Cerebroplacental Ratio Research Articles

Cerebroplacental ratio as a predictor of perinatal outcomes in intrauterine growth restriction

Intrauterine growth restriction (IUGR) complicates 7-15% of pregnancies and is associated with adverse perinatal outcomes. The primary goal of antenatal care is the early detection of such conditions. Doppler studies in fetus are used to predict the morbidity in IUGR. Studies show that cerebroplacental ratio is a better predictor of IUGR babies and adverse perinatal outcome. In this study we compare perinatal outcomes of IUGR babies with a normal CPR and an abnormal CPR. This prospective cohort study was carried out in the Department of Obstetrics and Gynaecology, Amala Institute of Medical Sciences, Thrissur, from January 2018 to June 2019. The study included 170 antenatal mothers diagnosed IUGR sonologically or are at risk of IUGR. CPR was calculated from Doppler parameters as ratio of MCA PI and Umbilical artery PI. CPR more than 1.08 was considered normal. Perinatal outcomes were compared between normal and abnormal CPR group. The incidence of abnormal CPR was found to be 39.4%. An abnormal CPR was associated with an increase in rate of emergency ceaserean rate for fetal distress (76.12%) and 64.18% had an APGAR of <7 at 5 mts of life. 97.02% babies with an abnormal CPR were admitted to NICU for several reasons. Frequency of adverse perinatal outcomes was increased in abnormal CPR group. These differences were statistically highly significant. In patients with IUGR, cerebroplacental ratio is a useful marker in prediction of adverse perinatal outcome. Integrating CPR into routine Doppler studies in clinical practice will help better identify fetuses at risk.

Role of myocardial performance index (MPI) and cerebro-placental ratio (CPR) in predicting adverse perinatal outcome.

This study aimed to evaluate the association of the Myocardial Performance Index (MPI) and Cerebro-Placental Ratio (CPR) in predicting adverse perinatal outcomes in fetuses who are appropriately-grown (AGA), small-for-gestational-age (SGA) and growth restricted (FGR). Singleton pregnancies were recruited after 24weeks. The patients were recruited after having been classified as AGA (AC/EFW>10thcentile), SGA (AC/EFW-3rd-10thcentile without doppler abnormalities), and FGR (AC/EFW<3rdcentile or 3rd-10thcentile with doppler abnormalities). A total of 103 cases comprising 48 AGA, 11 SGA, and 44 FGRfetuses were recruited. The Pulsatility Index of the Umbilical artery, Middle cerebral artery, Ductus Venosus, and Aortic Isthmus was obtained. MPI and CPR were calculated too. The primary outcome was to evaluate the predictive value of MPI and CPR for the composite adverse perinatal outcome. The mean gestational age of recruitment was 30weeks. The OR for Composite Adverse Perinatal Outcome in FGR groupfor MPI>.47 and CPR<1.67was 3.48 (95% CI: 1.00-12.24, p-value<.05)with sensitivity and specificity of 65% each and 11.08 (95% CI: 2.62-46.83, p-value=.001)with the sensitivity of 82% and specificity of 70%, respectively. When combined together, MPI and CPR yielded an OR of 58.5 (95% CI: 4.58-746.57, p-value=.002) with a sensitivity of 56.5% and specificity of 95% in the FGR group. MPI in conjunction with CPR can be used together to predict adverse perinatal outcomes in FGR.

The cerebroplacental ratio and prediction of fetal growth restriction in twin pregnancies

Objectives The cerebroplacental ratio (CPR) represents the relationship between blood flow in the placenta and blood flow in the fetal brain. A low CPR in the third trimester has been associated with poor perinatal outcomes in both singleton and twin gestations. This study aimed to evaluate whether low CPR defined or high CPR discordance at 20–24 weeks in twin pregnancies is associated with an increased risk of fetal growth restriction (FGR) in the third trimester. Methods A total of 247 twin pregnancies were included in this retrospective cohort study. Monoamniotic monochorionic twins were excluded. An abnormal CPR was defined as one or both CPR <5%-ile or CPR discordance between fetuses >20%. FGR was evaluated using the last growth measurement performed between 28 and 36 weeks. Results Of the candidates for study, 177 twin pregnancies had normal CPRs and 70 twin pregnancies had abnormal CPRs. Maternal demographics were similar between groups. There was no difference in the risk of selective FGR, FGR of both twins, or growth discordance >20% in the third trimester between twin pregnancies with normal vs. abnormal CPRs at 20–24 weeks. The adjusted odds ratio for any growth disturbance was 1.00 (95% CI 0.56–1.79). Conclusions This study suggests that FGR in twins may be the consequence of numerous maternal, fetal, and placental factors, and not fully explained by redistribution of blood flow or adaptive hypoxia in the mid-trimester.

Routine Doppler ultrasound in twin pregnancy

Doppler ultrasound when used appropriately is an invaluable tool in monitoring high risk twin pregnancy. There are no recent multicentre randomised controlled trials examining the value of routine umbilical artery doppler (UA), middle cerebral artery doppler (MCA), cerebroplacental ratio (CPR), uterine artery doppler (UtA) and ductus venosus doppler in uncomplicated twins. Thus, there is lack of international consensus in relation to incorporation of doppler ultrasound in the routine surveillance of uncomplicated multiples. In this chapter we will discuss how twins differ from singletons in their growth trajectories and progression of doppler abnormalities. International clinical guidelines are reviewed. Recommendations for doppler surveillance (routine or selective) with reference to recent studies are made.

Decreased fetal movements—the utility of ultrasound to identify infants at risk and prevent stillbirth is poor

Despite a paucity of evidence, it is widely accepted that a perceived reduction in fetal movements is associated with an increased risk of stillbirth and poor obstetrical outcome. Consequently, many international guidelines recommend urgent ultrasound assessment of fetal well-being in women presenting with decreased fetal movements. This study aimed to compare rates of abnormal ultrasound findings reflective of fetal compromise between women presenting with decreased fetal movements and gestation-matched controls in the third trimester. This was a retrospective cohort study performed at the Mater Mothers' Hospital in Brisbane between 2017 and 2020. We undertook propensity score matching analysis comparing abnormal ultrasound parameters in women with singleton, nonanomalous pregnancies presenting with decreased fetal movements after 28 weeks' gestation. The primary outcome was a composite of any abnormal scan parameter: umbilical artery pulsatility index >95th centile, middle cerebral artery pulsatility index <5th centile, cerebroplacental ratio <10th centile, estimated fetal weight <10th centile for gestation, middle cerebral artery peak systolic velocity >1.5 multiples of the median, or deepest vertical pocket of amniotic fluid <2 or >8 cm. After propensity score matching, the study cohort comprised 1466 cases and 2207 controls. The rate of the primary composite outcome was not significantly different between the 2 cohorts (20.2% vs 21.3%; P=.42). There were 30 new cases of small-for-gestational-age detected in the decreased fetal movements cohort, giving a number needed to scan of 48 in the decreased fetal movements group to detect 1 case of small-for-gestational-age. However, the frequency of the composite outcome was higher (13.0% vs 5.4%) at the final scan before birth in women with multiple decreased fetal movement presentations. Despite this, there was no significant difference in clinical outcomes between the 2 cohorts. Ultrasound abnormalities are not increased in women with decreased fetal movements compared with controls.

Blood-Brain Barrier Disintegration in Growth-Restricted Fetuses with Brain Sparing Effect.

The endothelial cells of the blood-brain barrier adhere closely, which is provided by tight junctions (TJs). The aim of the study was to assess the damage to the endothelial TJs in pregnancy, complicated by fetal growth restriction (FGR) and circulatory centralization (brain-sparing effect, BS). The serum concentrations of NR1 subunit of the N-methyl-D-aspartate receptor (NR1), nucleoside diphosphate kinase A (NME1), S100 calcium-binding protein B (S100B), occludin (OCLN), claudin-5 (CLN5), and zonula occludens protein – 1 (zo-1), and the placental expressions of OCLN, claudin-4 (CLN4), CLN5, and zo-1 were assessed with ELISA. The significantly higher serum NME1 concentrations and the serum CLN5/zo-1 index were observed in FGR pregnancy with BS, as compared to the FGR group without BS. The FGR newborns with BS were about 20 times more likely to develop an intraventricular hemorrhage (IVH) than the FGR infants without BS. The cerebroplacental ratio (CPR) allowed to predict the IVH in growth-restricted fetuses. The significantly lower placental CLN4 expression was observed in the FGR group with BS and who postnatally developed an IVH, as compared to the growth-restricted infants with BS without IVH signs. Pregnancy complicated by FGR and BS is associated with the destabilization of the fetal blood-brain barrier. The IVH in newborns is reflected in the inhibition of the placental CLN4 expression, which may be a useful marker in the prediction of an IVH among growth-restricted fetuses.

Current practice in the diagnosis and management of fetal growth restriction: An international survey.

The aim of this survey was to evaluate the current practice in respect of diagnosis and management of fetal growth restriction among obstetricians in different countries. An e-questionnaire was sent via REDCap with "click thru" links in emails and newsletters to obstetric practitioners in different countries and settings with different levels of expertise. Clinical scenarios in early and late fetal growth restriction were given, followed by structured questions/response pairings. A total of 275 participants replied to the survey with 87% of responses complete. Participants were obstetrician/gynecologists (54%; 148/275) and fetal medicine specialists (43%; 117/275), and the majority practiced in a tertiary teaching hospital (56%; 153/275). Delphi consensus criteria for fetal growth restriction diagnosis were used by 81% of participants (223/275) and 82% (225/274) included a drop in fetal growth velocity in their diagnostic criteria for late fetal growth restriction. For early fetal growth restriction, TRUFFLE criteria were used for fetal monitoring and delivery timing by 81% (223/275). For late fetal growth restriction, indices of cerebral blood flow redistribution were used by 99% (250/252), most commonly cerebroplacental ratio (54%, 134/250). Delivery timing was informed by cerebral blood flow redistribution in 72% (176/244), used from ≥32 weeks of gestation. Maternal biomarkers and hemodynamics, as additional tools in the context of early-onset fetal growth restriction (≤32 weeks of gestation), were used by 22% (51/232) and 46% (106/230), respectively. The diagnosis and management of fetal growth restriction are fairly homogeneous among different countries and levels of practice, particularly for early fetal growth restriction. Indices of cerebral flow distribution are widely used in the diagnosis and management of late fetal growth restriction, whereas maternal biomarkers and hemodynamics are less frequently assessed but more so in early rather than late fetal growth restriction. Further standardization is needed for the definition of cerebral blood flow redistribution.

Clinical utility of aortic isthmus Doppler in the prediction of perinatal outcomes

Doppler studies of uteroplacental-fetal circulation have been proven useful in diagnosing fetal growth restriction, appropriately timing delivery, and improving perinatal morbidity and mortality. There has been an extensive search for the ideal means to identify fetuses between the compensatory and acidemic phase (ie, the "preacidemic phase"), and the aortic isthmus Doppler seems to show promise. This study aimed to investigate: (1) the prevalence of abnormal aortic isthmus Dopplers in a cohort of small-for-gestational-age fetuses and their correlation with other conventional Doppler abnormalities, and (2) the predictive ability of abnormal aortic isthmus Dopplers with regard to short-term adverse neonatal outcomes. Fetuses diagnosed as small-for-gestational-age at ≥24 weeks' gestation were included. Management was as per the standard protocol. Aortic isthmus Doppler was performed within a week of delivery with other conventional Dopplers. The adverse perinatal outcomes studied were: requirement of neonatal resuscitation at birth, Apgar score at 5 minutes <7, cord blood pH <7, presence of bronchopulmonary dysplasia, hypoxic-ischemic encephalopathy, grade III/IV intraventricular hemorrhage, necrotizing enterocolitis, sepsis, neonatal intensive care unit stay longer than 14 days, and stillbirth or neonatal death. Among 121 small-for-gestational-age fetuses, 67 showed Doppler abnormalities in ≥1 vessels. The prevalence of abnormal aortic isthmus Doppler was 14.87%. Analysis was between group 1 with 103 normal aortic isthmus and group 2 with 18 abnormal aortic isthmus fetuses; 41 cases had some form of adverse perinatal outcome, the frequency of which was comparable between the groups. Abnormal aortic isthmus Doppler had a significant correlation with low cerebroplacental ratio, absent or reversed end-diastolic flow in the umbilical artery, and high pulsatility index in the ductus venosus. The positive likelihood ratio for predicting composite adverse perinatal outcome was 10.2 for absent or reversed end-diastolic flow in the umbilical artery, 9.6 for low cerebroplacental ratio, 2.28 for absent or retrograde flow in the aortic isthmus, and 2 for abnormal ductus venosus. Predelivery abnormal aortic isthmus Dopplers performed worse than other conventional Dopplers in predicting abnormal perinatal outcomes.

Combination of Doppler measurements with amniotic fluid volume for the prediction of perinatal outcomes in fetal growth restriction.

We aimed to evaluate a new ratio of amniotic fluid volume (AFV) to Doppler measurements, and compare its association with adverse perinatal outcomes (APOs) in fetal growth restriction (FGR). This prospective study included pregnant women with singleton fetal growth-restricted fetuses. Each participant underwent a detailed ultrasonographic examination. Uterine artery pulsatility index, umbilical artery pulsatility index (UA PI), middle cerebral artery pulsatility index (MCA PI), cerebroplacental ratio (CPR), and umbilical-to-cerebral ratio (UCR) were calculated, and the single deepest pocket (SDP) technique was used to estimate AFV. Amniotic-umbilical-to-cerebral ratio (AUCR) was calculated as the ratio of SDP to UCR: AUCR=SDP / (UA PI/MCA PI). APO was defined as umbilical venous cord blood pH <7.10, 5-minute APGAR score <7, and neonatal intensive care unit admission. We compared the fetal ultrasonographic and demographic features between the APO and the non-APO groups. The mean UA PI and UCR were significantly higher in the APO group. The mean SDP, CPR, and AUCR were significantly lower in the APO group. Receiver operating characteristic curve analyses demonstrated the highest area under the curve value (0.882; P < 0.001) for AUCR to APOs. The current study suggests that AUCR is the best predictor for APOs in FGR.

Middle cerebral artery to uterine artery pulsatility index ratios in pregnancy with fetal growth restriction regarding negative perinatal outcomes

Background/Aim: Fetal growth restriction (FGR) causes a high risk of perinatal morbidity and mortality, and the timing of the correct delivery time decision remains controversial. Cerebroplacental ratio (CPR), umbilical artery, uterine artery (UA) and middle cerebral artery (MCA) Doppler studies are used to predict adverse perinatal outcomes in FGR. However, since there is insufficient reliability for each separately and together, the search for new methods continues. This retrospective study was conducted to determine the degree of neonatal morbidity in fetuses suspected of having FGR by evaluating the MCA to UA pulsatility index (PI) ratios together with frequently used Doppler examinations. Methods: This was a retrospective cohort study conducted in a single-center hospital with the approval of the Medical Institutional Ethics Committee. A total of 424 pregnant women admitted to a tertiary hospital and diagnosed with FGR between July 2020 and December 2021 who were informed and approved were included in the study. Gestational age was confirmed by first trimester sonographic measurements of pregnancy. All pregnant women were examined by Doppler USG and umbilical artery, mean UA, fetal MCA, ductus venosus, CPR (MCA/umbilical artery pulsatility index ratio) and cerebrouterine ratio (MCA/UA) PI values were measured. Negative perinatal outcomes were recorded as blood gas level of the newborn at 7.2 and below, Apgar score of 7 and below at the fifth minute, and needing neonatal intensive care (NICU). Adverse perinatal and postnatal outcomes were recorded and compared with Doppler findings. If there were no signs of a negative perinatal outcome, it was considered a positive outcome. If at least one of the symptoms of adverse perinatal outcomes was present, it was considered a negative outcome Results: Decreased CPR and decreased MCA to UA PI were significantly and positively associated with an increased likelihood of exhibiting negative perinatal outcomes in pregnancies with FGR (P &lt; 0.001, P &lt; 0.001, respectively). The receiver operating characteristic (ROC) curve analysis showed that the optimal cut-off value for MCA to uterine artery PI was 1.41 to predict FGR with 57.37% sensitivity and 62.50% specificity (AUC: 0.629; 95% CI: 0.581–0.675). When the CPR cut-off value was taken as 1.2069, the sensitivity was 42.86% and the specificity 83.93% in predicting negative perinatal outcomes in CPR values below this value (P &lt; 0.001). Conclusion: CPR is the most successful criterion in distinguishing between positive and negative perinatal outcomes. It has been demonstrated that the MCA to uterine artery PI ratio values after CPR can also be used for this distinction. MCA to UA PI ratio sensitivity was higher than CPR and umbilical artery. This situation shows that MCA to uterine artery PI ratio (alone or when evaluated together with PPV and NPV ratios) is a criterion that can be added to other Doppler examinations in predicting negative perinatal outcomes.

Relationship between fetal middle cerebral artery pulsatility index and cerebroplacental ratio with adverse neonatal outcomes in low-risk pregnancy candidates for elective cesarean section: A cross-sectional study.

BackgroundThe cerebroplacental ratio (CPR) is an important factor for predicting adverse neonatal outcomes in appropriate-for-gestational-age fetuses.ObjectiveTo evaluate whether there is an association between the CPR level and adverse neonatal outcomes in appropriate-for-gestational-age fetuses.Materials and MethodsThis cross-sectional study included 150 low-risk pregnant women candidates for elective cesarean sections at the gestational age of 39 wk. CPR and middle cerebral artery pulsatility index (MCA PI) were calculated in participants just before cesarian section. Postnatal complications were defined as an adverse neonatal outcome such as an Apgar score of the neonate 7 at 5 min, neonatal intensive care unit (NICU) admission, cord arterial pH 7/14, and meconium stained liquor.ResultsThe mean age of participants was 31.53 4.91 yr old. The mean CPR was reported as 1.83 0.64. The Chi-square test analysis revealed that a low MCA PI and a low CPR were significantly associated with decreased cord arterial pH, decreased Apgar score at 5 min, and NICU admission (p 0.001). There was no significant association between umbilical artery PI with arterial cord pH, Apgar score at 5 min, NICU admission, or meconium stained liquor. The Mann-Whitney test showed that a lower fetal weight appropriate for the women's gestational age was significantly associated with a decreased CPR and MCA PI (p 0.005). There was no significant association between amniotic fluid index and CPR, umbilical artery PI, or MCA PI.Conclusion The CPR is a significant factor in predicting adverse neonatal outcomes and ultimately neonatal mortality and morbidity of low risk, appropriate-for-gestational-age fetuses.

Role of the cerebro-placental-uterine ratio in predicting adverse perinatal outcome in low-risk pregnancies at term

PurposeThe cerebroplacental ratio (CPR) is associated with adverse perinatal outcome (APO) in low-risk pregnancies near term. A Doppler parameter, which also includes information from the uterine vessels could potentially improve detection of subclinical placental dysfunction. The aim of this study is to investigate the performance of cerebro-placental-uterine ratio (CPUR) related to APO prediction in low-risk term pregnancies in > 40 + 0 weeks.MethodsThis is a retrospective cohort study. All low-risk pregnancies in which feto-maternal Doppler was examined from 40 + 0 weeks and an appropriate for gestational age fetus was present were included. ROC (receiver operating characteristic curves) analyses were performed to assess the predictive value of CPUR. The presence of at least one of the following outcome parameters was defined as composite APO (CAPO): operative delivery (OD) due to intrapartum fetal compromise (IFC), admission to the neonatal intensive care unit, umbilical cord arterial pH ≤ 7.15, 5 min APGAR ≤ 7.ResultsA total of n = 114 cases were included. Mean gestational age at examination and delivery were 40 + 3 weeks and 40 + 6 weeks, respectively. Overall, CAPO occurred in 38 of 114 cases (33.3%). ROC analyses showed a significant association of CPUR (AUC = 0.67, p = 0.004) and CPR (AUC = 0.68, p = 0.002) with CAPO. Additionally, CPUR (AUC = 0.64, p = 0.040) showed a predictive value for OD due to IFC.ConclusionThe CPUR in > 40 + 0 weeks showed a predictive value for CAPO and OD due to IFC in low-risk pregnancies. However, the extent to which CPUR can be used to optimize delivery management warrants further investigations in prospective interventional studies.

MIDDLE CEREBRAL ARTERY AND UMBILICAL ARTERY DOPPLER STUDIES TO PREDICT OUTCOME OF PREGNANCIES.

In about 30% of post term pregnancies, the foetuses develop a post maturity syndrome. post term pregnancy is associated with increased risk of both intrauterine and postnatal death. Nowadays, Doppler ultrasound velocimetry of uteroplacental umbilical and fetal vessels has become established method of antenatal monitoring, allowing noninvasive assessment of fetal circulation. Circulatory changes, reected in certain fetal Doppler waveforms, predict adverse perinatal outcome. Umbilical arteries are the common vessels assessed by Doppler ultrasound, but recent studies conrm the efcacy of middle cerebral artery (MCA) Doppler assessment for detecting fetal compromise. Objective- To predict outcome of pregnancies by using umbilical artery and Middle cerebral artery doppler ndings. Methodology- Study group consists of 65 pregnant women with gestational age of 40-42 weeks and control groups include the same number of pregnant women with gestational age of 36-40 weeks. All the antenatal women in the subject &amp; control groups were examined by routine ultrasound scan and Doppler subsequently.The peak systolic, end diastolic, and mean velocity were recorded from these vessels, and Umbilical artery S/D ratio, PI and Middle Cerebral Artery PI and CPR were calculated.Comparison of all variables were done using by·a software package Sensitivity, Specicity, Positive predictive value, Negative predictive value of different arterial Doppler indices and cerebroplacental ratio (CPR) were evaluated. ResultNo statistical signicant difference was noted in UA S/D, UAPI, UARI, MCA S/D, MCAPI MCARI in pregnancy with normal and adverse perinatal outcome. Only CPR showed signicant difference for predicting adverse perinatal outcome (p=0.001). Conclusion- None of the Doppler indices except CPR is sensitive enough. Although CPR cut-off value of 1.335 assures the obstetrician of fetal wellbeing, it's low specicity and high false positive results lead to unnecessary tests, undue concern and unnecessary interference.

Study protocol for a randomized trial on timely delivery versus expectant management in late preterm small for gestational age pregnancies with an abnormal umbilicocerebral ratio (UCR): the DRIGITAT study

BackgroundThe clinical inability to correctly identify late fetal growth restriction (FGR) within a group of fetuses who are identified as small for gestational age (SGA) is an everyday problem for all obstetrician-gynecologists. This leads to substantial overtreatment of healthy small fetuses but also inadequate detection of the growth-restricted fetuses that may benefit from timely delivery. Redistribution of the fetal circulation, signaled by an abnormal ratio of the Doppler velocity flow profiles of the umbilical artery and the middle cerebral artery, more specifically an increased umbilicocerebral ratio (UCR) (or its inverse: a decreased cerebroplacental ratio (CPR)), is an adaptation to chronic hypoxemia and nutritional scarcity with long-term consequences in survivors. The relevance of an abnormal UCR has been signaled extensively, and there is a general consensus that it is a signal of FGR, independent of size, with a strong association with poor outcomes. Yet, in the current literature, no comparisons of a monitoring-delivery strategy based on unfavorable UCR have been published. The objective of the Doppler Ratio In fetal Growth restriction Intervention Trial At (near) Term (DRIGITAT) is to evaluate if the timing of the delivery based on an abnormal UCR in late preterm fetuses identified as SGA improves neurodevelopmental outcomes at 2 years of age.MethodsThe DRIGITAT study is a national multicenter cohort study of women with singleton pregnancies between 32 and 37 weeks of gestation identified as SGA, with a nested randomized controlled trial (RCT) in case of an abnormal UCR (> 0.8). Recruiting centers are in The Netherlands. In the nested RCT, women are randomized to either immediate induction of labor or expectant management from 34 weeks in case of severely abnormal size (EFW or FAC < p3) and from 36 weeks in case of mildly abnormal size (EFW or FAC p3–p10). The primary outcome measure is the 7-point average difference in the composite cognitive score (CCS) and composite motor score (CMS) on the Bayley-3 at 2 years. Secondary outcome measures include a composite outcome of neonatal morbidity, perinatal mortality, mode of delivery, maternal quality of life, costs, and predictive value of serum biomarkers. Analyses will be by intention to treat. The required sample size is determined for the nested RCT as 185 patients.DiscussionThis study will provide insight into the diagnostic efficacy of UCR measurement in the evaluation of SGA fetuses in order to differentiate the healthy SGA fetus from the growth-restricted fetus and to determine if a fetus with abnormal UCR benefits from early delivery.Trial registrationHealthcare Evaluation Netherlands NTR6663. Registered on 14 August 2017.

Cerebro-placental and umbilico-cerebral ratios in uncomplicated monochorionic twins: Longitudinal references and comparison with singletons.

Monochorionic twins (MC) are at high risk of adverse outcomes and Doppler investigation of umbilical and cerebral flows is mandatory for their surveillance. The cerebro-placental (CPR) and umbilico-cerebral (UCR) ratios are considered non-invasive measures of fetal adaptation to hypoxemia. We aimed to provide longitudinal references for CPR and UCR from 16 to 37weeks of gestation that are specific for MC twins, and compare these with singleton charts. Longitudinal study of a cohort of consecutive uncomplicated MC twin pregnancies monitored at our unit from 2010 to 2018. The estimated centile curves were obtained estimating the median with fractional polynomials by a multilevel model and the external centiles through the residuals. The comparison with singletons references was made through graphic evaluation. One-hundred-fifty-two MC pregnancies were included with a median of 10 longitudinal ultrasounds each. References for CPR and UCR in function of gestational age are presented. Compared to singletons, MC twins showed an earlier and greater circulatory redistribution with lower CPR and higher UCR median values. MC twin-specific references for CPR and UCR suitable for serial monitoring are presented. The comparison with singleton references demonstrates substantial differences in the hemodynamic balance that must be considered when interpreting findings in MC twins.

Value of Cerebroplacental Ratio and Uterine Artery Doppler as Predictors of Adverse Perinatal Outcome in Very Small for Gestational Age at Term Fetuses.

The aim of this study was to evaluate the association between cerebroplacental ratio (CPR), mean uterine artery (mUtA) Doppler and adverse perinatal outcome (APO) and their predictive performance in fetuses with birth weight (BW) <3rd centile (very small for gestational age, VSGA) in comparison with fetuses with BW 3rd–10th centile (small for gestational age, SGA). This was a retrospective cohort study including singleton pregnancies delivered at term (37 + 0–41 + 6) in a single tertiary referral center over a six-year period. APO was defined as a composite of cesarean section for intrapartum fetal compromise (IFC), umbilical artery pH < 7.20, and admission to the neonatal intensive care unit for >24 h. The characteristics of the study population according to BW (VSGA and SGA) as well as the presence of composite APO were assessed. The prognostic performance of CPR and mUtA-PI was evaluated using receiver operating characteristic (ROC) analysis. In total, 203 pregnancies were included. Of these, 55 (27%) had CPR <10th centile, 25 (12%) mUtA-PI >95th centile, 65 (32%) VSGA fetuses, and 93 (46%) composite APO. VSGA showed a non-significantly higher rate of composite APO in comparison to SGA (52% vs. 43%; p = 0.202). The composite APO rate was significantly higher in SGA with CPR <10th centile (36% vs. 13%; p = 0.001), while in VSGA with CPR <10th centile was not (38% vs. 35%; p = 0.818). The composite APO rate was non-significantly higher both in VSGA (26% vs. 10%; p = 0.081) and SGA (14% vs. 6%; p = 0.742) with mUtA-PI >95th centile. The ROC analysis showed a significantly predictive value of CPR for composite APO in SGA only (AUC 0.612; p = 0.025). A low CPR was associated with composite APO in SGA fetuses. VSGA fetuses were more frequently affected by composite APO regardless of Doppler values. The predictive performance of CPR and uterine artery Doppler was poor.

Cerebroplacental Ratio Versus Nonstress Test in Predicting Adverse Perinatal Outcomes in Hypertensive Disorders of Pregnancy: A Prospective Observational Study.

Introduction: In developing countries, nonstress test (NST) is the most widely used method for antenatal fetal surveillance.Lately, cerebroplacental ratio (CPR) has emerged as a predictor for adverse perinatal outcomes, especially in hypertensive disorders in pregnancy (HDP). Against this background, the present study was conducted with the primary objective of quantifying the diagnostic accuracy of cerebroplacental ratio (CPR) versus nonstress test (NST) in predicting adverse perinatal outcomes in women with HDP.Methods: This was a prospective observational cohort study conducted in a tertiary care institute in eastern India. All consecutive women with hypertension in pregnancy at a gestational age of ≥32 weeks were recruited into the study. Both CPR and NST were performed at baseline and repeated weekly till delivery. The parameters obtained within one week of delivery were entered for analysis.Results: Sixty-two of the 65 women completed the study. There were 22 women (35.5%) in group A (both CPR and NST normal), 17 (27.4%) in group B (CPR abnormal, NST normal), 14 (22.6%) in group C (CPR normal and NST abnormal), and nine (14.5%) in group D (both CPR and NST abnormal). CPR had greater sensitivity (93.33% versus 46.67%), with higher positive predictive value (53.85% versus 30.43%), specificity (74.47% versus 65.91%), and negative predictive value (97.22% versus 79.49%) than NST for predicting neonatal intensive care unit admission. CPR also had higher sensitivity (84.62% versus 61.54%) and specificity (91.34% versus 69.39%) than NST in predicting neonatal complications. The negative predictive value (NPV) of CPR was 100% for predicting requirement of bag and mask ventilation and continuous positive airway pressure.Conclusion: CPR had greater diagnostic accuracy in terms of both higher sensitivity and greater specificity than NST in predicting adverse perinatal outcomes in women with hypertensive disorders of pregnancy.

Role of prenatal fetal echocardiography in the assessment of intrauterine growth restriction

BackgroundIntrauterine growth restriction (IUGR) is a common diagnosis in obstetrics and carries an increased risk of perinatal mortality and morbidity. Identification of IUGR is crucial because proper evaluation and management can result in a favourable outcome. Cardiovascular dysfunction and remodelling is a central feature of IUGR. The aim of the study was to use the left modified myocardial performance index (MPI), assess cardiac function in foetuses with intrauterine growth restriction (IUGR) compared to healthy foetuses, and to connect the relationship between changes in MPI and perinatal outcome. A prospective study was conducted with 60 singleton foetuses between 24 and 40 weeks of gestation without foetal chromosomal abnormalities or major malformations, divided into two groups: 30 women with intrauterine growth restriction (30 women) and another 30 women with normal pregnancies (foetal growth pattern appropriate for gestational age and normal heart findings with normal sinus rhythm) who were matched for gestational age and served as the controls. Trans-abdominal ultrasound examination was done with 3.5–7-MHz curvilinear Probe (GE Medical US equipment). The umbilical arteries, middle cerebral artery, and ductus venosus all had blood flow velocity waveforms recorded. The pulsatility index (PI), cerebroplacental ratio (CPR), and Doppler velocimetry (DV) of the umbilical artery were all measured. All foetuses had their myocardial performance index assessed. Normal and abnormal umbilical artery(UA) Doppler, as well as normal and abnormal MCA Doppler, were used to examine the intrauterine growth restriction group. Foetal growth restrictions (FGR) foetuses' Mod-MPI values were compared to gestation-matched controls. The outcomes of the perinatal period were documented.ResultsIntrauterine growth restriction foetuses with defective umbilical arteries Doppler had a substantially higher mean left myocardial performance index (mean 0.58 SD 0.093) than healthy foetuses (mean 0.45SD 0.070) (P 0.001). When compared to the control group, IUGR foetuses with abnormal left myocardial performance index had a significantly worse perinatal outcome and higher morbidity. When compared to intrauterine growth restriction foetuses with normal MPI, intrauterine growth restriction foetuses with defective left MPI had a significantly worse perinatal outcome (whether the UA Doppler was normal or abnormal). Based on the perinatal result, the foetal myocardial performance index was linked to the severity of foetal impairment in intrauterine growth restriction foetuses.ConclusionMPI has the potential to be a useful technique for evaluating IUGR pregnancies and predicting neonatal outcome. Within the IUGR foetuses, MPI foetal echocardiographic characteristics can define a high-risk group.

Role of cerebro-placental ratio in prediction of perinatal outcome in high-risk Pregnancies with intrauterine growth restriction

Background: Antenatal surveillance using Doppler ultrasound velocimetry of the uteroplacental umbilical and fetus arteries has been commonplace. The cerebroplacental ratio has been investigated as a way to predict newborn outcomes. Aim and objectives: In this research, we wanted to see whether the cerebro-placental ratio may help predict perinatal outcomes in high-risk gestation with intrauterine growth restriction. Subjects and methods: This was case-control research done at Al-Hussein University Hospital's Department of Obstetrics and Gynecology; The obstetric color Doppler investigation might be examined in two groups of 100 high-risk pregnant wome: Group Ⅰ - study group: 50 high risk pregnant women with IUGR and Group Ⅱ - control group: 50 high risk pregnant women without IUGR. Results: CPR achieved significance at cutoff point of 1.03 for predicting IUGR with sensitivity of 87.2% and specificity of 71.6% with PPV 83% and NPV 79%. Conclusion: Intrauterine growth restriction in high-risk gestations, the cerebral-placental ratio has a significant prognostic value for perinatal outcome.

Longitudinal changes in fetal head biometry and fetoplacental circulation in fetuses with congenital heart defects.

Objectives were to analyze changes in fetal cephalic biometry and fetoplacental circulation throughout pregnancy in fetuses with congenital heart defects. Prospective study conducted on three university tertiary referral hospitals. Fetuses with the diagnosis of isolated congenital heart defects attending between 2014 and 2018 were included. Congenital heart defects were divided into two groups according to the oxygen supply to the central nervous system: group I (expected low placental blood content and low oxygen delivery to the brain) and group II (expected intermediate and high placental blood content). Fetal biometry and Doppler parameters were collected between 25-30 weeks of gestation and 34-40 weeks of gestation and transformed into Z scores. The results were compared with healthy controls. Finally, general linear modeling was performed to analyze repeated measurements. In all, 71 fetuses met the inclusion criteria. Fetuses with congenital heart defects had significantly smaller head (biparietal diameter [p < 0.001], head circumference [p=0.001]) and abdominal circumference (p < 0.001), and lower estimated fetal weight (p < 0.001) than controls. When analyzing according to congenital heart defects type, head size was significantly smaller in group I compared with group II (p=0.04). Regarding Doppler parameters, fetuses with congenital heart defects showed higher umbilical artery pulsatility index (p < 0.001) and lower cerebroplacental ratio (p=0.044) than controls. In group I, umbilical artery pulsatility index was above the 95th centile in 15.4% of fetuses compared with 6.7% in group II and 1.9% in controls (p < 0.001); moreover, middle cerebral artery pulsatility index was below the 5th centile in 5.4% of group I fetuses compared with 0% in group II and 1.2% in controls (p=0.011). General linear model for two measurements showed significant longitudinal changes in biometric parameters. Growth rate of fetal head through pregnancy (head circumference Z score) was lower in fetuses with congenital heart defects compared with controls (p=0.043). In group I, the head circumference Z score longitudinal decrease was significantly higher than in group II (p < 0.001). Fetuses with congenital heart defects are at risk of smaller head size and Doppler changes. Growth rate of fetal head throughout pregnancy is also affected. These findings are mainly associated with cardiac defects with expected low oxygen supply to the central nervous system.