When is the optimal time to deliver late preterm IUGR fetuses with abnormal umbilical artery Dopplers?

Objective: To determine the optimal timing of delivery in late preterm intrauterine growth restriction (IUGR) fetuses with abnormal umbilical artery Doppler (UAD) indices.

Methods: A decision-analytic model was built to determine the optimal gestational age (GA) of delivery in a theoretic cohort of 10?000 IUGR fetuses with elevated UAD systolic/diastolic ratios diagnosed at 34 weeks. All inputs were derived from the literature. Strategies involving expectant management accounted for the probabilities of stillbirth, spontaneous delivery and induction of labor for UAD absent or reversed end-diastolic flow (AREDF) at each successive week. Outcomes included short- and long-term neonatal morbidity and mortality with quality-adjusted life years (QALYs) generated based on these outcomes. Base case, sensitivity analyses and a Monte Carlo simulation were performed.

Results: The optimal GA for delivery is 35 weeks, which minimized perinatal deaths and maximized total QALYs. Earlier delivery became optimal once the risk of stillbirth was threefold our baseline assumption; our model was also robust until the risk of AREDF at 35 weeks was half our baseline assumption, after which delivery at 36 weeks was preferred. Delivery at 35 weeks was the optimal strategy in 77% of trials in Monte Carlo multivariable sensitivity analysis.

Conclusions: Weighing the risks of iatrogenic prematurity against the poor outcomes associated with AREDF, the ideal GA to deliver late preterm IUGR fetuses with elevated UAD indices is 35 weeks.     

Small for gestational age preterm infants and relationship of abnormal umbilical artery Doppler blood flow to perinatal mortality and neurodevelopmental outcomes

Aim: To determine the outcomes of preterm small for gestational age (SGA) infants with abnormal umbilical artery (UA) Doppler studies.
Methods: A retrospective cohort study of SGA singleton infants delivered between 24 and 32 weeks gestation at King Edward Memorial Hospital, Perth, who had UA Doppler studies performed within seven days of birth. Main outcomes assessed were perinatal mortality and morbidity, and neurodevelopmental outcomes at ≥ 1 year of age. Outcomes were compared by normality of UA blood flow.
Results: There were 119 infants in the study: 49 (41%) had normal UA Doppler studies, 31 (26%) had an increased systolic–diastolic ratio ≥ 95th centile, 19 (16%) had absent end diastolic blood flow (AEDF) and 20 (17%) had reversed end-diastolic flow (REDF). Infants in the AEDF and REDF groups were delivered significantly more preterm ( P  = 0.006) and had lower birthweights ( P  < 0.001). Ninety four per cent (110 of 117) of live born infants survived. Neurodevelopmental follow-up at 12 months of age or more (median 24 months) was available on 87 of 108 (81%) of live children. Twenty-eight per cent (11 of 39) of fetuses who had had AEDF or REDF died or were classified with moderate or severe disability. There was no significant association between abnormality of UA blood flow, perinatal morbidity, perinatal mortality and neurodevelopmental disability after correction for gestational age.
Conclusion: Fetuses that are SGA with abnormal UA Doppler studies remain at significant risk of perinatal death, perinatal morbidity and long-term neurodevelopmental disability, associated with their increased risk of preterm birth.     

Growth restriction: identifying fetuses at risk

Purpose: Examine risks of intrauterine growth restriction (IUGR) and composite perinatal outcomes with estimated fetal weights (EFW) 10–20th%, and compare outcomes using umbilical artery Doppler (UAD).

Materials and methods: Retrospective, cohort evaluating ultrasound (US) EFW 10–20th%, between 2002 and 2012. Cases were identified with EFW % 10–20. Controls, EFW?>20th% were obtained for each case, matched by gestational age, and US date. Unadjusted and adjusted logistic regression was used for outcomes.

Results: Seven hundred and sixty-seven cases met criteria with matched controls. Fetuses having EFW 10–20th% (GA 33.6?±?3.7 weeks) had increased IUGR on follow up ultrasound (OR 26.5[10.2–68.7], p?p?p?p?p?Conclusions: Pregnancies with EFW 10–20th% at the time of initial US are at increased risk for developing IUGR and being SGA at birth, with more NICU admissions and composite perinatal outcomes; abnormal UAD evaluation in cases conveyed further increase in outcomes.     

Outcome of small-for-gestational-age fetuses according to umbilical artery Doppler: Is there any yield from additional middle cerebral artery Doppler?

Abstract

Objective.?To investigate the outcome of small-for-gestational-age (SGA) fetuses in relation to the features of umbilical artery (UA) Doppler and to explore the prognosticator of middle cerebral artery (MCA) Doppler in SGA fetuses with normal UA impedance.

Methods.?Two hundred ninety-seven patients were classified into Group 1 with normal UA and MCA pulsatility index (PI), Group 2 with normal UA but abnormal MCA PI and Group 3 with abnormal UA PI/absent or reversed end diastolic flow. Neonatal outcomes were compared between each group.

Results.?Neonatal intensive care unit (NICU) admission, duration of hospital stay and perinatal mortality were higher in Group 3 as compared to the others. Group 2 had a lower birth weight and more fetuses with 5-min Apgar score <7 than Group 1; NICU admission and need for ventilators were also significantly higher than Group 1.

Conclusions.?SGA fetuses with abnormal UA Doppler suffered more morbidity and mortality compared to those with normal UA Doppler. SGA fetuses with normal UA PI but abnormal MCA PI had worse outcomes compared to those with normal UA and MCA PI.     

The predictive value of lactate peak detected by the magnetic resonance spectroscopy in the brain of growth-restricted fetuses for adverse perinatal outcomes

Objective: To compare perinatal outcomes between patients with and without abnormal Doppler findings and lactate peak in the fetal brain detected by magnetic resonance spectroscopy (¹HMRS) and to assess the feasibility of fetal brain lactate in the prediction of adverse obstetric outcomes in growth-restricted fetuses.

Methods: Pregnancies with FGR fetuses underwent Doppler ultrasonography and 3 Tesla ¹HMRS for the presence of lactate peak prior to the delivery. Patients were assigned into the following groups; normal Doppler, no lactate peak (Group 1), normal Doppler, lactate peak (+) (Group II), abnormal Doppler, no lactate peak (Group III), abnormal Doppler, lactate peak (+) (Group IV).

Results: Five perinatal deaths, all in Group IV, were encountered (p?<?0.001). Perinatal death rate was higher in patients with Doppler flow abnormality ((5/12 (41.7%)) than in patients without Doppler abnormality (0/23) (p?<?0.001) and was significantly higher in the presence (5/18 (27.8%)) than in the absence of lactate peak (0/17) (p?=?0.019).

Conclusions: Fetuses with brain lactate peak detected by ¹HMRS in addition to altered Doppler findings are more likely to develop short-term morbidities and perinatal death. Fetal brain lactate detected by ¹HMRS may represent a clinical marker of altered brain metabolism and further perinatal complications.     

Predictive value of angiogenic factors,clinical risk factors and uterine artery Doppler for pre-eclampsia and fetal growth restriction in second and third trimester pregnancies in an Ecuadorian population

Objective: To evaluate the performance of angiogenic factors, maternal risks and uterine artery Doppler (UAD) in the prediction of pre-eclampsia (PE) and fetal growth restriction (FGR) in a high-risk Ecuadorian population.

Methods: Patients with singleton pregnancies (n?=?346) were investigated at two clinical visits (18–25 weeks and 28–32 weeks). Mean uterine artery (UA), pulsatility index (PI) and maternal biomarkers (soluble fms-like tyrosine kinase-1, placental growth factor, sFlt-1/PLGF ratio) were obtained. The main endpoints were PE and FGR. UA PI and angiogenic factor levels were compared for the groups with PE (n?=?34), FGR (n?=?26), PE & FGR (n?=?14) and controls (n?=?272). Multivariable stepwise logistic regression was used to construct prediction models.

Results: Pregnancies with either FGR or PE & FGR exhibited in the second trimester a significantly higher mean UA PI and sFlt-1/PLGF ratio and lower PLGF values compared to controls. In the third trimester, all groups with adverse outcome demonstrated significantly lower PLGF levels and a higher sFlt-1/PLGF ratio compared to normal pregnancies. Differences were most pronounced for pregnancies that developed PE and FGR for both time intervals. The combination of UAD and sFlt-1/PLGF ratio improved the predictive capacity for PE and FGR compared to each parameter alone. The best performance was obtained by integrating anamnestic risk factors, resulting in an area under the receiver operating curve for PE of 0.85 and 0.89 and for FGR of 0.79 and 0.77 in the second and third trimester, respectively.

Conclusion: In a high-altitude Ecuadorian population, angiogenic factors and UA PI were useful tools in the prediction of PE and/or FGR. The highest performance was achieved by the combination of these factors, including obstetric and medical history.     

Superior mesenteric artery Doppler is poor at predicting feed intolerance and NEC in preterm small for gestational age neonates

Abstract

Objective: To study SMA Doppler for predicting feed intolerance and necrotizing enterocolitis (NEC) in preterm SGA neonates with umbilical artery absent/reversed end diastolic flow (A/REDF).

Study design: Prospective study.

Patients: SGA neonates <36 weeks born with antenatally diagnosed A/REDF formed cases. Those with normal Doppler formed controls. Primary outcomes were feed intolerance and NEC. Peak systolic velocity, end diastolic velocity (EDV), time-averaged mean velocity, pulsatility index and resistive index (RI) were measured in SMA Doppler done postnatally on days 1 and 5.

Results: Fifty neonates were enrolled in each group. Gestation, birth weight, gender and Apgar scores were comparable. Feed intolerance rate was similar (A/REDF: 26% versus controls: 20%, p 0.48), NEC was commoner in A/REDF group (32% versus 4%, p?<?0.001). Baseline SMA Doppler indices were similar; RI on day 1 was higher in babies with A/REDF [5.4 (IQR 3.3, 7.3)] who developed NEC compared to controls [3.3 (IQR 1.7, 3.9)], (p 0.049). RI of 3.63 on day 1 had only a sensitivity of 61% and a specificity of 57% in predicting NEC in A/REDF group (area under curve (AUC) 0.61, 95% CI: 0.43–0.79, p?=?0.25). Similarly, EDV of 8.7?cm/s had only a sensitivity of 61% and a specificity of 60% for the prediction of NEC (AUC of 0.64, 95% CI: 0.47–0.81, p?=?0.16).

Conclusions: Postnatal SMA Doppler indices do not predict feed intolerance and NEC in preterm SGA babies with A/REDF.     

Outcome of monochorionic twin pregnancies with abnormal umbilical artery Doppler between 16 and 20 weeks of gestation

Objectives.?To study the perinatal outcome among monochorionic diamniotic (MCDA) twin pregnancies with absent or reversed end-diastolic flow of the umbilical artery (UA-AREDF) at 16–20 weeks of gestation.

Methods.?This was a retrospective study of 84 MCDA twin pregnancies, which were followed up since first trimester in a single obstetric unit. Pregnancies with fetal structural anomalies or genetic syndromes, and those with single intrauterine death before 16 weeks were excluded. The study group was divided into four groups based on the finding of UA-AREDF at the routine follow-up scan at 16–20 week, and the presence of complications at the same time of recruitment. The perinatal outcome between these groups was compared.

Results.?AREDF was present in 56.7% of the 30 monochorionic (MC) twins with complications at recruitment. The mortality was significantly higher among those with AREDF. Among the 54 uncomplicated cases at recruitment, only 7.41% had AREDF. The presence of isolated AREDF was associated with significantly higher incidence of growth discordance (25.0% vs. 2%). The incidence of perinatal mortality and twin-to-twin transfusion syndrome was almost doubled (25.0% vs. 9% and 25.0% vs. 14%).

Conclusions.?AREDF of the umbilical artery is uncommon in normal MC twin in mid-trimester. Once AREDF is present, the perinatal outcome is much worse. Doppler assessment of the umbilical artery should be considered in all MC twin pregnancies for risk assessment.     

The impact of fetal middle cerebral artery Doppler on the outcome of congenital hydrocephalus

Objectives: The objective of this study is to investigate the impact of abnormal middle cerebral artery (MCA) Doppler on the perinatal mortality in fetuses with congenital hydrocephalus (CH).

Methods: A prospective study of all fetuses with CH who delivered at our hospital over a period of 7 years. Data were obtained from the ultrasound, Labor room and intensive neonatal care unit (NICU) database. The Perinatal mortality rates were evaluated in relation to the following measures, associated congenital anomalies, cortical mantle thickness (CMT), and MCA Doppler abnormalities (absent or reversed diastole). The main outcome measure was perinatal mortality rate in relation to MCA Doppler changes.

Results: A total of 85 cases of CH were diagnosed and managed. The birth prevalence of CH was 2.44 per 1000 live births. On one hand, the perinatal mortality rate was higher in those fetuses with non-isolated hydrocephalus, (37.25% (19/51) versus (35.29% (12/34, p?=?0.854 and in those cases with CMT <10?mm, 38.78% (19/49) versus 33.33% (12/36) in those with CMT >10?mm, p?=?0.607. On the other hand, the perinatal mortality rate was significantly higher in those fetuses with abnormal MCA Doppler, (100% (13/13) versus 25% (18/72), OR?=?78.0, 95% CI (5.52–44085124.60), p?Conclusions: Abnormal fetal MCA Doppler (absent or reversed diastole) appears to be a poor prognostic indicator with significantly high perinatal mortality in fetuses with CH.     

Risk of donor demise after laser therapy for twin–twin transfusion when complicated by growth discordance and abnormal umbilical artery Doppler findings*

Objective: To investigate the natural course of abnormal umbilical artery Doppler (UAD) findings in donor fetuses after laser surgery and the prognostic significance of resolution, persistence, or new onset UAD abnormalities with and without the presence of preoperative growth discordance.

Study design: Retrospective cohort study of all monochorionic-diamniotic multi-fetal gestations diagnosed with twin-twin transfusion syndrome (TTTS) undergoing laser surgery at a single large metropolitan referral center from 2010-2016. The estimated fetal weight was measured preoperatively and the UAD were measured both pre- and postoperatively (median?=?8 days). Patients were grouped according to the presence of abnormal UAD with or without growth discordance pre- and postoperatively. Risk ratios (RR) were calculated for each group for risk of intrauterine fetal demise compared to the pre- and postoperative normal UAD groups as the referents.

Results: There were eighty-one women who met inclusion criteria throughout the study period. Forty-three (53.1%) patients had abnormal donor twin UAD preoperatively and 33 (40.7%) were diagnosed with growth discordance. However, 13 (44.8%) had normalization of the UAD postoperatively (median?=?8 days) with a similar rate of donor fetal demise as the non-discordant preoperative normal UAD group (7.7% versus 10.3%, p?=?.79). Abnormal preoperative UAD was associated with an increased risk of donor demise (RR 3.6, CI 1.1–12.1), which was further elevated in the presence of growth discordance (RR 5.2, CI 1.7–16.3). The greatest risk for donor demise was seen if the UAD remained abnormal postoperatively with concomitant growth discordance (RR 10.3, CI 2.5–41.6).

Conclusions: Preoperative abnormal donor UAD is a significant risk for donor demise post-laser therapy for TTTS. Persistent postoperative abnormal UAD with concomitant growth discordance confers the greatest risk for donor demise. However, resolution of abnormal UAD has a similar rate of donor demise when compared to patients with normal UAD preoperatively.     

The clinical value of maternal and fetal Doppler parameters in low-risk postdates pregnancies – a prospective study

Objective: The objective of this study is to determine the clinical significance of maternal and fetal ultrasound Doppler flow indices in postdates pregnancies.

Methods: This prospective study comprised 120 low-risk pregnant women beyond 40 weeks of gestation. All participants underwent Doppler assessment including of fetal middle cerebral artery (MCA), umbilical, and uterine arteries. Perinatal outcomes were recorded and evaluated for possible associations with Doppler flow values. Adverse perinatal outcomes were defined as umbilical cord arterial pH <7.1, Apgar score <7 at 5?min, neonatal admission to a neonatal intensive care unit, and emergency cesarean section due to abnormal intrapartum cardiotocogram

Results: Adverse perinatal outcome rate was 17.5% (n?=?21). Doppler indices of umbilical artery, MCA, uterine artery and the cerebroplacental ratio (CPR) did not differ significantly between pregnant women with and without adverse perinatal outcomes. Neonatal birth weight was found to correlate negatively with umbilical artery Doppler indices, including the peak systolic to end diastolic ratio (p?=?.04), the resistance index (p?=?.02), and the pulsatility index (p?=?.01). Doppler values of the uterine artery, MCA and CPR did not correlate with neonatal birth weight.

Conclusions: The contribution of maternal and fetal ultrasound Doppler to the prediction of adverse perinatal outcomes in low-risk postdates pregnancies is low. Hence, performing routine Doppler examination as part of postdates pregnancy assessments is unlikely to yield significant clinical benefit.     

The effect of low-dose aspirin on fetal weight of idiopathic asymmetrically intrauterine growth restricted fetuses with abnormal umbilical artery Doppler indices: a randomized clinical trial

Objective: To investigate the effect of aspirin on fetal weight in fetuses with idiopathic asymmetrical intrauterine growth restriction (IUGR) complicated by abnormal umbilical artery Doppler indices.

Materials and methods: The study was a randomized controlled trial conducted at Woman’s Health Hospital, Assiut, Egypt, between June 2016 and the January 2017 included 60 pregnant women (28?30 weeks) with idiopathic asymmetrical IUGR associated with abnormal umbilical artery Doppler indices. Women were randomly assigned to group I (aspirin 75?mg) daily for four weeks or group II (no intervention). The primary outcome was the fetal weight after four weeks. Secondary outcomes included Doppler blood flow changes in the umbilical artery plus delivery and neonatal outcomes.

Results: The estimated fetal weight and umbilical artery blood flow increased significantly in aspirin group (p?=?.00) when compared with no intervention group. As regard neonatal outcomes; aspirin group showed better results and encouraging outcomes (p?Conclusions: Aspirin improves fetal weight and umbilical artery blood flow in idiopathic asymmetrical IUGR fetuses complicated by abnormal umbilical artery Doppler blood flow.     

Significance of umbilical artery Doppler velocimetry in the perinatal outcome of the growth restricted fetuses

Objectives

To evaluate the role of umbilical artery Doppler in growth restricted fetuses.

Methods

In a prospective observational study, 100 pregnant women with growth restricted fetuses confirmed by ultrasound were evaluated by umbilical artery Doppler velocimetry after 28 weeks of gestation. Outcome of the pregnancy was recorded for the normal Doppler group (n=54) and abnormal Doppler group (n=46). Abnormal Doppler group consisted of low end diastolic flow group (n=29) and absent or reversed end diastolic flow (REDF) group (n=17).

Results

Fetuses with abnormal umbilical flow velocimetry had higher incidence of oligohydramnios and abnormal NST compared to the fetuses with normal umbilical flow. The average birth weight and gestational age at delivery were lower in the abnormal Doppler group. Neonates with abnormal umbilical artery velocimetry had increased incidence of caesarean delivery, low apgar scores at birth, increased NICU admissions, increased requirement of positive pressure ventilation, and higher perinatal morbidity and mortality.

Conclusion

Umbilical artery Doppler velocimetry should be used in the management of the intrauterine growth restricted fetuses, as it helps in differentiating fetus with pathological growth restriction at risk for perinatal complications from small and healthy fetuses.     

Maternal,fetal and perinatal characteristics of preeclampsia cases with and without abnormalities in uterine artery Doppler indexes

Abstract

Objective: To compare the maternal and fetal characteristics and perinatal outcome in mild and severe preeclampsia cases with and without uterine artery Doppler abnormalities.

Methods: Two hundred and fifty-nine mild and severe preeclampsia cases were evaluated retrospectively. Doppler measurements were done in the section where uterine artery raised from the hypogastric artery. Pulsatility index above the 95th percentile of the corresponding gestational age was accepted as abnormal.

Results: In mild and severe preeclampsia cases with abnormal Doppler (AD), the rate of intrauterine growth restriction, preterm birth and low birth weight was higher than, but the neonatal intensive care unit stay was similar to the cases with normal Doppler. Base excess was higher in the AD group, in mild and severe preeclampsia. The rate of low Apgar score at 5?min and perinatal mortality was higher in the AD group, in the mild preeclampsia. The strongest independent predictor of the perinatal morbidity and mortality was the presence of prematurity and of the prematurity was the presence of abnormal uterine artery Doppler.

Conclusions: Maternal and perinatal morbidity and perinatal mortality increase in mild to severe preeclampsia cases with abnormal uterine artery Doppler. The abnormal uterine artery Doppler increases the morbidity and mortality by increasing the risk of prematurity.     

Fetal umbilical artery Doppler pulsatility index as a predictor of cardiovascular risk factors in children – a long-term follow up study

Abstract

Objective: To determine if high umbilical artery Doppler (UAD) pulsatility index (PI) is associated with cardio-vascular (CV) risk-factors in children at age 12 years.

Methods: We studied 195 children at age 12 years who had had in-utero UAD studies performed at 28 weeks’ gestation. The children were grouped according to whether their umbilical Doppler PI was high (indicating poor feto-placental circulation) or normal. At age 12 years we assessed CV risk factors, including anthropometric measures, blood pressure, pulse wave velocity (a measure of arterial compliance), cardio-respiratory fitness, and homocysteine and cholesterol serum levels.

Results: Compared with children with a normal UAD PI (N?=?88), the children (N?=?107) with high UAD PI had higher resting pulse rate (p?=?0.04), higher pulse wave velocity (p?=?0.046), higher serum homocysteine levels (p?=?0.032) and reduced arterial compliance (7.58 versus 8.50?m/s, p?=?0.029) using univariate analysis. These differences were not present when adjusting for cofounders was modeled.

Conclusion: High PI on UAD testing in-utero may be associated with increased likelihood of some CV risk factors at age 12-years but confounding variables may be as important. Our study raises possible long-term benefits of in-utero UAD measurements.     

Utero-placental perfusion Doppler indices in growth restricted fetuses: effect of sildenafil citrate

Objective: To assess efficacy and tolerability of sildenafil citrate on utero-placental blood flow and fetal growth in pregnancies complicated by fetal growth restriction (FGR).

Methods: From March 2015, a randomized controlled trial of 54 patients at 24?weeks or more complicated by FGR and abnormal Doppler indices were randomly allocated 1:1 into an intervention arm (receive sildenafil citrate, 50?mg) or a control arm (receive placebo). The primary outcomes were changes occurred in the Doppler parameters 2?h following drug administration.

Results: Baseline characteristics were similar between groups. Significant difference was observed in the Delta uterine and umbilical Doppler indices among sildenafil group as compared to placebo group (p?p?=?0.979). Sildenafil was also associated with pregnancy prolongation (p?=?.0001), increased gestational age at delivery (p?=?.004), improved neonatal weight (p?=?.0001), and less admission to neonatal intensive care unit (p?=?.03). No adverse effects reported in both treatment arms.

Conclusion: Sildenafil citrate, by its vasodilator effect, can improve utero-placental blood flow in pregnancies complicated by FGR and abnormal Doppler.

Clinical Trial.gov Registry: NCT02362399     

First trimester maternal serum analytes and second trimester uterine artery Doppler in the prediction of preeclampsia and fetal growth restriction

Objective

This study aimed to determine whether pregnancy-associated plasma protein-A (PAPP-A), free β-human chorionic gonadotropin (β-hCG), a disintegrin and metalloprotease 12 (ADAM12), and placenta protein 13 (PP13) in the first trimester, and uterine artery Doppler (UAD) in the second trimester, predict preeclampsia and fetal growth restriction (FGR).

Online versus offline spatiotemporal image correlation (STIC) M-mode for the evaluation of cardiac longitudinal annular displacement in fetal growth restriction

Purpose: Our first aim was to compare online M-mode with offline spatiotemporal image correlation (STIC) M-mode for assessing longitudinal annular displacement (LAD) in growth-restricted fetuses (FGR). Our second aim was to compare LAD measures of FGR cases with controls.

Materials and methods: Prospective study including 40 FGR cases (defined estimated fetal weight and birth weight <10th centile) and 72 normally grown fetuses matched to cases by gestational age at scan. LAD was measured with online M-mode and offline STIC M-mode at the left and right ventricular free walls and septum in all fetuses.

Results: FGR cases had a significant decrease in LAD by STIC in all sites as compared to controls (e.g. right LAD in FGR mean 6.7?mm (SD 1.2) versus controls 7.2?mm (1.2), p?=?.033). There was a non-significant trend for lower values in FGR when using online M-mode (e.g. right LAD in FGR 6.9?mm (1.5) versus controls 7.4?mm (1.5), p?=?.084).

Conclusions: STIC M-mode seems a better method than online M-mode for detecting subtle changes in myocardial motion. STIC presents more precise results and allows an ideal placement of the M-mode arrow. These results confirm previous data suggesting decreased longitudinal motion in FGR.     

Doppler, cardiotocography, and biophysical profile changes in growth-restricted fetuses

OBJECTIVE: To assess from diagnosis to delivery the Doppler studies of the umbilical artery, middle cerebral artery, umbilical vein, ductus venosus, and amniotic fluid index of fetuses with idiopathic growth restriction. METHODS: A total of 145 singleton growth-restricted fetuses with abnormal umbilical artery pulsatility indexes were studied. Cesarean delivery was performed because of abnormal biophysical profile or nonreassuring fetal heart rate pattern. RESULTS: There were 4 fetal and 50 neonatal deaths. Two growth-restricted groups were identified: Group A (n = 44) included fetuses in whom all measures became abnormal preceding an abnormal biophysical profile or nonreassuring nonstress test. Group B (n = 101) included fetuses in whom 1 or more measures were normal at the time of cesarean delivery. There was no statistically significant difference in perinatal morbidity and mortality between the 2 groups. Neonatal death was increased in fetuses with umbilical artery reversed flow (odds ratio 2.34, 95% confidence interval 1.16-4.73; P < .05) and ductus venosus reversed flow (odds ratio 4.18, 95% confidence interval 2.01-8.69; P < .05). A significant correlation was also found between low birth weight and adverse perinatal outcome. CONCLUSION: In fetuses with idiopathic growth restriction, 1) low birth weight, 2) umbilical artery reversed flow, and 3) ductus venosus absent or reversed flow are associated with an increased perinatal morbidity and mortality.     

Late preterm and early term: when to induce a growth restricted fetus? A population-based study

Purpose: (1) Compare fetal and neonatal morbidity and mortality associated with induction of labor (IOL) versus expectant management (EM) in women with isolated fetal growth restriction (FGR) between 34^0/7 and 38^6/7 weeks; (2) Determine optimal gestational age for delivery of such fetuses.

Materials and methods: A retrospective population based cohort study of 2232 parturients with isolated FGR, including two groups: (1) IOL (n?=?1428); 2) EM (n?=?804).

Results: IOL group had a lower stillbirth and neonatal death rates (p?=?.042, p?p?=?.001, p?=?.039). In the early term cohort, EM was associated with a higher rate of NRFHR and low 1?min Apgar scores (p?=?.003, p?=?.002). IOL at 37 weeks protected from stillbirth but not from adverse composite neonatal outcomes.

Conclusions: IOL of FGR fetuses at 37?weeks had a protective effect against stillbirth. In addition, at late preterm, it is associated with lower rates of stillbirth, neonatal death, and NRFHR.