Outcome In Intrauterine Growth Restriction Research Articles

P10.06: Doppler predictors of delivery outcome in intrauterine growth restriction

P10.06: Doppler predictors of delivery outcome in intrauterine growth restriction

Middle cerebral artery Doppler indices better predictor for fetal outcome in IUGR

Objective(s) To compare the role of middle cerebral artery and umbilical artery Doppler pulsatility indices in predicting the fetal outcome in intrauterine growth restriction.

Human fetal cardiovascular profile score and neonatal outcome in intrauterine growth restriction

To determine whether low cardiovascular profile (CVP) score has prognostic value for predicting neonatal mortality and severe morbidity in human fetuses with growth restriction. Seventy-five consecutive growth-restricted fetuses with Doppler examination of cardiovascular hemodynamics within a week prior to delivery comprised the study population. Hydrops, heart size, cardiac function and venous and arterial hemodynamics were evaluated for CVP score. The primary outcome measures were neonatal mortality and cerebral palsy. During the neonatal period, six of 75 neonates died and two had cerebral palsy (Group 1, n = 8). Compared with the fetuses discharged home from hospital (Group 2, n = 67), those in Group 1 were delivered at an earlier gestational age (28 (range, 24-35) weeks vs. 35 (range, 26-40) weeks, P < 0.01) and had lower CVP scores (4 (range, 2-6) vs. 9 (range, 5-10), P < 0.0001). All CVP subscale scores were lower (P < 0.01) in Group 1 than in Group 2 fetuses. Gestational age-adjusted hazard ratios (95% CIs) for adverse neonatal outcome were highest for cardiomegaly (13.9 (1.7-114.3), P = 0.014), monophasic atrioventricular filling pattern or holosystolic tricuspid regurgitation (9.5 (2.3-38.4), P = 0.002) and atrial pulsations in the umbilical vein 7.7 (1.4-41.2), P = 0.017). Growth-restricted fetuses with adverse neonatal outcome have lower CVP scores than do fetuses with favorable neonatal outcome. The strongest predictors for adverse neonatal outcome in the CVP score were cardiomegaly, abnormal cardiac function with monophasic atrioventricular filling or holosystolic tricuspid regurgitation and increased systemic venous pressure. These assessments have independent prognostic power for adverse neonatal outcome even after adjustment for gestational age.

Relationship between abnormal fetal testing and adverse perinatal outcomes in intrauterine growth restriction

This study was undertaken to compare the efficacy of nonstress test, biophysical profile, or abnormal Dopplers in predicting adverse perinatal outcomes in intrauterine growth restriction. Retrospective cohort study of intrauterine growth restriction (birthweight < fifth percentile for gestation) over a 7-year period. We excluded twins or fetuses with aneuploidy or congenital malformations. Abnormal antenatal testing were defined as: nonstress test that was nonreactive or with significant decelerations, biophysical profile less than or equal to 6, and abnormal Doppler as umbilical artery with absent or reversed end diastolic flow. The outcomes studied included: umbilical artery pH less than 7, respiratory distress syndrome, periventricular leukomalacia, grades 3-4 intraventricular hemorrhage, perinatal mortality, necrotizing enterocolitis, and a composite of at least 1 adverse outcome. Statistical analysis included bivariate and multivariable techniques. We identified 151 singleton pregnancies with intrauterine growth restriction meeting the inclusion criteria. On bivariate analysis significant variables associated with adverse outcomes were as follows: history of chronic hypertension, corticosteroid administration, and gestational age of delivery. These were adjusted by using logistic regression. The positive predictive values of abnormal Doppler for respiratory distress syndrome and the composite of adverse outcomes were 36% and 42% respectively. Of the testing modalities compared, only abnormal Doppler significantly predicted respiratory distress syndrome and the composite of adverse outcome. In cases of intrauterine growth restriction, the presence of abnormal Doppler is the best predictor of adverse perinatal outcome.

OC112: Integrated fetal testing most accurately predicts perinatal outcome in intrauterine growth restriction (IUGR)

Objective: Longitudinal measurements of quantitative flow (QF) could clarify compensatory mechanisms to fetal hypoxia, and suggest predictive factors of fetal decompensation and adverse outcome. Our aims were to analyse in IUGR fetuses longitudinal changes of QF in umbilical vein (UV), ductus venosus (DV) and left cardiac output (LCO) and to identify which cardiovascular pattern is more frequently associated with adverse outcome. Methods: In 33 IUGR fetuses, two consecutive examinations were retrospectively considered: the last scan (LAST) within 3 days before delivery and the previous exam (FIRST) within 8 days before LAST. Doppler QF was measured at three different sites: intraamniotic UV, DV and ascending aorta, according to a standardized methodology. QF changes were compared between alive babies and perinatal deaths. A subset of viable fetuses delivered between 28 to 32 weeks was separately considered. QF changes suggestive of fetal decompensation (UV flow reduction, DV dilatation, DV flow increase, LCO reduction) were considered as a variation >10% from FIRST and LAST examination. Timing of delivery was independently decided by the clinical staff. Results: The gestational age at delivery was 29 ± 3.5 weeks (mean ± SD); the weight at delivery was 880 ± 450 g (mean ± SD).

Integrated fetal testing is the most accurate predictor of perinatal outcome in intrauterine growth restriction (IUGR)

OUTCOME IN INTRAUTERINE GROWTH RESTRICTION (IUGR) AHMET BASCHAT, MICHELLE KUSH, ANITA MANOGURA, DOLORES MOYANO, SIFA TURAN, UTE GERMER, CHRISTOPH BERG, AMARNATH BHIDE, DICK OEPKES, BASKARAN THILAGANATHAN, HENRY GALAN, SARAH BOWER, KYPROS NICOLAIDES, ULRICH GEMBRUCH, CHRISTOPHER HARMAN, University of Maryland, Obstetrics, Gynecology and Reproductive Sciences, Baltimore, Maryland, King’s College Hospital, London, United Kingdom, Medical University Lubeck, Obstetrics & Gynecology, Lubeck, Germany, Friedrich Wilhelm University, Obstetrics & Prenatal Medicine, Bonn, Germany, St. George’s Hospital Medical School, Fetal Medicine Unit, London, United Kingdom, Leiden University, Leiden, Ontario, Netherlands, University of Colorado Health Sciences Center, Obstetrics and Gynecology, Denver, Colorado, Medical University Lubeck, Obstetrics & Gynecology, Bonn, Germany OBJECTIVE: Biophysical profile scoring (BPS) and arterial and venous multivessel Doppler each test fetal behavioral and cardiovascular responses to compromised placental function. We aimed to study if integration of two testing modaIities improves prediction of critical perinatal outcomes in IUGR fetuses. STUDY DESIGN: Fetuses with IUGR (Abdominal Circumference !5%ile, elevated umbilical artery (UA) Doppler) were studied in a multicenter collaboration. UA end-diastolic velocity (EDV), middle cerebral artery brain sparing, abnormal ductus venosus Doppler (DV-RAV) and BPS were compared for their ability to predict stillbirth (SB), neonatal death (NND), birth acidemia, low 5 minute Apgar, and major neonatal morbidity (intraventricular hemorrhage OGrade 2, bronchopulmonary dysplasia, necrotizing enterocolitis). Integration of the two testing modalities was modelled to provide the best outcome prediction. RESULTS: In 534 IUGR fetuses, there were 38 stillborn, 32 neonatal deaths (PNM 13.1%). Low Apgar and birth acidemia occured in 7.3% and 9.6% respectively. In survivors, 67 (14.8%) had major morbidity. Prediction of PNM by single abnormal parameter ranged from Odds Ratios of 2.1 for brain sparing and fetal tone, to 14.6 for DV-RAV. However, DV-RAV was present in only 22 of deaths. No single parameter correctly predicted more than 2/3 of PNM. This pattern was repeated for all individual outcomes. The analysis was repeated for combined test domains. Combining DV index, UA-EDV, amniotic fluid volume, fetal movement, and fetal breathing (in declining order of statistical contribution), produced highest predictive accuracy for both normal and abnormal outcomes. Eighteen of twenty possible test domains (nine normal and nine abnormal parameters) provided enhanced outcome specifictity. CONCLUSION: Optimal prediction of critical perinatal outcome in IUGR requires combined evaluation of fetal cardiovacular and behavioral responses. For the clinincian, the combination of umbilical and venous Doppler with the four ultrasound parameters of BPS, can provide this optimal assessment.

The relationship between abnormal fetal testing and adverse perinatal outcomes in intrauterine growth restriction (IUGR)

The relationship between abnormal fetal testing and adverse perinatal outcomes in intrauterine growth restriction (IUGR)

Cerebroplacental Doppler Ratio and Adverse Perinatal Outcomes in Intrauterine Growth Restriction

The purpose of this study was to compare the impact of using gestational age-specific reference levels of the cerebroplacental Doppler ratio (CPR) with categorical threshold in the prediction of adverse perinatal outcomes in growth-restricted pregnancies. A retrospective cohort study of cases of intrauterine growth restriction over a 3-year period was conducted. The umbilical artery and middle cerebral artery pulsatility indices were converted to CPRs. The efficacy of using gestational age-specific reference levels of CPRs in predicting adverse outcomes was compared with the use of a CPR of less than 1.08. Adverse perinatal outcomes evaluated included cesarean delivery for nonreassuring fetal heart tones, umbilical artery pH less than 7.0, 5-minute Apgar scores less than 7.0, intraventricular hemorrhage greater than grade 2, periventricular leukomalacia, respiratory distress syndrome, and perinatal death. Of 183 pregnancies meeting our inclusion criteria, there were 70 with at least 1 adverse outcome. With the use of a CPR ratio below the 5th percentile for gestational age, the sensitivity, specificity, and positive and negative predictive values for predicting an adverse outcome were 65%, 73%, 73%, and 65%, respectively, with an odds ratio (95% confidence interval) of 5.2 (1.4-19.4; area under the receiver operating characteristic curve, 0.69). With a CPR threshold of less than 1.08, the sensitivity, specificity, and positive and negative predictive values were 72%, 62%, 68%, and 67%, with an odds ratio (95% confidence interval) of 4.2 (1.2-15.3; area under the receiver operating characteristic curve, 0.67). An abnormal CPR is associated with adverse perinatal outcomes in growth-restricted fetuses. The accuracy of using gestational age-specific reference levels was similar to that of using a categorical threshold.

Is fetal gender associated with adverse perinatal outcome in intrauterine growth restriction (IUGR)?

The purpose of this study was to determine if there is a difference in perinatal outcome by gender among growth-restricted fetuses. This was a retrospective cohort study of intrauterine growth restriction (IUGR) singleton pregnancies over a 5-year period. Clinical outcomes compared by gender included preterm delivery, perinatal mortality (PNM), respiratory distress syndrome (RDS), grade 3 or 4 intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), and periventricular leukomalacia (PVL). Statistical analysis included bivariate and multivariable techniques. Seven hundred and twenty-seven singleton pregnancies with IUGR were identified. Three hundred and forty-six (47.6%) were males. Birth weight was similar between the groups. After adjusting for maternal demographics, medical history, gestational age, mode of delivery, and antenatal corticosteroids, adverse perinatal outcomes were similar between the groups. Severity of outcomes was also similar between males and females (P = .66). Male fetuses with IUGR have similar outcomes when compared with female IUGR fetuses. Gender does not play a role in perinatal outcome in the setting of fetal growth restriction.

Is fetal gender associated with adverse perinatal outcome in intrauterine growth restriction (IUGR)?

To determine if there is a difference in perinatal outcome by gender among growth-restricted fetuses. Retrospective cohort study of IUGR singleton pregnancies (birthweight less than the 10th percentile for gestational age) over a 5 year period. Male gender was defined as the exposure of interest. Clinical outcomes compared between males and females included birthweight, gestational age at delivery, perinatal mortality (PNM), respiratory distress syndrome (RDS), grade 3 or 4 intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC) and periventricular leukomalacia (PVL). Statistical analysis included bivariate and multivariate techniques. We identified 789 singleton pregnancies with IUGR. 372 (47.2%) were males. Birthweight was similar between the groups. After adjusting for confounding variables using logistic regression, adverse perinatal outcomes were similar between the groups (P = .40). Our study had 82% power to detect a relative risk of at least 1.6 in the composite outcome of males when compared to females. Males fetuses with IUGR have similar outcomes to female IUGR fetuses. Gender does not play a role in perinatal outcome in the setting of fetal growth restriction.Tabled 1Outcomes for growth restricted fetuses by genderOutcomeMales (n=372)Females (n=417)Adjusted OR (95% C.I.)Delivery <37 weeks128 (34%)129 (31%)1.08 (0.78, 1.52)Delivery <34 weeks48 (13%)54 (13%)0.88 (0.55, 1.41) PNM15 (4%)17 (4%)0.97 (0.35, 2.68) RDS32 (8.6%)29 (7%)1.23 (0.63, 2.41) IVH13 (3.5%)10 (2.4%)1.47 (0.56, 3.87) NEC5 (1.3%)5 (1.2%)0.94 (0.23, 3.85) PVL1 (<1%)0 (0%)–Composite outcome50 (13.4%)52 (12.5%)0.98 (0.53, 1.82) Open table in a new tab

Abnormal multiple marker screens are associated with adverse perinatal outcomes in cases of intrauterine growth restriction

The purpose of this study was to determine if abnormal multiple marker screens (MMS) are associated with adverse perinatal outcomes in intrauterine growth restriction (IUGR) pregnancies. This was a case control study of IUGR pregnancies (birth weight <10th percentile for gestational age [GA]) delivered in our unit over 6 years. Cases were compared with controls for the association between abnormal MMS and adverse perinatal outcomes (APO). Of the 261 IUGR pregnancies, 39 (16%) had at least 1 APO. An elevated HCG was significantly associated with an APO (OR 2.6, 95% CI 1.1-6.4). A low uE3 was also associated with an APO (OR 5.5, 95% CI 2.2-14). The association between an elevated AFP and APO was not statistically significant (OR 1.6, 95% CI, 0.6-4.6). An elevated HCG and low uE3 were associated with APO in cases of IUGR. This information could be useful in identifying a subset of IUGR cases deserving closer surveillance.

Prospect for vaginal delivery of growth restricted fetuses with abnormal umbilical artery blood flow.

The best mode of delivery in cases of intrauterine growth restriction (IUGR) with umbilical artery blood flow changes is not well elucidated. To evaluate outcome in IUGR with umbilical artery blood flow changes planned for vaginal delivery after a negative oxytocin challenge test (OCT). In 84 term singleton pregnancies with suspected IUGR and no unanimous indication for abdominal delivery, Doppler velocimetry and OCT were performed. Positive OCT cases were delivered by cesarean section, negative OCT cases planned for vaginal delivery. Umbilical artery Doppler velocimetry was normal in 51 cases (normal group) and abnormal in 33 cases (increased pulsatility index with maintained forward diastolic flow). Gestational age at delivery was shorter (p = 0.008), positive OCT more common (33% vs. 16%; p = 0.06), and vaginal delivery less common (40% vs. 63%; p = 0.04) in the abnormal blood flow group compared with the normal flow group. When in labor, 68% in the abnormal flow group and 76% in the normal flow group delivered vaginally (p = 0.6). One baby had a lethal malformation and another suffered meconium aspiration and pneumothorax, but was discharged home healthy. The vaginal delivery rate was significantly lower in the abnormal flow group compared with the normal flow group, but in cases finally destined for a trial of labor the vaginal delivery rates were similar. There was no indication that any fetus was exposed to detrimental hypoxia or distress.

The Doppler cerebroplacental ratio and perinatal outcome in intrauterine growth restriction

Objective: Our purpose was to determine whether the Doppler cerebroplacental ratio predicts perinatal outcome in fetuses at risk for intrauterine growth restriction. Study Design: The middle cerebral and umbilical artery pulsatility index values were measured in 203 fetuses at risk for intrauterine growth restriction, of which 123 were delivered <3 weeks after the last Doppler examination. Perinatal outcome was categorized as (1) birth weight <10th percentile, (2) birth weight <5th percentile, (3) perinatal complications (meconium-stained fluid, cesarean section for fetal distress, 5-minute Apgar score <7, perinatal death, neonatal intensive care unit stay >24 hours, hypoglycemia, or polycythemia), (4) birth weight <10th percentile plus complications, and (5) birth weight <5th percentile plus complications. The cerebroplacental ratio (middle cerebral artery pulsatility index divided by umbilical artery pul-satility index) values were expressed as multiples of the normal median. Receiver-operator characteristic curves (sensitivity vs false-positive rates) were plotted for the prediction of each category of perinatal outcome and the areas under the curves were determined. Stepwise logistic regression analyses were used to determine whether the cerebroplacental ratio improved outcome prediction over umbilical artery Doppler imaging alone. Results: There was a statistically significant increase in perinatal morbidity and mortality in cases with an abnormal cerebroplacental ratio. The areas under the receiver-operator curves characteristics for the prediction of perinatal outcome with use of the cerebroplacental ratio were statistically very significant. For birth weight <10th percentile we noted P < .001, with P < .0001 for each of the other 4 outcome categories. As shown by regression analyses, the cerebroplacental ratio appeared to improve the prediction of perinatal outcome compared with umbilical artery velocimetry alone. An interesting finding was that the cerebroplacental ratio did not appear to correlate significantly with outcome in fetuses at >34 weeks. Conclusion: Doppler identification of the fetal “brain-sparing” effect strongly predicts outcome in fetuses at risk for intrauterine growth restriction. The brain-sparing effect predicted perinatal problems only in fetuses <34 weeks’ gestation at the Doppler examination. (Am J Obstet Gynecol 1999;180:750-6.)