Fetal Surveillance Research Articles

Doppler assessment of fetal well-being – A rational approach

Doppler sonography provides insight into the uteroplacental and fetoplacental circulation non-invasively. It has important diagnostic implications in fetal growth restriction (FGR), monitoring of multiple pregnancies complicated by discordancy and placental vascular communications in twin-to-twin transfusion syndrome (TTTS), and fetal anemia; particularly, red blood cell isoimmunization in Rh-negative pregnancies. There is a sequence of changes in UA Doppler velocimetry whenever there is fetal compromise, that is, increased S/D ratio, centralization of flow (brain-sparing effect) followed by absent end-diastolic flow and finally reversed end-diastolic flow. When venous Doppler studies {e.g., umbilical vein (UV), ductus venosus (DV), and inferior vena cava (IVC) Doppler} also become abnormal, perinatal mortality and still birth increase manifold. Vertebroplacental ratio (VPR) is proved to be an alternative to cerebroplacental ratio (CPR) in fetal surveillance near term. DV flow assessment in the first trimester has a vital role in screening for chromosomal abnormalities and cardiac defects.

Impaired validity of the new FIGO and Swedish CTG classification templates to identify fetal acidosis in the first stage of labor

Introduction Cardiotocography (CTG) is the main method of intrapartum fetal surveillance. In 2015 a new guideline was introduced by the International Federation of Gynecology and Obstetrics (FIGO), FIGO-15. In Sweden it was adjusted to SWE-17, replacing the previous national template, SWE-09. This study, conducted at one university hospital and one regional hospital in southern Sweden, evaluated the diagnostic validity of these three templates to detect fetal acidosis during the first stage of labor. Material and methods A total of 73 neonates with pH <7.1 in umbilical cord artery or vein at cesarean delivery during the first stage of labor were identified retrospectively. For each acidotic neonate, three non-acidemic neonates, with a pH ≥7.2 in cord artery and vein, and Apgar scores ≥9 at five and ten minutes, in all 219 neonates, were selected. The CTG tracings before birth in acidemic neonates, and tracings at the same cervical dilatation in the non-acidemic neonates, were independently assessed by three professionals from the obstetric staff, blinded to group and clinical data. Based on their categorizations of the included variables (baseline, variability, accelerations, decelerations and contraction rate), each CTG tracing was systematically classified according to the three templates. The sensitivity and specificity to identify acidemia by the classification pathological were determined for each template. Interobserver agreement in the assessments of tracings as pathological or not was analyzed, using free-marginal Kappa index. Results The sensitivity for patterns classified as pathological to identify acidemia was similar for FIGO-15 (71%) and SWE-17 (77%, p = .13), and the specificity was 97% for both. SWE-09 had a significantly higher sensitivity (95%, p < .001) albeit with a lower specificity (90%, p < .001) than the other two templates. Among acidemic neonates, the fraction of tracings classified as normal was higher with SWE-17 (9.6%) than with SWE-09 (0%; p = .01) and FIGO-15 (1.4%; p = .06). For tracings from neonates with acidemia, agreement for three independent assessors was strong (κ 0.85) with SWE-09, and weak for FIGO-15 (κ 0.47), and SWE-17 (κ 0.51). For tracings from neonates without acidemia, the agreement was almost perfect for FIGO-15 (κ 0.91), strong withSWE-17 (κ 0.90) and moderate with SWE-09 (κ 0.78). Conclusions The ability of FIGO-15 and SWE-17 to identify fetal acidosis is considered insufficient. The combination of a high sensitivity and a high specificity makes SWE-09 the most discriminatory template during the first stage of labor.

Ethical Issues and Management of Fetal Hemolytic Anemia Caused by Anti-Rh17 in a Multipara with Rare –D– Phenotype

Background: The development of allo-anti-Rh17 (anti-Hr0) in a –D– phenotype whose red blood cells (RBCs) lack CcEe antigens is most likely triggered by transfusion, transplantation, or pregnancy. Gene conversion is the predominating factor in generating RHD-CE-D and RHCE-D-CE hybrids like –D–. Methods: We report here immunohematological and obstetrical data from 2 of the 5 pregnancies of a 24-year-old woman presenting with the –D– phenotype with anti-Rh17. Blood group typing, antibody screening, antibody differentiation, direct antiglobulin test (DAT), and antibody titers were performed by routine gel technology and tube testing. Additionally, molecular genetic analysis was performed. Fetal surveillance was done by sonographic evaluation of the fetal middle cerebral artery peak systolic velocity (MCA-PSV). Results: Blood group typing showed O, C-c-D+E-e- and the DAT was negative. DNA sequencing revealed homozygosity for an RHCE-D(3–9)-CE null allele. Anti-Rh17 titers in the fourth pregnancy remained between 1:8 and 1:128, and no signs for a fetal anemia were observed. However, in the fifth pregnancy, the antibody titers increased up to 1:4,096. Signs of moderate fetal anemia were detected and cesarean section was performed at 34 + 6 weeks of gestation. The newborn presented with hemolytic anemia (cord blood hemoglobin [Hb] = 8.5 mg/dL). She received 2 compatible (small) packed RBC concentrates, phototherapy, and intravenous immunoglobulins. Conclusion: Our case shows that the risk for hemolytic complications increases with the number of pregnancies of sensitized women. Only people who also lack CcEe antigens are compatible as donors. The role of such rare donors as lifesavers, their freedom, and voluntariness conflict with the urgent need for compatible blood.

Considering evidence in the management of fetal growth restriction.

Considering evidence in the management of fetal growth restriction.

Vanishing Non-immune Hydrops in Giant Chorioangioma of Placenta

Giant Chorioangioma of placenta is a rare nontrophoblastic tumour of placenta. It may lead to various maternal and foetal complications like massive antepartum haemorrhage, sudden intrauterine foetal demise and non-immune hydrops, although in few cases mother and the foetus remain unaffected. This report is of a 35-year-old G3P1L1A1, presented to hospital at 32 weeks gestation with pain abdomen followed by watery discharge from vagina. Ultrasonography at 30 weeks revealed a huge mass on anterior wall with placenta on posterior wall of uterus although her previous antenatal sonography did not reveal any abnormality either in the foetus or in placenta. Diagnosis of preterm rupture of membranes was confirmed. Hence, she was kept on conservative management; received antibiotics and steroids for foetal lung maturity. Subsequently, the foetus developed mild, steady non-immune hydrops probably due to high output cardiac failure as Values of Middle Cerebral Artery’s Peak Systolic Velocity (MCA-PSV) were within normal limits. Biophysical profile and nonstress test were normal. Guarded foetal prognosis was given due to non-immune hydrops but she delivered a normal female baby with good Appearance, Pulse, Grimace, Activity and Respiration (APGAR) score with huge chorioangioma of placenta. Although rare, chorioangiomas of placenta should be kept in differential diagnosis of non-immune hydrops that needs regular foetal surveillance and timely intervention in affected foetuses to increase survival after birth.

Is COVID-19 Infection in Pregnancy A Risk Factor for Antepartum Fetal Compromise? A Case Series and Literature Review

This case series explores whether COVID-19 infection is an independent risk factor for abnormal antepartum Cardiotocogram (CTG). We describe retrospective case reviews of nine pregnant women with confirmed COVID-19 infection who were admitted to Al Wakra Hospital, Qatar between April 1 and May 22, 2021. Each woman had a prelabour abnormal cardiotocogram (CTG) that necessitated delivery by emergency caesarean section. Five patients were admitted at less than 32 weeks gestation; the other four were 36 weeks or more. One had preeclampsia and gestational diabetes, another had gestational diabetes. Four patients were admitted with severe COVID-19 pneumonia, whereas the other five had mild COVID-19 symptoms. The four severe cases were on remdesivir and dexamethasone, including one on tocilizumab. Three patients were on hydroxychloroquine and the other two were on symptomatic treatments. Four patients were on supplemental oxygen. Regarding fetal outcome, five babies had APGAR Scores of less than 5 at one minute, but all babies had APGAR Scores above 7 at five minutes. Five babies had arterial pH less than 7.20, two of them less than 7.00. Five babies were intubated, and one was cooled. None of the babies had a positive COVID-19 reverse transcription polymerase chain reaction (RT-PCR) result. We conclude that COVID-19 infection in pregnancy could be an independent risk factor for abnormal antepartum CTG. This study is small and so more research is needed to further ascertain this finding. We recommend enhanced antenatal fetal surveillance using CTG for pregnant women admitted with COVID-19 infection.

40 Weeks of Gestation is as High-Risk Gestation as 41 Weeks in Low-Risk Pregnancies

Introduction: Postdate pregnancy is associated with a higher frequency of obstetrical complications and perinatal morbidity. The incidence of meconium-stained amniotic fluid is 30% at 40 weeks which is very high. This study aimed to find out the need for fetal surveillance and delivery in our population, keeping in view that 40 weeks of gestation is as high risk as 41 weeks gestation in low-risk pregnancies.Material and Methods: The study was conducted at Obstetrics &amp; Gynecology Department, Unit-II, Holy Family Hospital, and Rawalpindi from 16 February to 15 August 2019 after ethical clearance. Postdate pregnant women from 40 to 41 weeks who meet study criteria were enrolled in the study. We divided participants into two groups. Group A (40 to 40+6 weeks of gestation) while group B had Group B (41 to 41+6 weeks of gestation). Results: A total of 236 postdate mothers presented of which 148(62%) were in group A while 88 (38%) were in group B. Mean gestational age in our study was 40.88 ± 0.71 weeks. overall vaginal delivery, cesarean delivery, and meconium stained liquor were found in 75.84%, 24.16%, and 35.17% patients respectively. 82 (34.7%) participants presented with meconium-stained liquor meconium-stained liquor with women in group B has a higher frequency of meconium-stained liquor, 45 (30.41%) in group A and 37 (42.04%) in group B, P-value 0.069. rate of vaginal delivery was 71.62% in group A and 82.95% in group B which was statistically significant. P-value 0.049Conclusion: High percentage of meconium-stained liquor was observed in the study population. Frequency of vaginal delivery increases if postdate women waited till 41 weeks. 30% of women at gestation age 40 to 40+6 have meconium-stained liquor which shows almost 1/3 of pregnant ladies are exposed to the compromised fetal status which is a considerable risk. This increases further as the gestation age advances. Appropriate interventions should be taken at 40 weeks in low-risk pregnancies to avoid perinatal risk.

A Pragmatic Approach to the Treatment of Women With Type 2 Diabetes in Pregnancy.

Type 2 diabetes mellitus (DM) is a growing problem among reproductive-aged women. Contemporary trends in obesity and delayed child-bearing are expected to result in an increasing number of pregnancies affected by type 2 DM. Women with known type 2 DM can greatly benefit from preconception care as improved periconception glycemic control and weight loss can decrease the neonatal and maternal risks associated with type 2 DM and pregnancy. Antenatal mainstays of management include frequent blood glucose monitoring, insulin therapy, optimization of coexisting medical conditions, and fetal surveillance. Careful attention to postpartum glucose control, infant feeding choices, and contraceptive counseling are important aspects of immediate postpartum care.

Evaluation of Modified Biophysical Profile in Pre-Eclamptic Patients and Measure its Impact on Perinatal Outcome

Introduction: Hypertensive disorders in pregnancy are a major cause of maternal and perinatal morbidity and mortality worldwide. Modified biophysical profile (MBPP) combines Non stress test as a short term marker of fetal status and the amniotic fluid index as a marker of long term placental function which is easier to perform and less time consuming. Aim: To study the antepartum fetal surveillance with modified biophysical profile and perinatal outcome in pre-eclamptic women. Materials and Methods: Prospective descriptive study of perinatal outcome included 150 ANC patients gestational age between 34 to 40 weeks both primi gravida and multigravida with pre-eclampsia admitted in SMIMER hospital during January 2017 to June 2018. Patients were treated in line with standard protocol and perinatal outcome were then studied. Results: Of the 150 NST’s in MBPP, 77% were reactive and 23% were non-reactive. When the MBPP was abnormal with respect to both parameters 60% of the cases had LSCS and 40% of them had vaginal delivery. When both parameters were normal there were only 3.63% cases were MSL. When NST was abnormal and AFI normal 45.45% cases were MSL and when NST was normal and AFI abnormal 42.8% cases were MSL. When both the parameters were abnormal 63.6% of the cases had APGAR &lt;7 `whereas when NST was normal and AFI was abnormal 2(28.5%) the cases had APGAR &lt;7. When AFI was normal and NST was abnormal 36.3% of the cases had APGAR &lt;7. Conclusions: Modified biophysical profile (MBPP) is easier, less time consuming, cost effective and patient compliant test.

Risk stratification for early-onset fetal growth restriction in women with abnormal serum biomarkers: a retrospective cohort study

Abnormal maternal serum biomarkers (AMSB), identified through the aneuploidy screening programme, are frequent incidental findings in pregnancy. They are associated with fetal growth restriction (FGR), but previous studies have not examined whether this association is with early-onset (< 34 weeks) or late-onset (> 34 weeks) FGR; as a result there is no consensus on management. The aims of this study were to determine the prevalence and phenotype of FGR in women with AMSB and test the predictive value of placental sonographic screening to predict early-onset FGR. 1196 pregnant women with AMSB underwent a 21–24 week “placental screen” comprising fetal and placental size, and uterine artery Doppler. Multivariable regression was used to calculate a predictive model for early-onset FGR (birthweight centile < 3rd/< 10th with absent umbilical end-diastolic flow, < 34 weeks). FGR prevalence was high (10.3%), however early-onset FGR was uncommon (2.3%). Placental screening effectively identified early-onset (area under the curve (AUC) 0.93, 95% confidence interval (CI) 0.87–1.00), but not late-onset FGR (AUC 0.70, 95% CI 0.64–0.75). Internal validation demonstrated robust performance for detection/exclusion of early-onset FGR. In this cohort, utilisation of our proposed algorithm with targeted fetal growth and Doppler surveillance, compared with universal comprehensive surveillance would have avoided 1044 scans, potentiating significant cost-saving for maternity services.

The association between threatened preterm labour and perinatal outcomes at term: a population-based cohort study.

To estimate the association between threatened preterm labour (TPTL) and perinatal outcomes of infants born at term. A population-based cohort study of perinatal outcomes following TPTL <37weeks of gestation with delivery at term. Nova Scotia, Canada. All non-anomalous, singleton pregnancies ≥37weeks of gestation without antepartum haemorrhage from 1988 to 2019. Using data from the Nova Scotia Atlee Perinatal Database, TPTL was defined as pregnancies with a hospital admission between 20 and 37weeks of gestation, with a diagnosis code denoting TPTL with administration of antenatal corticosteroids, or with administration of any tocolysis. Poisson regression models were used to estimate the risk ratios (RR) with 95% CI of maternal and perinatal outcomes in women who had an episode of TPTL relative to those who did not. Birthweight for gestational age below the tenth centile and a composite of perinatal mortality or severe perinatal morbidity. Of 256599 term deliveries meeting the inclusion criteria, 2278 (0.9%) involved TPTL. The risks of the primary outcomes were higher among those with TPTL relative to those without: birthweight for gestational age below the tenth centile (RR 1.24, 95% CI 1.11-1.39) and the composite of perinatal mortality/severe perinatal morbidity (RR 1.33, 95% CI 1.15-1.54). Although the prevalence of TPTL in term deliveries is low, affected pregnancies are at increased risk for adverse perinatal outcomes. Increased fetal surveillance should be considered in the management of pregnancies affected by TPTL.

Intrapartum Doppler ultrasound: where are we now?

Intrapartum hypoxic events most commonly occur in low-risk pregnancies with appropriately grown fetuses. Continuous intrapartum monitoring by means of cardiotocography has not demonstrated a reduction in the frequency of adverse perinatal outcome but has been linked with an increase in the caesarean section rate, particularly among women considered at low risk. Available data from the literature suggests that abnormalities in the uterine artery Doppler and in the ratio between fetal cerebral and umbilical Doppler (i.e. cerebroplacental ratio [CPR]) are associated with conditions of subclinical placental function occurring in fetuses who have failed to achieve their growth potential regardless of their actual size. In this review we summarize the available evidence on the use of intrapartum Doppler ultrasound for the fetal surveillance during labor and the identification of the fetuses at risk of intrapartum distress.

Revisiting Strategies for Maternal Health Care in the Face of COVID-19 Pandemic

Novel coronavirus (SARS-CoV-2) is a new strain of coronavirus causing COVID-19, first identified in Wuhan City, China towards the end of 2019. At present, there is no evidence that pregnant women are more likely to be severely ill, need ICU care, or die from the illness in comparison to non-pregnant adults. Evidences suggest that vertical transmission, might be possible. We searched and retrieved the published literature from PubMed and Google Scholar using various keywords. We further searched the official webpages of various organizations for the updated information. Pregnant individuals in particular are encouraged to take all available precautions to optimize health and avoid exposure to COVID-19. Adequate Testing should be prioritized in pregnant women admitted with suspected COVID-19. When a pregnancy is complicated by critical illness, the pregnant patient should ideally be cared for at a Level III or IV hospital. In the face of COVID-19, antenatal fetal surveillance and ultrasonography should continue as medically indicated when possible and elective ultrasound examinations should not be performed. Maternal immunizations continue to be an essential component of prenatal care and Obgyns should screen all pregnant individuals for mental health issues. Although the most commonly reported sign in COVID-19 is fever, nevertheless, other causes of intrapartum fever should not be overlooked. Cesarean delivery should be based on obstetric indications and not COVID-19 status alone. Infants born to patients with known COVID-19 should be considered infants with suspected COVID-19. The suspected or confirmed COVID-19 mother and infant can be allowed to remain together with enhanced precautions and suspected or confirmed maternal COVID-19 is not a contraindication to breastfeeding. If both the mother and the infant are healthy, it may be prudent to expedite discharge, so as to limit the risk of inadvertent exposure and infection. The Ob-gyns should commit to providing necessary care, although modifications to health care delivery approaches may be necessary.

Twin reversed arterial perfusion sequence in a monochorionic monoamniotic twin pregnancy: a very rare condition

BackgroundTwin reversed arterial perfusion sequence (TRAP) is a very rare congenital anomaly. We present sonographic findings of TRAP sequence in the case of a multiparous woman with a monochorionic monoamniotic twin pregnancy who was referred to our unit for blood sugar control.Case presentationThe patient had a history of co-twin demise at 13 weeks of gestation without appropriate fetal surveillance afterwards. We found a monochorionic placentation with a normal appearing pump twin, an abnormal appearing co-twin without obvious cardiac activity and reversed arterial flow toward instead of away from the anomalous acardiac fetus. Therefore, the sonographic diagnosis of TRAP sequence was confirmed.ConclusionsWe recommend considering the potential rare complications of monochorionic twin pregnancy which necessitates proper surveillance and intervention to monitor suitable growth of pump twin.

Role of Modified Biophysical Profile in High Risk Pregnancy in Predicting Fetal Outcome.

High risk pregnant women have increased risk of maternal and neonatal morbidity and mortality. Antepartum surveillance is important and should be effective in such conditions. Modified biophysical profile is the method of antepartum surveillance which comprises of cardiotocography and amniotic fluid index. A cross-sectional study was carried out in Paropakar Maternity and Women's Hospital from February 2019 to January 2020 to determine the effectiveness of modified biophysical profile. Cardiotocography was interpreted as reactive, equivocal and non-reactive. AFI was considered normal if it was 5 to 24 cm. In the study 172 high risk cases at term and not in labor were included. Each case was subjected to cardiotocography then amniotic fluid index was obtained using real time sonography where it was measured from all four quadrants. Modified biophysical results were obtained and then were divided into 2 arms as normal modified biophysical profile and abnormal modified biophysical profile then analysis was done. Of 172 cases, there were 97 (56.4%) cases in normal modified biophysical profile and remaining 75 (43.6%) in abnormal modified biophysical profile group. The rate of cesarean section increased when there was abnormal modified biophysical profile. Neonatal resuscitation and admission was increased in abnormal modified biophysical profile. Normal modified biophysical profile in high risk pregnancy had more cases of vaginal delivery and less adverse fetal outcome like low APGAR score, neonatal resuscitation and neonatal intensive care admission.

Measurement of Cerebro-Placental Doppler Ratio and Amniotic Fluid Index as a Predictor of Perinatal Outcome in Prolonged Pregnancy

Background: The terms post-term, prolonged, postdates and post mature are often loosely used interchangeably to signifypregnancies that have exceeded a duration considered to be the upper limit of normal.Objective: The aim of this work was to study the role of Doppler velocimetry of the umbilical and middle cerebral arteriesrepresented by the cerebroplacental ratio and amniotic fluid volume in the prediction of adverse fetal outcome in post-termpregnancies.Materials and Methods: This is a prospective case control study conducted at Ain-Shams University Teaching Hospitalfor Obstetrics and Gynecology, Egypt. The study included 50 pregnant patients who were divided into two groups; group1included 25 pregnant ladies with gestational age of 41 weeks attending the casuality department in labour or in prodromaof labor. while, group 2 included 25 pregnant ladies with gestational age of 41 weeks not in labor and reaching thehospital for ANC, who were selected for termination based on the biophysical profile and poor Doppler indices or CTGchanges. All patients were submitted to antenatal fetal surveillance tests including modified biophysical profile (MBPP)which consists of the non-stress test (NST), amniotic fluid index (AFI), and color Doppler velocimetry of fetoplacentaland fetal vessels including MCA PI, UA PI, and CPR. The accuracy of cerebroplacental ratios (the middle cerebral arteryPI divided by the umbilical artery PI) and amniotic fluid volume as a means of predicting intrauterine fetal distress andadverse perinatal outcome in post-term pregnancies.Results: Cerebroplacental ratio showed the highest sensitivity (95%) in comparison with other parameters, so it is a goodtest to reassure the obstetricians of the fetal well being. Prominent changes in AFI (i.e. 5.0 cm. Asignificant association with FHR decelerations and presence of meconium is proved to exist when AFI is <5.0 cm.Conclusion: The addition of cerebral/umbilical ratios to antenatal surveillance protocols is expected to improve the perinataloutcome. It should be tried in the various high risk pregnancies whenever uteroplacental insufficiency is suspected.

Is there a role for fetal interventions in gastroschisis management? - An updated comprehensive review.

We conducted a comprehensive evidence-based review on the epidemiology and current standard of care of gastroschisis management as well as the pathophysiology, rationale and feasibility of fetal therapy as a viable alternative. Gastroschisis is a periumbilical abdominal wall defect characterized by abdominal viscera herniation in utero. It affects 4 in 10 000 live births, but the prevalence has steadily increased in recent years. Gastroschisis is typically diagnosed on routine second-trimester ultrasound. The overall prognosis is favorable, but complex gastroschisis, which accounts for about 10% to 15% of cases, is associated with a higher mortality, significant disease burden and higher healthcare costs due to long- and short-term complications. The current standard of care has yet to be established but generally involves continued fetal surveillance and multidisciplinary perinatal care. Postnatal surgical repair is achieved with primary closure, staged silo closure or sutureless repair. Experimental animal studies have demonstrated the feasibility of in utero closure, antiinflammatory therapy and prenatal regenerative therapy. However, reports of early preterm delivery and amnioinfusion trials have failed to show any benefit in humans. Further experimental studies and human trials are necessary to demonstrate the potential benefit of fetal therapy in gastroschisis.

Pregnancy Outcomes in Women with Long-Duration Type 1 Diabetes-25 Years of Experience.

Aims: Our study aimed to examine the pregnancy outcomes (maternal and fetal) concerning different models of antenatal care across a period of over 25 years (1993–2018) in 459 women with type 1 diabetes. Data from patients with a history of the condition lasting at least 15 years were considered eligible for analysis. Methods: The study group was divided into three cohorts based on the different models of treatment used in Poznan University Hospital, Poland: 1993–2000 (cohort I, n = 91), 2001–2005 (cohort II, n = 83), 2006–2018 (cohort III, n = 284). To identify predictors for the selected dichotomous outcomes, we calculated the risks for fetal or maternal complications as dependent variables for cohorts II and III against cohort I, using multivariate logistic regression analysis. Results: The mean gestational age was 36.8 ± 2.4 weeks in the total cohort. The percentages of deliveries before the 33rd and the 37th weeks was high. We observed a decreasing percentage during the following periods, from 41.5% in the first period to 30.4% in the third group. There was a tendency for newborn weight to show a gradual increase across three time periods (2850, 3189, 3321 g, p < 0.0001). In the last period, we noticed significantly more newborns delivered after 36 weeks with a weight above 4000 g and below 2500 g. Caesarean section was performed in 88% of patients from the whole group, but in the subsequent periods this number visibly decreased (from 97.6%, 86.7%, to 71%, p = 0.001). The number of emergency caesarean sections was lowest in the third period (27.5%, 16.7%, 11.2%, p = 0.006). We observed a decreasing number of “small for gestational age” newborns (SGA) in consecutive periods of treatment (from 24.4% to 8.7%, p = 0.002), but also a higher percentage of “large for gestational age” (LGA) newborns (from 6.1% to 21.6%, p = 0.001). Modification of treatment might be associated with the gradual reduction of SGA rates (cohort I 3.6%, cohort III 2.3% p < 0.0005). Conclusions: Strict glycemic and blood pressure control from the very beginning of pregnancy, as well as modern fetal surveillance techniques, may contribute to the improvement of perinatal outcomes in women with long-duration type 1 diabetes.

The Effect of Fetal Trisomy 21 on Adverse Perinatal Obstetrical Outcomes in Nova Scotia, 2000-2019.

To understand the risks associated with trisomy 21 in pregnancy in order to inform obstetrical care and improve outcomes. A population-based retrospective cohort study was undertaken of all pregnancies involving a fetus with trisomy 21 in Nova Scotia, Canada, from 2000 to 2019. Cases were identified from the provincial laboratory genetics database, linked to the Nova Scotia Atlee Perinatal Database for pregnancy outcomes, and compared with the general obstetrical population. A total of 350 pregnancies were identified, of which 23% were ongoing pregnancies in which trisomy 21 was diagnosed prenatally and 24% involved diagnoses made after delivery. Compared with the general obstetrical population, women with ongoing pregnancies affected by trisomy 21 were more likely to be older (mean age 34 vs. 29 y), multiparous (67% vs. 55%), and in a relationship (79% vs. 68%). Trisomy 21 was associated with a significantly increased risk of preterm birth (<37 weeks; 24.1% vs. 8.3%); small for gestational age (<10th percentile; 21.7% vs. 8.2%); cesarean delivery (31.5% vs. 27.1%); and combined perinatal/neonatal mortality (8.0% vs. 0.8%) (P < 0.001 for all). Trisomy 21 is associated with significant adverse perinatal and neonatal risks. Population screening to identify trisomy 21 can be used to optimize perinatal outcomes with appropriate fetal surveillance in these pregnancies.

VP37.13: Clinical value of TEI index as an adjunct to Doppler velocimetry in diagnosis, surveillance and management of fetal growth restriction: a case report

A 31-year-old G2P0 (0100) was noted at 30 weeks gestation to have fetal growth lag on prenatal sonography. Cerebroplacental ratio was abnormal. Placental infarcts were noted. Placental mapping further revealed a Battledore placenta. At this time, TEI index was normal at 0.35. The patient was non-diabetic and non-hypertensive. She had a previous stillbirth at 28 weeks in her previous pregnancy. Anomaly scan was reviewed, infectious disease screening was carried out and results were unremarkable. Work-up for antiphospholipid antibody syndrome was suggested but patient was unable to comply. The patient was given antenatal steroids. Close fetal surveillance was carried out, with daily CTG, BPP twice weekly and weekly Doppler velocimetry. At 32 weeks, umbilical artery Doppler showed intermittent absent end diastolic flow with elevated pusatility index (PI). MCA PI was decreased, with an abnormal cerebroplacental ratio of 0.6. TEI index was 0.53. Family conference was done, with the decision to push as near to term as possible. At 33 weeks of gestation, absent end diastolic flow in the umbilical artery was noted, with deepening A-wave of the ductus venosus, and an elevated TEI index of 0.59. NST revealed persistently minimal variability. Thus intervention was done and patient delivered a livebaby boy weighing 1.7kg. Grossly, the placenta was small weighing 300 grams and the cord was thin, measuring 1cm, inserted at the placental edge. Histopathology report revealed placenta with infarcts and umbilical cord with venous thrombosis. Both mother and baby had unremarkable postpartum course and were discharged well. This case shows how TEI index can be used to augment findings on Doppler velocimetry in the surveillance and management of preterm fetuses with IUGR, secondary to uteroplacental insufficiency. Results from these investigations can guide the clinicians in making decisions regarding the timing of delivery to ensure the best maternal and fetal outcomes.