1.
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
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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2.
Neurodevelopmental outcome of full‐term small‐for‐gestational‐age infants with normal placental function
Savchev, S.; Sanz‐Cortes, M.; Cruz‐Martinez, R. ...
Ultrasound in obstetrics & gynecology,
August 2013, 2013-Aug, 2013-08-00, 20130801, Volume:
42, Issue:
2
Journal Article
ABSTRACT
Objective
To evaluate the 2‐year neurodevelopmental outcome of full‐term, small‐for‐gestational‐age (SGA) newborns with normal placental function, according to current criteria based on ...
umbilical artery Doppler findings.
Methods
A cohort of consecutive full‐term, SGA newborns with normal prenatal umbilical artery Doppler was compared with a group of full‐term, appropriate‐for‐gestational‐age (AGA) infants sampled from our general neonatal population. Neurodevelopmental outcome was evaluated at 24 months' corrected age using the Bayley Scales of Infant and Toddler Development, 3rd Edition (Bayley‐III), which evaluates cognitive, language, motor, social‐emotional and adaptive competencies. The effect of the study group on each domain was adjusted with MANCOVA and logistic regression for gestational age at delivery, socioeconomic status, gender, tobacco smoking and breastfeeding.
Results
A total of 223 infants (112 SGA and 111 AGA) were included. The groups differed significantly with respect to socioeconomic status and gestational age at delivery. All studied neurodevelopmental domains were poorer in the SGA group, reaching significance for the cognitive (92.9 vs 100.2, adjusted P = 0.027), language (94.7 vs 101, adjusted P = 0.025), motor (94.2 vs 100, adjusted P = 0.027) and adaptive (89.2 vs 96.5, adjusted P = 0.012) scores. Likewise, the SGA group had a higher risk of low scores in language (odds ratio (OR) = 2.63; adjusted P = 0.045) and adaptive (OR = 2.72; adjusted P = 0.009) domains.
Conclusions
Compared with normal‐sized babies, full‐term SGA infants, without placental insufficiency defined according to currently used criteria, have lower 2‐year neurodevelopmental scores. These data challenge the concept that SGA fetuses with normal umbilical artery Doppler are ‘constitutionally small’ but otherwise completely normal. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.
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3.
Placental findings in late-onset SGA births without Doppler signs of placental insufficiency
Parra-Saavedra, M; Crovetto, F; Triunfo, S ...
Placenta (Eastbourne),
12/2013, Volume:
34, Issue:
12
Journal Article
Abstract Objectives To describe placental pathological findings in late-onset small-for-gestational age (SGA) births for which Doppler signs of placental insufficiency are lacking. Methods A series ...
of placentas were evaluated from singleton pregnancies of SGA births (birth weight below the 10th percentile) delivered after 34 weeks with normal umbilical artery Doppler (pulsatility index below the 95th percentile), that were matched by gestational age with adequate-for-gestational age (AGA) controls. Using a hierarchical and standardized system, placental lesions were classified histologically as consequence of maternal underperfusion, fetal underperfusion or inflammation. Results A total of 284 placentas were evaluated (142 SGA and 142 AGA). In the SGA group, 54.2% (77/142) of the placentas had weights below the 3rd percentile for GA while it was a 9.9% (14/142) in the AGA group ( p < 0.001). Only 21.8% (31/142) of SGA placentas were free of histological abnormalities, while it was 74.6% (106/142) in the AGA group ( p < 0.001). In the abnormal SGA placentas (111/142) there were a total of 161 lesions, attributable to MUP in 64% (103/161), FUP in 15.5% (25/161), and inflammation in 20.5% (33/161). Discussion In most placentas of term SGA neonates with normal UA Doppler histological abnormalities secondary to maternal underperfusion prevail, reflecting latent insufficiency in uteroplacental blood supply. This is consistent with the higher risk of adverse perinatal outcome reported in this population and underscores a need for new markers of placental disease. Conclusions A significant proportion of late-onset SGA births with normal umbilical artery Doppler may still be explained by placental insufficiency.
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4.
Estimated weight centile as a predictor of perinatal outcome in small‐for‐gestational‐age pregnancies with normal fetal and maternal Doppler indices
Savchev, S.; Figueras, F.; Cruz‐Martinez, R. ...
Ultrasound in obstetrics & gynecology,
March 2012, Volume:
39, Issue:
3
Journal Article
Objective
To evaluate the risk of adverse perinatal outcome according to estimated fetal weight (EFW) in a cohort of term small‐for‐gestational‐age (SGA) pregnancies with normal umbilical, fetal ...
middle cerebral and maternal uterine artery Doppler indices.
Methods
A cohort of 132 term SGA fetuses with normal umbilical artery pulsatility index (PI), mean uterine artery PI and cerebroplacental ratio was compared to a control group of 132 appropriate‐for‐gestational‐age babies, matched by gestational age at delivery. The capacity of the EFW percentile to predict Cesarean delivery, Cesarean delivery for non‐reassuring fetal status (NRFS), neonatal acidosis and days of neonatal hospitalization was analyzed.
Results
As a whole, SGA fetuses with normal Doppler findings did not show a statistically significant difference for intrapartum Cesarean delivery (22.0 vs. 15.9%; P = 0.21) and neonatal acidosis (3.3 vs. 1.5%; P = 0.30), but had significantly higher risk for Cesarean delivery for NRFS (15.9 vs. 5.3%; P < 0.01) and longer neonatal hospitalization (1.39 vs. 0.87 days; P < 0.05) than did controls. SGA fetuses with EFW < 3rd centile had a significantly higher incidence of intrapartum Cesarean delivery (30.0 vs. 15.3%; P = 0.04), Cesarean delivery for NRFS (25.0 vs. 8.3%; P < 0.01) and longer neonatal hospitalization (2.0 vs. 0.9 days; P < 0.01) than those with EFW ≥ 3rd centile. SGA cases with EFW ≥ 3rd centile had perinatal outcomes similar to those of controls with normal EFW.
Conclusion
Among SGA fetuses with normal placental and cerebral Doppler ultrasound findings, EFW < 3rd centile discriminates between those with a higher risk for adverse perinatal outcome and those with outcomes similar to those of normally grown fetuses. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.
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5.
Cervical condition and fetal cerebral Doppler as determinants of adverse perinatal outcome after labor induction for late‐onset small‐for‐gestational‐age fetuses
Garcia‐Simon, R.; Figueras, F.; Savchev, S. ...
Ultrasound in obstetrics & gynecology,
December 2015, Volume:
46, Issue:
6
Journal Article
ABSTRACT
Objective
To estimate the combined value of fetal cerebral Doppler examination and Bishop score for predicting perinatal outcome after labor induction for small‐for‐gestational‐age (SGA) ...
fetuses in the presence of normal umbilical artery Doppler recordings.
Methods
We conducted a cohort study in two tertiary centers, including 164 women with normal umbilical artery Doppler recordings who underwent induction of labor because of an estimated fetal weight < 10th percentile. The fetal middle cerebral artery pulsatility index and cerebroplacental ratio (CPR) were obtained in all cases within 24 h before induction. Cervical condition was assessed at admission using the Bishop score. A predictive model for perinatal outcomes was constructed using a decision‐tree analysis algorithm.
Results
Both a very unfavorable cervix, defined as a Bishop score < 2, (odds ratio (OR), 3.18; 95% CI, 1.28–7.86) and an abnormal CPR (OR, 2.54; 95% CI, 1.18–5.61) were associated with an increased likelihood of emergency Cesarean section for fetal distress, but only the latter was significantly associated with the need for neonatal admission (OR, 2.43; 95% CI, 1.28–4.59). In the decision‐tree analysis, both criteria significantly predicted the likelihood of Cesarean section for fetal distress.
Conclusion
Combined use of the Bishop score and CPR improves the ability to predict overall Cesarean section (for any indication), emergency Cesarean section for fetal distress, and neonatal admission after labor induction for late‐onset SGA in the presence of normal umbilical artery Doppler recordings. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
Linked Comment: Ultrasound Obstet Gynecol 2015; 46: 649–649
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6.
Clinical utility of third‐trimester uterine artery Doppler in the prediction of brain hemodynamic deterioration and adverse perinatal outcome in small‐for‐gestational‐age fetuses
Cruz‐Martinez, R.; Savchev, S.; Cruz‐Lemini, M. ...
Ultrasound in obstetrics & gynecology,
March 2015, Volume:
45, Issue:
3
Journal Article
ABSTRACT
Objective
To assess the clinical value of third‐trimester uterine artery (UtA) Doppler ultrasound in the prediction of hemodynamic deterioration and adverse perinatal outcome in term ...
small‐for‐gestational‐age (SGA) fetuses.
Methods
UtA Doppler parameters, cerebroplacental ratio (CPR) and fetal middle cerebral artery (MCA) pulsatility index (PI) were evaluated weekly, starting from the time of SGA diagnosis until 24 h before induction of labor, in a cohort of 327 SGA fetuses with normal umbilical artery PI (< 95th centile), delivered at > 37 weeks' gestation. Differences in the sequence of CPR and MCA‐PI changes < 5th centile, between the group with normal UtA Doppler indices at diagnosis and those with abnormal UtA indices, were analyzed by survival analysis. In addition, the use of UtA Doppler value, alone or in combination with a brain Doppler scan before delivery, to predict the risk of Cesarean section, Cesarean section for non‐reassuring fetal status (NRFS), neonatal acidosis and neonatal hospitalization was evaluated by logistic regression analysis, adjusted for gestational age at birth and birth‐weight percentile.
Results
Abnormal UtA Doppler at diagnosis of SGA was associated with a higher risk of developing abnormal brain Doppler indices before induction of labor than in those with a normal UtA at diagnosis (62.7% vs 34.6%, respectively; P < 0.01). Compared to those with normal UtA Doppler indices, those with abnormal UtA Doppler findings were associated with a higher risk of intrapartum Cesarean section (52.2% vs 37.3%, respectively; P = 0.03), Cesarean section for NRFS (35.8% vs 23.1%, respectively; P = 0.03), neonatal acidosis (10.4% vs 7.7%, respectively; P = 0.47) and neonatal hospitalization (23.9% vs 16.5%, respectively; P = 0.16). Logistic regression analysis indicated that UtA Doppler findings were not significantly associated with adverse perinatal outcome independent of brain Doppler findings.
Conclusion
UtA Doppler indices predict adverse perinatal outcome, but do not help to improve the predictive value of brain Doppler indices. However, at the time of SGA diagnosis they identify the subgroup of fetuses at highest risk of progression to abnormal brain Doppler findings. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.
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7.
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
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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8.
Added value of umbilical vein flow as a predictor of perinatal outcome in term small‐for‐gestational‐age fetuses
Parra‐Saavedra, M.; Crovetto, F.; Triunfo, S. ...
Ultrasound in obstetrics & gynecology,
August 2013, 2013-Aug, 2013-08-00, 20130801, Volume:
42, Issue:
2
Journal Article
ABSTRACT
Objective
To compare umbilical vein (UV) flow with standard Doppler parameters in prediction of adverse perinatal outcome in late‐onset small‐for‐gestational age (SGA) fetuses.
Methods
...
Umbilical, uterine and middle cerebral arteries, and UV blood flow were evaluated by Doppler before delivery in a cohort of 193 term SGA fetuses. The value of the Doppler parameters to predict risk of emergency delivery for non‐reassuring fetal status and neonatal metabolic acidosis was analyzed.
Results
Fifty‐three (27%) fetuses had non‐reassuring fetal status requiring emergency delivery, whereas 21 (11%) newborns developed neonatal metabolic acidosis. Multivariable analysis showed that significant contributions to prediction of emergency delivery for non‐reassuring fetal status and neonatal metabolic acidosis were provided by middle cerebral artery (MCA) pulsatility index (PI) and UV blood flow normalized by fetal weight. Decision tree analysis defined three groups with increasing risk of need for emergency delivery for non‐reassuring fetal status: MCA‐PI > 1.46 (risk 15.6%); MCA‐PI ≤ 1.46 and UV blood flow > 68 mL/min/kg (risk 25%); and MCA‐PI ≤ 1.46 and UV flow ≤ 68 mL/min/kg (risk 53.1%); and two groups with different risks of neonatal metabolic acidosis: UV flow > 68 mL/min/kg or UV flow ≤ 68 mL/min/kg and MCA‐PI > 1.23 (risk ≤ 10%); and UV flow ≤ 68 mL/min/kg and MCA‐PI ≤ 1.23 (risk 39.1%).
Conclusion
The evaluation of UV blood flow with spectral brain Doppler allows better identification of SGA fetuses with late‐onset intrauterine growth restriction at risk of adverse perinatal outcome. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.
Linked Comment: Ultrasound Obstet Gynecol 2013:42:130
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9.
Fetal cardiac ventricle volumetry in the second half of gestation assessed by 4D ultrasound using STIC combined with inversion mode
Messing, B.; Cohen, S. M.; Valsky, D. V. ...
Ultrasound in obstetrics & gynecology,
August 2007, Volume:
30, Issue:
2
Journal Article
Objective
Quantification of fetal heart ventricle volume can aid in the evaluation of functional and anatomical aspects of congenital heart disease. The aim of this study was to establish nomograms ...
for ventricular volume using three‐dimensional (3D) inversion mode ultrasonography with the spatio‐temporal image correlation (STIC) modality and to calculate ejection fraction and stroke volume.
Methods
The fetal heart was scanned using the STIC modality, during fetal quiescence with abdomen uppermost, at an angle of 30–50°, without color Doppler flow mapping. In post‐processing, starting with the classic four‐chamber view plane in the A‐frame, the reference point was moved to the center of the ventricle. The operator used the edit volume followed by Virtual Organ Computer‐aided AnaLysis (VOCAL) mode options; in manual trace the VOCAL settings were set to 15°. The trace was drawn and included the myocardium; inversion mode thresholding provided the volume of the intraventricular (anechoic) voxels within the region of interest. The total volume and the intraventricular volume were displayed. The process was repeated for right (R) and left (L) ventricles at end diastole (EDV) and end systole (ESV). The stroke volume (SV = EDV − ESV) and ejection fraction (EF = SV/EDV) were calculated from these measurements. Intraclass correlation was used to evaluate intra‐ and interobserver agreement.
Results
One hundred fetuses ranging from 20 + 5 to 40 + 0 gestational weeks were included in the study. In addition, six fetuses diagnosed during the study period with a cardiac anomaly were examined and their ventricular volumes compared with those of the main study group. LEDV ranged from a mean of 0.53 cm3 at midgestation to a mean of 3.96 cm3 at term. LESV ranged from a mean of 0.17 cm3 at midgestation to 1.56 cm3 at term. REDV ranged from a mean of 0.68 cm3 at midgestation to a mean of 5.44 cm3 at term. RESV ranged from a mean of 0.26 cm3 at midgestation to 2.29 cm3 at term. Total stroke volume ranged from a mean of 0.78 cm3 at midgestation to a mean of 5.5 cm3 at term. The mean right : left ventricle ratio was 1.4, and left ejection fraction ranged from 42.5 to 86% in these fetuses. Nomograms were created for RESV, LESV, REDV, LEDV and total stroke volumes vs. estimated fetal weight and gestational age. Intra‐ and interobserver agreement reached 96%.
Conclusions
3D inversion mode sonography combined with STIC represents a simple and reproducible method for estimating fetal cardiac ventricle volume. This innovative methodology may add to overall evaluation of cardiac volume and function, and improve our understanding of normal and abnormal cardiac structure, as well as the severity and prognosis of cardiac lesions. Copyright © 2007 ISUOG. Published by John Wiley & Sons, Ltd.
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10.
Postpartum evaluation of the anal sphincter by transperineal three‐dimensional ultrasound in primiparous women after vaginal delivery and following surgical repair of third‐degree tears by the overlapping technique
Valsky, D. V.; Messing, B.; Petkova, R. ...
Ultrasound in obstetrics & gynecology,
February 2007, Volume:
29, Issue:
2
Journal Article
Objective
Intrapartum damage to the anal sphincter is an important factor in fecal incontinence. Recognized lacerations occur in 0.36–8.4% of vaginal deliveries, and occult sphincter damage in up to ...
35% of primiparous women. We examined the role of three‐dimensional transperineal ultrasound (3DTUS) in the evaluation of the anal sphincter in primiparous women after vaginal delivery and after surgical repair of third‐degree intrapartum tears by the overlapping technique.
Methods
During 2004–2005 139 primiparous women without clinically recognized third‐ to fourth‐degree anal sphincter tears were prospectively studied 24–72 h postpartum (Group 1) and 13 primiparous women were examined 48 h to 4 months following surgical repair of third‐degree tears with the overlapping technique (Group 2). A 3D 5–9‐MHz transvaginal probe was placed in the area of the fourchette and perineal body in transverse and sagittal planes and 2–4 volumes were stored. The parameters studied were: examination duration; continuity of the internal and external sphincters; occult sphincter damage; internal sphincter and external sphincter width—measured 1.5 cm from the distal margin of the anus—at the ‘12, 3, 6 and 9 o'clock positions’; length of the posterior internal sphincter.
Results
Scanning was possible in all women and the stored volumes were adequate in 127/139 (91.4%) cases. Mean examination time was 3.5 min. In Group 1, occult sphincter defect was suspected in 10/127 women (7.9%). These patients were excluded from measurement calculations, leaving 117 cases for analysis. The internal sphincter was consistently visualized in all the remaining patients (n = 117), while the external sphincter was fully visualized in 99/117 women (84.6%), and partially visualized in the remainder. Mean internal sphincter thickness was 2.60, 2.55, 2.60 and 2.72 mm at the 12, 3, 6 and 9 o'clock positions, respectively, and mean internal sphincter length was 3.34 cm. Mean external sphincter thickness was 4.15, 4.20, 4.21 and 4.20 mm at the 12, 3, 6 and 9 o'clock measurement points. In Group 2, 3DTUS confirmed anatomic abnormalities in all the women in the area surrounding the 12 o'clock position. Evaluation of sphincter tears and their position and length was possible using the longitudinal view. Thinning of the internal sphincter in the area of damage and thickening on the opposite side, the ‘half moon sign’, sphincter discontinuity, thickening of the external sphincter in the area of repair and abnormality of mucous folds, seemed to be common signs of third‐degree intrapartum sphincter tears, even after repair.
Conclusions
3DTUS is an accessible and promising method for postpartum sphincter evaluation, that is apparently well tolerated by patients. Reference data for sphincter anatomy representative of findings at transperineal ultrasound in primiparous women in the postpartum period have been established. Copyright © 2007 ISUOG. Published by John Wiley & Sons, Ltd.
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