Absent/reverse flow in the umbilical artery: A very poor prognosis

Abstract

ANNA ARYA, BERNARD STUART, SEAN DALY, Coombe Women’s Hospital, Dublin 8,Ireland, OB/GYN, Dublin, Ireland, Coombe Women’s Hospital, Dublin, Ireland OBJECTIVE: From a tertiary referral unit with more than 8000 births a year and a corrected perinatal mortality rate of 5-6 per annum, we report a six year study of outcome data on all women whose pregnancies were complicated with absent or reverse flow in the umbilical artery. STUDY DESIGN: Using the database generated from the ultrasound department we identified all women whose pregnancies were complicated with either absent or reverse flow in the umbilical artery. The obstetric and paediatric charts were reviewed. Statistical analysis was parametric and nonparametric where appriopiate. RESULTS: The total number of births over the study period was 45,620. Eighty six cases were identified giving an incidence of 0.19%. The mean gestational age at diagnosis was 30.5 (4.2) weeks. Delivery was as indicated by fetal testing (CTG and Biophysical Profile Score). The indication for the ultrasound evaluation was clinical concern about growth in 78 cases. Fifty three cases (61.6%) were hypertensive. The median birth weight was 1110g, there were 9 infants whose birth weight was!500g and none survived. Nine of the 52 times a cord ph was obtained the value was 7.2 or less. There were ten stillbirths (11.6) and 65 infants were admitted to the SCBU. There were 14 neonatal deaths giving a perinatal mortality rate of 279. The median duration of stay was 41 days (IQR 56). Fifty four (62.7%) of infants were discharged home well. CONCLUSION: Abnormal umbilical artery Doppler is associated with significant perinatal complications, even when managed and delivered within a tertiary referral unit. While these outcomes are influenced by the gestational age and birth weight intervention options to improve outcomes need to be investigated. 321 INTEGRATING DOPPLER AND BIOPHYSICAL PARAMETERS IN MANAGEMENT OF INTRAUTERINE GROWTH RESTRICTION (IUGR): MIDDLE CEREBRAL ARTERY (MCA) DOPPLER IS IRRELEVANT AHMET BASCHAT, MICHELLE KUSH, ANITA MANOGURA, DOLORES MOYANO, SIFA TURAN, CHRISTOPH BERG, AMARNATH BHIDE, BASKARAN THILAGANTHAN, HENRY GALAN, SARAH BOWER, KYPROS NICOLAIDES, ULRICH GEMBRUCH, CHRISTOPHER HARMAN, University ofMaryland at Baltimore, Obstetrics, Gynecology and Reproductive Sciences, Baltimore, Maryland, University of Maryland at Baltimore, Obstetrics & Gynecology Maternal Fetal Medicine, Baltimore, Maryland, King’s College Hospital, Obstetrics &Gynaecoloy, London, United Kingdom, King’s College Hospital, London, United Kingdom, Friedrich Wilhelm University, Bonn, Obstetrics & Prenatal Medicine, Bonn, Germany, St. George’s Hospital Medical School, Fetal Medicine Unit, London, United Kingdom, St. George’s Hospital Medical School, London, United Kingdom, University of Colorado Health Sciences Center, Obstetrics and Gynecology, Denver, Colorado OBJECTIVE: The best assessment of IUGR fetuses requires a combination of parameters testing both circulatory and behavioral responses to placental insufficiency. Integration of five Doppler measures and five componments of biophysical profile scoring may be difficult, producing a combination of alarming and reassuring results. This study addresses the need to eliminate redundant parameters from this assessment. STUDY DESIGN: In 502 IUGR fetuses (!5%ile abdominal circumference, O95%ile umbilical artery resistance), behavior of multiple test parameters was studied. Umbilical artery end-diastolic velocity, brain sparing in middle cerebral artery (MCA), ductus venosus (DV) index, reversal of a-wave in DV (DV-RAV), umbilical venous pulsation, fetal movement, tone, breathing movement, amniotic fluid volume and non-stress test were assessed in both abnormal (alarming) and normal (reassuring) domains. Using a Chi square matrix, with p value adjusted to 0.01 recognizing multiple tests, we evaluated individual parameter ability to stratify prediction of critical outcomes. A test stratified by multiple other parameters (per cent stratification O90%) was defined as redundant. A test infuencing results of other parameters !10 %, had weak stratifying power. RESULTS: Individual parameters had varying stratifying power: DV-RAV 66%, UA-EDV 61%, fetal movement 56% were most dominant, while weakest were Non-reactive NST (5.6%) and MCA (0%), for prediction of stillbirth. The tests least dependent on other tests were: UA positive EDV (0)%), DV-RAV (0%) and reactive NST (0%) and oligohydramnios (11% stratification). MCA brain sparing was 100% stratified by other tests when present, and 89% acocounted for when absent. These results were emulated for all four critical outcome paramteres. CONCLUSION: In the complex evaluation of IUGR fetsuses, multiple tests must be integrated to give the best prediction. Most parameters yield significant improvement when added to the assessment, although they differ in strength. MCA Doppler, whether alarming or reassuting, adds little or nothing.