Absent End-diastolic Flow Research Articles

Umbilical Artery Doppler and Adverse Outcomes in Severe Preeclampsia Without Fetal Growth Restriction: A Retrospective Cohort Study.

Background and objective Severe preeclampsia may be managed expectantly before 34 weeks gestation with close surveillance.Utilized in fetal growth restriction (FGR), evidence supports umbilical artery (UA) Dopplerpreventing neonatal morbidity from hypertensive disease and predicting adverse outcomes in preeclampsia. We evaluated the association of abnormal UA Doppler waveforms with early delivery (before 34 weeks gestation) and adverse maternal-fetal outcomes in patients with early severe preeclampsia without FGR. Methodology This is a retrospective cohort study of singleton pregnancies with International Classification of Diseases (ICD) Ninth or Tenth Revision, defined severe preeclampsia diagnosed before 34 weeks gestation without FGR from January 1, 2018, through January 27, 2023, at a large tertiary care center where S/D ratios were calculated from UA Doppler interrogation of a free loop of cord at least once weekly. This study was approved by the IRB (ID:00002216) and granted a full Health Insurance Portability and Accountability Act (HIPAA) waiver of consent. Exclusion criteria were major congenital anomalies, congenital infection, aneuploidy, leaving against medical advice >24 hours, and patient instability on admission defined as condition(s) precluding expectant management by the American College of Obstetrics and Gynecology. The primary outcome was delivery before 34 weeks gestation. Secondary outcomes were the mode of delivery and maternal/fetal complications. Patient characteristics and outcomes for normal versus abnormal UA Doppler groups were compared with chi-square, t-tests, and Fisher's exact test. Odds ratios and relative risks were calculated to compare outcomes. Results Of 194 patients with severe preeclampsia, 107 met inclusion criteria. Thirty-four patients had abnormal UA Doppler studies. There were no differences in demographic and clinical data between patients with normal and abnormal UA Doppler studies. Patients with abnormal UA Doppler studies were more likely to deliver before 34 weeks (OR=3.91; 95%CI 1.24-12.33) for worsening severe features (OR=3.85; 95% CI 1.42-10.41), and were less likely to deliver vaginally (OR=0.12; 95% CI 0.03-0.54). Abnormal UA Doppler studies were associatedwith an increased risk of neonatal complications (OR=6.46; 95% CI 1.42-29.42) and respiratory distress syndrome (RDS) (OR=4.75; 95%CI 1.32-17.16). Abnormal UA Doppler subgroups were divided into patients with elevated S/D >95% Acharya (N=22) and absent end-diastolic flow (EDF) (N=10). The elevated S/D group tended to deliver before 34 weeks gestation for worsening severe features (OR=3.71, 95% CI 1.144-12.050) and had a higher risk of neonatal complications (RR 1.404; 95% CI 1.213-1.624). The absent EDF subgroup was more likely to deliver before 34 weeks (RR=1.52; 95%CI 1.29-1.79) for abnormal fetal testing (OR=6.92; 95%CI 1.71-28.08) and undergo primary cesarean delivery (OR=7.23; 95%CI 1.43-36.61). Conclusion Pregnancies with severe preeclampsia without FGR displayed a high incidence of abnormal UA Doppler waveforms associated with loss of clinical stability and adverse fetal outcomes. The groups with more impedance to umbilical artery flow tended to deliver earlier, and as the Doppler shifted from elevated S/D to absent end-diastolic flow, the mode of delivery shifted to cesarean delivery with increased risk of abnormal fetal testing. These results support the utility of UA Doppler surveillance in severe preeclampsia.

Neurodevelopmental outcomes at 2 years in children who received sildenafil therapy in utero: The STRIDER randomised controlled trial.

Severe early-onset fetal growth restriction (FGR) causes stillbirth, neonatal death and neurodevelopmental impairment. Poor maternal spiral artery remodelling maintains vasoactive responsiveness but is susceptible to treatment with sildenafil, a phosphodiesterase type 5 (PDE5) inhibitor, which may improve perinatal outcomes. Superiority, double-blind randomised controlled trial. A total of 20 UK fetal medicine units. Pregnancies affected by FGR, defined as an abdominal circumference below the tenth centile with absent end-diastolic flow in the umbilical artery between 22+0 and 29+6 weeks of gestation. Treatment with sildenafil (25 mg three times/day) or placebo until delivery or 32 weeks of gestation. All infants alive at hospital discharge were assessed for cardiovascular function and cognitive, speech/language and neuromotor impairment at 2 years of age. The primary outcome was survival without cerebral palsy or neurosensory impairment, or a Bayley-III composite score of >85. In total, 135 women were randomised between November 2014 and July 2016 (70 to sildenafil and 65 to placebo). We previously published that there was no improvement in time to delivery or perinatal outcomes with sildenafil. In all, 75 babies (55.5%) were discharged alive, with 61 infants eligible for follow-up (32 sildenafil and 29 placebo). One infant died (placebo), three mothers declined and ten mothers were uncontactable. There was no difference in neurodevelopment or blood pressure following treatment with sildenafil. Infants who received sildenafil had a larger head circumference at 2 years of age (median difference 49.2 cm, IQR 46.4-50.3, vs 47.2 cm, 95% CI 44.7-48.9 cm). Sildenafil therapy did not prolong pregnancy or improve perinatal outcomes and did not improve infant neurodevelopment in FGR survivors. Therefore, sildenafil should not be prescribed for this condition.

Doppler Ultrasonographic Assessment of Abdominal Aortic Flow to Evaluate the Hemodynamic Relevance of Left-to-Right Shunting Patent Ductus Arteriosus in Dogs.

In this multicenter, prospective, observational study, abdominal aortic flow was examined with pulsed-wave Doppler ultrasound in dogs with a left-to-right shunting patent ductus arteriosus (PDA) and in apparently healthy dogs. Forty-eight dogs with a PDA and 35 controls were included. In the dogs with a PDA, 37/48 had hemodynamically significant PDAs (hsPDAs) while 11/48 had non-hsPDAs, based on the presence or absence of echocardiographic signs of left-sided volume overload, respectively. In 12 dogs (4/35 control dogs, 7/37 dogs with an hsPDA and 1/11 dogs with a non-hsPDA), the diastole was too short to visualize the end-diastolic flow. Antegrade end-diastolic flow was observed in 30/35 controls and 6/11 dogs with a non-hsPDA. Absent end-diastolic flow was observed in 1/35 control dogs and 3/11 dogs with a non-hsPDA. Retrograde end-diastolic flow was observed in 30/37 dogs with an hsPDA and 1/11 dogs with a non-hsPDA. Twenty-one dogs (15 with an hsPDA and 6 with a non-hsPDA) were reassessed after PDA closure, and, in 19/21, end-diastolic flow was visualized: 17/19 showed an antegrade flow, 1/19 an absent flow and 1/19 a retrograde flow. Sensitivity and specificity of retrograde end-diastolic flow for detection of hsPDAs were 100% and 90%, respectively. In conclusion, ultrasonographic assessment of abdominal aortic flow was feasible in dogs with PDA. However, end-diastolic flow was not always visualized. The presence of a retrograde end-diastolic flow was an accurate finding for discriminating hsPDAs and non-hsPDAs.

The association between discordant umbilical arterial resistance in growth-restricted fetuses and adverse outcomes

Assessing the umbilical artery pulsatility index via Doppler measurements plays a crucial role in evaluating fetal growth impairment. This study aimed to investigate perinatal outcomes associated with discordant pulsatility indices of umbilical arteries in fetuses with growth restriction. In this retrospective cohort study, all singleton pregnancies were included if their estimated fetal weight and/or abdominal circumference fell below the 10th percentile for gestational age (2017-2022). Eligible cases included singleton pregnancies with concurrent sampling of both umbilical arteries within 14 days of birth at the ultrasound evaluation closest to delivery. The exclusion criteria included births before 22 weeks of gestation, evidence of absent or reverse end-diastolic flow in either umbilical artery, and known fetal genetic or structural anomalies. The study compared cases with discordant umbilical artery pulsatility index values (defined as 1 umbilical artery pulsatility index at ≤95th percentile and the other umbilical artery pulsatility index at >95th percentile for gestational age) to pregnancies where both umbilical artery pulsatility indices had normal pulsatility index values and those with both umbilical arteries displaying abnormal pulsatility index values. The primary outcome assessed was the occurrence of composite adverse neonatal outcomes. Multivariable logistic regressions were performed, adjusting for relevant covariates. The study encompassed 1014 patients, including 194 patients (19.1%) with discordant umbilical artery pulsatility index values among those who had both umbilical arteries sampled close to delivery, 671 patients (66.2%) with both umbilical arteries having normal pulsatility index values, and 149 patients (14.7%) with both umbilical arteries exhibiting abnormal values. Pregnancies with discordant umbilical artery pulsatility index values displayed compromised sonographic parameters compared with those with both umbilical arteries showing normal pulsatility index values. Similarly, the number of abnormal umbilical artery pulsatility index values was associated with adverse perinatal outcomes in a dose-response manner. Cases with 1 abnormal (discordant) umbilical artery pulsatility index value showed favorable sonographic parameters and perinatal outcomes compared with cases with both abnormal umbilical artery pulsatility index values, and cases with both abnormal umbilical artery pulsatility index values showed worse sonographic parameters and perinatal outcomes compared with cases with discordant UA PI values. Multivariate analysis revealed that discordant umbilical artery pulsatility indices were significantly and independently associated with composite adverse perinatal outcomes, with an adjusted odds ratio of 1.75 (95% confidence interval, 1.24-2.47; P = .002). Evaluating the resistance indices of both umbilical arteries may provide useful data and assist in assessing adverse perinatal outcomes among fetuses with growth restriction.

The predictive value of uterine artery Doppler in the success rate of pregnancy from the first frozen embryo transfer during the implantation window

BackgroundWorldwide, frozen embryo transfer (FET) has become a new strategy for the treatment of infertility. The success of FET is closely related to endometrial receptivity. Does uterine artery Doppler during the implantation window predict pregnancy outcome from the first FET?MethodsA total of 115 retrospectively collected cycles were included in the study, with 64 cycles of clinical pregnancy and 51 cycles of nonclinical pregnancy; There were 99 nonabsent end-diastolic flow (NAEDF) cycles and 16 absent end-diastolic flow (AEDF) cycles. The differences in uterine artery Doppler findings between different pregnancy outcomes were investigated. The clinical pregnancy rate and spontaneous abortion rate in the NAEDF and AEDF groups were compared. The predictive value of uterine artery Doppler during the implantation window in the success rate of pregnancy from the first FET was also investigated.ResultsBetween the clinical pregnancy group and the nonclinical pregnancy group, there were no significant differences in the mean resistance index (mRI) (Z = -1.065, p = 0.287), mean pulsatility index (mPI) (Z = -0.340, p = 0.734), and mean peak systolic/end-diastolic velocity(mS/D) (Z = -0.953, p = 0.341); there were significant differences in the mean peak systolic velocity (mPSV) (Z = -1.982, p = 0.048) and mean end-diastolic velocity (mEDV) (Z = -2.767, p = 0.006). Between the NAEDF and AEDF groups, there was no significant difference in the clinical pregnancy rate (χ2 = 0.003, p = 0.959), and there was a significant difference in the spontaneous abortion rate (χ2 = 3.465, p = 0.019). Compared with uterine artery Doppler alone, its combination with artificial abortion history, waist-to-hip ratio, LH (Luteinizing hormone) of P (Progesterone) administration day, mPSV and mEDV had a higher predictive value regarding clinical pregnancy from the first FET [ROC-AUC 0.782, 95% CI (0.680–0.883) vs. 0.692, 95% CI (0.587–0.797)].ConclusionsUterine artery Doppler, particularly mPSV and mEDV during the implantation window, was useful for predicting clinical pregnancy, and AEDF was related to spontaneous abortion in the first trimester. Uterine artery Doppler combined with artificial abortion history, waist-to-hip ratio, LH of P administration day, mPSV and mEDV have a higher predictive value than uterine artery Doppler alone regarding the pregnancy from the first FET.

Bilateral fetal hydrothorax accompanying with absent umbilical arterial end-diastolic flow, trisomy 21 and polyhydramnios.

Bilateral fetal hydrothorax accompanying with absent umbilical arterial end-diastolic flow, trisomy 21 and polyhydramnios.

Neurodevelopmental outcomes of very preterm infants born following early foetal growth restriction with absent end-diastolic umbilical flow

This study aims to assess the impact of time of onset and features of early foetal growth restriction (FGR) with absent end-diastolic flow (AEDF) on pregnancy outcomes and on preterm infants’ clinical and neurodevelopmental outcomes up to 2 years corrected age. This is a retrospective, cohort study led at a level IV Obstetric and Neonatal Unit in Bologna, Italy. Pregnant women were eligible if having singleton pregnancies, with no major foetal anomaly detected, and diagnosed with early FGR + AEDF (defined as FGR + AEDF detected before 32 weeks gestation). Early FGR + AEDF was further classified according to time of onset and specific features into very early and persistent (VEP, FGR + AEDF first detected at 20–24 weeks gestation and persistent at the following scans), very early but transient (VET, FGR + AEDF detected at 20–24 weeks gestation and progressively improving at the following scans) and later (LA, FGR + AEDF detected between 25 and 32 weeks gestation). Pregnancy and neonatal outcomes and infant follow-up data were collected and compared among groups. Neurodevelopment was assessed using the revised Griffiths Mental Developmental Scales (GMDS-R) 0–2 years. A regression analysis was performed to identify early predictors of preterm infants’ neurodevelopmental impairment. Fifty-two pregnant women with an antenatal diagnosis of early FGR + AEDF were included in the study (16 VEP, 14 VET, 22 LA). Four intrauterine foetal deaths occurred, all in the VEP group (p = 0.010). Compared to LA infants, VEP infants were born with lower gestational age and lower birth weight, had lower arterial cord blood pH and were at higher risk for intraventricular haemorrhage and periventricular leukomalacia (p < 0.05 for all comparisons). At 12 months, VEP infants had worse GMDS-R scores, both in the general quotient (mean [SD] 91.8 [12.4] vs 104.6 [8.7] in LA) and in the performance domain (mean [SD] 93.3 [15.4] vs 108.8 [8.8] in LA). This latter difference persisted at 24 months (mean [SD] 68.3 [17.0] vs 92.9 [17.7] in LA). In multivariate analysis, at 12 months corrected age, PVL was found to be an independent predictor of impaired general quotient, while the features and timing of antenatal Doppler alterations predicted worse scores in the performance domain. Conclusion: Timing of onset and features of early FGR + AEDF might impact differently on neonatal clinical and neurodevelopmental outcomes. Shared awareness of the importance of FGR + AEDF features between obstetricians and neonatologists may offer valuable tools for antenatal counselling and for tailoring pregnancy management and neonatal follow-up in light of specific antenatal and neonatal risk factors.What is Known:• Foetal growth restriction (FGR), together with antenatal umbilical Doppler abnormalities, is known to affect maternal and neonatal outcomes.• Infants born preterm and growth-restricted face the highest risk for neurodevelopmental impairment, especially when FGR occurs early during pregnancy (early FGR, before 32 weeks gestation).What is New:• The timing of onset and features of FGR and antenatal umbilical Doppler abnormalities impact differently on maternal and neonatal outcomes; when FGR and Doppler abnormalities occur very early, at the limit of neonatal viability, and persist until delivery, infants face the highest risk for neurodevelopmental impairment.• Shared knowledge between obstetricians and neonatologists about timing of onset and features of FGR would provide a valuable tool for informed antenatal counselling in high-risk pregnancies.

Impact on postoperative, neonatal and 2-year neurodevelopmental outcomes of UA-AREDF during and after fetal spina bifida repair.

Absent or reversed end-diastolic flow (AREDF) in the umbilical artery (UA) on Doppler is a known phenomenon during fetal interventions, such as fetal open spina bifida (OSB) repair. We aimed to evaluate the clinical importance of these Doppler findings by investigating the impact of UA-AREDF on postoperative, neonatal and 2-year neurodevelopmental outcomes. This was a prospective study of pregnancies undergoing fetal OSB repair at the Zurich Center for Fetal Diagnosis and Therapy between 2010 and 2019. The group with UA-AREDF during or immediately after the intervention was compared to the group with normal UA Doppler. Primary endpoint was the FIGO scores of cardiotocography (CTG) 1, 2 and 6 h postoperatively and on day 1 after surgery. Secondary endpoints were the neonatal parameters and 2-year neurodevelopmental outcome assessed using the Bayley Scales of Infant and Toddler Development, Third Edition. Data of 130 patients were analyzed. None of the fetuses had UA-AREDF before OSB repair. Normal UA Doppler was observed in 107 (82%) patients and UA-AREDF was observed in 23 (18%) during or immediately after OSB surgery. UA-AREDF was more often observed after version of the fetus (P = 0.045). Seventeen (13%) cases had absent end-diastolic flow (UA-AEDF) and six (5%) cases had reversed end-diastolic flow (UA-REDF). UA-AREDF disappeared in all 23 cases within the first day after OSB surgery. One-third of all CTGs were restricted in oscillation after surgery, but no significant difference in CTG 1, 2 and 6 h postoperatively or on the first postoperative day was found between the UA-AREDF and normal-Doppler groups (P > 0.05). Gestational age at delivery, UA pH, 5-min Apgar score and birth weight were comparable between the two groups, and there was no difference in the 2-year neurodevelopmental outcome (P > 0.05). The neonatal and 2-year neurodevelopmental outcomes also did not differ significantly between the UA-REDF and UA-AEDF groups. Postoperative CTG abnormalities occur and recover at a similar rate in fetuses with transitory UA-AREDF and those with normal Doppler during fetal OSB repair. UA-AREDF during fetal OSB repair did not negatively influence postnatal or 2-year neurodevelopmental outcomes. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Aortic Isthmus Retrograde Blood Flow in Intrauterine Child as a Sign of the Terminal Stage of Placental Dysfunction: Clinical Observation

Background. Aortic isthmus retrograde blood flow in intrauterine children with growth delay and centralization of blood circulation in the late stages of placental dysfunction is associated with a high risk of perinatal death. Timely diagnosis of such condition is crucial to select further obstetric tactics and delivery time. Clinical case description. Growth delay and absent end-diastolic flow in umbilical artery and no A-wave in the venous duct were diagnosed in intrauterine child (gestational age — 36 weeks) at ultrasound study. Peripheral resistance indices in middle cerebral artery in the intrauterine child were lower than peripheral resistance indices in umbilical artery. Color Doppler imaging has revealed aortic isthmus retrograde blood flow. The woman was recommended delivery due to critical circulatory disorder in the intrauterine child. Female child was delivered via Caesarean section, child’s weight — 890 g, APGAR score — 3/4. The newborn girl died due to multi-organ failure within the first day.Conclusion. Revealing the retrograde blood flow in intrauterine child in the aortic isthmus throughout the entire ventricular diastole is an unfavorable prognostic sign of the terminal stage of cerebral blood flow disturbance associated with placental dysfunction.

A case of type III selective intrauterine growth restriction in a monochorionic twin pregnancy with a myriad of Doppler changes of the umbilical and vitelline arteries

Monochorionic twins have higher mortality rates than dichorionic twins. Selective intrauterine growth restriction (sIUGR) is a common complication found in monochorionic twins. We report such a case of type III sIUGR monochorionic twins. There was positive end-diastolic flow of umbilical arteries, which corresponded to type I sIUGR at 15 weeks. Then, the umbilical arteries showed persistently absent end-diastolic flow at 17 weeks which corresponded to type II sIUGR. Finally, the umbilical artery showed intermittent absent/reversed end-diastolic flow which corresponded to type III sIUGR. This case demonstrated a unique myriad of Doppler changes during the pregnancy, indicating its significance in being reported. The twins were delivered by caesarean section at 32 weeks and were developing well. Placental examination showed unequal placental sharing and the presence of an arterio-arterial anastomosis. These are characteristic findings of a type III sIUGR. Type III sIUGR may not be obvious at the initial examination but may only be obvious at later examinations.

Fetal büyüme kısıtlılığı ile komplike gebeliklerde fetal timus boyutunun değerlendirilmesi

Aim: To evaluate fetal thymus size using the thymic-thoracic ratio (TTR) in women with a pregnancy complicated with fetal growth restriction (FGR) and to assess the relationship with adverse perinatal outcomes. &#x0D; Materials and Method: A total of 35 pregnant women with FGR and 42 healthy pregnant women with similar demographic characteristics were included in this prospective study. In the FGR group, cases with pathological doppler flow parameters of absent end-diastolic flow (AEDF) in an umbilical artery and cerebroplacental ratio (CPR)

Maternal Steroids on Fetal Doppler Indices, in Growth-Restricted Fetuses with Abnormal Umbilical Flow from Pregnancies Complicated with Early-Onset Severe Preeclampsia.

Corticoids are largely used for fetal interest in expected preterm deliveries. This study went further, evaluating the effect of maternal administration of dexamethasone (Dex) on the umbilical artery (UA), middle cerebral artery (MCA), and ductus venous (DV) spectrum, in growth-restricted fetuses, with the absent end-diastolic flow (AEDF) in UA, from singleton early-onset severe preeclamptic pregnancies. Supplementary, the impact on both uterine arteries (UTAs) flow was also evaluated. In 68.7% of cases, the EDF was transiently restored (trAEDF group), in the rest of 31.2% remained persistent absent (prAEDF group). UA-PI significantly decreased in the first day after Dex (day 1/0; p < 0.05), reaching its minimum during day 2 (day 2/1; p > 0.05), revealing a significant recovery to day 4 (day 4/2; p < 0.05), in both groups. The MCA-PI decreased from day 1 until day 3 in both groups, but significantly only in the trAEDF group (p = 0.030 vs. p = 0.227. The DV-PI's decrease (during day 1) and the CPR's increase (between days 0 and 2) were not significant in both groups. UTAs-PIs did not vary. The prAEDF group had a significantly increased rate of antenatal worsening Doppler and a poorer perinatal outcome compared with the trAEDF group. In conclusion, Dex transiently restored the AEDF in UA in the majority of cases, a "positive" effect being a useful marker for better perinatal prognosis. UA-PI significantly decreased in all cases. The improvement in umbilical circulation probably was responsible for the short but not significant DV-PI reduction. MCA-PI decreased only in sensitive cases, probably due to an already cerebral "full" vasodilation in the prAEDF group. Furthermore, the CPR's nonsignificant improvement was the result of a stronger effect of Dex on UA-PI than on MCA-PI. Finally, despite the same etiology, it was only a weak correlation between the severity of the umbilical and uterine abnormal spectrum.

Factors associated with latency duration in growth-restricted fetuses with absent end diastolic flow

Gestational latency after findings of abnormal umbilical artery doppler indices, such as absent end diastolic flow (AEDF), in the setting of fetal growth restriction (FGR), is important yet difficult to predict. Our objective was to describe latency and factors associated with prolonged latency in growth-restricted fetuses with AEDF.

Machine learning of umbilical artery doppler flow improves prognostication in fetal growth restriction

Umbilical artery doppler (UAD) is an important tool in deciding appropriate delivery timing in fetal growth restriction (FGR) cases. UAD flow demonstrating absent or reversed end diastolic flow is associated with stillbirth, but early abnormal UAD are not clearly predictive of poor outcomes. Machine learning (ML) is a useful tool in detecting nuances in blood flow data that may more accurately predict outcomes. The purpose of this study is to determine if UAD ML improves FGR prognostication. UAD and clinical data were obtained from FGR affected pregnancies from the Iowa Intergenerational Health Knowledgebase containing data for pregnancies receiving prenatal care at a major midwestern academic medical center since 2009 (N >63000). UAD severity groups were determined (Normal, Elevated S/D [ > 95% percentile], Absent End Diastolic Flow [AEDF], and Reversed EDF [REDF]). The UAD images were optimized for ML analyses. Xception (Google) machine learning framework was used. Regression analyses were performed to identify important clinical covariates. Birth weight decreased with severity of UAD category (p < 0.001). Gestational age at delivery was shown to decrease with increasing severity of IUGR as well (p < 0.001). In line with clinical practices, diagnosis to delivery time (DDT) increased from Normal to Absent End Diastolic Flow, and then decreased for Reversed End Diastolic Flow (P = 0.03). Preeclampsia was associated with the higher categories of UAD severity (P = 0.0007). Poor neonatal outcomes were not more severe for one group, but high in all categories, ranging from 64-82 percent (p = 0.4). Machine learning of the UAD alone (R2 = 0.84) was more associated with DDT than clinical variables alone (R2 = 0.24) and clinical variables with UAD categorization (R2 = 0.75) ML of UAD alone was more associated with the diagnosis to delivery time then other traditional prediction factors in FGR pregnancies. We conclude that ML of UAD images will add additional predictive power to FGR prognostication.

Clinical significance of intermittent absent end-diastolic flow of the umbilical artery in fetal growth restriction

Fetal growth restriction can result from a variety of maternal, fetal, and placental conditions. Umbilical artery Doppler assesses the impedance to blood flow along the fetal component of the placental unit. An abnormal umbilical artery waveform reflects the presence of placental insufficiency and can help differentiate a growth-restricted fetus from the constitutionally small, thus guiding further management. The presence of persistently absent end-diastolic flow and reversed end-diastolic flow is an indication for inpatient antenatal surveillance and preterm delivery. There is no consensus on the optimal management of intermittent absent end-diastolic flow owing to a lack of data to support the ideal delivery timing for growth-restricted fetuses with this finding. This study aimed to estimate the risks of adverse perinatal outcomes among growth-restricted pregnancies with persistently elevated, intermittently absent, and persistently absent end-diastolic flow. Fetal growth restriction is a common condition that is associated with an increased risk of fetal morbidity and mortality. Intermittently absent umbilical artery end-diastolic flow may be identified among pregnancies with fetal growth restriction. The fetal risks associated with persistently absent end-diastolic flow have been described. However, the risks associated with intermittent absent end-diastolic flow are not as well-known. We performed a retrospective cohort study including nonanomalous, singleton, growth-restricted pregnancies that received umbilical artery Doppler assessment at our institution from 2009 to 2020. Fetuses were classified into the following 3 categories: elevated umbilical artery Doppler, intermittent absent end-diastolic flow, and persistently absent end-diastolic flow. The Doppler categories were classified by the most severe in the pregnancy. The primary outcome was a composite of neonatal morbidity. Total 233 fetuses met the criteria. Of which 78 (33.0%) had elevated umbilical artery Doppler waveforms, 37 (16.0%) had intermittent absent end-diastolic flow, and 119 (51.0%) had absent end-diastolic flow. The composite outcome was statistically different between the groups, occurring in 16.9% with elevated umbilical artery Doppler waveforms (13/77), 35.1% (12/39) with intermittent absent end-diastolic flow, and 56.3% (65/127) with absent end-diastolic flow (P<.001).The odds ratio for the composite outcome was significantly increased in absent end-diastolic flow (odds ratio, 6.15; 95% confidence interval, 3.14-12.80) and was not significantly increased for intermittently absent end-diastolic flow (odds ratio, 2.46; 95% confidence interval, 0.98-6.19) when compared with elevated umbilical artery Doppler waveforms. When adjusted for gestational age at delivery and antenatal steroids, no difference was seen in the primary outcome for intermittent absent end-diastolic flow (adjusted odds ratio, 0.73; 95% confidence interval, 0.20-2.68) and absent end-diastolic flow (adjusted odds ratio, 1.44; 95% confidence interval, 0.51-4.07). Among growth-restricted pregnancies, intermittent absent end-diastolic flow is associated with a similar rate of composite neonatal morbidity as persistently elevated Doppler waveforms. In addition, there is no difference in composite neonatal morbidity between the 3 groups when corrected for gestational age at delivery and antenatal steroid administration. These similar outcomes should be considered when creating an antenatal surveillance plan and discussing the potential for outpatient management.

Adverse Perinatal Outcomes of True Knot of the Umbilical Cord: A Case Series and Review of Literature

A true knot of the umbilical cord (TKUC) is an actual knot formed in pregnancy. It is seen in approximately 0.3%-1.2% of all pregnancies. True knots are of significance as they can cause a wide spectrum of adverse perinatal outcomes like small for gestational age (SGA) fetus, low appearance, pulse, grimace, activity, and respiration (Apgar) score at birth, fetal hypoxia, and even fetal demise.Here, we report a case series of three patients with TKUC and the varied adverse perinatal outcomes associated with them. A low-risk primigravida at term gestation had a suspicious non-stress test (NST). Repeat NST after maternal resuscitation became pathological. Emergency cesarean delivery was performed in view of pathological NST persisting despite intrauterine resuscitation. A healthy male baby weighing 2920 g was delivered, and the umbilical cord had a true knot.A multigravida at 33 + 3 weeks of gestation was referred with fetal growth restriction (FGR). Color Doppler examination showed absent end-diastolic flow (AEDF) in the umbilical artery (UA). Cesarean delivery was performed in view of FGR stage two with AEDF in the UA at 34 weeks of gestation as per the Barcelona criteria. A male baby weighing 1505 g was delivered. The umbilical cord had a true tight knot. The baby had an Apgar score of 7 at one minute after birth but was shifted to the neonatal intensive care unit (NICU) in view of low birth weight and prematurity. The baby slowly gained weight and was discharged from NICU after 15 days in stable condition.A multigravida at 32 weeks of gestation was referred with intrauterine fetal demise. Ultrasonography confirmed the presence of a single intrauterine dead fetus corresponding to 30 + 4 weeks of gestation with an estimated fetal weight (EFW) of 1633 g, amniotic fluid index (AFI) equal to nine, and presence of Spalding’s sign. Induction of labor was done, and she expelled a dead macerated male fetus weighing 1825 g. The infantogram was normal. A true umbilical cord knot was found.The umbilical cord is the source of fetal blood supply; therefore, any cord abnormality can have a significant impact on the fetal outcome. There are various factors that can predispose to TKUC, such as polyhydramnios, increased cord length, monoamniotic twins, male baby, grand multiparity, small fetus, and amniocentesis. TKUC can lead to various adverse outcomes in pregnancy and labor like SGA fetus, low Apgar score at birth, fetal hypoxia, and fetal demise. TKUC increases the risk of fetal demise by as much as four times.With the development of advanced techniques such as three-dimensional/four-dimensional color Doppler ultrasounds, TKUC can be diagnosed antenatally in the form of a four-leaf-clover, a “hanging-noose sign,” or by an unusual multicolor pattern in the cord. The prenatal detection rate of TKUC is only 12%. It mostly remains undetected unless visualized incidentally. Although TKUC is not rare and can have serious outcomes, the importance of its antenatal diagnosis has not been determined. It should be suspected in patients with risk factors, and emphasis should be placed on its antenatal diagnosis on ultrasonography to avoid obstetric disasters in otherwise low-risk females. Though there is no specific management of these cases, a good clinical outcome can be achieved if TKUC is diagnosed antenatally and monitored closely until fetal maturity is attained.

Identifying the High-Risk Fetus in the Low-Risk Mother Using Fetal Doppler Screening.

Identifying the high-risk fetus in the low-risk pregnant mother (LRM) is a neglected area of research. Fetal growth restriction (FGR) is a major cause of stillbirths, especially in low- and middle-income countries (LMICs). FGR is very poorly detected particularly in healthy pregnant women classified as low risk. Umbiflow is an inexpensive continuous-wave Doppler ultrasound (CWDU) apparatus that is suitable for use by low-level health care providers for screening low-risk pregnant populations. It can easily detect umbilical artery blood flow in the cord, which correlates well with placental function, and poor placental function correlates well with FGR.Use of CWDU to screen an LMIC population of more than 7,000 LRMs has demonstrated a high prevalence of abnormal umbilical artery flow of 13%, and absent end-diastolic flow, which is associated with end-stage placental disease, was found in 1.2%. This is 10 times higher than previously reported in high-income countries. Screening with CWDU together with a standard protocol managing those pregnancies with abnormal placental blood flow resulted in a 43% reduction in stillbirths (risk ratio: 0.57; 95% confidence interval=0.29, 0.85) in this LRM population. Further, follow-up of infants who had abnormal umbilical artery blood flow showed that these infants had significantly less fat-free mass at ages 6 weeks, 10 weeks, 14 weeks, and 6 months, than those with normal umbilical artery blood flow (P&lt;.015), confirming that CWDU was able to detect true FGR.Thus, screening with CWDU can detect the fetus at risk of stillbirth, and infants likely to have suboptimal growth and development postnatally. Screening with CWDU in LRMs opens the door to a step change in preventing stillbirths in LMICs.

Maternal Blood Angiogenic Factors and the Prediction of Critical Adverse Perinatal Outcomes Among Small-for-Gestational-Age Pregnancies.

Our objective was to determine whether maternal blood angiogenic factors in suspected-small-for-gestational-age (sSGA) fetuses can predict critical adverse perinatal outcomes (CAPO) and improve risk assessment. Women with singleton pregnancies diagnosed with sSGA, between 24 and 356/7 weeks' gestation, were included. Clinical and sonographic comprehensive evaluations were performed at enrolment. Plasma angiogenic factors, soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF), were obtained at diagnosis. In parallel, three attending maternal-fetal-medicine specialists predicted the risk (1-5 scale) of these pregnancies to develop CAPO, based on the clinical presentation. CAPOs were defined as prolonged neonatal intensive care unit hospitalization, fetal or neonatal death, and major neonatal morbidity. Statistical analysis included sensitivity, specificity, positive and negative predictive values, and receiver-operating characteristic (ROC) curve analyses. Of the 79 cases included, 32 were complicated by CAPO (40.5%). In SGA fetuses with CAPO, the sFlt-1/PlGF ratio was higher (p < 0.001) and PlGF was lower (p < 0.001) as compared with uncomplicated pregnancies. The areas under the ROC curves for specialists were 0.913, 0.824, and 0.811 and for PlGF and sFlt-1/PlGF ratio 0.926 and 0.900, respectively. CAPO was more common in pregnancies with absent end-diastolic flow or reversed end-diastolic flow (AEDF or REDF) in the umbilical artery upon enrolment (91.6%). Yet, 65.6% of cases involving CAPO occurred in patients without AEDF or REDF, and 66.6% of these cases were not identified by one or more of the experts. The sFlt-1/PlGF ratio identified 92.9% of the experts' errors in this group and 100% of the errors in cases with AEDF or REDF. Among sSGA pregnancies prior to 36 weeks' gestation, angiogenic factors testing can identify most cases later complicated with CAPO. Our data demonstrate for the first time that these markers can reduce clinician judgment errors. Incorporation of these measures into decision-making algorithms could potentially improve management, outcomes, and even health care costs. · Angiogenic factors at diagnosis of sSGA can be used to predict CAPO.. · The sFlt-1/PlGF ratio can flag sSGA pregnancies at increased risk.. · The sFlt-1/PlGF ratio at admission of sSGA adds to clinical assessment..

Antihypertensive Drugs and Perinatal Outcomes in Hypertensive Women Attending a Specialized Tertiary Hospital.

ObjectivesWe sought to identify the most commonly used antihypertensive medications in pregnant women and to determine the impact of these medications on perinatal (maternal and fetal) outcomes.MethodsThe medical records of 484 hypertensive pregnant women who attended a tertiary university hospital during the study period were retrospectively evaluated for eligibility. Singleton pregnancies of women on antihypertensive medications and who delivered in the hospital were included in the study.ResultsA total of 210 women (mean age of 32.4±5.6 years and mean body mass index of 34.0±8.1 kg/m2) were eligible for inclusion in the study. The most prevalent subtype of hypertension was preeclampsia (41.4%). Low birth weight (LBW), preterm delivery (PTD), intrauterine growth restriction (IUGR), small for gestational age (SGA), respiratory distress syndrome, and neonatal care unit admissions were significantly higher in women with preeclampsia than in the women with other types of hypertension. Labetalol was the most commonly prescribed antihypertensive drug. There were 101 (48.1%) women on combined therapy. LBW, PTD, IUGR, SGA, respiratory distress syndrome, absent end diastolic flow, neonatal care unit admission, preeclampsia, and high dependency unit admissions of mothers were significantly higher in the women who received combined therapy.ConclusionsLabetalol was the most commonly prescribed antihypertensive drug in this cohort, and women on combined antihypertensive medications had significantly higher maternal and fetal complications. A larger prospective study including hypertensive women with or without antihypertensive medications in more than one center is needed to evaluate the effect of these drugs on perinatal outcomes.

The relationship between postnatal hypoglycemia and umbilical artery Doppler ultrasonography in neonates with intrauterine growth restriction: A longitudinal follow-up study

BackgroundIntrauterine growth restriction (IUGR) refers to fetuses with an estimated ultrasonography weight below the 10% percentile. Hypoglycemia is a major concern in neonates with IUGR.ObjectiveTo investigate the relationship between umbilical artery (UA) Doppler ultrasonography and neonate hypoglycemia and IUGR.Materials and MethodsThis was a longitudinal follow-up study consisting of 114 neonates (gestational age of 28-40 wk) born with IUGR in the third trimester of pregnancy at Shahid Sadoughi Hospital, Yazd, Iran between May 2016 and October 2017. The neonates were assigned into three subgroups of normal UA Doppler, absent end-diastolic flow (EDF) in UA Doppler, and reverse EDF in UA Doppler. The blood glucose of the neonates was checked one, two, three, six, 12, 24 and 48 hr after birth, and the neonates were placed in the hypoglycemia or euglycemia groups according to guidelines.ResultsOut of the 114 neonates included in the study, 75 (65.8%) had normal UA Doppler, 29 (25.4%) had absent EDF in UA Doppler, and 10 (8.8%) had reverse EDF in UA Doppler. There was a significant difference in the mean blood glucose in the first hr between the normal UA Doppler group and the reverse EDF in UA Doppler group (p 0.01).ConclusionPostnatal hypoglycemia in neonates with IUGR is associated with the result of UA Doppler ultrasonography during pregnancy.