Analysis of the Correlation/Agreement of Maternal-fetal Doppler Parameters in Normal and Growth-Restricted Fetuses.

OBJECTIVE: To assess the degree of correlation/agreement of maternal-fetal Doppler parameters between normal and growth-restricted fetuses (fetal growth restriction [FGR]). METHODS: The present observational and retrospective study included 274 singleton pregnancies. The following maternal-fetal Doppler parameters were assessed: uterine artery (UAt), umbilical artery (UA), middle cerebral artery (MCA), cerebroplacental ratio (CPR), and umbilical-cerebral ratio (U/C). The assessment of FGR was based on the Figueiras and Gratacós9 criteria. Spearman correlation coefficients were estimated to assess the correlation between resistance (RI) and pulsatility (PI) indices of Doppler parameters. The agreement between two Doppler parameters was assessed by the Kappa coefficient. RESULTS: In total, 502 Doppler examinations were included, and FGR was observed in 19 out of 274 fetuses. A strong correlation was observed between RI and PI of UAt, UA, and MCA in all of the samples (p < 0.001). Of the 502 Doppler examinations, there was agreement between U/C and CPR percentiles for 480 (95.6%) and disagreement for 22 (4.4%), with Kappa coefficient of 0.26, thereby corresponding to weak agreement. Of the 68 cases with estimated fetal weight ≤ 9th percentile (small for gestational age [SGA]), there was agreement between U/C > 1.0 and CPR < 5th percentile in 61 (88.4%) and disagreement in 7 (5.8%) with Kappa coefficient of 0.49, thereby corresponding to moderate agreement. CONCLUSION: Strong correlation was observed among RI and PI UAt, UA, and MCA Doppler examinations in the present study; however, weak agreement was observed between U/C and CPR in the normal and FGR fetuses. In SGA, U/C and CPR demonstrated moderate agreement.

OBJETIVO: Avaliar o grau de correlação/concordância dos parâmetros Doppler materno-fetal entre fetos normais e com restrição do crescimento (restrição de crescimento fetal [RCF]). MéTODOS: O presente estudo observacional e retrospectivo incluiu 274 gestações únicas. Os seguintes parâmetros Doppler materno-fetal foram avaliados: artéria uterina (AUt), artéria umbilical (AU), artéria cerebral média (ACM), razão cérebro-placentária (RCP) e razão umbilical-cerebral (U/C). A avaliação da RCF baseou-se nos critérios de Figueiras e Gratacós.9 Os coeficientes de correlação de Spearman foram estimados para avaliar a correlação entre os índices de resistência (IR) e pulsatilidade (IP) dos parâmetros Doppler. A concordância entre dois parâmetros do Doppler foi avaliada pelo coeficiente Kappa. RESULTADOS: No total, 502 exames Doppler foram incluídos e RCF foi observado em 19 de 274 fetos. Observou-se forte correlação entre IR e IP da AUt, AU e ACM em todas as amostras (p < 0,001). Dos 502 exames Doppler, houve concordância entre os percentis U/C e RCP para 480 (95,6%) e discordância para 22 (4,4%), com coeficiente Kappa de 0,26, correspondendo a concordância fraca. Dos 68 casos com peso fetal estimado ≤ 9° (pequeno para a idade gestacional [PIG]), houve concordância entre U/C > 1,0 e RCp < 5o percentil em 61 (88,4%) e discordância em 7 (5,8%) com coeficiente Kappa de 0,49, correspondendo a concordância moderada. CONCLUSãO: Forte correlação foi observada entre o IR e IP dos exames Doppler AUt, AU e ACM no presente estudo; entretanto, fraca concordância foi observada entre U/C e RCP em fetos normais e com RCF. Nos PIG, U/C e RCP demonstraram concordância moderada.

Prediction of Lung Maturity in Fetuses with Growth Restriction through Quantitative Ultrasound Analysis.

The present study aimed to evaluate the performance of QuantusFLM software, which performs quantitative analysis of lung tissue texture through ultrasound images, in predicting lung maturity in fetal growth restriction (FGR). We included patients with singleton gestations between 34 and 38 6/7 wk and divided them into two groups: FGR and control (appropriate for gestational age [AGA]). The images were captured by ultrasound according to a specific protocol up to 48 h before delivery and analyzed with QuantusFLM software. The main clinical outcome evaluated was lung maturity (i.e., the absence of neonatal respiratory morbidity). We included 111 patients; one was excluded because of low image quality, leaving 55 patients in each group. The FGR group had a lower birth weight (2207 g vs. 2891 g, p < 0.001) and a longer stay in the neonatal intensive care unit (NICU) (10 d vs. 5 d, p = 0.043). QuantusFLM software was able to predict lung maturity in FGR with accuracy, sensitivity, specificity and positive and negative predictive values of 94.5%, 96.2%, 50%, 98.1% and 33.3%, respectively. QuantusFLM had good accuracy in predicting lung maturity in FGR with reliability in identifying pulmonary maturity.

Perinatal unusual rhabdomyoma location - case report and systematic reviews of the literature.

Objective: To report a case of prenatal diagnosis of cardiac rhabdomyoma (CR) and neonatal surgical treatment as well as undertaking a systematic review of the literature to determine most frequent localization of CR, common signs and symptoms, associated pathologies, incidence of surgery, and prognoses for CR.Methods: We conducted systematic review of the literature on CR that were diagnosed and treated in the perinatal period, searching for English language articles in the PubMed/Medline database that were published within the past 20 years, using the following search terms: "cardiac rhabdomyoma"; "neonates"; "newborn"; "surgery".Results: Eighty-two studies were selected, but only 46 studies met the inclusion criteria. After birth, the majority of newborns were asymptomatic; however, murmurs and arrhythmia were also the two most prevalent signs of CR. The most prevalent location was the ventricles, corresponding to 40.3% of all cases, with 53% of these having a rhabdomyoma in the left ventricle. The incidence of multiple tumors was 56%, and in those cases the location of tumors was also most common in the ventricles. Tuberous sclerosis was the most commonly associated pathology, being present in 72% of cases of CR. Surgical treatment occurred in 27% of cases, and 3% of cases required surgery and prostaglandin. Regarding the perinatal outcome, 6% of cases resulted in fetal or neonatal death.Conclusion: CR are benign tumors which tend to spontaneously regress during early childhood but may have unfavorable outcomes in the presence of obstructive lesions and arrhythmias. Surgery is generally necessary in symptomatic patients.

Fetal growth restriction: current knowledge.

BACKGROUND: Fetal growth restriction (FGR) is a condition that affects 5-10% of pregnancies and is the second most common cause of perinatal mortality. This review presents the most recent knowledge on FGR and focuses on the etiology, classification, prediction, diagnosis, and management of the condition, as well as on its neurological complications. METHODS: The Pubmed, SCOPUS, and Embase databases were searched using the term "fetal growth restriction". RESULTS: Fetal growth restriction (FGR) may be classified as early or late depending on the time of diagnosis. Early FGR (<32 weeks) is associated with substantial alterations in placental implantation with elevated hypoxia, which requires cardiovascular adaptation. Perinatal morbidity and mortality rates are high. Late FGR (≥32 weeks) presents with slight deficiencies in placentation, which leads to mild hypoxia and requires little cardiovascular adaptation. Perinatal morbidity and mortality rates are lower. The diagnosis of FGR may be clinical; however, an arterial and venous Doppler ultrasound examination is essential for diagnosis and follow-up. There are currently no treatments to control FGR; the time at which pregnancy is interrupted is of vital importance for protecting both the mother and fetus. CONCLUSION: Early diagnosis of FGR is very important, because it enables the identification of the etiology of the condition and adequate monitoring of the fetal status, thereby minimizing risks of premature birth and intrauterine hypoxia.

Macrosomia.

Fetal macrosomia is defined as birth weight >4000 g and is associated with several maternal and fetal complications such as maternal birth canal trauma, shoulder dystocia, and perinatal asphyxia. Early identification of risk factors could allow preventive measures to be taken to avoid adverse perinatal outcomes. Prenatal diagnosis is based on two-dimensional ultrasound formulae, but accuracy is low, particularly at advanced gestation. Three-dimensional ultrasound could be an alternative to soft tissue monitoring, allowing better prediction of birth weight than two-dimensional ultrasound. In this article, we describe the definition, risk factors, diagnosis, prevention, ultrasound monitoring, prenatal care, and delivery in fetal macrosomia cases.

Evaluation of biochemical markers combined with uterine artery Doppler parameters in fetuses with growth restriction: a case-control study.

PURPOSE: Assessing the biochemical markers levels and the uterine artery Doppler (UtA) parameters in fetuses with growth restriction (FGR). METHODS: Prospective case-control study included 66 patients with diagnosis of FGR and 64 healthy pregnancies at 24-41 weeks of gestation. For both groups, maternal circulating concentrations of biochemical factors of soluble fms-like tyrosine kinase-1 (sFlt-1), soluble endoglin(sEng), adiponectin, A disintegrin and metalloproteinases (ADAM-12), pregnancy-associated plasma protein-A (PAPP-A), angiopoietin-2 (ANGI-2), vascular endothelial growth factor (VEGF) and transforming growth factor-ß (TGF-ß) were assayed by ELISA and UtA by Doppler were performed. ANOVA, Mann-Whitney tests and Pearson correlation coefficient were applied to compare the biochemical factors, UtA Doppler and EFW Z-score between the groups. RESULTS: Concentrations of sFlt-1, sEng, PAPP-A were significantly higher in FGR than controls (p < 0.0001, p = 0.02 and p = 0.03, respectively), but concentration of ANGI-2 (p < 0.0001) was significantly lower in FGR than controls and ADAM-12 levels had a tendency to be lower in the FGR, though not statistically significant (p = 0.059). Increased sEng concentrations were correlated with abnormal UtA Doppler in FGR. CONCLUSION: Fetal growth restriction fetuses showed increased serum levels of sFlt-1, sEng and PAPP-A with levels of ANGI-2 decreased and a positive association between elevated concentrations of sEng and changing impedance of UtA Doppler were observed.

Assessment of Intracranial Structure Volumes in Fetuses With Growth Restriction by 3-Dimensional Sonography Using the Extended Imaging Virtual Organ Computer-Aided Analysis Method.

OBJECTIVES: To assess intracranial structure volumes by 3-dimensional (3D) sonography in fetuses with growth restriction. METHODS: We conducted a prospective cross-sectional case-control study involving 59 fetuses with growth restriction (38 fetuses with estimated weight <3rd percentile and 21 fetuses with estimated weight between 3rd and 10th percentiles, according to Hadlock et al [Radiology 1984; 150:535-540]) and 54 controls between 24 and 34 weeks' gestation. The following fetal intracranial structure volumes were assessed: cerebellum, brain, and frontal region. The volume was assessed by 3D sonography using the extended imaging virtual organ computer-aided analysis method with 10 sequential planes. Analysis of variance was used to compare fetal groups. The intraclass correlation coefficient was used to assess intraobserver and interobserver reproducibility. RESULTS: Statistical significance between the brain, frontal region, and cerebellar volumes and a relationship between the frontal region and the brain in fetuses with estimated weights below the 3rd percentile and controls were observed (P < .001; P < .001; and P = .002; and P = .008, respectively). Good intraobserver and interobserver reproducibility was observed for the fetal brain, frontal region, and cerebellar volumes, with intraclass correlation coefficients of 0.998, 0.997, 0.997, 0.999, 0.997, and 0.998, respectively. CONCLUSIONS: The intracranial structure volumes assessed by 3D sonography using the extended imaging virtual organ computer-aided analysis method were reduced in fetuses with growth restriction (estimated weight <3rd percentile).

Assessment of maternal Doppler parameters of ophthalmic artery in fetuses with growth restriction in the third trimester of pregnancy: A case-control study.

AIM: The aim of this study was to assess the Doppler parameters of the ophthalmic artery of pregnant women carrying fetuses with growth restriction (FGR) compared with normal fetuses. MATERIAL AND METHODS: A prospective cross-sectional study was conducted with 120 pregnant women (60 FGR and 60 normal fetuses) between 32 and 40 weeks of gestation. FGR diagnosis was based on an estimated fetal weight below the 10th percentile of the Hadlock curve. Ophthalmic artery Doppler images were obtained with a linear transducer, with color Doppler examination of the region medial to the optic nerve. The following indices were obtained: pulsatility index, resistance index, peak systolic velocity, second peak velocity (P2), end diastolic velocity, and P2 / peak systolic velocity ratio. The Mann-Whitney U-test and Student's t-test were used to compare the groups with regard to quantitative variables, and the χ(2) -test was used for categorical variables. RESULTS: Pulsatility index and resistance index were significantly lower in pregnant women with FGR than in those with normal fetuses, with P < 0.001 in both indices. P2 and end diastolic velocity were significantly higher in pregnant women with FGR than in those with normal fetuses (P = 0.002 and P = 0.004, respectively). The P2 / peak systolic velocity ratio was significantly higher in the FGR group than in the control group (P < 0.001). In FGR subgroups, with (17 fetuses) and without (43 fetuses) uterine artery Doppler abnormalities, no significant changes were observed between the groups. CONCLUSION: In the third trimester of pregnancy, we observed significant differences in the ophthalmic artery Doppler parameters of pregnant women with FGR compared with those with normal fetuses.

Como deve ser o rastreamento e o diagnóstico do diabetes mellitus gestacional? / What should be the screening and diagnostic strategies for gestational diabetes?

O diabetes mellitus gestacional (DMG) é uma das patologias mais comuns na gravidez. Quando não diagnosticado e não tratado, pode determinar sérias complicações durante a gravidez e parto com aumento da morbidade e mortalidade perinatal, além de ser marcador de risco de complicações tanto para a mãe como para a criança e de desenvolverem doenças no futuro. Apesar disso, não há consenso sobre a melhor forma de rastrear e diagnosticar essa doença na gravidez. Esta revisão teve como objetivo demonstrar quais os métodos descritos na literatura recente e nos consensos de especialistas para esse rastreamento, além de mostrar o esforço que tem sido feito para sistematizar e unificar o rastreamento e o diagnóstico do DMG.

Gestational diabetes (GD) is one of the most prevalent clinical disorders in pregnancy. When it is not diagnosed and treated, it can lead to serious complications during pregnancy and at delivery, as well as increase perinatal morbidity and mortality, besides being a condition that predisposes the mother and the child to future complicatons. Nevertheless, there is no consensus as to the best way of screening and diagnosing this disorder in pregnancy. This review presents the methods recently described in the literature and the consensus of specialists on screening, as well as the efforts to standardize and unify GD screening and dignosis.