Early Intrauterine Growth Restriction Research Articles

Fetal chronic hypoxia does not affect urinary presepsin levels in newborns at birth.

Early sepsis detection and diagnosis still constitutes an open issue since the accuracy of standard-of care parameters is biased by a series of perinatal factors including hypoxia. Therefore, we aimed at investigating the effect of fetal chronic hypoxia insult on urine levels of a promising new marker of sepsis, namely presepsin (P-SEP). We conducted a prospective case-control study in 22 cases of early-intrauterine growth restriction (E-IUGR) compared with 22 small-for-gestational-age (SGA) newborns and 66 healthy controls. P-SEP urine samples were collected over the first 72 h from birth. Blood culture and C-reactive protein (CRP) blood levels were measured in E-IUGR and SGA infants. Perinatal standard monitoring parameters and main outcomes were also recorded. No significant urinary P-SEP differences (p>0.05, for all) were observed among studied groups. Moreover, no significant correlations (p>0.05, for both) between urinary P-SEP and blood CRP levels in both E-IUGR and SGA groups (R=0.08; R=0.07, respectively) were observed. The present results showing the lack of influence of fetal chronic hypoxia on urinary P-SEP levels offer additional data to hypothesize the possible use of urinary P-SEP measurement in neonates in daily clinical practice. Further multicenter prospective data are needed, including infants with early-onset sepsis.

Early changes in S100B maternal blood levels can predict fetal intrauterine growth restriction.

Intrauterine growth restriction (IUGR) represents one of the main causes of perinatal mortality and morbidity. Nowadays, IUGR early diagnosis is mandatory in order to limit the occurrence of multiorgan failure, especially the brain. Therefore, we investigated whether longitudinal S100B assessment in maternal blood could be a trustable predictor of IUGR. We conducted a prospective study in 480 pregnancies (IUGR: n=40; small for gestational age, SGA: n=40; controls: n=400) in whom S100B was measured at three predetermined monitoring time-points (T1: 8-18 GA; T2: 19-23 GA; T3: 24-28 GA). Lower S100B in IUGR fetuses than SGA and controls (p<0.05, for all) at T1-T3. Receiver operating characteristic curve showed that S100B at T1 was the best predictor of IUGR (sensitivity: 100 %; specificity: 81.4 %) than T2, T3. The early lower S100B concentration in pregnant women lately complicated by IUGR support the notion that non-invasive early IUGR diagnosis and monitoring is becoming feasible. Results open the way to further studies aimed at diagnosing and monitoring fetal/maternal diseases at earliest time.

SLC38A4 Amino Acid Transporter Expression Is Significantly Lower in Early Preterm Intrauterine Growth Restriction Complicated Placentas.

Intrauterine growth restriction (IUGR), predominantly caused by placental insufficiency, affects partitioning of nutrients to the fetus. The system A sodium-coupled transporters (SNAT or SLC38), of types A1, A2, and A4, control non-essential amino acid uptake and supply. Here, we aimed to investigate the expression of these transporters across different placental disease cohorts and cells. To determine disease impact, transporter expressions at the gene (qPCR) and protein (western blots) level were assessed in gestationally matched placental tissues. Early (&lt;34 weeks), and late (34-36 weeks) onset IUGR cases with/out preeclampsia were compared to preterm controls. We also investigated level of transporter expression in primary trophoblasts under glucose deprivation (n = 6) and hypoxia conditions (n = 7). SLC38A4 protein was significantly downregulated in early preterm pregnancies complicated with IUGR with/out preeclampsia. There were no differences in late preterm IUGR cohorts. Furthermore, we demonstrate for the first time in primary trophoblast cells, that gene expression of the transporters was sensitive to and induced by glucose starvation. SLC38A4 mRNA expression was also significantly upregulated in response to hypoxia. Thus, SLC38A4 expression was persistently low in early preterm IUGR pregnancies, regardless of disease aetiology. This suggests that gestational age at delivery, and consequently IUGR severity, may influence loss of its expression.

Early Onset Intrauterine Growth Restriction-Data from a Tertiary Care Center in a Middle-Income Country.

Background and Objectives: In this study, we aimed to describe the clinical and ultrasound (US) features and the outcome in a group of patients suspected of or diagnosed with early onset intrauterine growth restriction (IUGR) requiring iatrogenic delivery before 32 weeks, having no structural or genetic fetal anomalies, managed in our unit. A secondary aim was to report the incidence of the condition in the population cared for in our hospital, data on immediate postnatal follow-up in these cases and to highlight the differences required in prenatal and postnatal care. Materials and Methods: We used as single criteria for defining the suspicion of early IUGR the sonographic estimation of fetal weight < p10 using the Hadlock 4 technique at any scan performed before 32 weeks’ gestation (WG). We used a cohort of patients having a normal evolution in pregnancy and uneventful vaginal births as controls. Data on pregnancy ultrasound, characteristics and neonatal outcomes were collected and analyzed. We hypothesized that the gestational age (GA) at delivery is related to the severity of the condition. Therefore, we performed a subanalysis in two subgroups, which were divided based on the GA at iatrogenic delivery (between 27+0 WG and 29+6 WG and 30+0−32+0 WG, respectively). Results: The prospective cohort study included 36 pregnancies. We had three cases of intrauterine fetal death (8.3%). The incidence was 1.98% in our population. We confirmed that severe cases (very early diagnosed and delivered) were associated with a higher number of prenatal visits and higher uterine arteries (UtA) pulsatility index (PI) centile in the third trimester—TT (compared with the early diagnosed and delivered). In the very early suspected IUGR subgroup, the newborns required significantly more NICU days and total hospitalization days. Conclusions: Patients with isolated very early and early IUGR—defined as ultrasound (US) estimation of fetal weight < p10 using the Hadlock 4 technique requiring iatrogenic delivery before 32 weeks’ gestation—require closer care prenatally and postnatally. These patients represent an economical burden for the health system, needing significantly longer hospitalization intervals, GA at birth and UtA PI centiles being related to it.

Lung function in young adults born small for gestational age at term.

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Platelet Changes in Pregnancies with Severe Early Fetal Intrauterine Growth Restriction.

Background and Objectives: In this study, we investigated the changes of platelet count and other platelet indices, such as mean platelet volume (MPV), in cases with severe early intrauterine fetal growth restriction (IUGR). Materials and Methods: We retrospectively analyzed all pregnancies diagnosed with severe early onset IUGR, that were followed up in our hospital between 2010 and 2015 (before implementation of screening and prophylaxis with aspirin). Pregnancies which resulted in birth of a newborn with a birthweight less than 5th percentile for gestational age, that required delivery for fetal or maternal indication before 32 weeks, were selected for the IUGR group. The IUGR cases were divided into two groups according to preeclampsia (PE) association. All cases with a complete blood count (CBC) performed within 7 days prior to delivery were included in the study, as the IUGR group. The control group included normal singleton pregnancies, delivered at term, with birthweight above 10th centile and a CBC taken at 30–32 weeks. Results: There was a significant difference in platelet count and MPV values between the IUGR group and control. Cases with IUGR presented lower platelet count and higher MPV values; there was no significant difference of these parameters when PE was associated with IUGR. Conclusions: Our results suggest that in cases of severe early IUGR, even in the absence of clinically diagnosed PE, there may be maternal endothelial damage and platelet consumption in the systemic and uteroplacental circulation. Platelet count and MPV values are simple and widely available laboratory tests that might be used as indicator of placental insufficiency; however, prospective data are required to establish the mechanistic link and to which extent these parameters are good predictors of severity or adverse perinatal outcomes.

Minimum evidence-based care in intrauterine growth-restricted fetuses and neonatal prognosis.

Introduction: There is clear evidence that fetuses with intrauterine growth restriction (IUGR) do not receive the minimum evidence-based care during their antenatal management. Considering that optimal management of IUGR may reduce neonatal morbi-mortality in IUGR, the objective of the present study was to evaluate the impact of antenatal management of IUGR according to the recommendations of the French college of gynecologists and obstetricians (CNGOF) on the neonatal prognosis of IUGR fetuses. From a historical cohort of 31,052 children, born at the Femme Mère Enfant hospital (Lyon, France) between January 1, 2011 and December 31, 2017, we selected the population of IUGR fetuses. The minimum evidence-based care (MEC) in the antenatal management of fetuses with IUGR was defined according to the CNGOF recommendations and neonatal prognosis of early and late IUGR fetuses were assessed based on the whether or not they received MEC. The neonatal prognosis was defined according to a composite criterion that included neonatal morbidity and mortality. A total of 1020 fetuses with IUGR were studied. The application of MEC showed an improvement in the neonatal prognosis of early-onset IUGR (p = 0.003), and an improvement in the neonatal prognosis of IUGR born before 32weeks (p = 0.030). Multivariate analysis confirmed the results showing an increase in neonatal morbi-mortality in early-onset IUGR in the absence of MEC with OR 1.79 (95% CI 1.01-3.19). Diagnosed IUGR with MEC had a better neonatal prognosis when born before 32weeks. Regardless of the birth term, MEC improved the neonatal prognosis of fetuses with early IUGR. Improvement in the rate of MEC during antenatal management has a significant impact on neonatal prognosis.

Features of the functional state of the fetoplacental complex in pregnant women with a history of sexually transmitted infections

The objective: a study of the features for the formation and functioning of the fetoplacental complex in pregnant women with a history of sexually transmitted infections.Materials and methods. We examined 50 pregnant women with a history of sexually transmitted infections (I group – the main group). The control group consisted of 30 pregnant women without somatic and gynecological pathology, who had vaginal delivery. All pregnant women underwent a comprehensive clinical examination, taking into account complaints, medical history, objective and additional methods of examination. The levels of estriol, cortisol, placental lactogen and progesterone in the blood serum of pregnant women and the state of fetoplacental complex in terms of 18–20th, 28–30th and 38–40th weeks were determined.Results. In the pregnant women in I group, starting from the 18th weeks there was a significant decrease in the secretion of progesterone (160,8±15,9 nmol/L versus 202,4±5,5 nmol/L, respectively; p&lt;0,05), placental lactogen (77,5±13,2 nmol/L versus 91,3±23,8 nmol/L)/ This means that already in these stages of pregnancy there are signs of placental dysfunction in pregnant women with a history of sexually transmitted infections. The changes in the functional state of the fetoplacental complex at the 28–30th weeks are more pronounced, as evidenced by an increase in the frequency of early intrauterine growth restriction (12.0 %), disorders of fetal breathing (11.0 %) and fetal movements (18.0 %) (according to the biophysical profile score assessment); premature of the placenta, increased hormonal insufficiency of the fetoplacental complex and the first signs of hemodynamic disorders (an increased blood flow in the umbilical artery and uterine arteries and a slight decrease in blood circulation in the middle cerebral artery of the fetus). At the final assessment of the condition of the fetoplacental complex at the 38–40th weeks in pregnant women with a history of sexually transmitted infections, a satisfactory condition was observed in 24 % of cases, compensated ultrasound changes occurred in 46.0 % of cases; subcompensated – in 20.0 % and decompensated – in 10.0 % of cases, respectively, which causes a high frequency of obstetric and perinatal complications in this group of pregnant women.Conclusions. The formation and functional state of the fetoplacental complex in pregnant women with a history of sexually transmitted infections, from early pregnancy is characterized by a significant level of functional disorders of the fetus, placenta and the amount of amniotic fluid on the background of pronounced hemodynamic and endocrinological disorders, which requires prevention in the pre-pregnancy period.

Rapid BMI Increases and Persistent Obesity in Small-for-Gestational-Age Infants.

Purpose: In order to compensate for the early intrauterine growth restriction, small-for-gestational age (SGA) infants have “catch-up growth” after birth. Increased caloric intake has been suggested for SGA infants conventionally. It is important to determine if the early growth rate of body mass index (BMI) is associated with risk of persistent obesity later in life. In this longitudinal cohort study, we assessed the BMI of a large cohort of children who were SGA at birth to determine their risk of persistent obesity at school age (6–7 years) due to excessive weight gain in the first 3 years of life.Methods: We collected the height and weight data of 23,871 SGA babies. A polynomial function was used to fit the BMI-for-age z-score (BAZ) values of 0–6 years old SGA children and interpolate their growth trajectory. In addition, we screened out 6,959 children from 23,871 children to further evaluate the dynamic changes of early childhood BMI. We divided the school-age children into groups as non-obese (BAZ < 2) and obese (BAZ > 2), and determined the association between changes in BMI and school-age obesity.Results: From the perspective of BMI distribution, the interpolated growth trajectory indicated that SGA children reaching overweight status or developing obesity by 3 years of age, continued to have obesity until school age (R2, 0.65; R2, 0.21). The retrospective analysis showed that children who were overweight and had obesity during school age had a high BMI from early age. By analyzing the changes in early BMI, we found that the fastest growth of SGA children occurred in the early infancy before 6 months and they continued to grow rapidly for a period of time. Interestingly, former SGA children who maintained a near overweight (1 < BAZ < 2) status before the age of 2 maintained an appropriate growth rate and usually did not develop obesity.Conclusions: A rapid increase in BMI during early infancy in former SGA newborns leads to a persistent risk of obesity. The energy intake of SGA infants should appropriately meet the infants' growth needs and early BMI changes should be closely monitored for an optimal integrated management.

Extremely early intrauterine growth restriction with dramatic sFlt-1/PlGF ratio

Extremely early intrauterine growth restriction with dramatic sFlt-1/PlGF ratio

How does subchorionic hematoma in the first trimester affect pregnancy outcomes?

IntroductionSubchorionic hematoma (SCH) in pregnancy has been associated with increased risk of adverse pregnancy outcomes. We aimed to investigate the association of SCH with adverse pregnancy outcomes in pregnant women in relation to size of hematoma and control subjects.Material and methodsThis study included 178 pregnant women with sono-graphically detected SCH in the 1st trimester, and 350 pregnant controls without SCH. Data on maternal age, smoking status, gestational week at diagnosis, location of SCH, medications before diagnosis, gestational week at delivery, delivery route and pregnancy outcomes (first trimester vaginal bleeding, pre-eclampsia, gestational diabetes, intrauterine growth restriction (IUGR), placental abruption, preterm delivery < 37 weeks, early pregnancy loss and intrauterine death) were retrieved retrospectively from hospital records. Pregnant women with SCH were divided into 3 groups according to the size of hematoma including small SCH (SCH-I group, n = 47), medium-size SCH (SCH-II group, n = 110) and large SCH (SCH-III group, n = 21) groups.ResultsSubchorionic hematoma was associated with significantly lower gestational age at delivery (p < 0.001) and higher rate of first trimester bleeding (p < 0.001) compared with the control group, regardless of the size of the hematoma. Placental abruption (p = 0.002) and early pregnancy loss (p < 0.001) were significantly more common in SCH-II and -III groups than in the control group. SCH-III group was associated with a significantly higher rate of < 37 gestational weeks at delivery (p < 0.001), first trimester vaginal bleeding (p < 0.001), early pregnancy loss (p < 0.001), IUGR (p = 0.003) and preterm delivery (p < 0.001) compared to both lesser size hematoma and control groups.ConclusionsOur findings suggest that large SCH might indicate an increased risk of adverse pregnancy outcomes such as 1st trimester vaginal bleeding, early pregnancy loss, IUGR, placental abruption or preterm delivery. These findings are important to guide the patients with SCH for detailed clinical evaluation.

A STATISTICAL ANALYSIS OF OBSTETRIC AND PERINATAL COMPLICATIONS IN SINGLETON AND MULTIPLE PREGNANCIES ONCE ASSISTED REPRODUCTIVE TECHNOLOGIES ARE USED

The aim: To carry out a comparative statistical analysis of obstetric and perinatal complications in singleton and multiple pregnancies once assisted reproductive technologies (ART) are applied according to the records taken from archival materials (maternity and delivery records) and identify the clinical features of multiple pregnancy. Materials and methods: Over the period of 2017-2019, 522 women gave birth in LELEKA Maternity Hospital LLC after using assisted reproductive technologies and 331 women among them were followed-up in the women's health center of LELEKA maternity hospital. Among these women (522) with singleton pregnancy 445 women gave birth, while in multiple pregnancy - 77. The statistical analysis of 150 maternity and delivery records was carried out. All pregnant women were divided into two groups: group 1 - 75 women having singleton pregnancy after ART; group 2 - 75 women having multiple pregnancy after ART. Women getting pregnant after ART, or in vitro fertilization (IVF) and five-day frozen embryo transfer to be exact, turned out to be the selection criterion for a comparative statistical analysis. Mathematical methods for research were used as O.P. Mintser (2013) suggested. The reliability of the digit cancellation test was calculated using the Fisher's exact test and Student's T-test. Graphs were designed using Microsoft Excel. Results: The complications of early multiple pregnancy were the following: anemia (47.8% as opposed to 22.9%, p<0.01), placental insufficiency (43.3% in contrast to 22.9%, p<0.01), threatened abortion (41.8% in contrast to 28.6%, p<0.01). The complications in late pregnancy are as follows: preeclampsia (52.7% as opposed to 20.6%, p <0.01), intrauterine growth restriction (20.0% as opposed to 7.4%, p <0.01), anemia in pregnancy (76.4% in contrast to 32.4%, p<0.01), placental insufficiency (47.3% in contrast to 22.1%, p<0.05). Conclusions: Multiple pregnancy is a high risk for anemia in pregnancy, preeclampsia, placental insufficiency, early intrauterine growth restriction and fetal distress in pregnancy and labor. It predetermines the high level of a caesarean section. Therefore, further research aimed at prediction and prevention of obstetric and perinatal complications in multiple pregnancy after ART is currently topical.

Cardiac Morphology in Neonates with Intrauterine Growth Restriction

Background: Intrauterine growth restriction (IUGR) affects cardiac development. We hypothesized that IUGR impacts early cardiac modelling. Aim: To assess the impact of IUGR on cardiac morphology in premature and term neonates. Study design: Prospective, observational cohort study Subjects: Pregnant women and their neonates with early (week 30+0 -31+6, n=9) and late (week 32+0 -42+0, n=19) IUGR with centralized fetal circulation. A gestational age matched control group (n=41) of non-IUGR neonates with normal prenatal growth and circulation. Outcome measures: Heart size measured by echocardiography. Results: Adjusted for gestational age, birth weight, sex and twin/singleton, IUGR neonates had significantly shorter mean (SEM) left ventricular septum length than non-IUGR neonates (27.8 mm (0.4) vs 29.7 (0.3)), shorter diameter of left atrium (9.4 (0.2) vs 10.8 (0.2)), left ventricle (15.0 (0.3) vs 17.3 (0.2)) and right ventricle (8.3 (0.3) vs 9.9 (0.3)) (p<0.01). In unadjusted estimates, IUGR had more impact on atrial cavities and right ventricle areas and diameters than on longitudinal dimensions, but less impact on atrioventricular valve orifices and left ventricle cavity diameters. This indicated a globular shape of the left ventricle and a symmetrical-to-oblong shape of right ventricle in IUGR. In adjusted estimates, the right ventricle dimensions exhibited an oblong shape whereas left ventricle dimensions were symmetrical. Conclusion: IUGR neonates had smaller hearts compared with non-IUGR neonates. In unadjusted estimates, IUGR hearts portrayed a symmetrical-to-oblong shape of the right ventricle and a globular shape of the left ventricle. In adjusted estimates, right ventricle shape remained oblong, whereas left ventricle shape was symmetrical. Funding Information: The research did not receive any grant from funding agencies in the public, commercial, or not-for-profit sector. Declaration of Interests: None declared. Ethics Approval Statement: The Hospital’s Data Protection Officer and The Regional Ethics Committee of Research, South East, Norway approved the study (2016/923D). The parents gave written informed consent.

Histological changes of human placenta in early intrauterine growth restriction with and without preeclampsia

Background: Intra uterine growth restriction (IUGR) is a common pregnancy complication, pre-eclamsia (PE) is an importantcause of this complication and is responsible for maternal and fetal morbidity and mortality. Idiopathic intrauterine growthrestriction without obvious causes is not uncommon.Objective: The aim of this study is to examine the placental histology in both conditions trying to find specific criteria for eachdisorder.Materials and Methods: This study was conducted on three groups; group I was the control group, group II was preeclampsiainduced IUGR (PE-IUGR) group and group III was idiopathic IUGR (I-IUGR). Each group contained 15 placentas. Placentalspecimens from each group were analyzed histopathologically and immunohistochemically.Results: we found that PE-IUGR and I-IUGR cases in this study share common histological changes suggesting a similarpathogenesis. Maternal mal-perfusion lesions predominated in PE-IUGR. Findings consistent with fetal vascular malperfusionwere higher in I-IUGR. Hofbauer cells (HBC) were increased in both PE-IUGR and I-IUGR.Conclusion: abnormal utero-placental blood vessels and utero-placental insufficiency and the resulting histological changes inthe chorionic villi, and chronic inflammatory lesions may be the primary disease processes related to the placental pathologyof PE-IUGR and I-IUGR.

The Efficacy of Doppler Indices in Third Trimester of IUGR Pregnancies

Objective: To identify the usefulness of Doppler indices in the third trimester for intra-uterine growth- restricted pregnancies. Materials and Methods: It was an observational case-control study of singletons with intra-uterine growth restriction (fetal weight <10th percentile). Intra-uterine growth restricted fetuses (cases) and normal (controls) were examined for the umbilical artery. Time intervals between progressive Doppler abnormalities and configurations of worsening were related to umbilical artery Doppler status and gestational age. This study was conducted from August 2015 to January 2016 at Gilani Ultrasound Center Lahore Pakistan. A total of 60 pregnant females were studied with normal and abnormal umbilical artery Doppler ultrasound. Results: Doppler indices measurements of umbilical artery in intra-uterine growth restriction fetuses in the third trimester showed higher values as compared to normal fetuses. 30 females had normal umbilical artery Doppler indices and waveforms and 30 females showed (either thinning, absent or reversed Diastolic flow Doppler waveform) with higher indices. Conclusion: Fetal umbilical artery Doppler ultrasound is an effective tool in the detection of early intra-uterine growth restriction fetuses.

Doppler Indices of Uterine, Umbilical and Fetal Middle Cerebral Arteries Before and After Sildenafil Citrate and Transdermal Nitroglycerin in Cases Suffering from Intrauterine Growth Restriction

Introduction Intrauterine growth restriction (IUGR) is a major cause of perinatal morbidity and mortality. Its diagnosis and treatment constitute one of the most important challenges of present day obstetrics. A drug that could improve maternal and fetal hemodynamics in the setting of early intrauterine growth restriction has potential benefit for at least palliation of this ominous condition. In most instances the etiology of IUGR is unknown. The absence of a uniform etiology may help one understand the existence of the large number of treatments suggested for correcting the problem Patients and methods The objective of this study was to compare the effect of transdermal nitroglycerin and oral Sildenafil citrate on Doppler indices of uterine, umbilical and fetal middle cerebral arteries, and changes in fetal weigh, abdominal circumference and amniotic fluid volume in fifty pregnant women who attended inpatient and outpatient clinics in the department of Obstetrics &amp; Gynecology in Tanta University Hospitals, and suffering from asymmetrical intrauterine growth restriction. Results of the study proved a clear significance of the growing role of transdermal nitroglycerin and Sildenafil citrate for augmenting, feto-placental blood flow in the setting of placental vascular insufficiency and IUGR, as a significant reduction in umbilical artery RI, uterine artery RI in the two groups, also abdominal circumference, AFI and estimated fetal weight were significantly increased after 21 days from treatment. That gives a promising treatment for IUGR patients.

Study protocol for a randomised controlled trial: treatment of early intrauterine growth restriction with low molecular weight heparin (TRACIP)

IntroductionThe incidence of intrauterine growth restriction (IUGR) is estimated at about 3% of pregnancies, and it is associated with 30% of all perinatal mortality and severe morbidity with adverse neurodevelopmental...

Doppler-based fetal heart rate analysis markers for the detection of early intrauterine growth restriction.

One indicator for fetal risk of mortality is intrauterine growth restriction (IUGR). Whether markers reflecting the impact of growth restriction on the cardiovascular system, computed from a Doppler-derived heart rate signal, would be suitable for its detection antenatally was studied. We used a cardiotocography archive of 1163 IUGR cases and 1163 healthy controls, matched for gestation and gender. We assessed the discriminative power of short-term variability and long-term variability of the fetal heart rate, computed over episodes of high and low variation aiming to separate growth-restricted fetuses from controls. Metrics characterizing the sleep state distribution within a trace were also considered for inclusion into an IUGR detection model. Significant differences in the risk markers comparing growth-restricted with healthy fetuses were found. When used in a logistic regression classifier, their performance for identifying IUGR was considerably superior before 34weeks of gestation. Long-term variability in active sleep was superior to short-term variability [area under the receiver operator curve (AUC) of 72% compared with 71%]. Most predictive was the number of minutes in high variation per hour (AUC of 75%). A multivariate IUGR prediction model improved the AUC to 76%. We suggest that heart rate variability markers together with surrogate information on sleep states can contribute to the detection of early-onset IUGR.

Fetal monitoring indications for delivery and 2-year outcome in 310 infants with fetal growth restriction delivered before 32 weeks' gestation in the TRUFFLE study.

In the TRUFFLE (Trial of Randomized Umbilical and Fetal Flow in Europe) study on the outcome of early fetal growth restriction, women were allocated to one of three groups of indication for delivery according to the following monitoring strategies: (1) reduced fetal heart rate (FHR) short-term variation (STV) on cardiotocography (CTG); (2) early changes in fetal ductus venosus (DV) waveform (DV-p95); and (3) late changes in fetal DV waveform (DV-no-A). However, many infants per monitoring protocol were delivered because of safety-net criteria, for maternal or other fetal indications, or after 32 weeks of gestation when the protocol was no longer applied. The objective of the present posthoc subanalysis was to investigate the indications for delivery in relation to 2-year outcome in infants delivered before 32 weeks to further refine management proposals. We included all 310 cases of the TRUFFLE study with known outcome at 2 years' corrected age and seven fetal deaths, excluding seven cases with inevitable perinatal death. Data were analyzed according to the allocated fetal monitoring strategy in combination with the indication for delivery. Overall, only 32% of liveborn infants were delivered according to the specified monitoring parameter for indication for delivery; 38% were delivered because of safety-net criteria, 15% for other fetal reasons and 15% for maternal reasons. In the CTG-STV group, 51% of infants were delivered because of reduced STV. In the DV-p95 group, 34% of infants were delivered because of abnormal DV and, in the DV-no-A group, only 10% of infants were delivered accordingly. The majority of infants in the DV groups were delivered for the safety-net criterion of spontaneous decelerations in FHR. Two-year intact survival was highest in the DV groups combined compared with the CTG-STV group (P = 0.05 for live births only, P = 0.21 including fetal death), with no difference between DV groups. A poorer outcome in the CTG-STV group was restricted to infants delivered because of FHR decelerations in the safety-net subgroup. Infants delivered because of maternal reasons had the highest birth weight and a non-significantly higher intact survival. In this subanalysis of infants delivered before 32 weeks, the majority were delivered for reasons other than the allocated monitoring strategy indication. Since, in the DV group, CTG-STV criteria were used as a safety net but in the CTG-STV group, no DV safety-net criteria were applied, we speculate that the slightly poorer outcome in the CTG-STV group might be explained by the absence of DV data. The optimal timing of delivery of fetuses with early intrauterine growth restriction may therefore be best determined by monitoring them longitudinally, with both DV and CTG monitoring. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

OP25.01: Natural history of early selective intrauterine growth restriction in monochorionic diamniotic pregnancies

To compare outcomes between interventional and expectant management of monochorionic twin pregnancies complicated with early severe intrauterine growth restriction (IUGR). We studied a series of selective IUGR defined as an AC<5th centile and absent or reverse end-diastolic flow in the umbilical arteries before 18+6 weeks, between 2011 and 2017. Treatment options included selective fetoscopic laser coagulation (SFLC) of inter-twin anatomoses, cord coagulation (CC), or expectant management (EM). Discordance in EFW and gestational age at diagnosis were considered as potential predictors for perinatal survival. A total of 74 cases were identified: 23 diagnosed <16+0 weeks (group 1) and 51 ≥16+0 weeks (group 2). In group 1, 3 were managed by SFLC, 9 by CC and 11 had an EM. The overall survival was 33,3% (2/6), 33,3% (6/18) and 86,3% (19/22) respectively. Intrauterine demise of the co-twin occurred in 33,3% (1/3), 33,3% (3/9) and 9,1% (1/11) respectively and was associated with 100% mortality in the smaller twin following SFLC and 18,2% (2/11) with EM. When discordance in EFW was <30% survival of both twin occurred in 100% with EM. In group 2, 10 were treated by SFLC, 27 by CC and 14 underwent EM with overall survival of 25% (5/20), 42,6% (23/54) and 67,8% (19/28) respectively. Intrauterine demise of the co-twin occurred in 60% (6/10), 14,8% (4/27) and 28,6% (4/14) respectively and was associated with the death of the smaller twin in 90% (9/10) following SFLC and in 35,7% (5/14) with EM. When discordance in EFW was <30% both twins survived in 70% of cases managed expectantly. Unexpected spontaneous demise occurred with EM in 13,6% (3/22) and in 21,4% (6/28) in cases diagnosed <16+0 weeks and ≥16+0 weeks respectively. Early IUGR is at high risk of fetal demise. Expectant management is a valid option as some will improve and allow a favourable neonatal outcome with a low rate of unexpected spontaneous fetal demise during follow-up.