Perinatal Mortality In Fetuses Research Articles

Extracardiac Doppler indices predict perinatal mortality in fetuses with Ebstein anomaly and tricuspid valve dysplasia.

Ebstein anomaly and tricuspid valve dysplasia (EA/TVD) carry high perinatal mortality. Past studies have focused on cardiac predictors of mortality; we sought to describe the fetal echo (FE) extracardiac Dopplers in this cohort and determine their association with perinatal mortality. Fetuses with EA/TVD at 23 centers from 2005-2011 were included for retrospective study. Doppler pattern and velocity of the umbilical artery (UA), umbilical vein (UV), ductus venosus (DV), and middle cerebral artery (MCA) were collected. Bivariate and multivariate analyzes were performed. The primary outcome measure was perinatal mortality, defined as fetal demise or neonatal death. Of 190 cases that met eligibility criteria, alterations were seen in 50% of UA, 16% of UV, 48% of DV, and 8% of MCA Doppler indices on the last FE (median 27.4 weeks). Independent predictors of perinatal mortality included abnormal UA Doppler pattern of absence or reversed end diastolic flow (OR 9.7) and UV velocity z score <1 (OR 2.5), in addition to diagnosis <32 weeks (OR 4.2) and tricuspid valve (TV) annulus z score ≥6 (OR 5.3). Abnormal UA Doppler pattern and decreased UV velocity are independent predictors of perinatal mortality in EA/TVD fetuses and should be used to refine mortality risk and guide perinatal management.

Fetal echocardiographic prediction score for perinatal mortality in tricuspid valve dysplasia and Ebstein's anomaly.

Tricuspid valve dysplasia (TVD) and Ebstein's anomaly (EA) diagnosed by fetal echocardiography vary greatly in terms of clinical severity and prognosis. The Celermajer index and Simpson-Andrews-Sharland (SAS) score have been reported previously for the prediction of prognosis in cases of TVD/EA; however, they do not take into account the hemodynamic impact of left ventricular (LV) function, which has recently been implicated as being important in the pathophysiology of TVD/EA. The aim of this study was to develop a novel scoring system that includes LV function for the prediction of perinatal death in fetuses diagnosed with TVD/EA. The clinical records of 36 fetuses diagnosed prenatally with TVD/EA between 2000 and 2015 in our hospital were reviewed. Univariate analysis was used to assess the association between perinatal death (defined as death between 22 weeks' gestation and 4 weeks after delivery) and gestational age at diagnosis, cardiothoracic area ratio (CTAR), degree of pulmonary artery flow, direction of ductal flow, right-to-left ventricular diameter ratio, tricuspid regurgitation (TR) maximum velocity, Celermajer index, SAS score and LV-Tei index. A new prognostic score, the TRIPP score (TRIcuspid malformation Prognosis Prediction score), was developed using the parameters found to be associated significantly with perinatal death. The predictive value of this score was assessed in an additional nine fetuses diagnosed with TVD/EA. Thirty-six fetuses were diagnosed prenatally with TVD/EA, two of which were terminated, one was lost to follow-up and two died before 22 weeks' gestation. Of the 31 included fetuses, 10 (32%) died in the perinatal period. Univariate analysis demonstrated that TR maximum velocity was significantly lower (2.22 ± 0.17 m/s vs 3.26 ± 0.12 m/s; P < 0.001) and SAS score was significantly higher (5.7 ± 0.6 points vs 2.8 ± 0.4 points; P = 0.0014) in cases of perinatal death than in surviving fetuses. The degree of pulmonary artery flow and the direction of ductal flow were also associated significantly with perinatal death (P < 0.01 for both). Notably, LV-Tei index was significantly higher in cases of perinatal death than in surviving fetuses (0.81 ± 0.08 vs 0.50 ± 0.05; P < 0.001). In contrast, there was no significant difference in Celermajer index, CTAR or right-to-left ventricular diameter ratio. Finally, we established a novel combinatorial scoring system, the TRIPP score, including the four significant factors: TR maximum velocity, pulmonary artery flow, direction of ductal flow and LV-Tei index. The TRIPP score was found to predict efficiently perinatal mortality in fetuses with TVD/EA. Our novel combinatorial score of echocardiographic parameters, the TRIPP score, including LV-Tei index, is easy to measure and provides a good tool for the prediction of perinatal mortality in fetuses diagnosed prenatally with TVD/EA. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

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

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

The Efficacy of Antepartum Testing in Pregnancies Complicated by Fetal Gastroschisis [32M

INTRODUCTION: Our objective was to determine if our approach to antepartum testing is effective at reducing perinatal mortality in fetuses with gastroschisis. METHODS: This retrospective case series analyzed fetuses with gastroschisis that underwent intensive fetal surveillance from 2008 to 2016. Data collected included maternal demographics, antenatal fetal testing, influence of testing on timing of delivery, gestational age at delivery, indication for delivery, and perinatal complications. The antenatal fetal surveillance was guided by the following testing protocol: monthly growth scan, twice weekly fetal testing with BPP/NST, consultation with a perinatologist, and strict maternal kick counting. RESULTS: This study had 11 patients, majority of which were young primiparous Hispanic women. IUGR complicated 59.5% of our pregnancies with gastroschisis. Bowel dilation greater than 18mm was noted in 31.8% of fetuses with gastroschisis; one was delivered due to bowel dilatation greater than 25 mm. Fourteen patients were sent to L&amp;D from ATU, of which 9 were for nonreassuring fetal testing and 2 related to ultrasound findings. All patients sent from ATU for fetal compromise diagnosed on testing were delivered within 48 hours. Eleven patients were delivered for compromised fetal status as determined by abnormal fetal testing and/or decreased fetal movement. Prevalence of IUFD in fetal gastroschisis in our case series was 0%, as compared to 4.48% reported in the literature. CONCLUSION: Our protocol for antenatal fetal surveillance was effective in identifying the compromised fetus with gastroschisis leading to timely delivery. Increased awareness of IUFD and our comprehensive fetal testing protocol resulted in survival of all fetuses in this study.

The impact of fetal middle cerebral artery Doppler on the outcome of congenital hydrocephalus

Objectives: The objective of this study is to investigate the impact of abnormal middle cerebral artery (MCA) Doppler on the perinatal mortality in fetuses with congenital hydrocephalus (CH).Methods: A prospective study of all fetuses with CH who delivered at our hospital over a period of 7 years. Data were obtained from the ultrasound, Labor room and intensive neonatal care unit (NICU) database. The Perinatal mortality rates were evaluated in relation to the following measures, associated congenital anomalies, cortical mantle thickness (CMT), and MCA Doppler abnormalities (absent or reversed diastole). The main outcome measure was perinatal mortality rate in relation to MCA Doppler changes.Results: A total of 85 cases of CH were diagnosed and managed. The birth prevalence of CH was 2.44 per 1000 live births. On one hand, the perinatal mortality rate was higher in those fetuses with non-isolated hydrocephalus, (37.25% (19/51) versus (35.29% (12/34, p = 0.854 and in those cases with CMT <10 mm, 38.78% (19/49) versus 33.33% (12/36) in those with CMT >10 mm, p = 0.607. On the other hand, the perinatal mortality rate was significantly higher in those fetuses with abnormal MCA Doppler, (100% (13/13) versus 25% (18/72), OR = 78.0, 95% CI (5.52–44085124.60), p < 0.001.Conclusions: Abnormal fetal MCA Doppler (absent or reversed diastole) appears to be a poor prognostic indicator with significantly high perinatal mortality in fetuses with CH.

Association of isolated single umbilical artery with perinatal outcomes: Systemic review and meta-analysis.

ObjectiveThe aim of this study was to evaluate the association between prenatally diagnosed isolated single umbilical artery (iSUA) and perinatal outcomes.MethodsWe searched Medline, Embase, the Cochrane Library, and KoreaMed from inception to January 2016, with no language or regional restrictions, for cohort and case-control studies reporting on the relationship of iSUA and perinatal outcomes. We assessed the odds ratios (ORs) and 95% confidence intervals (CIs) for the occurrence of small for gestational age, preterm birth, pregnancy-induced hypertension, neonatal intensive care unit admission, and perinatal mortality in fetuses with iSUA compared with those in fetuses with three vessel cord.ResultsEleven articles totaling 1,731 pregnancies with iSUA met the selection criteria. Studies varied in design, quality, outcome definition, and results. Meta-analysis carried out within predefined groups showed that the presence of an iSUA was associated with small for gestational age (OR, 2.75; 95% CI, 1.97 to 3.83; P<0.00001), preterm birth (OR, 2.10; 95% CI, 1.72 to 2.57; P<0.00001), pregnancy-induced hypertension (OR, 1.62; 95% CI, 1.00 to 2.63; P=0.05), neonatal intensive care unit admission (OR, 2.06; 95% CI, 1.33 to 3.19; P=0.001), and perinatal mortality (OR, 2.29; 95% CI, 1.32 to 3.98; P=0.003).ConclusionPregnancies complicated by iSUA are at increased risk for small for gestational age, preterm birth, pregnancy-induced hypertension, neonatal intensive care unit admission and perinatal mortality. Further, large prospective cohort studies are required to improve the quality of prenatal counseling and the neonatal care for pregnancies with iSUA.

Outcomes and Predictors of Perinatal Mortality in Fetuses With Ebstein Anomaly or Tricuspid Valve Dysplasia in the Current Era

Background— Ebstein anomaly and tricuspid valve dysplasia are rare congenital tricuspid valve malformations associated with high perinatal mortality. The literature consists of small, single-center case series spanning several decades. We performed a multicenter study to assess the outcomes and factors associated with mortality after fetal diagnosis in the current era. Methods and Results— Fetuses diagnosed with Ebstein anomaly and tricuspid valve dysplasia from 2005 to 2011 were included from 23 centers. The primary outcome was perinatal mortality, defined as fetal demise or death before neonatal discharge. Of 243 fetuses diagnosed at a mean gestational age of 27±6 weeks, there were 11 lost to follow-up (5%), 15 terminations (6%), and 41 demises (17%). In the live-born cohort of 176 live-born patients, 56 (32%) died before discharge, yielding an overall perinatal mortality of 45%. Independent predictors of mortality at the time of diagnosis were gestational age &lt;32 weeks (odds ratio, 8.6; 95% confidence interval, 3.5–21.0; P &lt;0.001), tricuspid valve annulus diameter z-score (odds ratio, 1.3; 95% confidence interval, 1.1–1.5; P &lt;0.001), pulmonary regurgitation (odds ratio, 2.9; 95% confidence interval, 1.4–6.2; P &lt;0.001), and a pericardial effusion (odds ratio, 2.5; 95% confidence interval, 1.1–6.0; P =0.04). Nonsurvivors were more likely to have pulmonary regurgitation at any gestational age (61% versus 34%; P &lt;0.001), and lower gestational age and weight at birth (35 versus 37 weeks; 2.5 versus 3.0 kg; both P &lt;0.001). Conclusion— In this large, contemporary series of fetuses with Ebstein anomaly and tricuspid valve dysplasia, perinatal mortality remained high. Fetuses with pulmonary regurgitation, indicating circular shunt physiology, are a high-risk cohort and may benefit from more innovative therapeutic approaches to improve survival.

Perinatal course of Ebstein's anomaly and tricuspid valve dysplasia in the fetus

We sought to better define echocardiographic predictors of perinatal mortality in fetuses with Ebstein's anomaly (EA) or tricuspid valve dysplasia (TVD). Parameters included measured chamber size, the presence of hydrops, and Doppler recordings of the left ventricular (LV) myocardial performance index (MPI). Between 1 January 2000 and 31 December 2008, 21 fetuses were diagnosed with either EA (17) or TVD (4). Five fetuses were lost to follow-up, and 12 of 16 fetuses were born live (75%). Survivors were found to have smaller right atrial area index scores when compared with non-survivors (1.025 ± 0312 vs 1.502 ± 0.105, respectively, p = 0.013) and were less likely to present with hydrops (0% survivors vs 75% of non-survivors, p < 0.01). LV MPI sub-analysis revealed a shorter combined isovolemic contraction and relaxation time for non-survivors compared wth survivors (46.5 ± 8.2 ms vs 82.3 ± 21.2 ms, respectively, p = 0.004) although no difference was observed for LV ejection times or overall LV MPI between survivors and non-survivors. Physiologic analysis of left ventricular function via the LV Tei index and its component measurements demonstrates potentially novel insights into hemodynamic derangements and their association with outcomes in patients with EA/TVD.

Relationship Between the Fetal Heart Rate Pattern and Perinatal Mortality in Fetuses With Absent End-Diastolic Velocities of the Umbilical Artery

Fetal decompensation is usually diagnosed by the onset of late decelerations and decreased fetal heart rate (FHR) variability and is associated with fetal hypoxemia and acidemia and has a high perinatal mortality. Objective analysis of the FHR pattern can be performed using the Fischer score and a score of less than 6 correlates with fetal decompensation. Fetuses with absent end-diastolic velocities (AEDV) of the umbilical artery have severe placental disease and coupled with this a high perinatal mortality and morbidity. Importantly, AEDV is usually observed before the occurrence of fetal decompensation. In fetuses with AEDV, delivery before decompensation may improve the perinatal mortality and morbidity. To test this hypothesis, the perinatal outcome of fetuses with AEDV delivered before decompensation (Fischer score of 6 or more), were compared with similar fetuses delivered after decompensation (Fischer score of less than 6). All FHR pattern records of fetuses who had AEDV with a birthweight greater than 750 g and a gestational age of 28 weeks or more were evaluated using Fischer's score by a single observer unaware of the perinatal outcome. Fifty-seven fetuses qualified for the study and 17 of these babies subsequently died. The babies who died had significantly lower mean Fischer scores during the preceding 6 hours before delivery (5.9 ± 1.8 SD) than the survivors (7.7 1.9; p <0.05), but also had lower birthweights and gestational ages. To obviate this effect, babies with a Fischer score of less than 6 at 6 hours before delivery (group 1) were matched to within 3 days gestational age and 10% birthweight with those with a Fischer score of 6 or more at 6 hours before delivery (group 2). Nineteen pairs were obtained. There were no differences in perinatal mortality and morbidity between the groups, although the surviving babies in group 1 spent significantly less time in the hospital (p <0.02). Therefore, waiting until a decompensation, as is evident from a low Fisher score, develops does not adversely affect the prognosis of the fetus.

Relationship between the fetal heart rate pattern and perinatal mortality in fetuses with absent end-diastolic velocities of the umbilical artery: a case-controlled study.

Fetal decompensation is usually diagnosed by the onset of late decelerations and decreased fetal heart rate (FHR) variability and is associated with fetal hypoxemia and acidemia and has a high perinatal mortality. Objective analysis of the FHR pattern can be performed using the Fischer score and a score of less than 6 correlates with fetal decompensation. Fetuses with absent end-diastolic velocities (AEDV) of the umbilical artery have severe placental disease and coupled with this a high perinatal mortality and morbidity. Importantly, AEDV is usually observed before the occurrence of fetal decompensation. In fetuses with AEDV, delivery before decompensation may improve the perinatal mortality and morbidity. To test this hypothesis, the perinatal outcome of fetuses with AEDV delivered before decompensation (Fischer score of 6 or more), were compared with similar fetuses delivered after decompensation (Fischer score of less than 6). All FHR pattern records of fetuses who had AEDV with a birthweight greater than 750 g and a gestational age of 28 weeks or more were evaluated using Fischer's score by a single observer unaware of the perinatal outcome. Fifty-seven fetuses qualified for the study and 17 of these babies subsequently died. The babies who died had significantly lower mean Fischer scores during the preceding 6 hours before delivery (5.9 +/- 1.8 SD) than the survivors (7.7 1.9; p < 0.05), but also had lower birthweights and gestational ages.(ABSTRACT TRUNCATED AT 250 WORDS)