An abnormal cerebroplacental ratio (CPR) is predictive of early childhood delayed neurodevelopment in the setting of fetal growth restriction

Abstract

Monteith at al1Monteith C. Flood K. Pinnamaneni R. et al.An abnormal cerebroplacental ratio (CPR) is predictive of early childhood delayed neurodevelopment in the setting of fetal growth restriction.Am J Obstet Gynecol. 2019; 221: 27.e1-27.e9Abstract Full Text Full Text PDF Scopus (19) Google Scholar wrote that “the presence of altered in utero neurologic hemodynamic as detailed by an abnormal cerebroplacental ratio (CPR) value is associated with poorer neurodevelopmental outcome in comparison to children from pregnancies complicated by SGA [small for gestational age].” We do not agree that this interpretation can be drawn from their data. The authors acknowledge that children with fetal growth restriction (FGR) with abnormal CPR values were born at earlier gestation and had lower birthweights. However, their concern was not that this would introduce an inherent bias to their analysis but instead that this might affect neurodevelopmental outcome assessments based on postnatal- rather than postterm-date age. Both prematurity and severity of growth restriction represent the major determinants of short- and long-term outcomes.2Van Wassenaer-Leemhuis A.G. Marlow N. Lees C. Wolf H. TRUFFLE investigatorsThe association of neonatal morbidity with long-term neurological outcome in infants who were growth restricted and preterm at birth: secondary analyses from TRUFFLE (Trial of Randomized Umbilical and Fetal Flow in Europe).BJOG. 2017; 124: 1072-1078Crossref PubMed Scopus (16) Google Scholar The authors might not be aware of a secondary analysis from the TRUFFLE study3Stampalija T. Arabin B. Wolf H. Bilardo C.M. Lees C. TRUFFLE investigatorsIs middle cerebral artery Doppler related to neonatal and 2-year infant outcome in early fetal growth restriction?.Am J Obstet Gynecol. 2017; 216: 521.e1-521.e13Abstract Full Text Full Text PDF Scopus (61) Google Scholar on 374 infants with FGR (<32 weeks) where we demonstrated that middle cerebral artery pulsatility index z-score and umbilicocerebral ratio z-score at diagnosis had some impact on 2-year infant adverse neurodevelopmental outcome; however, this effect was driven mainly by gestational age at delivery and severity of FGR. Observational studies, such as the 1 reported by Monteith et al,1Monteith C. Flood K. Pinnamaneni R. et al.An abnormal cerebroplacental ratio (CPR) is predictive of early childhood delayed neurodevelopment in the setting of fetal growth restriction.Am J Obstet Gynecol. 2019; 221: 27.e1-27.e9Abstract Full Text Full Text PDF Scopus (19) Google Scholar can demonstrate only an association between CPR and severity of FGR but cannot provide evidence that the use of the CPR to trigger delivery will improve infant outcome. The only prospective randomized study that supported the use of Doppler scanning to optimize the time of delivery in early FGR is the TRUFFLE study,4Lees C.C. Marlow N. van Wassenaer-Leemhuis A. et al.2 year neurodevelopmental and intermediate perinatal outcomes in infants with very preterm fetal growth restriction (TRUFFLE): a randomised trial.Lancet. 2015; 385: 2162-2172Abstract Full Text Full Text PDF PubMed Scopus (255) Google Scholar which showed a better 2-year neurodevelopment among survivors when computerized cardiotocography was combined with ductus venosus assessment to trigger delivery. Interestingly, a secondary analysis of these data showed that, in those managed with ductus venosus assessment, the CPR had no association with long-term outcome.5Ganzevoort W. Mensing Van Charante N. et al.How to monitor pregnancies complicated by fetal growth restriction and delivery before 32 weeks: post-hoc analysis of TRUFFLE study.Ultrasound Obstet Gynecol. 2017; 49: 769-777Crossref PubMed Scopus (39) Google Scholar Thus, we call for great caution when interpreting long-term outcome data from FGR cohorts with such a wide gestational age range without adjustment for the impact of prematurity and FGR severity. Delivery decision-making in early FGR should not be made on cerebral redistribution; in late FGR, there is still no evidence from a randomized trial that management based on cerebral redistribution might be beneficial. The impact of maternal prepregnancy impaired fasting glucose on preterm birth and large for gestational age: a large population-based cohort studyAmerican Journal of Obstetrics & GynecologyVol. 222Issue 3PreviewThe impact of maternal prepregnancy impaired fasting glucose on preterm birth and large for gestational age has been poorly understood. Full-Text PDF