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Consensus definition and essential reporting parameters of selective fetal growth restriction in twin pregnancy: a Delphi procedure
Khalil, A.; Beune, I.; Hecher, K. ...
Ultrasound in obstetrics & gynecology,
January 2019, 2019-Jan, 2019-01-00, 20190101, Volume:
53, Issue:
1
Journal Article
Peer reviewed
Open access
ABSTRACT
Objectives
Twin pregnancy complicated by selective fetal growth restriction (sFGR) is associated with increased perinatal mortality and morbidity. Inconsistencies in the diagnostic criteria ...
for sFGR employed in existing studies hinder the ability to compare or combine their findings. It is therefore challenging to establish robust evidence‐based management or monitoring pathways for these pregnancies. The main aim of this study was to determine, by expert consensus using a Delphi procedure, the key diagnostic features of and the essential reporting parameters in sFGR.
Methods
A Delphi process was conducted among an international panel of experts in sFGR in twin pregnancy. Panel members were provided with a list of literature‐based parameters for diagnosing sFGR and were asked to rate their importance on a five‐point Likert scale. Parameters were described as solitary (sufficient to diagnose sFGR, even if all other parameters are normal) or contributory (those that require other abnormal parameter(s) to be present for the diagnosis of sFGR). Consensus was sought to determine the cut‐off values for accepted parameters, as well as parameters used in the monitoring, management and assessment of outcome of twin pregnancy complicated by sFGR. The questions were presented in two separate categories according to chorionicity.
Results
A total of 72 experts were approached, of whom 60 agreed to participate and entered the first round; 48 (80%) completed all four rounds. For the definition of sFGR irrespective of chorionicity, one solitary parameter (estimated fetal weight (EFW) of one twin < 3rd centile) was agreed. For monochorionic twin pregnancy, at least two out of four contributory parameters (EFW of one twin < 10th centile, abdominal circumference of one twin < 10th centile, EFW discordance of ≥ 25%, and umbilical artery pulsatility index of the smaller twin > 95th centile) were agreed. For sFGR in dichorionic twin pregnancy, at least two out of three contributory parameters (EFW of one twin < 10th centile, EFW discordance of ≥ 25%, and umbilical artery pulsatility index of the smaller twin > 95th centile) were agreed.
Conclusions
Consensus‐based diagnostic features of sFGR in both monochorionic and dichorionic twin pregnancies, as well as cut‐off values for the parameters involved, were agreed upon by a panel of experts. Future studies are needed to validate these diagnostic features before they can be used in clinical trials of interventions. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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An integrated model with classification criteria to predict small‐for‐gestational‐age fetuses at risk of adverse perinatal outcome
Figueras, F.; Savchev, S.; Triunfo, S. ...
Ultrasound in obstetrics & gynecology,
March 2015, Volume:
45, Issue:
3
Journal Article
Peer reviewed
Open access
Objective
To develop an integrated model with the best performing criteria for predicting adverse outcome in small‐for‐gestational‐age (SGA) pregnancies.
Methods
A cohort of 509 pregnancies with a ...
suspected SGA fetus, eligible for trial of labor, was recruited prospectively and data on perinatal outcome were recorded. A predictive model for emergency Cesarean delivery because of non‐reassuring fetal status or neonatal acidosis was constructed using a decision tree analysis algorithm, with predictors: maternal age, body mass index, smoking, nulliparity, gestational age at delivery, onset of labor (induced vs spontaneous), estimated fetal weight (EFW), umbilical artery pulsatility index (PI), mean uterine artery (UtA) PI, fetal middle cerebral artery PI and cerebroplacental ratio (CPR).
Results
An adverse outcome occurred in 134 (26.3%) cases. The best performing predictors for defining a high risk for adverse outcome in SGA fetuses was the presence of a CPR < 10th centile, a mean UtA‐PI > 95th centile or an EFW < 3rd centile. The algorithm showed a sensitivity, specificity and positive and negative predictive values for adverse outcome of 82.8% (95% CI, 75.1–88.6%), 47.7% (95% CI, 42.6–52.9%), 36.2% (95% CI, 30.8–41.8%) and 88.6% (95% CI, 83.2–92.5%), respectively. Positive and negative likelihood ratios were 1.58 and 0.36.
Conclusions
Our model could be used as a diagnostic tool for discriminating SGA pregnancies at risk of adverse perinatal outcome. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.
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Fetal cardiovascular remodeling persists at 6 months in infants with intrauterine growth restriction
Cruz‐Lemini, M.; Crispi, F.; Valenzuela‐Alcaraz, B. ...
Ultrasound in obstetrics & gynecology,
September 2016, 2016-Sep, 20160901, Volume:
48, Issue:
3
Journal Article
Peer reviewed
Open access
ABSTRACT
Objectives
Intrauterine growth restriction is associated with increased cardiovascular risk later in life but the link between fetal disease and postnatal risk is not well‐documented. We ...
evaluated longitudinally the association between cardiovascular remodeling in small‐for‐gestational‐age (SGA) fetuses and at 6 months of age.
Methods
A cohort of 80 SGA fetuses (defined by estimated fetal and birth weights < 10th centile) delivered > 34 weeks' gestation was compared with 80 normally grown age‐matched control fetuses, with follow‐up at 6 months of corrected age (i.e. 6 months from estimated date of delivery according to first‐trimester crown–rump length). Cardiovascular evaluation included a comprehensive echocardiographic assessment in both fetuses and infants and blood pressure and aortic intima–media thickness (aIMT) measurement in infants. Parameters were adjusted by linear regression analysis for gender, gestational age at delivery, pre‐eclampsia, prenatal glucocorticoid exposure, Cesarean delivery, admission to neonatal intensive care unit and body surface area.
Results
Both pre‐ and postnatally, when compared with controls, the SGA group showed a more globular cardiac shape (left sphericity index: controls 2.06 vs SGA 1.87 (P = 0.022) prenatally and 1.92 vs 1.67 (P = 0.007) postnatally), as well as signs of systolic longitudinal dysfunction (systolic annular peak velocity (S′): 7.2 vs 6.3 cm/s (P = 0.003) prenatally and 7.9 vs 6.4 cm/s (P < 0.001) postnatally; tricuspid annular plane systolic excursion: 7.2 vs 6.8 mm (P = 0.015) prenatally and 16.0 vs 14.2 mm (P < 0.001) postnatally) and diastolic dysfunction (left isovolumetric relaxation time: 46 vs 52 ms (P < 0.001) prenatally and 50 vs 57 ms (P = 0.034) postnatally). In addition, infants in the SGA group had increased mean blood pressure (mean: 61 vs 70 mmHg, P < 0.001) and maximum aIMT (0.57 vs 0.66 mm; P < 0.001).
Conclusions
Primary cardiovascular changes are already present in the SGA fetus and persist at 6 months of age. These data support prenatal cardiovascular remodeling as a mechanistic pathway of increased risk later in life in cases of SGA, regardless of Doppler abnormalities. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Prediction of delivery of small‐for‐gestational‐age neonates and adverse perinatal outcome by fetoplacental Doppler at 37 weeks' gestation
Triunfo, S.; Crispi, F.; Gratacos, E. ...
Ultrasound in obstetrics & gynecology,
March 2017, 2017-Mar, 2017-03-00, 20170301, Volume:
49, Issue:
3
Journal Article
Peer reviewed
Open access
ABSTRACT
Objective
To explore the predictive capacity of fetoplacental Doppler at 37 weeks' gestation in identifying small‐for‐gestational‐age (SGA) neonates, fetal growth restriction (FGR) and ...
adverse perinatal outcome.
Methods
This was a prospective cohort study of low‐risk singleton pregnancies undergoing ultrasound assessment at 37 weeks. At study inclusion, biometry for estimated fetal weight (EFW), and fetoplacental Doppler variables (uterine artery pulsatility index (UtA‐PI), cerebroplacental ratio (CPR) and umbilical vein blood flow (UVBF) normalized by EFW) were measured. SGA was defined as a customized birth weight between the 3rd and 10th centiles, and FGR was defined as a birth weight < 3rd centile, according to local standards. Adverse perinatal outcomes included emergency Cesarean section for non‐reassuring fetal status, 5‐min Apgar score < 7 and neonatal acidosis at birth.
Results
A total of 946 pregnancies were included in the study. Of these, 89 (9.4%) were classified as SGA and 40 (4.2%) as FGR, with an overall rate of adverse perinatal outcome of 4.9%. At a fixed 10% false‐positive rate (FPR), the detection rate of SGA by EFW, UtA‐PI, CPR, UVBF and by a combination of Doppler variables (UtA‐PI and CPR) and EFW was 59.2%, 10.5%, 13.7%, 3.2% and 61.0%, respectively. At a fixed 10% FPR, the detection rate of FGR by EFW, UtA‐PI, CPR, UVBF and a combination of CPR and EFW centile was 83.3%, 13.9%, 27.8%, 13.9% and 88.6%, respectively. At a fixed 10% FPR, the detection rate of adverse perinatal outcome by EFW, UtA‐PI, CPR and UVBF was 19.2%, 9.2%, 23.1% and 16.9%, respectively, while combining EFW with Doppler variables (including CPR and UVBF normalized by EFW) improved the detection rate to nearly 30%.
Conclusion
In low‐risk pregnancies, Doppler evaluation at 37 weeks' gestation did not improve the prediction of SGA and FGR compared with that given by EFW alone, however, combining Doppler variables with EFW improved the prediction of adverse perinatal outcomes given by these parameters alone, although not markedly. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Reference ranges for uterine artery mean pulsatility index at 11–41 weeks of gestation
Gómez, O.; Figueras, F.; Fernández, S. ...
Ultrasound in obstetrics & gynecology,
August 2008, Volume:
32, Issue:
2
Journal Article
Peer reviewed
Open access
Objectives
To construct gestational age (GA)‐based reference ranges for the uterine artery (UtA) mean pulsatility index (PI) at 11–41 weeks of pregnancy.
Methods
A prospective cross‐sectional ...
observational study was carried out of 20 consecutive singleton pregnancies for each completed gestational week at 11–41 weeks. UtAs were examined by color and pulsed Doppler imaging, and the mean PI, as well as the presence or absence of a bilateral protodiastolic notch, were recorded. Polynomials were fitted by means of least‐square regression to estimate the relationship between the mean UtA‐PI and GA.
Results
A total of 620 women were included. A second‐degree polynomial (Loge mean UtA‐PI = 1.39 − 0.012 × GA + GA2 × 0.0000198, with GA measured in days), after a natural logarithmic transformation, was selected to model our data. There was a significant decrease in the mean UtA‐PI between 11 weeks (mean PI, 1.79; 95th centile, 2.70) and 34 weeks (mean PI, 0.70; 95th centile, 0.99). It then became more stable up until 41 weeks (mean PI, 0.65; 95th centile, 0.89).
Conclusions
The mean UtA‐PI shows a progressive decrease until the late stages of pregnancy. Reference ranges for mean UtA‐PI may have clinical value in screening for placenta‐associated diseases in the early stages of pregnancy, and in evaluating patients with pregnancy‐induced hypertension and/or small‐for‐gestational age fetuses during the third trimester. Copyright © 2008 ISUOG. Published by John Wiley & Sons, Ltd.
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Validation of a first‐trimester screening model for pre‐eclampsia in an unselected population
Scazzocchio, E.; Crovetto, F.; Triunfo, S. ...
Ultrasound in obstetrics & gynecology,
February 2017, 2017-Feb, 20170201, Volume:
49, Issue:
2
Journal Article
Peer reviewed
Open access
ABSTRACT
Objective
To validate the performance of a previously constructed first‐trimester predictive model for pre‐eclampsia (PE) in routine care of an unselected population.
Methods
A validation ...
cohort of 4621 consecutive women attending their routine first‐trimester ultrasound examination was used to test a prediction model for PE that had been developed previously in 5170 women. The prediction model included maternal factors, uterine artery Doppler, blood pressure and pregnancy‐associated plasma protein‐A. Model performance was evaluated using receiver–operating characteristics (ROC) curve analysis and ROC curves from both cohorts were compared unpaired.
Results
Among the 4203 women included in the final analysis, 169 (4.0%) developed PE, including 141 (3.4%) cases of late‐onset PE and 28 (0.7%) cases of early‐onset PE. For early‐onset PE, the model showed an area under the ROC curve of 0.94 (95% CI, 0.88–0.99), which did not differ significantly (P = 0.37) from that obtained in the construction cohort (0.88 (95% CI, 0.78–0.99)). For late‐onset PE, the final model showed an area under the ROC curve of 0.72 (95% CI, 0.66–0.77), which did not differ significantly (P = 0.49) from that obtained in the construction cohort (0.75 (95% CI, 0.67–0.82)).
Conclusion
The prediction model for PE achieved a similar performance to that obtained in the construction cohort when tested on a subsequent cohort of women, confirming its validity as a predictive model for PE. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
Linked Comment: Ultrasound Obstet Gynecol 2017; 49: 169–169
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Association of Doppler parameters with placental signs of underperfusion in late‐onset small‐for‐gestational‐age pregnancies
Parra‐Saavedra, M.; Crovetto, F.; Triunfo, S. ...
Ultrasound in obstetrics & gynecology,
September 2014, Volume:
44, Issue:
3
Journal Article
Peer reviewed
ABSTRACT
Objective
To elucidate the association between Doppler parameters and histological signs of placental underperfusion in late‐onset small‐for‐gestational‐age (SGA) babies.
Methods
Umbilical, ...
fetal middle cerebral and uterine artery pulsatility indices and umbilical vein blood flow (UVBF), which had been recorded within 7 days prior to delivery, were analyzed from a cohort of SGA singleton pregnancies delivered after 34 weeks' gestation and confirmed as having a birth weight < 10th percentile by local standards. In each case, the placenta was histologically evaluated for signs of placental underperfusion using a hierarchical and standardized classification system. The independent association of the Doppler parameters with placental underperfusion was evaluated using logistic regression and decision tree analysis.
Results
In 51 cases (53.7%), there were 61 placental histological findings indicative of placental underperfusion. These cases had a significantly higher incidence of Cesarean section for non‐reassuring fetal status (52.1% vs 11.9%; P < 0.001) and neonatal metabolic acidosis at birth (21.6% vs 0%; P = 0.001). Significant and independent contributions to the presence of placental underperfusion lesions were provided by increased mean UtA pulsatility index (PI) (P = 0.018; odds ratio (OR) 2 (95% CI, 1.1–3.7)) and decreased UVBF normalized to estimated fetal weight (P = 0.027; OR 0.97 (95% CI, 0.95–0.99)). The combination of both parameters revealed three groups with differing risks for placental underperfusion: normalized UVBF > 82 mL/min/kg (risk 31.3%), normalized UVBF ≤ 82 mL/min/kg and mean UtA‐PI ≤ 95th percentile (risk 65.5%), and normalized UVBF ≤ 82 mL/min/kg and UtA‐PI > 95th percentile (risk 94.4%).
Conclusions
In late‐onset SGA pregnancies, uterine Doppler and UVBF are surrogates for placental underperfusion. These findings facilitate phenotypic profiling of cases of fetal growth restriction among the general population of late‐onset SGA babies. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd
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Chorioamniotic membrane separation after fetoscopy in monochorionic twin pregnancy: incidence and impact on perinatal outcome
Ortiz, J. U.; Eixarch, E.; Peguero, A. ...
Ultrasound in obstetrics & gynecology,
March 2016, Volume:
47, Issue:
3
Journal Article
Peer reviewed
Open access
ABSTRACT
Objective
To evaluate the incidence of chorioamniotic membrane separation (CMS) after fetoscopy in monochorionic diamniotic (MCDA) twins and its impact on pregnancy outcome.
Methods
The ...
study group comprised a consecutive series of 338 women with an MCDA pregnancy complicated by twin–twin transfusion syndrome (TTTS) or selective intrauterine growth restriction (sIUGR) treated with selective laser photocoagulation of communicating vessels (SLPCV) or cord occlusion (CO). Data obtained included cervical length, gestational age at procedure, type and duration of surgery and placental location. The incidence of CMS, the rates of miscarriage and preterm prelabor rupture of membranes (PPROM), gestational age at delivery and neonatal survival were recorded.
Results
Of the study population of MCDA pregnancies, 270 (79.9%) had TTTS and 68 (20.1%) had sIUGR. SLPCV was performed in 252 (74.6%) cases and CO in 86 (25.4%). Postoperative CMS was observed in 70 (20.7%) cases. Patients with CMS had higher rates of miscarriage (14.3% vs 7.1%; P = 0.049), PPROM before 32 weeks (43.3% vs 13.7%; P < 0.001) and preterm delivery before 32 weeks (53.3% vs 26.1%; P < 0.001) and a lower rate of neonatal survival of at least one twin (81.7% vs 93.6%; P = 0.003). Multivariate analysis showed that gestational age at surgery was the only independent predictor, with the highest proportion of CMS occurring in cases that underwent surgery before 18 weeks' gestation (odds ratio, 2.941 (95% CI, 1.640–5.275); P < 0.001). There was no influence of cervical length, placental location, duration of surgery or type of surgery on the risk of CMS.
Conclusions
CMS complicated one‐fifth of all MCDA pregnancies that underwent fetoscopy. It appeared to be more common in those who underwent surgery before 18 weeks' gestation and was associated with poorer outcomes. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
Linked Comment: Ultrasound Obstet Gynecol 2016; 47: 280–280
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Gestational age‐ and estimated fetal weight‐adjusted reference ranges for myocardial tissue Doppler indices at 24–41 weeks' gestation
Comas, M.; Crispi, F.; Gómez, O. ...
Ultrasound in obstetrics & gynecology,
January 2011, Volume:
37, Issue:
1
Journal Article
Peer reviewed
Open access
Objectives
To construct gestational age (GA)‐ and estimated fetal weight (EFW)‐adjusted reference ranges for tissue Doppler cardiac function parameters from 24 to 41 weeks' gestation.
Methods
This ...
was a prospective cross‐sectional observational study involving 213 singleton pregnancies between 24 and 41 weeks' gestation. Myocardial peak velocities and myocardial performance index (MPI′) were measured by tissue Doppler ultrasonography (values indicated by ‘prime’) in the left and right annulus and interventricular septum. Left and right atrioventricular parameters were also measured by conventional Doppler and ratios between the values found by the two methods calculated. Regression analysis was used to determine GA‐ and EFW‐adjusted reference ranges and to construct nomograms for tissue Doppler parameters.
Results
All myocardial peak velocities, left and right E′/A′ and left MPI′ showed a progressive increase with GA. In contrast, left and right E/E′ showed a progressive decline. Septal E′/A′, and right and septal MPI′ remained constant. Myocardial peak velocities showed a progressive increase with increasing fetal weight.
Conclusions
Normal data of fetal myocardial peak velocities, their ratios and MPI′ by tissue Doppler adjusted by GA and EFW are provided. The reported reference values may be useful in research or clinical studies and can be used in fetuses with intrauterine growth restriction. Copyright © 2011 ISUOG. Published by John Wiley & Sons, Ltd.
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