Perinatal Outcome of Selective Intrauterine Growth Restriction in Monochorionic Twins: Evaluation of a Retrospective Cohort in a Developing Country.

Selective intrauterine growth restriction (sIUGR) in monochorionic twin pregnancies is associated with greater morbidity and mortality for both fetuses when compared to singleton and dichorionic pregnancies. This retrospective cohort study aimed to assess the perinatal outcomes of monochorionic twin pregnancies affected by this disorder and conducted expectantly, by analyzing the results according to the end-diastolic flow in the umbilical artery Doppler of the smaller twin (type I: persistently forward/type II: persistently absent or reversed/type III: intermittently absent or reversed). Seventy-five monochorionic diamniotic twin pregnancies with sIUGR were included in this study. sIUGR was defined by estimated fetal weight below the 3rd centile for gestational age, or below the 10th centile, when associated with at least one of the following three criteria: abdominal circumference below the 10th percentile, umbilical artery pulsatility index of the smaller twin above the 95th percentile, or estimated fetal weight discordance of 25% or more. Perinatal outcomes were analyzed from the prenatal period to hospital discharge and included perinatal death, neurological injury, retinopathy of prematurity (ROP), bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), and sepsis. The mortality rate was 1.33% in this cohort. The overall morbidity rate was lower in type I twin pregnancies. In conclusion, this study shows that sIUGR type I has lower morbidity than types II and III in expectant management.

Predictors of perinatal outcome in early-onset fetal growth restriction: A study from an emerging economy country.

OBJECTIVE: To identify antenatal predictors of adverse perinatal outcomes in a population of preterm fetuses with early placental insufficiency diagnosed by Doppler abnormalities. METHOD: In this cross-sectional study of a cohort of singleton pregnant women diagnosed with early placental insufficiency, relationships between perinatal variables (arterial and venous Doppler, gestational age, birth weight, oligohydramnios, estimated fetal weight, and fetal weight z-scores) and major neonatal complications were analyzed by logistic regression. RESULTS: Two hundred sixty-five women were delivered, between 24 and 33 weeks gestation. The overall frequency of intact survival was 57.9% (n = 154). Gestational age thresholds for best prediction of survival was 27 + 6 weeks and for intact survival was 29 + 0 weeks gestation. Fetal weight and absent/reversed ductus venosus a-wave were the main predictors of survival in the regression model. When fetal weight was substituted for fetal weight z-score, ductus venosus abnormal Doppler predicted mortality and absent or reversed umbilical artery diastolic velocities predicted intact survival. CONCLUSIONS: This study illustrates the impact of gestational age and fetal weight on perinatal outcomes in early placental insufficiency, with well-defined thresholds. Gestational age and fetal weight, or a combination of fetal weight z-scores and fetal Doppler parameters, were the best predictors of intact survival in our sample.

Analysis of the Performance of 11 Formulae for Fetal Weight Estimation in Preterm Fetuses with Abnormal Doppler Velocimetry - A Retrospective Multicenter Study.

OBJECTIVE: To assess 11 formulae commonly used to estimate fetal weight in a population of premature fetuses who had abnormal Doppler velocimetry due to early-onset placental insufficiency. The performance of each formula was evaluated in subgroups of fetuses with expected growth and intrauterine growth restriction. METHODS: Data were collected from fetuses and mothers who delivered at three Brazilian hospitals between November 2002 and December 2013. We used the following formulae: Campbell; Hadlock I, II, III, IV and V; Shepard; Warsof; Weiner I and II; and Woo III. RESULTS: We analyzed 194 fetuses. Of these, 116 (59.8%) were considered appropriate for gestational age (AGA), and 103 (53.1%) were male. The amniotic fluid volume was reduced in 87 (44.8%) fetuses, and the umbilical artery Doppler revealed absence or inversion of diastolic flow in 122 (62.9%) cases, and the analysis of the ductus venosus revealed abnormal flow in 60 (34.8%) fetuses. The Hadlock formulae using three or four fetal biometric parameters had low absolute percentage error in the estimated fetal weight among preterm fetuses with abnormal Doppler studies who were born within 5 days of the ultrasound evaluation. The results were not influenced by the clinical and ultrasound parameters often found in early-onset placental insufficiency. CONCLUSION: In this study, the formulae with the best performance for fetal weight estimation in the analyzed population were Hadlock I and IV, which use four and three fetal biometric parameters respectively to estimate the weight of preterm fetuses with abnormal Doppler studies.

OBJETIVO: Avaliar o desempenho de 11 fórmulas comumente utilizadas para estimativa de peso fetal em uma população de fetos prematuros com dopplervelocimetria alterada devido a insuficiência placentária de início precoce. O desempenho de cada fórmula foi avaliado em subgrupos de fetos com crescimento adequado e com crescimento intrauterino restrito. MéTODOS: Foram coletados os dados de mães e fetos cujos partos foram acompanhados em 3 instituições brasileiras entre novembro de 2002 e dezembro de 2013. As fórmulas selecionadas para análise foram: Campbell; Hadlock I, II, III, IV e V; Shepard; Warsof; Weiner I e II; e Woo III. RESULTADOS: Foram analisados os pesos de 194 fetos, dos quais 116 (59,8%) foram considerados adequados para a idade gestacional, 103 (53,1%) eram do sexo masculino, em 87 (44,8%) havia redução do volume de líquido amniótico, em 122 (62,9%) o Doppler de artéria umbilical demonstrou ausência ou inversão do fluxo na diástole, e em 60 (34,8%) a análise do duto venoso indicou fluxo anormal. A média do erro percentual absoluto (EPA) demonstrou que as fórmulas de Hadlock que utilizam 3 ou 4 parâmetros biométricos fetais apresentaram o melhor desempenho. Os resultados obtidos para essas fórmulas não sofreram influência dos parâmetros clínicos e ultrassonográficos frequentemente encontrados na insuficiência placentária de início precoce. CONCLUSãO: O presente estudo demonstrou o melhor desempenho das fórmulas de Hadlock que contêm 3 ou 4 parâmetros da biometria para estimativa de peso de fetos prematuros com anormalidades ao mapeamento Doppler.

Neonatal outcome in women with preterm premature rupture of membranes (PPROM) between 18 and 26 weeks.

OBJECTIVE: The aim of this study was to identify adverse neonatal outcomes and identifies the predictors of adverse neonatal outcomes in premature rupture of membranes before 26 weeks. METHODS: Data were collected between January 2005 and December 2011 from all pregnant women who presented preterm premature rupture of membranes (PPROM) between 18 and 26 complete weeks of gestation and were admitted to one of three Brazilian institutes. The adverse outcomes included mortality or the development of a severe morbidity during the length of stay in the neonatal intensive care unit (NICU). The descriptive statistics of the population were reported. A multiple logistic regression was performed for each predictor of neonatal adverse outcomes. The area under the receiver operating characteristics curves for the birth weight was calculated. RESULTS: Composite adverse outcomes during the NICU stay occurred in 82.1% (n = 23) of the cases and included 33 (54%) neonatal deaths, 19 (67.8%) cases of retinopathy of prematurity (ROP), 13 (46.4%) cases of pulmonary hypoplasia (BPD), 8 (28.5%) cases of periventricular-intraventricular hemorrhage (PIH) and 3 (10.7%) cases of periventricular leukomalacia (PVL). Only 17.8% (n = 5) of the neonates survived without morbidity. The area under the curve for the birth weight was 0.90 (95% IC: 0.81-0.98) for the prediction of mortality. CONCLUSIONS: PPROM before 26 weeks has a high morbidity and mortality, and the significant predictors of neonatal mortality and adverse outcomes were antibiotic prophylaxis, latency period, GA at birth and birth weight. Nevertheless, the only independent significant predictor of survival rate was birth weight.

Doppler velocimetry of ductus venous in preterm fetuses with brain sparing effect: neonatal outcome.

OBJECTIVE: to evaluate the relationship between ductus venous (DV) and Doppler velocimetry in neonatal outcome in severe compromised preterm fetuses. METHODS: the study was designed as an observational and cross-sectional study with 52 premature neonates with brain sparing effect. The criteria of neonatal severe morbidity were: severe intraventricular hemorrhage (grades 3 or 4), retinopathy of prematurity (grade 3 or 4), cystic periventricular leukomalatia, bronchopneumo dysplasia and neonatal mortality. The fetuses were divided in two groups: group 0 - all the fetuses with ventricular systole/atrial contraction (S/A) in DV ratio values less them 3.4; group 1 - fetuses with values of S/A ratio greater than 3.4. RESULTS: 42% of fetuses showed abnormal S/A ratio in DV and 48% showed birth weight below percentile 3 for gestational age. There was no statistical significance comparing the 02 groups according to bronchopneumo dysplasia, retinopathy of prematurity (grade 3 or 4) and intraventricular hemorrhage (grade 3 or 4). Only one fetus presented cystic periventricular leukomalatia. We found statistically significant association between abnormal DV S/A ratio and neonatal mortality (CI 95%, 1.28 -38.22, p< 0.002). CONCLUSIONS: our results suggest that abnormal DV blood flow detected by Doppler examination isn't associated with severe neonatal morbidity but with neonatal mortality.