Absent Or Reversed End-diastolic Research Articles

Placental Vascularization in Early Onset Small for Gestational Age and Preeclampsia

The objective was to determine whether chorionic villous vascularization is diminished in cases of early onset (<34 weeks) small for gestational age (SGA) and/or preeclampsia (PE). Placental morphometrical measurements were performed in 4 gestational-age-matched groups complicated by SGA, SGA with PE, PE, and spontaneous preterm delivery without SGA or PE as the reference group. Using a video image analysis system, in randomly selected intermediate and terminal villi, the stromal area and the following villous vascular parameters were manually traced and analyzed: number of total, centrally and peripherally localized vessels, vascular area, and vascular area density. No differences were observed in intermediate and terminal villous vascular area. Preeclampsia was associated with smaller terminal villous stromal area (reference 2299 μm2, SGA 2412 μm2, SGA + PE 2073 μm2, and PE 2164 μm2, P = .011), whereas SGA was associated with an increased terminal villous vascular area density (reference 26.1%, SGA 35.7%, SGA + PE 33.4%, and PE 32.0%, P = .029). Compared with preserved flow, lower terminal villous vascular area density was found in cases with absent or reversed end-diastolic (ARED) umbilical artery flow (39.3% vs. 30.3%, P = .013). These data demonstrate that villous vascularization was not influenced by PE, whereas in terminal villi an increased vascular area density was associated with SGA. Lower terminal villous vascular area density was associated with ARED flow in SGA pregnancies, indicating an increased risk of fetal compromise.

Ductus venosus Doppler and postnatal outcomes in fetuses with absent or reversed end-diastolic flow in the umbilical arteries

Objective To evaluate the relationship between ductus venosus Doppler findings on the day of delivery and postnatal outcomes in pregnancies with absent or reversed end-diastolic (ARED) flow in the umbilical arteries. Study design Postnatal outcomes of 103 newborns of pregnancies with a diagnosis of ARED flow on Doppler velocimetry of the umbilical arteries were analyzed retrospectively between January 1997 and December 2004. Single pregnancies and fetuses without malformations were included. The cases were divided into two groups according to the flow during atrial contraction (a-wave) in the ductus venosus on the day of delivery: group A, 20 cases with absent or reversed flow in the ductus venosus and group B, 83 cases with positive flow. The results were analyzed statistically using the chi-square test, Fisher's exact test and the Mann-Whitney U test with the level of significance set at 5%. Results All newborns were delivered by cesarean section. Gestational age was similar in the two groups (group A: 30 weeks and group B: 30.9 weeks, P = 0.23). Absent or reversed ductus venosus flow was associated with the following adverse postnatal outcomes: lower birthweight ( P < 0.001), lower Apgar scores in the first ( P = 0.001) and fifth minute ( P = 0.001), a higher frequency of orotracheal intubation ( P = 0.001) and pH at birth less than 7.20 ( P < 0.001), pulmonary hemorrhage ( P = 0.03), thrombocytopenia ( P = 0.02), hypoglycemia ( P = 0.01), intracranial hemorrhage ( P = 0.02), and postnatal death ( P = 0.007). Conclusion The study of ductus venosus flow may provide additional information regarding the best time for interruption of pregnancies with ARED flow in the umbilical arteries characterized by extreme prematurity.

Overcoiling of the Umbilical Cord

1 m 4 2 i female infant was born at 35 weeks of gestation by cesarean ection, performed because of intrauterine growth restriction nd absent or reversed end-diastolic (ARED) flow in the mbilical artery. Birth weight was 1690 g (3rd percentile), ength was 41 cm ( 3rd percentile), and head circumference as 33.3 cm (75-90th percentile). Apgar scores were 8 and 9 t 1 and 5 minutes, respectively. The umbilical cord had 38 ounterclockwise complete coils (Figure), and the length was 1 cm. The umbilical cord is usually spiraled. A counterclockise spiral is more frequent than a clockwise spiral with a ratio f 7:1. The origin of umbilical cord coiling is unknown. ypotheses include fetal movements, active or passive torsion f the embryo, differential umbilical vascular growth rates, etal hemodynamic forces, and the arrangements of muscular bers in the umbilical arterial wall. The coiling of the umbilcal vessels develops as early as 28 days after conception and is resent in about 95% of fetuses by 7 weeks of conception. The elices may be seen by ultrasonographic examination as early igure. Umbilical cord with counterclockwise complete coils. (Available n color at www.jpeds.com.)

Changes in the ductus venosus in fetuses with intrauterine growth restriction during maternal hyperoxygenation

RESTRICTION DURING MATERNAL HYPEROXYGENATION JOHN VISINTINE, DENNIS WOOD, ATHITA CHANTHASENONT, JASON BAXTER, STUART WEINER, VINCENZO BERGHELLA, Thomas Jefferson University, Philadelphia, Pennsylvania, Thomas Jefferson University, Obstetrics and Gynecology, Philadelphia, Pennsylvania OBJECTIVE: To demonstrate the changes of the ductus venosus (DV) pulsatility index (PI) and diameter in intrauterine growth restriction (IUGR) fetuses after maternal hyperoxygenation. STUDY DESIGN: Patients identified with an IUGR fetus (!10%) and absent or reversed end diastolic (ARED) flow umbilical artery (UA) were evaluated before and after maternal hyperoxygenation (60% oxygen via face mask). Fetuses with structural heart disease or aneuploidy were excluded. Measurements included the cardiac circumference to thoracic circumference ratio, mmode measurements of the fetal heart, and peripheral pulmonary, umbilical artery and middle cerebral artery PI. The PI and diameter of the DV were measured and compared to a standard nomogram previously developed at our institution. All measurements were performed during fetal quiescence. RESULTS: Nine fetuses were identified, gestational age range from 23-34 weeks. The DV size decreased from an average of 3.2 to 1.8 mm, while MCA PI, which had been abnormal in room air, normalized in 5 of 9 fetuses. Two IUGR fetuses with abnormal DV PI in room air normalized during maternal hyperoxygenation. PI in the umbilical artery improved in 6 of the 9 fetuses. PI of the distal pulmonary artery did not change with maternal hyperoxygen. CONCLUSION: The diameter of the DV changes with maternal hyperoxygenation. Maternal hyperoxygenation may be used to discriminate between compromised fetuses who would benefit from long term oxygen therapy and those who would not. Maternal hyperoxygenation therapy may be useful in postponing delivery in fetuses with IUGR and ARED.

OP07.28: The perinatal outcome of 48 IUGR fetuses with ARED

Objective: To determine the perinatal outcome of fetuses with absent or reversed end-diastolic (ARED) flow in the umbilical artery (UA) Doppler. Methods: Forty-eight IUGR fetuses between 24 and 34 gestational weeks with findings of ARED flow in the UA were prospectively followed. The fetuses monitored by repeat blood flow Doppler measurements of arterial and venous vessels, cardiotocography and biophysical scoring. Maternal evaluation and follow up was also carried out for detection of development of pre-eclampsia. Delivery was planned when nonreassuring findings were detected in any test. Perinatal outcomes were investigated up to the end of the first month of life. Results: The overall survival of the fetuses until the end of neonatal period with ARED was 22.9% (37/48). Intrauterine fetal death was observed in three (6.3%) cases. All the three fetuses which had ARED before 26 weeks were all died in-utero. Of the three fetuses died in utero, two had reverse flow in umbilical artery, but normal ‘A wave’ in ductus venosus. Eight fetuses died in neonatal period (16.6%). The indications for delivery of the live born neonates which were subsequently died were nonreassuring CTG in three cases, reverse flow in UA and in a wave of DV in three cases, and reverse flow detected in UA in one case. Six cases were delivered between 26–28 weeks, and early neonatal death was observed in two cases. Among the 32 cases delivered between 28–32 weeks, fetal death is observed in one case and six of 31 live born neonates delivered between 28–32 weeks were subsequently died in neonatal period. All fetuses delivered at or beyond 34 weeks were survived. Conclusions: ARED in UA Doppler is an ominous finding associated with high perinatal mortality, and the mortality rate decreases as the gestational age at delivery advances.

OP08.01: Femoral soft tissue thickness as potential parameter for ultrasound estimation of fetal weight

Objective: To determine the perinatal outcome of fetuses with absent or reversed end-diastolic (ARED) flow in the umbilical artery (UA) Doppler. Methods: Forty-eight IUGR fetuses between 24 and 34 gestational weeks with findings of ARED flow in the UA were prospectively followed. The fetuses monitored by repeat blood flow Doppler measurements of arterial and venous vessels, cardiotocography and biophysical scoring. Maternal evaluation and follow up was also carried out for detection of development of pre-eclampsia. Delivery was planned when nonreassuring findings were detected in any test. Perinatal outcomes were investigated up to the end of the first month of life. Results: The overall survival of the fetuses until the end of neonatal period with ARED was 22.9% (37/48). Intrauterine fetal death was observed in three (6.3%) cases. All the three fetuses which had ARED before 26 weeks were all died in-utero. Of the three fetuses died in utero, two had reverse flow in umbilical artery, but normal ‘A wave’ in ductus venosus. Eight fetuses died in neonatal period (16.6%). The indications for delivery of the live born neonates which were subsequently died were nonreassuring CTG in three cases, reverse flow in UA and in a wave of DV in three cases, and reverse flow detected in UA in one case. Six cases were delivered between 26–28 weeks, and early neonatal death was observed in two cases. Among the 32 cases delivered between 28–32 weeks, fetal death is observed in one case and six of 31 live born neonates delivered between 28–32 weeks were subsequently died in neonatal period. All fetuses delivered at or beyond 34 weeks were survived. Conclusions: ARED in UA Doppler is an ominous finding associated with high perinatal mortality, and the mortality rate decreases as the gestational age at delivery advances.

Perinatal outcome in monochorionic twin pregnancies complicated by amniotic fluid discordance without severe twin–twin transfusion syndrome

To assess the natural history and perinatal outcome in monochorionic diamniotic twin pregnancies with discordant amniotic fluid volume without signs of severe twin-twin transfusion syndrome (TTTS). This was an observational study of 84 consecutive monochorionic twin pregnancies which did not meet the criteria for severe TTTS and endoscopic laser coagulation of placental anastomoses at initial presentation. The population was subdivided into two groups. Group 1 consisted of 64 pregnancies (median gestational age, 20.1 (range, 15.6-24.7) weeks) with amniotic fluid discordance and no signs of congestive heart failure in the twin with the larger amniotic fluid volume (Twin 1) and positive end-diastolic flow in the umbilical artery of the twin with the smaller amniotic fluid volume (Twin 2). Group 2 (median gestational age, 19.1 (range, 16.0-24.4) weeks) consisted of 20 pregnancies with amniotic fluid discordance and intrauterine growth restriction (IUGR) (abdominal circumference < 5th percentile) in combination with absent or reversed end-diastolic (ARED) flow in the umbilical artery of Twin 2. After exclusion of one patient from Group 1, who opted for termination of pregnancy, nine patients in Group 1 and one in Group 2 developed severe TTTS, and laser coagulation was offered. The remaining 54 pregnancies of Group 1 were compared with the remaining 19 pregnancies of Group 2. Fetuses in Group 1 showed significantly higher survival rates (overall survival, 100/108 (92.6%) vs. 23/38 (60%), P < 0.0001; survival of both fetuses, 49/54 (90.7%) vs. 9/19 (47.4%), P = 0.0002) and median gestational age at delivery (33.6, (range, 27.6-37.8) weeks vs. 32.0 (range, 26.9-36.3) weeks, P = 0.0457). Overall, there was a significantly higher incidence of complications, defined as necessity for intrauterine intervention, fetal or neonatal death or delivery prior to 32 weeks, in Group 2 (Group 1: 30/63 (47.6%); Group 2: 16/20 (80%), P = 0.0188). Our data suggest that amniotic fluid discordance in monochorionic diamniotic twin pregnancies in combination with IUGR and umbilical artery ARED flow in one fetus represents an extremely high-risk constellation for adverse pregnancy outcome.

Qualitative Venous Doppler Flow Waveform Analysis in Preterm Intrauterine Growth-Restricted Fetuses with ARED Flow in the Umbilical Artery???Correlation With Short-Term Outcome

Controversy continues about the best time for delivery when intrauterine growth restriction (IUGR) is present. Although many practitioners use arterial and venous Doppler, biophysical parameters, and fetal heart tracings,there is no standard management. The risk of prematurity-usually before 32 weeks gestation-must be balanced against the risks of prolonged fetal exposure to hypoxemia and acidemia with their possible consequences of persistent fetal damage, stillbirth, and neonatal death. This retrospective study enrolled 74 fetuses with IUGR and absent or reversed end-diastolic (ARED) flow in the umbilical artery (UA) with delivery taking place at 24 to 34 weeks gestation. Perinatal outcomes were related to absent or reversed flow during atrial contraction (a-wave) in the ductus venosus (DV) and pulsatile flow in the umbilical vein (UV). Color Doppler imaging was performed, and flow velocity waveforms were recorded from the UA, DV, UV, and middle cerebral artery. End-diastolic flow in the UA was absent in 43% of fetuses and reversed in 57%. Brain sparing was observed in 53% and 90.5% of fetuses, respectively. Flow was absent or reversed during the a-wave in the DV in 41% of cases and UV pulsations in 31%. In 18% of fetuses, Doppler waveforms were abnormal in both the DV and the UV. More than half (54%) of fetuses were acidotic at birth and 6.5% had birth asphyxia. Perinatal mortality was 19% with 12 perinatal and 2 neonatal deaths. Eight of these 12 fetuses were stillborn. On logistic regression analysis, the strongest predictors of perinatal death were abnormal. Only gestational age correlated significantly with neonatal deaths. Abnormal venous Doppler waveforms were more frequent in fetuses with acidemia, oligohydramnios, or intraventricular hemorrhage at birth. In this series, venous Doppler flow patterns predicted stillbirths and perinatal deaths with better specificity and higher positive predictive values than did reversed flow in the UA or brain sparing. Fetal and perinatal deaths were significantly associated with an absent or reversed DV a-wave or UV pulsations, especially before 32 weeks gestation. Preterm IUGR fetuses in this study with severe venous Doppler flow abnormalities were delivered at a time when multiorgan failure and persistent damage were already present. These translate into a high number of stillbirths and perinatal/neonatal deaths. The question of when to deliver preterm infants with IUGR will be addressed in a planned prospective, randomized multicenter trial, the TRUFFLE study.

Outcome of 60 neonates who had ARED flow prenatally compared with a matched control group of appropriate‐for‐gestational age preterm neonates

To describe the course and outcome of fetuses with absent or reversed end-diastolic (ARED) flow in the umbilical artery (UA) and to examine the influence of prematurity according to gestational age at delivery. Sixty pregnancies complicated by ARED flow in the UA were monitored by repeat Doppler measurements of arterial and venous vessels, non-stress tests (cardiotocogram (CTG)) and maternal investigations, and were delivered between 24 and 34 weeks. Fetal outcome was investigated and compared to a control group of appropriate-for-gestational age (AGA) preterm neonates, matched for gestational age. Mortality, birth weight, Apgar scores, postnatal cord arterial pH and need for ventilation were all recorded, as were cases of respiratory distress syndrome, bronchopulmonary dysplasia, persistent ductus arteriosus, necrotizing enterocolitis, intraventricular hemorrhage, periventricular leukomalacia, abnormal neurological findings and those requiring surgical intervention. Additionally, the group of fetuses with ARED flow was divided into three subgroups of different degrees of prematurity (delivery between 24 + 0 and 28 + 6 weeks, delivery between 29 + 0 and 31 + 6 weeks, and delivery after 32 weeks) and compared according to the above parameters. Pre- or postnatal death occurred in 16 cases. Comparing the 44 (61%) that were born alive with the AGA neonates, significant differences were found in birth weight (P < 0.001), arterial pH value (P < 0.001), bronchopulmonary dysplasia (P = 0.002) and intestinal complications (P < 0.01). Prematurity-related complications were: need for ventilation (P = 0.001), respiratory distress syndrome (P < 0.0001), periventricular leukomalacia (P = 0.002) and pathological neurological testing (P = 0.005). Neonates displaying ARED flow before birth are growth restricted, acidemic at delivery and are at high risk of developing bronchopulmonary dysplasia and intestinal complications. While perinatal mortality seems to be related to abnormal fetal Doppler velocimetry, age at delivery has a significant impact on short-term morbidity. After 32 weeks, morbidity is low and delivery should be considered. It could be speculated from our data that prolongation of pregnancy with Doppler velocimetry monitoring could help to reduce morbidity, although prolongation remains limited in most cases.

Qualitative venous Doppler flow waveform analysis in preterm intrauterine growth‐restricted fetuses with ARED flow in the umbilical artery—correlation with short‐term outcome

The aim of this retrospective study was to examine the significance of severe Doppler waveform abnormalities in the ductus venosus (DV) and the umbilical vein (UV) for the prediction of adverse outcomes in very preterm growth-restricted fetuses with absent or reversed end-diastolic flow in the umbilical artery (UA) at 24-34 weeks of gestation. Seventy-four fetuses with intrauterine growth restriction (IUGR) and absent or reversed end-diastolic (ARED) flow in the UA at 24-34 weeks of gestation, which were delivered before 34 weeks' gestation, were examined. Absent or reversed flow during atrial contraction (a-wave) in the DV and pulsatile flow in the UV were examined to predict severe perinatal outcomes (stillbirth, neonatal death, perinatal death, acidemia, 5 min Apgar < 7, intraventricular hemorrhage and elevated nucleated red blood cell counts at delivery). Twelve (16.2%) perinatal deaths, of which eight were stillbirths (10.8%), and two (2.7%) neonatal deaths occurred among 74 fetuses. Logistic regression analysis confirmed that abnormal DV Doppler waveforms (R2 = 0.57, P < 0.001) together with gestational age at delivery (R2 = 0.57, P < 0.001) showed the strongest association with perinatal death, whereas only gestational age was significantly related to neonatal death (R2 = 0.67, P < 0.05). Abnormal DV Doppler waveforms (R2 = 0.86, P < 0.001) and gestational age (R2 = 0.49, P < 0.05) were strongly associated with adverse outcome (including stillbirth, perinatal death or neonatal death). Abnormal venous Doppler flow patterns performed better in the prediction of fetal or perinatal demise than did ARED flow or brain sparing. Abnormal venous Doppler waveforms in preterm IUGR fetuses with ARED flow are strongly related to adverse fetal and perinatal outcomes before 32 weeks of gestation. The possible benefit of prolonging these pregnancies can only be evaluated in a prospective randomized study.

The fetal cardiovascular response to antenatal steroids in severe early-onset intrauterine growth restriction

ObjectiveOur aim was to study the hemodynamic effects of betamethasone on fetuses with intrauterine growth restriction (IUGR) with absent or reversed end-diastolic (ARED) umbilical artery flow. Study designColor/pulsed Doppler waveforms were obtained before and after intramuscular injections of betamethasone in 19 consecutive fetuses with IUGR/ARED and 6 control fetuses. Peak velocities and pulsatility index (PI) values were obtained from the umbilical (UA) and middle cerebral (MCA) arteries and intrahepatic umbilical vein (UV). ResultsTen ARED fetuses developed transient positive umbilical end-diastolic flow after steroids, whereas nine fetuses showed persistent ARED. The persistent ARED subgroup demonstrated increased UA and UV peak velocities after steroids, which may indicate fetal hypertension. Fetal death (n=2) and severe acidosis (n=2) were confined to the subgroup with persistent ARED. ConclusionPreterm IUGR/ARED fetuses exhibit divergent cardiovascular responses to prenatal steroids. Intensive Doppler-based fetal monitoring may identify a subset of fetuses prone to decompensation after maternal steroid administration.

P108The importance of studying the ductus venosus for predicting acidosis at birth in pregnancies with absent or reversed end‐diastolic (ARED) velocity flow in the umbilical arteries

BackgroundA study of the relation between methods for assessment of fetal well‐being and birth weight.MethodsA prospective study was conducted to assess the fetal well‐being in 61 singleton pregnancies with ARED. The results of these methods were compared with the occurrence of umbilical artery pH at birth &lt; 7.20 and &lt; 7.15. All data were analyzed and compared using logistic regression.ConclusionThe pulsatility index for veins in the ductus venosus is the most important predictor for acidosis at birth. Once the ductus venosus pi is known, it is possible to estimate the probability of fetal acidosis in pregnancies with AREDV.

Maternal and fetal plasma concentrations of endothelin, lipidhydroperoxides, glutathione peroxidase and fibronectin in relation to abnormal umbilical artery velocimetry

Objective: To study plasma concentrations of endothelin (ET), lipidhydroperoxides (LOOH), glutathione peroxidase (GSHpx) and fibronectin in relation to abnormal umbilical artery velocimetry. Study design: Plasma concentrations of ET, LOOH, GSHpx and fibronectin were measured in fetal and maternal venous blood in: (i) a control group ( n=10); (ii) in pregnancies complicated by intrauterine growth retardation (IUGR) ( n=6) or preeclampsia ( n=5) with positive end diastolic flow; and in (iii) pregnancies complicated by absent or reversed end diastolic (ARED) flow in the umbilical artery ( n=18). All children were delivered by primary caesarean section. Results: The significantly highest maternal and fetal ET concentrations were found in plasma collected in pregnancies complicated by ARED flow in the umbilical artery. Maternal fibronectin levels were significantly raised in the ARED flow group. Maternal plasma ET levels were lowest in pregnancies complicated by IUGR. The maternal and fetal plasma concentrations of LOOH and GSHpx did not differ significantly between the groups. Conclusion: Abnormal Doppler velocimetry, especially ARED flow is associated with elevated maternal and fetal plasma levels of ET. The exact mechanism causing the placental vasoconstriction is unknown yet, but oxidative stress seems not to be involved.

Placenta morphology and absent or reversed end diastolic flow velocities in the umbilical artery: a clinical and morphometrical study

The aim of the study was to investigate if a relation exists between absent or reversed end diastolic (ARED) flow in the umbilical artery and morphometric characteristics of the placenta. Geometric parameters were measured in the terminal villi of nine placentae, collected after a pregnancy complicated by ARED flow. Placentae from pregnancies with normal Doppler velocimetry in the umbilical artery were matched for gestational age and formed the control group. Mean placental weight in the ARED group was significantly lower than in the control group. Morphometric characteristics of the terminal placental villi did not differ substantially between the two groups before 30 weeks gestation. After 30 weeks mean villous profile cross sectional area and diameter were significantly smaller in the ARED group than in the control group. The mean profile cross sectional villous diameter in the ARED group did not differ substantially before and after 30 weeks of gestation (2287 μm 2 and 2303 μm 2, respectively). Accelerated maturation of terminal villi occurs in placentae delivered after a pregnancy with ARED flow in the umbilical artery. Morphometric characteristics are significantly different between placentae expelled after ARED velocities or after normal Doppler recordings in the umbilical artery. In ARED placentae, a significantly more uniform pattern of small villi is found compared with control placentae.

Doppler-Sonographie der Arteria umbilicalis bei Feten mit sonograpisch auffälligem Befund

We performed 77 Doppler blood flow studies of the umbilical artery in 45 foetuses with malformations and/or chromosomal abnormalities. 20 foetuses had chromosomal abnormalities and 34 records of the second and third trimester were analysed. In 25 foetuses with malformations, but without chromosomal abnormalities, 43 investigations were performed between 21st and 40th weeks of gestation. In the second trimester, 3 of 11 foetuses with chromosomal abnormalities had an absence of enddiastolic flow velocities, whereas the other foetuses had pulsatility indices within the range for foetuses with a normal karyotype. In the third trimester, 7 of 10 foetuses with chromosomal abnormalities had pathological Doppler findings. Four cases had absent or reversed enddiastolic (ARED) flow velocities. Altogether 10 of 13 foetuses beyond the 19th weeks of gestation had pathological Doppler findings (sensitivity = 77%). The structure and the function of the placenta is influenced by the abnormal karyotype, which is demonstrated by pathological Doppler findings. Only 3 of 43 investigations in foetuses with malformations but normal karyotype, showed abnormal PI values and there was no case of ARED flow. In a group of 24 foetuses with ARED flow, 6 foetuses had chromosomal abnormalities. All foetuses with malformations and ARED flow had an abnormal karyotype. Prenatal chromosome analyses of foetuses with suspicious sonographic findings, revealed a rate of 29% chromosomal abnormalities, nearly all of them with a maternal age under 35 years. Whereas Doppler sonography cannot exclude chromosomal abnormalities before the 20th weeks of gestation, there is a good correlation between chromosomal abnormalities and abnormal Doppler findings later on.(ABSTRACT TRUNCATED AT 250 WORDS)