Absent Or Reversed End-diastolic Flow Research Articles

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.

Fetal Doppler Evaluation to Predict NEC Development.

Antenatal factors play a role in NEC pathogenesis. This study aimed to investigate the predictive value of fetal ductus venosus doppler (DV) for NEC in fetal growth restriction fetuses (FGRF) and to assess the predictive accuracy of IG21 and Fenton curves in NEC development. Data from FGRF, postnatal findings, and Doppler characteristics were collected between 2010 and 2020 at a single center. Patients were then divided into two groups (i.e., with and without NEC). Bivariate and multivariate analyses were performed. We identified 24 cases and 30 controls. Absent or reversed end-diastolic flow (AREDF) and increased resistance in the DV were more impaired in cases (p < 0.05). Although the median birthweight was not different, the Fenton z-score was lower in NEC (p < 0.05). Fetal cardiopulmonary resuscitation, synchronized intermittent mandatory ventilation, neonatal respiratory distress, persistent patent ductus arteriosus (PDA), and inotropic support were more frequent in the NEC group. Furthermore, NEC patients had lower white blood cells (WBC) (p < 0.05). The predictive model for NEC (model 4), including Fenton z-score, WBC, PDA, and DV had an AUC of 84%. Fetal Doppler findings proved effective in predicting NEC in FGR. The Fenton z-score was the most predictive factor considering the fetal growth assessment showing high sensitivity.

Effect of early feeding regimen in pre-terms with abnormal antenatal dopplers: a prospective analytical COHORT study

Background: Enteral feeding in preterm neonates with intrauterine growth restriction (IUGR) and absent or reversed end diastolic flow (AREDF) on umbilical artery (UA) Doppler is delayed owing to an increased risk of necrotizing enterocolitis (NEC). Delaying enteral feeding with longer duration of parenteral nutrition (PN) carries an increased risk of various neonatal morbidities.Methods: It was a prospective observational non randomized cohort study. Data was collected prospectively from the NICU records. Neonates fulfilling the inclusion criteria were classified as early feeding regimen and late feeding regimen. A strict feeding regimen was followed. Data was analyzed for primary and secondary outcomes.Results: The 50 neonates were enrolled. Baseline characteristics were comparable. A significantly higher time to full feeds was recorded in the delayed feeding regimen by a mean of 3.9 days. The duration of hospital stay was significantly higher for delayed feeding regimen (+12.7 days). Days of mechanical ventilation were also significantly higher (+1.6 days) in the neonates in delayed feeding group. There was no difference in the incidence of feed intolerance, NEC, incidence of culture positive sepsis and mortality across the two regimens, however neonates in the delayed feeding group needed longer support with parenteral nutrition.Conclusions: Early feeding will lead to earlier time to full feeds and decreased duration of hospital stay without additional increase the incidence of feeding intolerance and NEC in neonates with AEDF/REDF. Individualized feeding strategy in these compromised neonates should be the primary objective to optimize outcomes.

Impact of different prenatal management strategies in short‐ and long‐term outcomes in monochorionic twin pregnancies with selective intrauterine growth restriction and abnormal flow velocity waveforms in the umbilical artery Doppler: a retrospective observational study of 108 cases

To review perinatal and neurodevelopmental outcome (NDO) following selective fetoscopic laser coagulation (SFLC), cord coagulation (CC) or expectant management of monochorionic diamniotic twin pregnancies complicated with selective intrauterine growth restriction (sIUGR) and absent or reverse end-diastolic flow (AREDF) in the umbilical arteries (UA). Single-centre retrospective observational study. 108 cases of sIUGR diagnosed before 26+6 weeks' gestation with AREDF in the UA. Survival rate and potential risk factors were analysed. NDO was assessed using parental questionnaires. Survival, gestational age at delivery and NDO. SFLC, CC and EM were performed in 13, 50 and 45 cases, respectively, with an overall survival of 23.1, 40 and 77.8% and intrauterine demise of the co-twin of 30.8, 10 and 6.7% respectively. Intrauterine demise of the sIUGR twin occurred in 76.9 and 17.8% following SFLC and EM, respectively. The discordance in EFW at diagnosis was higher and absent/negative a-wave in the ductus venosus (DV) was more prevalent in the surgical groups. NDO in survivors at follow up was abnormal in 0 and 18% in the smaller twin following SFLC and EM, respectively, and in 25, 24 and 21% in the larger twin following SFLC, CC and EM, respectively. SFLC yielded a poor result. EM seems a valid option when EFW discordance is <30% and a-wave in DV is positive. Otherwise, CC should be considered to protect the AGA co-twin. The long-term outcome of both small and large twins seems unaffected by the choice in primary prenatal management strategy. In type II sIUGR in MC twins, long-term neurodevelopment is normal in over 80% of the survivors.

Use of birth weight- vs. ultrasound-derived fetal weight classification methods: implications for detection of abnormal umbilical artery Doppler.

Objectives To compare a birth weight-derived (Brenner) and multiple ultrasound-derived [Hadlock, National Institute of Child Health and Human Development (NICHD), International Fetal and Newborn Growth Consortium (INTERGROWTH)] classification systems' frequency of assigning an antenatal estimated fetal weight (EFW) <10% and subsequent detection rate for abnormal umbilical artery Doppler (UAD). Methods We analyzed 569 consecutive non-anomalous singleton gestations identified by ultrasound with either an abdominal circumference (AC) <3% or EFW <10% at a tertiary medical center between 1/2012 and 12/2016. The biometric measurements were exported for all serial ultrasounds and the sensitivity, specificity, positive and negative predictive values, and area under the curve (AUC) were calculated for the diagnosis of any abnormal UAD, absent or reversed end-diastolic flow (AREDF), and small for gestational age (SGA) for each classification method. Results Brenner classified less patients with EFW <10% (49.7%) vs. the comparison methods (range: 84.2-85.0%; P < 0.001). The sensitivity was highest using Hadlock for detection of any abnormal UAD [96.6%; confidence interval (CI) 92.8-98.8%], AREDF (100%; CI 95.1-100%), and SGA (89.0%; CI 85.4-91.6%). However, there was minimal variation between the Hadlock, NICHD, and INTERGROWTH methods for detection of the studied outcomes. The AUCs for any abnormal UAD, AREDF, and SGA were highest for the Brenner method, but there were a substantial number of false-negative results with lower overall detection rates. Conclusions Use of a birth weight-derived method to assign a fetal weight <10% as the threshold to initiate UAD surveillance has a lower detection rate for abnormal UAD when compared to ultrasound-derived methods. Despite substantial methodological differences in the creation of the Hadlock, NICHD, and INTERGROWTH methods, there were no differences in the detection rates of abnormal UAD.

Management and perinatal outcome of selective intrauterine growth restriction in monochorionic pregnancies

Introduction Selective intrauterine growth restriction (sIUGR) is a complication observed in about 10–15% of all monochorionic (MC) pregnancies, causing a significant increase in perinatal mortality and morbidity. Objective To evaluate clinical management options and perinatal outcomes of sIUGR in MC pregnancies monitored in a single tertiary center. Methods A retrospective study was performed on 55-MC pregnancies with sIUGR between January 2012 and May 2018 at the Fetal Medicine Unit of La Paz Hospital. Cases were classified according to the umbilical artery (UA) Doppler pattern as type I (positive end-diastolic flow; n = 25), type II [persistently absent or reversed end-diastolic flow (AREDF); n = 5] and type III [intermittently absent or reversed end-diastolic flow (iAREDF); n = 25]. Types II and III were then merged together as severe sIUGR cases. Subsequently, two possible approaches were considered: expectant management (EM) with elective preterm delivery in case of fetal deterioration, or in-utero therapy via fetoscopic laser photocoagulation (FLP) of intertwin anastomosis or selective umbilical cord occlusion (CO) of the growth-restricted fetus. Results Gestational age (GA) at diagnosis was progressively lower with each type. Severe sIUGR cases delivered significantly earlier than type I, showing lower birth weights and higher intertwin biometric discordance. Unintended fetal demise occurred in 14% (6/25) of severe sIUGR pregnancies as opposed to 0% (0/19) in type I, p = .028. A significantly higher proportion of twins was admitted in NICU in severe cases when compared to type I [87% (33/38) versus 47% (18/38), p < .001]. In addition, brain damage at birth was also found to be more prevalent in this group [21% (8/38) versus 11% (4/38), p = .346], especially in the larger twin, when comparing any short-term neurological sequel [30% (7/23) versus 0% (0/19), p = .011] or specifically periventricular leukomalacia [PVL; 22% (5/23) versus 0% (0/19), p = .053]. Although the overall mortality rate was significantly higher in severe sIUGR that underwent CO instead of EM [58% (7/12) versus 11% (4/36), p = .002], NICU admissions were higher in the latter [94% (17/18) versus 40% (2/5), p = .021]. Neurological sequels at birth were similar in both groups [39% (7/18) versus 40% (2/5), p = 1.000], similarly when considering only the larger twin for any brain lesion [28% (5/18) versus 40% (2/5), p = .621] or just PVL [22% (4/18) versus 20% (1/5), p = 1.000]. Conclusion Given the good prognosis of type I sIUGR, expectant management is the first approach to consider. However, due to the poorer clinical evolution of types II and III sIUGR, the decision-making is challenging and needs to be individualized depending on the UA Doppler pattern, GA at diagnosis, severity of growth restriction and biometric discordance, technical issues and parents’ preferences.

70: Neonatal blood biomarkers associated with absent or reversed end diastolic flow (AREDF)

AREDF in intrauterine growth restricted fetuses (IUGR) indicate significant uteroplacental insufficiency, with approximately 70% obliteration of placental arteries, and is associated with an 80-fold increased risk of perinatal mortality. Our objective is to investigate the relationship between AREDF just prior to delivery and biomarkers in umbilical cord blood at the time of birth and during the 1st week of life. This was a case-cohort study of liveborn non-anomalous chromosomally normal infants admitted to the NICU from April 2009 to March 2016. Women whose fetuses had AREDF in the setting of IUGR in this cohort were compared to gestational age matched controls. Neonates with major congenital malformations and chromosomal abnormalities were excluded. Neonates were longitudinally evaluated for seven serum biomarkers - glial fibrillary acidic protein (GFAP), vascular endothelial growth factor (VEGF), brain-derived neurotrophic factor (BDNF), neurogranin (NRGN), IL-6, IL-8 and IL-10 in cord blood at delivery (day 0) and day 4 of life (table 1). Multivariate marginal linear regression models and repeated measures analysis of variance (ANOVA) were used to investigate the relationship between mean umbilical cord blood biomarkers levels and AREDF, adjusting for gestational age, birth weight and mode of delivery. Statistical analysis was done using STATA 15. Of 2,204 pregnancies that met inclusion criteria, 228 (10.3%) were complicated by AREDF. Gestational ages ranged from 23.3 to 37.3 (mean 29.5) weeks, and mean birthweight was 907 (±351) vs 1539 (±955) grams in cases and controls respectively. Mean VEGF levels were significantly lower at baseline (1.02 ng/mL in cases vs 91.34 ng/mL in controls; p=0.048) and on day 4 of life (222.9 ng/mL in cases vs 341.9 ng/mL in controls; p=0.011). Mean serum levels of GFAP, NRGN, BDNF, IL-6, IL-8 and IL-10 were similar at baseline and on the 4th day of life in AREDF neonates compared to gestational age matched controls (table 1). Compared to gestational age matched controls, neonates with AREDF just prior to delivery had significantly lower circulating levels of VEGF at delivery which persisted through day 4. Changes in VEGF levels associated with AREDF are potential novel pathways for prognosis and treatment, which will require further prospective validation. Supported by NICHD R01HD086058.

Feed intolerance in preterm neonates with antenatal reverse end diastolic flow (REDF) in umbilical artery: a retrospective cohort study

Background: Feed intolerance is common in growth-restricted infants with antenatal AREDF (absent or reverse end-diastolic flow) and presumed to be more severe in those with reverse end diastolic flow (REDF). Natural history of feeding in REDF is rarely reported in the literature.Aims and objectives: To determine the incidence of feed intolerance and necrotizing enterocolitis (NEC) in neonates with antenatal REDF.Design: Preterm inborn neonates with gestation <37 weeks with antenatal REDF diagnosed between January 2015 and September 2017 were included in this retrospective cohort study. The primary outcome was the proportion of neonates having feed intolerance and NEC till discharge or death or transfer to other hospitals and time to achieve full enteral feeding (150 ml/kg/day).Results: Out of total 67 born with antenatal REDF, 8 were transferred out within 48 hours, 8 records not available and 4 excluded due to major malformations. The mean (SD) gestation and birth weight of the remaining 48 neonates were 32 (2) weeks and 1096 (291) g. The median (IQR) age of initiation of feeds was 30 (24–37) hours. Feeds were advanced by median (range) 20 (10–20) ml/kg/day in which 22 babies (45%) had at least 1 episode of feed intolerance at a median (IQR) age of 79 (40–120) hours requiring nil per oral for next 48 (18–96) hours. Full feeds were reached by median age (IQR) of nine (8–12) days. Only 3 neonates (6%) had NEC stage 2 or above as per Bell’s staging.Conclusions: Feed intolerance is common in neonates with REDF though the risk of NEC is not high.What is known on this subject?Neonates with antenatal AREDF are at increased risk of feed intolerance and necrotizing enterocolitis.Early introduction of enteral feeds in neonates with AREDF with appropriate monitoring is safe without increased risk of necrotizing enterocolitis.AEDF which progresses to REDF is associated with increased morbidity.What does this study add?Early enteral feeding as early as 24 hours can be initiated in REDF if there are no abdominal symptoms and signs.Feed intolerance is high in REDF cases.The risk of NEC is not higher than what is seen in AEDF cases.

121. Neonatal outcome after natural course of preterm IUGR fetuses with abnormal umbilical Doppler flow in combination with preeclampsia

Introduction The natural course of preterm IUGR pregnancies with absent or reversed end diastolic flow (AREDF) in the umbilical artery and preeclampsia has not been investigated so far. Objectives Determine neonatal outcome of preterm IUGR pregnancies with AREDF and preeclampsia after expectant obstetric management. Methods Patients were admitted between 2004 and 2014 in the Erasmus Medical Centre with preterm IUGR. Inclusion criteria: singletons, IUGR, 24–32 weeks, birth weight 500–1250 g. Admission was on clinical grounds and/or because of AREDF. Patients were allocated to the AREDF group or the normal end-diastolic flow (NEDF) group. After expectant management, pregnancies were terminated because of fetal distress or for maternal reasons. Short-term primary outcomes: idiopathic respiratory distress syndrome (IRDS), sepsis, bronchopulmonary dysplasia, necrotizing enterocolitis, intraventricular hemorrhage, composite neonatal outcome and perinatal mortality. Long-term primary outcome: cognitive and motor neurodevelopment at two years of age with Bayley III (BSID III). Results 433 women with preterm IUGR were admitted, 184 met the inclusion criteria, 33 were also diagnosed with preeclampsia. AREDF had no adverse effects on perinatal morbidity and mortality. NEDF seemed to increase the risk for IRDS (P = 0.021). Between the two groups, no differences were found on cognitive (P = 0.078) and motor development (P = 0.568). There were no differences in gestational age at delivery. Expectant management had positive effects on sepsis (P = 0.006) and perinatal mortality (P = 0.042). Delivery was postponed between 1 day and 10 weeks. Preeclampsia had no additional adverse effects on the prevalence of perinatal morbidity and mortality (P = 0.402) and cognitive and motor neurodevelopment (P = 0.611 and P = 0.640). Discussion No significant differences in neonatal outcome were found between the AREDF and NEDF group irrespective of co-existing preeclampsia after expectant management. It seems that postponing the delivery reduces perinatal morbidity and mortality. NEDF seemed to increase the risk of IRDS.

Incidence and Management of Umbilical Artery Flow Abnormalities during Open Fetal Surgery

Introduction: Umbilical artery (UA) Doppler ultrasound is used to assess uteroplacental insufficiency. Absent or reversed end diastolic flow (AREDF) in the UA is associated with increased perinatal mortality in fetuses with intrauterine growth restriction. We describe the incidence of UA Doppler abnormalities during open fetal surgery. Methods: We conducted a retrospective review of patients undergoing open in utero myelomeningocele (MMC) repair between 2008 and 2015. Intermittent UA Dopplers were performed during key portions of all cases. Our primary outcome was the rate of any AREDF. Secondary outcomes included analysis of absent versus reversed end diastolic flow (EDF), vasopressor use, and volatile anesthetic and clinical outcomes. Results: Thirty-four of 47 fetuses developed UA Doppler abnormalities intraoperatively. Nineteen had absent EDF and 15 had reversed EDF. No AREDF was present before induction, and all AREDF resolved by postoperative day 1. Ten of 19 (52.6%) patients who received sevoflurane had reversed EDF, versus 5/28 (17.9%) for desflurane, odds ratio (95% CI) 5.11 (1.36-19.16), p = 0.02. One intraoperative fetal death occurred in the AREDF group. Discussion: AREDF is a common phenomenon during open MMC repair. Anesthetic agent choice may influence this risk. Future studies of UA flow during fetal surgery are needed to further evaluate the impact of intraoperative AREDF on fetal well-being.

Early feeding tolerance in small for gestational age infants with normal versus abnormal antenatal Doppler characteristics

To determine differences in feeding tolerance amongst preterm small for gestational age (SGA) infants with normal versus abnormal umbilical artery Doppler flow defined as absent or reversed end diastolic flow (AREDF). This was a retrospective cohort study of infants <35 weeks gestational age (GA) and birth weight (BW) <10th percentile. Day of initiation of feeds, days to full feeds and CRIB II scores were the primary outcomes. Clinical characteristics were compared between the groups of SGA infants with normal and AREDF. Multivariable regression models were fit to the data to adjust for potential confounders of the association of AREDF and feeding intolerance. 120 infants with normal and 64 infants with AREDF were included. The infants with AREDF were smaller (971 g vs. 1183 g, p = 0.0002), less mature (29.9 wks vs. 31.2 wks, p = 0.0009), had higher CRIB II score (7.2 vs. 5.2, p = 0.0033), started feeding later (4.1 days vs. 3.3 days, p = 0.020) and advanced slower to full feeds (17.7 days vs. 13.7 days, p = 0.0017). Necrotizing enterocolitis was similar between the groups (p = 0.18). After adjusting for confounders, Doppler flow was no longer a significant predictor of the initiation (p = 0.37) and advancement of feeds (p = 0.44). Infants with AREDF are sicker at birth and have more feeding difficulties; after adjusting for BW and GA, Doppler flow was no longer a significant predictor of feeding intolerance.

Early versus Late Enteral Feeding in Preterm Intrauterine Growth Restricted Neonates with Antenatal Doppler Abnormalities: An Open-Label Randomized Trial.

Enteral feeding in preterm neonates with intrauterine growth restriction (IUGR) and absent or reversed end diastolic flow (AREDF) on umbilical artery (UA) Doppler is delayed owing to an increased risk of necrotizing enterocolitis (NEC). Delaying enteral feeding with longer duration of parenteral nutrition (PN) carries an increased risk of sepsis. To study early versus late feeding in preterm IUGR neonates for time required to attain sufficient feed volume to discontinue PN and increased risk of NEC or feed intolerance (FI). Open-label randomized controlled trial. Tertiary care neonatal unit and fetal-maternal medicine unit in India. Preterm intrauterine growth restricted neonates' ≤32 weeks with AREDF on UA Doppler enrolled from 1 January 2014 to 31 July 2015. Randomized to receive early or late feeding using mothers own or donor breast milk as per a feed initiation and advancement protocol. Time in days required to attain sufficient feed volume allowing discontinuation of PN and incidence of NEC in neonates fed early versus late. There were 77 eligible neonates. Sixty-two neonates were included and stratified as extreme preterm (27-29 weeks) (n = 20) and very preterm (30-32 weeks) (n = 42). Ten extreme preterm and 21 very preterm neonates were randomized to each early feeding and late feeding arm. There was a significantly faster attainment of sufficient feeds in the early feeding arm of both the stratified groups [extreme preterm: median 14 days (Interquartile range IQR: 12-15) compared with 18 days (IQR: 18-20), hazard ratio (HR): 1.59, 95% CI: 0.626-4.078; very preterm: 12 days (IQR: 10-14) as compared with 16 days (IQR 15-17), HR: 1.89, 95% CI: 1.011-3.555]. There was no difference in the incidence of NEC, FI and combined outcome of NEC and FI. Early feeding in preterm IUGR neonates with AREDF on antenatal UA Doppler allowed earlier discontinuation of PN, allowing birth weight to be regained earlier and did not increase the incidence of NEC and FI.

ISUOG Practice Guidelines: role of ultrasound in twin pregnancy.

ISUOG Practice Guidelines: role of ultrasound in twin pregnancy.

Outcome of monochorionic twin pregnancies with moderate amniotic fluid discordance adjoining twin-twin transfusion syndrome.

This study aimed to assess the perinatal outcome in monochorionic diamniotic (MD) twin pregnancies complicated by amniotic fluid discordance (AFD) adjoining twin-twin transfusion syndrome (TTTS). An observational study of 84 consecutive MD twin pregnancies complicated by AFD that resembled TTTS was conducted. AFD adjoining TTTS was defined by a maximal vertical pocket of amniotic fluid ≤3 cm in one twin and ≥7 cm in the other excluding TTTS. The study population was divided into two groups, group 1 and group 2, according to positive and absent or reversed end-diastolic flow (AREDF) in the umbilical artery, respectively. Fifteen of the 35 (42.9%) group 1 cases and 30 of the 49 (61.2%) group 2 cases progressed to TTTS. The overall survival and intact survival rate in constant AFD that never progressed to TTTS in group 1 was 100% (40/40) and 90% (36/40), respectively. The overall survival and intact survival rate of constant AFD in group 2 with selective intrauterine growth restriction (sIUGR) was 54.2% (13/24) and 41.7% (10/24), respectively, and for those without sIUGR was 64.3% (9/14) and 57.1% (8/14), respectively. Constant AFD with AREDF in the umbilical artery represents an extremely high risk for adverse outcomes regardless of the presence of sIUGR.

When is the optimal time to deliver late preterm IUGR fetuses with abnormal umbilical artery Dopplers?

Objective: To determine the optimal timing of delivery in late preterm intrauterine growth restriction (IUGR) fetuses with abnormal umbilical artery Doppler (UAD) indices.Methods: A decision-analytic model was built to determine the optimal gestational age (GA) of delivery in a theoretic cohort of 10 000 IUGR fetuses with elevated UAD systolic/diastolic ratios diagnosed at 34 weeks. All inputs were derived from the literature. Strategies involving expectant management accounted for the probabilities of stillbirth, spontaneous delivery and induction of labor for UAD absent or reversed end-diastolic flow (AREDF) at each successive week. Outcomes included short- and long-term neonatal morbidity and mortality with quality-adjusted life years (QALYs) generated based on these outcomes. Base case, sensitivity analyses and a Monte Carlo simulation were performed.Results: The optimal GA for delivery is 35 weeks, which minimized perinatal deaths and maximized total QALYs. Earlier delivery became optimal once the risk of stillbirth was threefold our baseline assumption; our model was also robust until the risk of AREDF at 35 weeks was half our baseline assumption, after which delivery at 36 weeks was preferred. Delivery at 35 weeks was the optimal strategy in 77% of trials in Monte Carlo multivariable sensitivity analysis.Conclusions: Weighing the risks of iatrogenic prematurity against the poor outcomes associated with AREDF, the ideal GA to deliver late preterm IUGR fetuses with elevated UAD indices is 35 weeks.

Neurodevelopmental outcome in very low birthweight infants with pathological umbilical artery flow

ObjectiveTo assess neurodevelopmental outcome during toddlerhood in very low birthweight (VLBW) infants with absent or reverse end-diastolic flow (AREDF) in the umbilical artery (UA) during pregnancy.DesignRetrospective cohort study with matched...

Hemodynamic Impact of Absent or Reverse End-Diastolic Flow in the Two Umbilical Arteries in Growth-Restricted Fetuses

ObjectiveTo determine if bilateral absent or reverse end-diastolic (ARED) flow in the two umbilical arteries (UAs) at the perivesical (PVC) segment represents a more severe degree of hemodynamic compromise than unilateral ARED flow at the PVC segment in singleton pregnancies complicated by intrauterine growth restriction (IUGR).MethodsThis was a prospective observational study. One hundred nine fetuses with IUGR underwent a total of 225 ultrasound (US) examinations. We measured the pulsatility index (PI) from the two UAs at the PVC segment, UA in the free floating cord (FFC), middle cerebral artery (MCA), ductus venosus (DV) and the aortic isthmus blood flow index (IFI). Three groups were classified according to bilateral positive end-diastolic (PED) flow, unilateral ARED flow or bilateral ARED flow in the UAs at the PVC segment.ResultsThe proportions of US examinations with PED flow, unilateral ARED flow and bilateral ARED flow in the UAs were 54.7%, 20.4%, and 24.9%, respectively. At the last US examination, the IFI z-scores were significantly lower in the bilateral ARED group (-6.28±4.30) compared to the unilateral ARED group (-1.72±3.18, p<0.05) and the bilateral PED group (-0.83±2.36, p<0.05), the DV-PI z-scores were significantly higher in the bilateral ARED group (2.15±3.79) compared to the bilateral PED group (0.64±1.50, p<0.05). Before 32 weeks of gestation, the interval between US examination and delivery was significantly shorter in the bilateral ARED group (8.9 days ±8.2) than the unilateral ARED group (15.9 days ±13.4, p<0.05) and the bilateral PED group (30.3 days±25.7, p<0.05).ConclusionThere are significant differences in fetal blood fluxes between left and right UA. Doppler examination at the PVC segment significantly improves the comparability of UA-PI between two successive US examinations and allows a longitudinal and independent hemodynamic investigation of each UA. Examination of a single UA in free floating cord may miss a large fraction of unilateral ARED flow. In singleton IUGR fetuses, a bilateral ARED flow in the UAs at the PVC segment indicates more severe hemodynamic compromise and worse fetal conditions than unilateral ARED flow.

Risk of Necrotizing Enterocolitis and Feeding Interventions for Preterm Infants With Abnormal Umbilical Artery Doppler

Infants exposed to absent or reversed end-diastolic flow (ARE DF) in utero may be at an increased risk of developing necrotizing enterocolitis (NEC). This article reviews placental function and the development of ARE DF. Studies examining the relationship between AREDF and NEC are reviewed, yet research remains inconclusive regarding this relationship. Recent studies reveal that early minimal enteral feeding does not increase the incidence of NEC in infants with AREDF. Initiation and advancement of enteral feedings should be monitored closely in this subset of the neonatal intensive care unit (NICU) population.

Active management of selective intrauterine growth restriction with abnormal Doppler in monochorionic diamniotic twin pregnancies diagnosed in the second trimester of pregnancy

This study aims to compare outcomes of active management of monochorionic diamniotic twin pregnancies complicated with severe intrauterine growth restriction (IUGR) of one twin before 24 weeks with continuous or intermittent absent or reversed end-diastolic flow (AREDF) in the umbilical artery, with or without twin-to-twin transfusion syndrome (TTTS). This study is a retrospective comparison of 45 consecutive cases of severe selective IUGR (s-IUGR) defined as an estimated fetal weight at or below the fifth centile with a >25% weight discordance and AREDF in the umbilical artery before 24 weeks and 166 consecutive cases of TTTS stage III, with AREDF in the donor (TTTS3D) and also with s-IUGR. These were treated by either selective laser photocoagulation of chorionic vessels (SLPCV) or cord coagulation (CC). The 166 cases of TTTS3D were treated by SLPCV, whereas 23 and 22 cases of s-IUGR were treated by SLPCV and CC, respectively. Overall survival was 52.17% or 45.45% in s-IUGR treated by SLPCV or CC, respectively, and 48.49% in TTTS3D. The survival of appropriately grown for gestational age (AGA) twins following CC (90.9%) was higher than that following SLPCV in s-IUGR (74%) or in recipient twins of TTTS3D (55.42%) (p = 0.001). Survival of the IUGR twin was 30% and 41.56% with SLPCV in s-IUGR and TTTS3D, respectively. Active management of severe IUGR with AREDF in the umbilical artery seems beneficial. Survival rates with SLPCV were similar in s-IUGR and TTTS3D. However, there was a trend for higher survival rates in the AGA twin for CC. The choice of the technique should be driven by objective counseling on survival of both IUGR and AGA twins and therefore by the utility-based ethical values expressed by the pregnant woman.

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.