Ultrasound evaluation of left ventricular and aortic fibrosis after pre-eclampsia.

OBJECTIVES: Myocardial fibrosis is associated with adverse clinical outcome in adults. Our aim was to investigate using echocardiographic calibrated integrated backscatter (cIBS) the presence of myocardial and/or aortic fibrosis in asymptomatic women with a history of early-onset (EO) or late-onset (LO) pre-eclampsia (PE). METHODS: Thirty non-pregnant women whose most recent pregnancy was complicated by EO-PE, 30 with previous LO-PE pregnancy and 30 controls who had experienced only uncomplicated pregnancy previously were selected retrospectively from our electronic database and recalled between 6 months and 4 years after delivery. Data regarding gestational age (GA) and mean uterine artery (UtA) pulsatility index (PI) at diagnosis of PE were collected from their medical records. The women underwent cardiovascular assessment, during which the presence of fibrosis was investigated, by means of cIBS, at the basal interventricular septum (cIBSIVS ), the basal posterior wall (cIBSPW ) and the anterior wall of the ascending aorta, 3 cm above the valve (cIBSAO ). These findings were compared between the three patient groups. RESULTS: Using cIBS imaging, we found significant left ventricular (LV) fibrosis in women with a history of EO-PE compared with those with previous LO-PE pregnancy and controls (intergroup ANOVA P < 0.001 for cIBSIVS and P = 0.005 for cIBSPW ), whereas aortic fibrosis did not differ significantly among cases and controls. Stepwise multivariate regression analysis showed that LV fibrosis was associated independently with lower GA and higher mean UtA-PI at diagnosis of PE, while cIBSAO correlated with aortic diameters, stiffness and ventricular-arterial coupling. CONCLUSIONS: Women with a history of EO-PE show LV fibrosis in the short-medium term after delivery compared with women with previous LO-PE pregnancy and controls. LV fibrosis is associated with GA and mean UtA-PI at onset of PE. Larger studies using cardiac magnetic resonance imaging are needed to validate and confirm our findings. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Maternal cardiac function after HELLP syndrome: an echocardiography study.

OBJECTIVE: To evaluate maternal hemodynamics in asymptomatic women with a previous pregnancy affected by hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome and compare the findings to those of women with previous pre-eclampsia (PE) and controls with a previous uncomplicated pregnancy. METHODS: Women with a history of PE (n = 60) or HELLP syndrome (n = 49) and matched healthy controls (n = 60) underwent echocardiography at 6 months to 4 years after delivery, recording left ventricular (LV) dimensions, ejection fraction (LVEF) and mass, right ventricular (RV) tricuspid annular plane systolic excursion and fractional area change (FAC). Diastolic filling (E/A and E/E' ratios) and tissue Doppler imaging were evaluated for both ventricles and the myocardial performance index was calculated. RESULTS: Only women with previous HELLP syndrome showed significant LV concentric hypertrophy (20.4%). However, in both HELLP and PE groups, LV concentric remodeling (46.9% and 46.7%, respectively), diastolic dysfunction (expressed as altered E/A and E/E' ratios) and reduced LVEF (14.3% and 21.7%, respectively) were documented. RV variables did not differ significantly between cases and controls, except for FAC and E/E' ratio, which were slightly impaired in women with previous HELLP syndrome compared to those with previous PE (16.3% vs 10.0%, P = 0.04; 14.3% vs 3.3%, P = 0.03, respectively). CONCLUSIONS: The significant overlap of echocardiographic features in women with previous PE and HELLP syndrome suggests that these two conditions share the same pathophysiology. However, HELLP syndrome may lead to more severe cardiovascular remodeling in the short to medium term after delivery. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

How to monitor pregnancies complicated by fetal growth restriction and delivery before 32 weeks: post-hoc analysis of TRUFFLE study.

OBJECTIVES: In the recent TRUFFLE study, it appeared that, in pregnancies complicated by fetal growth restriction (FGR) between 26 and 32 weeks' gestation, monitoring of the fetal ductus venosus (DV) waveform combined with computed cardiotocography (CTG) to determine timing of delivery increased the chance of infant survival without neurological impairment. However, concerns with the interpretation were raised, as DV monitoring appeared to be associated with a non-significant increase in fetal death, and some infants were delivered after 32 weeks, at which time the study protocol no longer applied. This secondary sensitivity analysis of the TRUFFLE study focuses on women who delivered before 32 completed weeks' gestation and analyzes in detail the cases of fetal death. METHODS: Monitoring data of 317 pregnancies with FGR that delivered before 32 weeks were analyzed, excluding those with absent outcome data or inevitable perinatal death. Women were allocated randomly to one of three groups of indication for delivery according to the following monitoring strategies: (1) reduced fetal heart rate short-term variation (STV) on CTG; (2) early changes in fetal DV waveform; and (3) late changes in fetal DV waveform. Primary outcome was 2-year survival without neurological impairment. The association of the last monitoring data before delivery and infant outcome was assessed by multivariable analysis. RESULTS: Two-year survival without neurological impairment occurred more often in the two DV groups (both 83%) than in the CTG-STV group (77%), however, the difference was not statistically significant (P = 0.21). Among the surviving infants in the DV groups, 93% were free of neurological impairment vs 85% of surviving infants in the CTG-STV group (P = 0.049). All fetal deaths (n = 7) occurred in the groups with DV monitoring. Of the monitoring parameters obtained shortly before fetal death in these seven cases, an abnormal CTG was observed in only one case. Multivariable regression analysis of factors at study entry demonstrated that a later gestational age, higher estimated fetal weight-to-50th percentile ratio and lower umbilical artery pulsatility index (PI)/fetal middle cerebral artery-PI ratio were significantly associated with normal outcome. Allocation to DV monitoring had a smaller effect on outcome, but remained in the model (P < 0.1). Abnormal fetal arterial Doppler before delivery was significantly associated with adverse outcome in the CTG-STV group. In contrast, abnormal DV flow was the only monitoring parameter associated with adverse outcome in the DV groups, while fetal arterial Doppler, STV below the cut-off used in the CTG-STV group and recurrent decelerations in fetal heart rate were not. CONCLUSIONS: In accordance with the findings of the TRUFFLE study on monitoring and intervention management of very preterm FGR, we found that the proportion of infants surviving without neuroimpairment was not significantly different when the decision for delivery was based on changes in DV waveform vs reduced STV on CTG. The uneven distribution of fetal deaths towards the DV groups was probably a chance effect, and neurological outcome was better among surviving children in these groups. Before 32 weeks, delaying delivery until abnormalities in DV-PI or STV and/or recurrent decelerations in fetal heat rate occur, as defined by the study protocol, is likely to be safe and possibly benefits long-term outcome. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Endothelial dysfunction and vascular stiffness in women with previous pregnancy complicated by early or late pre-eclampsia.

OBJECTIVES: Pre-eclampsia (PE) is associated with an increased cardiovascular risk later in life. The persistence of endothelial dysfunction after delivery may represent the link between PE and cardiovascular disease. We aimed to evaluate endothelial function and arterial stiffness after delivery of pregnancy complicated by early-onset (EO) or late-onset (LO) PE and their correlation with gestational age and mean uterine artery pulsatility index at PE diagnosis and birth-weight percentile. METHODS: The study included 30 women with previous EO-PE, 30 with previous LO-PE and 30 controls with no previous PE. Participants were examined at between 6 months and 4 years after delivery. All included women were free from cardiovascular risk factors and drugs. Data on demographic and clinical characteristics during pregnancy were collected retrospectively from obstetrical charts. Endothelial function and arterial stiffness were assessed by peripheral arterial tonometry and pulse-wave analysis. RESULTS: All vascular parameters were significantly different, indicating circulatory impairment, in women with previous EO-PE. Women with previous LO-PE had higher vascular rigidity than did controls and all had normal values of reactive hyperemia index, although they were significantly lower when compared with those of controls. On multivariate analysis, gestational age and mean uterine artery pulsatility index at the time of PE diagnosis, and birth-weight percentile were all statistically related to the vascular indices studied, after correcting for confounding parameters. CONCLUSIONS: Women with previous pregnancy complicated by PE, in particular those with early-onset disease, showed persistent microcirculatory dysfunction, as suggested by a significant reduction in reactive hyperemia index value, and increased arterial stiffness. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Maternal endothelial function and vascular stiffness after HELLP syndrome: a case-control study.

OBJECTIVES: To assess endothelial function and arterial stiffness in women with a previous pregnancy complicated by pre-eclampsia (PE) with hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome, and to compare these findings to those in women with previous PE but no HELLP and to those in controls with previous uncomplicated pregnancy, in order to investigate the influence of HELLP syndrome on subsequent cardiovascular impairment. METHODS: In this prospective single-center case-control study, we performed peripheral arterial tonometry (PAT) (using the EndoPAT method) and pulse-wave velocity (PWV) assessment in 109 women who had had a singleton pregnancy complicated by PE with (n = 49) or without (n = 60) HELLP syndrome, as well as in 60 controls with previous uncomplicated pregnancy, between 6 months and 4 years after delivery. The following EndoPAT and PWV indices were compared between groups: reactive hyperemia index (RHI), as an indication of endothelial function, and peripheral and aortic heart-rate-corrected augmentation indices (AIx) standardized for a heart rate of 75 bpm (AIx@75) and carotid-femoral pulse-wave velocity (cfPWV), as indications of arterial stiffness. RESULTS: PAT and arterial stiffness indices were significantly different between PE cases, with or without previous HELLP, and controls, except for carotid-femoral PWV. There were no significant differences among PE groups: women who had experienced HELLP and those with a history of PE without HELLP showed similar rates of RHI ≤ 1.67 (28.6% vs 18.3%, P = 0.254) and RHI ≤ 2.00 (61.2% vs 41.7%, P = 0.055), peripheral AIx@75 ≥ 17% (38.8% vs 30.0%, P = 0.417), aortic AIx@75 ≥ 35% (29.2% vs 20.0%, P = 0.461) and cfPWV × 0.8 > 9.6 m/s, which occurred in only three women, all in the group without previous HELLP (0% vs 5.0%, P = 0.251). On multivariate regression analysis, HELLP syndrome, intrauterine growth restriction (IUGR) and early-onset PE independently predicted endothelial dysfunction at 6 months to 4 years postpartum, after correcting for uterine artery pulsatility index, birth-weight percentile, and maternal blood pressure, age and body mass index. Women with both previous HELLP and early-onset IUGR had a significantly higher prevalence of endothelial dysfunction (P = 0.001). CONCLUSION: Similar vascular abnormalities were found in women previously affected by HELLP syndrome and those with previous PE without HELLP. However, a history of HELLP syndrome, IUGR and early-onset PE seems to identify a subgroup of women with a higher risk for future development of endothelial dysfunction. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Insights into cardiac alterations after pre-eclampsia: an echocardiographic study.

OBJECTIVES: To investigate cardiovascular (CV) performance status several years after early-onset (EO) or late-onset (LO) pre-eclampsia (PE), using echocardiography to assess myocardial strain and left ventricular (LV) torsional mechanics and ventricular-arterial coupling (VAC). METHODS: Thirty non-pregnant women with a previous singleton pregnancy complicated by EO-PE, 30 who had experienced LO-PE and 30 controls underwent echocardiography with two-dimensional (2D) speckle tracking between 6 months and 4 years after delivery and their findings were compared. All women were free from CV risk factors. VAC was defined as the ratio between aortic elastance (Ea) and LV end-systolic elastance (Ees). RESULTS: Women in the EO-PE group showed a persistent subclinical impairment in LV systole and a slight alteration in right ventricular function, with reductions in LV 2D strain (circumferential, radial and longitudinal) and right ventricular 2D strain and impairment of LV torsional mechanics, when compared both with women in the LO-PE group and with healthy controls. Although VAC was within the normal range in the whole study cohort, its individual components Ea and Ees were significantly altered more often in the EO-PE group than in both the LO-PE group and controls. All parameters investigated (except right ventricular 2D strain) were associated independently with gestational age at the time of diagnosis of PE. CONCLUSIONS: Women with a history of EO-PE are more likely to have subclinical impairment of systolic biventricular function than are those with a history of LO-PE and controls. The components of VAC (Ea and Ees) show subclinical alterations which are more significant in women with a history of EO-PE than in those with a history of LO-PE and controls, although VAC itself is maintained. Our study supports the use of closer CV monitoring in previously pre-eclamptic women, particularly those in whom PE was preterm. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Longitudinal study of computerized cardiotocography in early fetal growth restriction.

OBJECTIVES: To explore whether, in early fetal growth restriction (FGR), the longitudinal pattern of fetal heart rate (FHR) short-term variation (STV) can be used to identify imminent fetal distress and whether abnormalities of FHR recordings are associated with 2-year infant outcome. METHODS: The original TRUFFLE study assessed whether, in early FGR, delivery based on ductus venosus (DV) Doppler pulsatility index (PI), in combination with safety-net criteria of very low STV on cardiotocography (CTG) and/or recurrent FHR decelerations, could improve 2-year infant survival without neurological impairment in comparison with delivery based on CTG monitoring only. This was a secondary analysis of women who delivered before 32 weeks and had consecutive STV data recorded > 3 days before delivery and known infant outcome at 2 years of age. Women who received corticosteroids within 3 days of delivery were excluded. Individual regression line algorithms of all STV values, except the last one before delivery, were calculated. Life tables and Cox regression analysis were used to calculate the daily risk for low STV or very low STV and/or FHR decelerations (below DV group safety-net criteria) and to assess which parameters were associated with this risk. Furthermore, it was assessed whether STV pattern, last STV value or recurrent FHR decelerations were associated with 2-year infant outcome. RESULTS: One hundred and forty-nine women from the original TRUFFLE study met the inclusion criteria. Using the individual STV regression lines, prediction of a last STV below the cut-off used by the CTG monitoring group had sensitivity of 42% and specificity of 91%. For each day after study inclusion, the median risk for low STV (CTG group cut-off) was 4% (interquartile range (IQR), 2-7%) and for very low STV and/or recurrent FHR decelerations (below DV group safety-net criteria) was 5% (IQR, 4-7%). Measures of STV pattern, fetal Doppler (arterial or venous), birth-weight multiples of the median and gestational age did not usefully improve daily risk prediction. There was no association of STV regression coefficients, a low last STV and/or recurrent FHR decelerations with short- or long-term infant outcomes. CONCLUSION: The TRUFFLE study showed that a strategy of DV monitoring with safety-net criteria of very low STV and/or recurrent FHR decelerations for delivery indication could increase 2-year infant survival without neurological impairment. This post-hoc analysis demonstrates that, in early FGR, the daily risk of abnormal CTG, as defined by the DV group safety-net criteria, is 5%, and that prediction is not possible. This supports the rationale for CTG monitoring more often than daily in these high-risk fetuses. Low STV and/or recurrent FHR decelerations were not associated with adverse infant outcome and it appears safe to delay intervention until such abnormalities occur, as long as DV-PI is within normal range. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Placental histological patterns and uterine artery Doppler velocimetry in pregnancies complicated by early or late pre-eclampsia.

OBJECTIVES: To study placental patterns in pregnancies complicated by pre-eclampsia (PE) and to verify whether the findings are related to gestational age (GA) at PE onset and second-trimester uterine artery (UtA) Doppler. METHODS: For all pre-eclamptic women who delivered between January 2010 and December 2013, we collected retrospectively data related to placental findings and UtA Doppler velocimetry performed at PE onset. The study cohort was divided into groups according to early-onset (EO) or late-onset (LO) PE. Regression analysis was performed to test the ability of UtA Doppler velocimetry to predict subsequent development of placental lesions, after correcting for possible confounders. RESULTS: Placental abnormalities occurred with a significantly lower incidence in the LO-PE group (n = 72) than in the EO-PE group (n = 105) (P = 0.02). Irrespective of GA at PE onset, UtA pulsatility index (PI) was able to predict macroscopic infarctions (P = 0.001), distal villous hypoplasia (P = 0.03), decidual arteriolopathy (P = 0.03), villous infarcts (P < 0.001), syncytiotrophoblast 'knots' (P = 0.02), microcalcifications (P = 0.02), perivillous fibrin deposition (P = 0.02) and placental hemorrhage (P = 0.01). CONCLUSIONS: Similar placental abnormalities were present in both EO-PE and LO-PE groups, although with quantitative differences according to GA and UtA Doppler velocimetry at PE onset. Histological patterns were predicted by UtA-PI, independently of GA, supporting the use of UtA Doppler velocimetry as the key criterion in PE classification. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Elastic properties of ascending aorta in women with previous pregnancy complicated by early- or late-onset pre-eclampsia.

OBJECTIVES: To evaluate the elastic properties of the ascending aorta in women with a previous pregnancy complicated by early-onset (EO) or late-onset (LO) pre-eclampsia (PE) and the correlation with gestational age (GA), systolic/diastolic blood pressure (SBP/DBP) and mean uterine artery pulsatility index (UtA-PI) at diagnosis of the disease as well as with birth weight of the neonate. METHODS: Thirty women who had a previous pregnancy complicated by EO-PE, 30 with a previous pregnancy complicated by LO-PE and 30 normal controls were selected retrospectively from our electronic database and then recalled for assessment from 6 months to 4 years after delivery. Data regarding GA, SBP/DBP and mean UtA-PI at the diagnosis of PE were obtained from medical records. At our assessment, aortic M-mode and tissue Doppler imaging (TDI) parameters were measured. Aortic diameters were assessed at end-diastole at four levels: Valsalva sinuses, sinotubular junction, tubular tract and aortic arch. Aortic compliance, distensibility, stiffness index (SI), Peterson's elastic modulus (EM), pulse-wave velocity and M-mode strain were calculated using standard formulae. Aortic expansion velocity, early and late diastolic retraction velocities and peak systolic tissue strain (TDI-ϵ) were determined. RESULTS: Aortic diameters at the four levels were significantly greater in both EO-PE and LO-PE groups than in controls. Aortic compliance and distensibility and TDI-ϵ were lower in EO-PE than in LO-PE (P = 0.001, P = 0.002 and P = 0.011, respectively) and controls (P = 0.037, P = 0.044 and P = 0.013, respectively). SI and EM were higher in EO-PE than in LO-PE (P = 0.001 and P < 0.001, respectively) and than in controls (P = 0.035 and P = 0.036, respectively). Multivariate analysis showed GA, DBP and UtA-PI at diagnosis of PE to be independent predictors of aortic elastic properties. CONCLUSIONS: Elastic properties of the ascending aorta were altered in women with a previous pregnancy complicated by EO-PE, but not in those with LO-PE. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Perinatal morbidity and mortality in early-onset fetal growth restriction: cohort outcomes of the trial of randomized umbilical and fetal flow in Europe (TRUFFLE).

OBJECTIVES: Few data exist for counseling and perinatal management of women after an antenatal diagnosis of early-onset fetal growth restriction. Yet, the consequences of preterm delivery and its attendant morbidity for both mother and baby are far reaching. The objective of this study was to describe perinatal morbidity and mortality following early-onset fetal growth restriction based on time of antenatal diagnosis and delivery. METHODS: We report cohort outcomes for a prospective multicenter randomized management study of fetal growth restriction (Trial of Randomized Umbilical and Fetal Flow in Europe (TRUFFLE)) performed in 20 European perinatal centers between 2005 and 2010. Women with a singleton fetus at 26-32 weeks of gestation, with abdominal circumference < 10(th) percentile and umbilical artery Doppler pulsatility index > 95(th) percentile, were recruited. The main outcome measure was a composite of fetal or neonatal death or severe morbidity: survival to discharge with severe brain injury, bronchopulmonary dysplasia, proven neonatal sepsis or necrotizing enterocolitis. RESULTS: Five-hundred and three of 542 eligible women formed the study group. Mean ± SD gestational age at diagnosis was 29 ± 1.6 weeks and mean ± SD estimated fetal weight was 881 ± 217 g; 12 (2.4%) babies died in utero. Gestational age at delivery was 30.7 ± 2.3 weeks, and birth weight was 1013 ± 321 g. Overall, 81% of deliveries were indicated by fetal condition and 97% were by Cesarean section. Of 491 liveborn babies, outcomes were available for 490 amongst whom there were 27 (5.5%) deaths and 118 (24%) babies suffered severe morbidity. These babies were smaller at birth (867 ± 251 g) and born earlier (29.6 ± 2.0 weeks). Death and severe morbidity were significantly related to gestational age, both at study entry and delivery and also with the presence of maternal hypertensive morbidity. The median time to delivery was 13 days for women without hypertension, 8 days for those with gestational hypertension, 4 days for pre-eclampsia and 3 days for HELLP syndrome. CONCLUSIONS: Fetal outcome in this study was better than expected from contemporary reports: perinatal death was uncommon (8%) and 70% survived without severe neonatal morbidity. The intervals to delivery, death and severe morbidity were related to the presence and severity of maternal hypertensive conditions.

PP057. The role of uterine artery pulsatility index for prediction of pregnancy outcome, in women affected by pre-eclampsia.

INTRODUCTION: Uterine artery (UtA) Pulsatility index assessed in the second trimester is known to be the best predictor of Pre-eclampsia (PE) in women with risk factors. The role of this index when PE occurs seems to be related with clinical outcome. OBJECTIVES: To detect if there does exist a correlation between mean UtA PI, assessed at diagnosis of PE, and: (A) Gestational Age (GA) at delivery; (B) birth weight (BW) percentile. To detect the predictive value of mean UtA PI and the development of adverse pregnancy outcome (APO). METHODS: Cohort study on 100 consecutive singleton pregnancies complicated with pre-eclampsia referred to our Department from January 2010 and December 2011. Doppler evaluations were performed from diagnosis to delivery. Mean UtA PI obtained at time of diagnosis of PE were analysed. PE was defined according to ISSHP criteria. Clinical and perinatal outcomes were reviewed. APO was defined as Apgar score less than 7 at five minutes, pH <7.20; birth weight <5th percentile (SGA), stillbirth or neonatal death. Receiver-operating characteristics (ROC) curve was used to determine the predictive ability for subsequent development of APO. RESULTS: Maternal characteristics and main pregnancy outcomes are shown in Table 1. Fifty-six pregnancies developed APO. One case of stillbirth and four cases of neonatal death were observed. SGA occurred in 56/100 neonates; 52/95 (55%) live births were admitted to Neonatal Intensive Care Unit. Table 1. Mean UtA PI at diagnosis of PE was 1.40 (SD±0.28) in women that developed APO and 1.10 (SD±0.41) in women that did not develop APO (p=0.02). Pearson's Correlation coefficient for mean UtA PI and GA at Delivery was -0.533 (p=0.002); while for mean UtA PI and BW percentile was -0.466 (p=0.007). The prediction of subsequent development of APO, expressed as the area under ROC curve, was 61.6 (95% CI 0.44-0.79) for UtA PI at Diagnosis of PE. CONCLUSION: Our data confirm that mean UtA PI, assessed at diagnosis of PE, represent a good independent predictor for GA at delivery end BW percentile. However the predictive value for development of APO seems to be poor.

PP110. The role of doppler to predict adverse pregnancy outcome in patients with pre-eclampsia.

INTRODUCTION: Recently Middle Cerebral Artery (MCA) to uterine artery (UtA) Pulsatility Index (PI) ratio and MCA to Umblical Artery (UA) PI ratio have been described to be good predictors of neonatal outcome in pre-eclamptic patients in the third trimester and have been proposed to identify fetuses at risk of morbidity and mortality. OBJECTIVES: To investigate the value of doppler indexes such as MCA PI, UA PI; MCA to UtA PI ratio and MCA to UA PI ratio to predict adverse pregnancy outcome (APO) in patients affected by Pre-eclampsia (PE). METHODS: Cohort study on 100 consecutive singleton pregnancies complicated with pre-eclampsia referred to our Department from January 2010 and December 2011.Doppler evaluations were performed from diagnosis to delivery.UtA, UA and ACM PI were assessed at each scan, Measurements obtained within one week from delivery were analysed, and MCA/UA PI ratio and MCA/UtA PI ratio calculated.PE was defined according to ISSHP criteria.Clinical and perinatal outcomes were reviewed.APO was defined as Apgar score less than 7 at five minutes, pH<7.20; birth weight <5th percentile (SGA), stillbirth or neonatal death. Receiver-operating characteristics (ROC) curves were used to determine the predictive ability for subsequent development of APO. Logistic regression was run to assess the additional value to the routine indexes for both ratios. RESULTS: One case of stillbirth and four cases of neonatal death were observed.SGA was present in 56/100 neonates; 52/95 (55%) live births were admitted to Neonatal Intensive Care Unit.Maternal Age was 33years (mean, SD±5yy), mean maternal BMI was 23.6Kg/mq (SD±4.9Kg/mq), gestational age (GA at diagnosis of PE was 32+5w (mean, SD±3+6w), GA at delivery was 33+4w (mean, SD±3+4w), birth weight percentile was 13.33 (mean, SD±18.23), pH was 7.26 (mean, SD±0.11)Fifty-six pregnancies developed APO. Doppler findings assessed within one week from delivery are shown in Table 1, values are expressed as mean (±SD). The prediction of subsequent development of APO, expressed as the area under ROC curve, was 0.695 (95% CI 0.59-0.80) for UtA PI; 0.730 (95% CI 0.62-0.81) for UAPI; 0.677 (95% CI 0.55-0.78) for MCA PI; 0.785 (95% CI 0.66-0.87) for MCA/UA PI; 0.774 (95% CI 0.66-0.86) for MCA/UtA PI. Moreover, a MCA/UA PI=1.28 showed a sensitivity of 74.4% and a specificity of 76.0% in predicting APO. Logistic regression analysis showed that the better index combination is represented by MCA/UA PI and MCA/UtA PI. CONCLUSION: In addition to UtA and UAPI, MCA/UA PI ratio and MCA/UtA PI ratio are useful predictors of neonatal outcome in pregnancies complicated with PE.

PP149. Hypertensive risk factors: Do they influence pregnancy outcome in women affected by new onset pre-eclampsia?

INTRODUCTION: Pre-eclampsia (PE) is a leading cause of maternal and foetal mortality and morbidity. Chronic Hypertension (CH) and a previous PE are well known risk factors for PE. If the prevalence of PE in nulliparous is about 2%, it raise up to 7-10% in women with CH or a previous PE. However, the role of these risk factors when PE occurs is still under discussion OBJECTIVES: To detect if maternal history of previous PE and/or Chronic Hypertension (CH) is associated with a worse clinical outcome in women affected by PE. METHODS: Cohort study on 100 consecutive singleton pregnancies complicated by PE referred to our Department from January 2010 to December 2011. PE and CH were defined according to ISSHP criteria. Small for Gestational Age (SGA) was defined as Birth Weight under the 5th percentile per Gestational Age. Patients were divided into two groups depending on positive (Group A, n=25) or negative (Group B, n=75) history for PE and/or Chronic Hypertension (CH). Patients assessed to group A were under prophylactic therapy with ASA 100mg oid. Clinical and perinatal outcomes were reviewed. Adverse Pregnancy Outcome (APO) was defined as Apgar score less than seven at five minutes, pH<7.20; birth weight<5th percentile (SGA), stillbirth or neonatal death. RESULTS: Groups were comparable for Maternal Age (Group A: 34years median, IQR 30-36yy; Group B: 34years, IQD 28-36yy ) and BMI (Group A: 23.7Kg/mq median, IQR 20.8-27.1Kg/mq; Group B: 22.4Kg/mq median IQR 20.3-26.0Kg/mq). One case of stillbirth (Group A) and four cases of neonatal death were observed, 1/25 in Group A (4%) and 3/75 (4%) in Group B. No differences were found in Gestational Age (GA) at diagnosis of PE (Group A: 32+2w median, IQR 28+0-35+4w; Group B: 33+2w median, IQR 30+0-36+1w); GA at delivery (Group A: 34+1w median, IQR 31+5-36+5w; Group B: 34+2w median, IQR 32+0-36+3w) Birth Weight percentile (Group A: 6th percentile median, IQR 2-21th percentile; Group B: 5th percentile median, IQR 1-15th percentile), prevalence of Small for Gestational Age (14/25 and 42/75, for Group A and B respectively), prevalence of APO (13/25 and 44/75, for Group A and B respectively). CONCLUSION: Our data suggest that a positive history for PE and/or CH does not influence clinical outcome in women affected by PE. This result could be explained by the administration of prophylactic ASA 100mg oid in this group of patients.

PP173. The role of mean artery blood pressure in the prediction of pre-eclampsia in pregnancies complicated with chronic hypertension.

INTRODUCTION: Chronic hypertension (CH) is a common disorder occurring in approximately 1-5% of pregnant women. Many studies emphasize that the development of superimposed preeclampsia (PE) is associated with high rates of adverse pregnancy outcome. Accurate prediction of women at risk for PE is crucial to judicious allocation of monitoring resources and use of preventive treatment, in order to improve maternal and neonatal outcome. Recent systematic review and meta-analysis showed that mean arterial pressure (MAP) is a better predictor for pre-eclampsia than systolic blood pressure and diastolic blood pressure OBJECTIVES: To detect the value of MAP in the first and second trimesters to predict PE in women with CH. To determine if MAP, assessed in the second trimester, can increase the predictive value for PE of II trimester UtA PI. METHODS: Cohort study on 100 consecutive singleton pregnancies complicated with CH referred to our Department from January 2008 to June 2011. Blood pressure was measured by a mercury sphygmomanometer at 11-14+6w and 23+0-25+6w, MAP was calculated. Doppler-velocimetry was performed at 23+0-25+6w, mean UtA PI was calculated. PE and CH were defined according to ISSHP criteria. Clinical and perinatal outcomes were reviewed. Receiver-operating characteristic (ROC) curves were used to determine the predictive ability of I and II trimesters MAP and II trimester mean UtA PI for subsequent development of PE. Logistic regression analysis was run to assess the additional value of II trimester MAP to II trimester UtA PI. RESULTS: Mean maternal age was 36 years (SD ±5yy); mean Body mass Index was 24Kg/mq (SD ±5Kg/mq); GA at I Trimester evaluation was 11+4w (SD ±1+5w); I trimester MAP was 100.46mmHg (mean, SD ±9.94mmHg); GA at Doppler and II trimester MAP was 24+4w (SD ±4dd); II trimester MAP 97.53mmHg (mean, SD ±10.27mmHg). Nineteen cases of PE were observed. Seventy patients were under prophylactic ASA 100mg oid. Fifty-two patients were under anti-hypertensive therapy from the first trimester. No differences in prevalence of PE were observed between patients in and out prophylactic treatment, as well as no differences in prevalence of PE were observed between patients under anti-hypertensive treatment or not. The prediction of subsequent development of PE, expressed as the area under ROC curve, was 0.469 (95% CI 0.34-0.59) for I trimester MAP; 0.659 (95% CI 0.55-0.76) for II trimester MAP; 0.748 (95% CI 0.65-0.83) for II trimester mean UtA PI; GA at delivery was 37+4w(mean, SD ±3+2w); mean BW was 2958g (SD ±735g); BW percentile was 38 (mean SD ±29 percentiles); mean BW z-Score was -0.63 (SD ±1.6). Logistic regression analysis showed that MAP does not increase the predictive ability of II trimester UtA PI in women with CH. CONCLUSION: In our findings, MAP seems not to be a good predictor for subsequent development of PE in women with CH, moreover, it seems to be not useful to increase the predictive value for PE of II trimester UtA PI. II trimester UtA PI has been confirmed to be the best predictor for subsequent development of PE.

Mid- and long-term outcome of extremely low birth weight (ELBW) infants: an analysis of prognostic factors.

OBJECTIVE: To evaluate morbidity and long-term neurological outcome in a group of extremely low birth weight infants (ELBW; <1000 g) and to correlate the neurological outcome in a small group of intrauterine growth retarded (IUGR) infants with Doppler indices in the umbilical artery. METHODS: One hundred and eighty-three live births with birth weight <1000 g and gestational age < or=34 weeks were included in the study. Neonatal mortality and morbidity were evaluated. At 24 months of corrected age an evaluation of the neurological development of the children was made by pediatric neuropsychiatrists. The children were classified as: normal, with minor neurological sequelae, and with major neurological sequelae. The evaluation of umbilical artery velocimetry was applied to 84 fetuses presenting with IUGR and the velocimetric patterns were correlated with neurological outcome. RESULTS: In the 183 infants discharged from the Department of Neonatology, respiratory distress syndrome (RDS) was the most frequent pathology (76.6%); less frequent were bronchopulmonary dysplasia (BPD; 19.5%), patent ductus arteriosus (PDA; 29.7%) and necrotizing enterocolitis (NEC; 5.5%). Retinopathy of prematurity (ROP) affected 34 children (26.6%), and 14.8% of the children developed intraventricular hemorrhage (IVH) and 14.1% periventricular leukomalacia (PVL). Out of the 183 infants included in the study, 107 had a neurological assessment at two years: 22 (20.6%) suffered from severe neurological sequelae, 20 (18.7%) from minor neurological sequelae, and 65 (60.7%) had a normal neurological development. In 84 IUGR fetuses a Doppler evaluation of the umbilical artery was performed: the incidence of neurologically normal children was 67% in the group with normal umbilical velocimetry, 93% in the group with increased umbilical resistances, and 59% in those with absent or reversed end-diastolic velocity (ARED). CONCLUSIONS: This study, confirms that an extremely low birth weight implies a high risk of perinatal mortality and neonatal morbidity, but that the most significant variable that can be correlated to the long-term neurological outcome is the gestational age.