

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.