Uterine Artery Doppler Pulsatility Index Research Articles

Adverse perinatal outcomes are strongly associated with degree of abnormality in uterine artery Doppler pulsatility index.

To investigate the association between varying degrees of abnormality in the uterine artery Doppler pulsatility index (UtA-PI) and adverse perinatal outcomes. Prospective study of 33,364 women who gave birth to singleton, non-anomalous babies in Oxford, following universal measurement of UtA-PI in mid-pregnancy. Relative risk ratios for the primary outcomes of extended perinatal mortality and live birth with severe small-for-gestational-age (SGA) were calculated by multinomial logistic regression, for early preterm birth (<34+0) and late preterm/term birth (≥34+0). The risks were also investigated for iatrogenic preterm birth or a composite adverse outcome before 34+0 weeks. Compared with women with normal UtA-PI, the risk of extended perinatal mortality before 34+0 weeks was higher in women with UtA-PI >90th centile (RRR 4.7, 95% CI 2.7-8.0, p<0.001), but this was not demonstrated in later births. The risk of severe SGA birth was strongly associated with abnormal UtA-PI for both early births (RRR 26.0, 95% CI 11.6-58.2, p<0.001), and later births (RRR 2.3, 95% CI 1.8-2.9, p<0.001). Women with a raised UtA-PI were more likely to undergo early iatrogenic birth (RRR 7.8, 95% CI 5.5-11.2, p<0.001). For each of the outcomes and the composite outcome, the risk increased significantly in association with the degree of abnormality, through the 90th, 90-94th, 95-99th and >99th centiles (ptrend<0.001). An elevated UtA-PI is a key predictor of iatrogenic preterm birth, severe SGA and perinatal loss up to 34+0 weeks. It is the 90th centile that should be used, and management should be further tailored to the degree of abnormality, as pregnancies with very raised UtA-PI measurements constitute a group at extreme risk. This article is protected by copyright. All rights reserved.

A new Doppler index, cerebro-placental-uterine ratio, and fetal cardiac parameters in early onset preeclampsia.

Our aim was to investigate the significance of cerebro-placento-uterine ratio CPUR, a new Doppler index, and fetal cardiac parameters (Mod MPI, EFT) in early-onset preeclampsia (EOPE) and to examine whether these parameters are related to perinatal outcome. Forty participants diagnosed with EOPE (preeclampsia cases diagnosed before 34 weeks of gestation) and 40 healthy pregnant women were included in this study. Demographic data were recorded. Doppler parameters such as middle cerebral artery (MCA), umbilical artery (UA), and uterine artery (Ut-A), and left modified myocardial performance index (Mod-MPI) and epicardial fat thickness (EFT) were measured. Cerebroplacental ratio (CPR) was determined by dividing MCA pulsatility index (PI) by UA PI. CPUR was calculated as the ratio of CPR to mean UtA-PI (CPUR = CPR/UtA-PI). All parameters were compared between the EOPE and control groups. Correlation tests were used to examine the relationship between Doppler parameters and perinatal outcome. p values less than 0.05 were considered statistically significant. The pulsatility index of the middle cerebellar artery, CPUR and CPR values were statistically lower in the EOPE group than in the control group (p = 0.002; p = <0.001; p = <0.001; respectively). No statistical differences were found between groups for isovolumetric contraction time (ICT), isovolumetric relaxation time (IRT), ejection time (ET), left mod-MPI, EFT (p = 0.117; p = 0.093; p = 0.398; p = 0.882; p = 0.202, respectively). Umbilical artery Doppler pulsatility index (PI), mean uterine artery Doppler pulsatility index (PI), were higher in the EOPE group than in the control group (p = 0.006; and p = <0.001, respectively). The CPUR value for predicting EOPE was ≤1.3652 with 74. 4% sensitivity and 94.9% specificity. Positive correlations were found between CPUR, CPR, and some neonatal parameters. CPUR, a new index combining fetal and uterine Doppler indices, may add contribution to predict adverse perinatal outcome and EOPE.

Comparison of Doppler ultrasound indices of uterine artery and sub endometrial blood supply in frozen embryo transfer with and without repeated implantation failure: A cross-sectional study.

Background: Uterine blood supply has been identified as a potential factor in implantation failure. Objective: This study aimed to investigate Doppler indices in the uterine artery, including vascular flow and resistance, as well as the amount of sub-endometrial blood supply in women with a history of repeated implantation failure (RIF) compared to the non-RIF group. Materials and Methods: This cross-sectional study was conducted with 139 women candidates for frozen embryo transfer in Yazd Reproductive Sciences Institute, Yazd, Iran from February to July 2023. Group A (n = 68) included women with a history of more than 2 RIF, and group B (n = 71) included women candidates for implantation for the first time without RIF. Doppler ultrasound indices of uterine artery and sub-endometrium, including sub-endometrial flow, uterine artery flow, uterine artery resistance, and peak systolic velocity, were recorded. Results: No significant differences were observed in uterine artery Doppler pulsatility index and peak systolic velocity between groups, but the uterine artery resistance index was significantly higher in the A group (p 0.001). A significant difference was observed in the perfusion area between groups. 60/68 women in the group A had endometrial perfusion in areas 2 and 3 (p 0.001). Conclusion: Our study revealed that women with RIF exhibited higher resistance index in sub-endometrial arteries compared to the non-RIF group.

Comparative evaluation of gestosis score vs uterine artery pulsatility index in predicting gestational hypertension: A study protocol

Background: Gestational hypertension and its consequences such as preeclampsia, eclampsia is a leading cause of maternal mortality in India. Multiple risk factors are already known to cause hypertension in pregnancy and with newer advances in the field of medicine, newer risk factors are also being detected which contribute to gestational hypertension. There is need to detect these risk factors so that women who are susceptible to developing hypertension in their pregnancy can be identified at the earliest and monitored and managed accordingly. This study includes two methods, gestosis score which is a newer method, and uterine artery Doppler pulsatility index which is commonly utilized in usually urban centers where ultrasonography facilities are available to look for these risk factors. Objective: The study intends to compare the results of both prediction approaches, the Gestosis score and the Uterine Artery Pulsatility Index in identifying women at risk for gestational hypertension so that these women can be monitored vigilantly for the development of hypertension during their pregnancies and contribute to better management and healthy outcomes of pregnancy. Methods: This study will include 140 pregnant women with gestational ages between 13 to 20 weeks. The gestosis score and mean uterine artery pulsatility index will be calculated. Women with a gestosis score of three or more are deemed at risk for gestational hypertension. Women with mean pulsatility index of 95th percentile or higher are labeled at risk of gestational hypertension. The outcomes of these two methods will be compared to assess which is more effective in predicting developing gestational hypertension. Expected outcome: The study aims to provide insights into the effectiveness of both the Gestosis Score and the Uterine Artery Pulsatility Index in predicting gestational hypertension. The results will contribute to employing better risk assessment in clinical practice and the management of high-risk pregnancies.

Second-trimester Uterine Artery Doppler Pulsatility Index in Singleton Pregnant Women with and without Risk of Pre-eclampsia

Background: Preeclampsia (PE) is gestational hypertension and one of the most serious disorders in pregnant women. Objective: This study aimed to compare second-trimester uterine artery Doppler pulsatility index (UA-PI) in singleton pregnant women with and without risk of PE. Methods: A case-control study was carried out among 200 singleton pregnant women in the second trimester of pregnancy, who were referred to Imam Hospital in Ahvaz (Iran). The data were recorded on their demographic, obstetric, clinical characteristics, and Doppler indices. The average UA-PI value was considered as the mean PI between the right and left arteries. Women who were categorized into Groups 1 and 2 had a moderate-high and low risk of PE, respectively. Results: The mean UA-PI, right UA-PI, left UA-PI, systolic and diastolic blood pressures (BP), age, body mass index (BMI), and abdominal circumference (AC) of women in Group 1 were significantly higher than those in Group 2 (p&lt;0.05). Furthermore, Group 1 had a higher frequency of abortions, comorbidities, abnormal UA Doppler results, and nulliparous women than Group 2 (p&lt;0.05). Based on maternal age (&lt;35, ≥35), BMI (&lt;25, ≥25), comorbidities (yes, no), and nulliparity (yes, no) categories, those who were in Group 1 had a significantly higher mean systolic and diastolic BP, UA-PI, right UA-PI, and left UA-PI than their counterparts in Group 2 (P&lt;0.001). Conclusion: This study declared the second-trimester UA-PI had good potential for timely prediction of PE risk in pregnant women.

Impact of Angiogenic and Cardiovascular Biomarkers for Prediction of Placental Dysfunction in the First Trimester of Pregnancy.

Algorithms for first-trimester prediction of pre-eclampsia usually include maternal risk factors, blood pressure, placental growth factor (PlGF), and uterine artery Doppler pulsatility index. However, these models lack sensitivity for the prediction of late-onset pre-eclampsia and other placental complications of pregnancy, such as small for gestational age infants or preterm birth. The aim of this study was to assess the screening performance of PlGF, soluble fms-like tyrosine kinase-1 (sFlt-1), N-terminal pro-brain natriuretic peptide (NT-proBNP), uric acid, and high-sensitivity cardiac troponin T (hs-TnT) in the prediction of adverse obstetric outcomes related to placental insufficiency. This retrospective case-control study was based on a cohort of 1390 pregnant women, among which 210 presented pre-eclampsia, small for gestational age infants, or preterm birth. Two hundred and eight women with healthy pregnancies were selected as controls. Serum samples were collected between weeks 9 and 13 of gestation, and maternal serum concentrations of PlGF, sFlt-1, NT-proBNP, uric acid, and hs-TnT were measured. Multivariate regression analysis was used to generate predictive models combining maternal factors with the above-mentioned biomarkers. Women with placental dysfunction had lower median concentrations of PlGF (25.77 vs. 32.00 pg/mL; p < 0.001), sFlt-1 (1212.0 vs. 1363.5 pg/mL; p = 0.001), and NT-proBNP (51.22 vs. 68.71 ng/L; p < 0.001) and higher levels of uric acid (193.66 µmol/L vs. 177.40 µmol/L; p = 0.001). There was no significant difference between groups regarding the sFlt-1/PlGF ratio. Hs-TnT was not detected in 70% of the maternal serums analyzed. Altered biomarker concentrations increased the risk of the analyzed complications both in univariate and multivariate analyses. The addition of PlGF, sFlt-1, and NT-proBNP to maternal variables improved the prediction of pre-eclampsia, small for gestational age infants, and preterm birth (area under the curve: 0.710, 0.697, 0.727, and 0.697 vs. 0.668, respectively). Reclassification improvement was greater in maternal factors plus the PlGF model and maternal factors plus the NT-p roBNP model (net reclassification index, NRI: 42.2% and 53.5%, respectively). PlGF, sFlt-1, NT-proBNP, and uric acid measurements in the first trimester of pregnancy, combined with maternal factors, can improve the prediction of adverse perinatal outcomes related to placental dysfunction. In addition to PlGF, uric acid and NT-proBNP are two promising predictive biomarkers for placental dysfunction in the first trimester of pregnancy.

Fetal Growth Restriction Is Associated with Pregnancy Associated Plasma Protein A and Uterine Artery Doppler in First Trimester

Fetal growth restriction (FGR) is a major cause of stillbirth and poor neurodevelopmental outcomes. The early prediction may be important to establish treatment options and improve neonatal outcomes. The aim of this study was to assess the association of parameters used in first-trimester screening, uterine artery Doppler pulsatility index and the development of FGR. In this retrospective cohort study, 1930 singleton pregnancies prenatally diagnosed with an estimated fetal weight under the third percentile were included. All women underwent first-trimester screening assessing maternal serum pregnancy-associated plasma protein A (PAPP-A), free beta-human chorionic gonadotrophin levels, fetal nuchal translucency and uterine artery Doppler pulsatility index (PI). We constructed a Receiver Operating Characteristics curve to calculate the sensitivity and specificity of early diagnosis of FGR. In pregnancies with FGR, PAPP-A was significantly lower, and uterine artery Doppler pulsatility index was significantly higher compared with the normal birth weight group (0.79 ± 0.38 vs. 1.15 ± 0.59, p < 0.001 and 1.82 ± 0.7 vs. 1.55 ± 0.47, p = 0.01). Multivariate logistic regression analyses demonstrated that PAPP-A levels and uterine artery Doppler pulsatility index were significantly associated with FGR (p = 0.009 and p = 0.01, respectively). To conclude, these two parameters can predict FGR < 3rd percentile.

Is mid-gestational uterine artery Doppler still useful in a setting with routine first-trimester pre-eclampsia screening? A cohort study.

To evaluate whether routine mid-gestational uterine artery Doppler (UtAD) modifies the risk for preterm pre-eclampsia after first-trimester combined pre-eclampsia screening. Retrospective cohort study. London Tertiary Hospital. A cohort of 7793 women with singleton pregnancies, first-trimester pre-eclampsia screening using the Fetal Medicine Foundation (FMF) algorithm and UtAD pulsatility index (PI) assessment at the mid-gestation ultrasound. Pregnancies were divided into four groups: high risk in both trimesters (H1 H2 ), high risk in the first but not in the second trimester (H1 L2 ), low risk in the first but high risk in the second trimester (L1 H2 ) and low risk in both trimesters (L1 L2 ). Small for gestational age (SGA), hypertensive disorders of pregnancy (HDP) and stillbirth. In this cohort, 600 (7.7%) and 620 (7.9%) women were designated as being at high risk in the first and second trimesters, respectively. Preterm pre-eclampsia was more prevalent in the H1 L2 group (4.5%) than in women considered at low risk in the first trimester (0.4%, p < 0.0001). The prevalence of preterm pre-eclampsia in the L1 H2 group (3.3%) was significantly lower than that in women considered at high risk in the first trimester (7.0%, p=0.0076), and was higher than that observed in the L1 L2 group (0.2%, p < 0.0001). The prevalence of SGA and term HDP followed similar trends. Pre-eclampsia risk after first-trimester FMF pre-eclampsia screening may be stratified through mid-gestational routine UtAD assessment. Pregnancy care should not be de-escalated for low mid-gestational UtAD resistance in women classified as being at high risk in the first trimester. The escalation of care may be justified in women at low risk but with high mid-gestational UtAD resistance.

Uterine Artery Doppler Pulsatility Index in the First Trimester as a Forecaster of Pre-Eclampsia in Primary Gravida

Objective: To uncover a correlation between a high uterine artery pulsatility index on Doppler ultrasound and the early onset of pre-eclampsia to reduce maternal and fetal morbidity and mortality.&#x0D; Study Design: Quasi-experimental study.&#x0D; Place and Duration of Study: Department of Gynecology and Obstetrics, Combined Military Hospital, Multan Pakistan, from Jun 2020 to Dec 2021.&#x0D; Methodology: After Ethical Approval and informed consent, the umbilical artery pulsatility (UAPI) of the patients was measured by a transabdominal scan(TAS) between 75 and 100 days. Raised UAPI was correlated with early onset preeclampsia.&#x0D; Results: One hundred and sixty pregnant women were included in the study, out of which 34(21.3%) women developed preeclampsia, and 126(78.8%) were normal patients. Maternal weight (p=0.001), maternal BMI (p=0.002), gestational age and weight at delivery (p=0.001), and uterine artery doppler pulsatility index (p=0.001) had statistically significant differences with pre-eclampsia and regular patients among the target population.&#x0D; Conclusion: First-trimester uterine artery pulsatility index on Doppler ultrasound is a beneficial technique to recognize the women by risk status and target them to prevent pre-eclampsia.

Implementation of Uterine Artery Doppler Scanning: Improving the Care of Women and Babies High Risk for Fetal Growth Restriction.

While stillbirth rates have declined in many countries, these declines are less marked in the UK. Fetal growth restriction (FGR) affects about 3% to 7% of all pregnancies and is by far the single strongest risk factor for stillbirth. FGR implies a pathological restriction of the genetic growth potential and is not synonymous with small-for-gestational age (SGA). The Royal College of Obstetricians and Gynaecologists (RCOG) defines SGA as an estimated fetal weight (EFW) or abdominal circumference (AC) less than the 10th centile. The likelihood of FGR is higher in severe SGA defined as an EFW or AC less than the 3rd centile. The second version of Saving Babies' Lives Care Bundle (SBLCBv2) recommends the second trimester uterine artery Doppler (UtAD) pulsatility index (PI) screening for pregnancies at high risk of FGR. This study was aimed at determining the prevalence of FGR and assess pregnancy outcomes following the implementation of UtAD at the United Lincolnshire Hospitals NHS Trust (ULHT). One-year retrospective cohort study (1st September 2020-31st August 2021) was conducted across both ULHT hospitals in the UK (Lincoln County Hospital in Lincoln and Pilgrim Hospital in Boston). During the study period, 5197 women were booked at ULHT. Of 5197, 349 were identified as high risk for FGR. When numbers were compared for the two hospitals, FGR rate was higher in Lincoln 8.10% vs. 4.51% in Boston. In addition, an increased proportion of abnormal UtAD scans was observed in Lincoln (35.7%) vs. in Boston (22%) (P = 0.014). Of the 349 UtAD scans, 237 were normal (67.9%), 41 showed unilateral notching (11.7%), 43 bilateral notching (12.3%), and 28 raised PI (8%). Babies in the bilateral notching group exhibited the lowest birth weight (P = 0.005), born at an earlier gestation (P = 0.029), and with low Apgar scores at 1 (P = 0.007) and 5 minutes (P < 0.001). Discussion. UtAD is a useful second trimester screening tool for women identified as high risk for FGR and helps stratify the intensity of surveillance. However, the findings call into question a focus solely on the UtAD PI for improving FGR detection without taking into account bilateral notching.

Sensitivity of uterine artery Doppler pulsatility index in screening for adverse pregnancy outcome in first and second trimesters.

In a poor resource country where screening for adverse pregnancy outcomes using maternal biomarkers seems unattainable, there is a need to search for credible alternatives. This study is, therefore, aimed at determining the sensitivity of uterine artery Doppler pulsatility index (UtAD-PI) in predicting pregnancy outcomesin the first and second trimesters and to establish any statistical difference in mean UtAD-PI in first and second trimesters screening of women with normal and abnormal pregnancy outcomes respectively. This clinical-based, longitudinal, and unpaired cohort study involved 500 pregnant women, who were screened for adverse outcomes using UtAD-PI and delivered in the hospital. These were divided into two groups, each having a training set and a test set. The training set was used to generate the receiver operator characteristic curve and cut-off point while the test set was used to test for sensitivity and specificity of the Ut-ADI in each trimester. The sensitivity and specificity of UtAD-PI in first-trimester screening are 97% and 76.5% while second-trimester gave sensitivity and specificity of 57.5% and 63.3% respectively. The uterine artery Doppler pulsatility index shows statistically significant differences between normal pregnancy and pregnancy with adverse outcomes (p-value = 0.000). The uterine artery Doppler pulsatility index is a good screening tool for adverse pregnancy outcomes. First-trimester screening of patients for adverse outcomes is more sensitive than the second-trimester screening using UtAD-PI. There is also a statistically significant difference between mean UtAD-PI between normal pregnancy and pregnancy with adverse pregnancy outcomes.

Combination of Maternal Serum ESM-1 and PLGF with Uterine Artery Doppler PI for Predicting Preeclampsia.

This study aimed to determine whether the combination of pregnancy-associated endothelial cell-specific molecule 1 (ESM-1), the placental growth factor (PLGF) in the first- and second-trimester maternal serum, and the uterine artery Doppler pulsatility index (PI) in the second trimester can predict preeclampsia (PE). The serum levels of ESM-1 and PLGF in 33 severe preeclampsia (SPE) patients, 18 mild preeclampsia patients (MPE), and 60 age-matched normal controls (CON) were measured. The Doppler ultrasonography was performed, and the artery pulsatility index (PI) was calculated for the same subjects. The 2nd PLGF level was significantly lower and the 2nd PI was higher than those in the MPE group. Combining the 2nd PLGF with the 2nd PI yielded an AUC of 0.819 (83.33% sensitivity and 70.00% specificity). In the SPE group, the 1st ESM-1 level and the 2nd PLGF level were significantly lower, and the 2nd ESM-1 level and the 2nd PI were significantly higher in the SPE group. The combination of the 1st ESM-1, the 2nd PLGF, and the 2nd PI yielded an AUC of 0.912 (72.73% sensitivity and 95.00% specificity). The 1st ESM-1 and the 2nd PLGF levels and the 2nd PI were associated with PE. The combination of serum biomarkers and the PI improved the screening efficiency of the PE prediction, especially for SPE.

Prediction of Gestational Diabetes Mellitus and Hypertensive Disorders in Pregnancy Using Insulin Resistance at 11-14 Weeks Period of Gestation

Background: Hypertensive disorders of pregnancy and gestational diabetes (GDM) are all associated with increased risks of poor maternal and perinatal outcomes. It has been hypothesized that the association could be due to at least in part, to insulin resistance. Although insulin resistance is a physiologic phenomenon in normal pregnancy, in predisposed individuals it could lead to hyper-insulinemia with development of GDM, hypertensive disorders of pregnancy (gestational hypertension, pre-eclampsia and eclampsia) or both. In the present study the role of insulin resistance in early prediction of gestational diabetes mellitus and hypertensive disorders in pregnancy. Researchers attempted to study the correlation of insulin resistance at 11 to 14 weeks period of gestation and outcome in terms of GDM and hypertensive disorders in pregnancy and explore the possible use of insulin resistance in their early prediction. Objectives: Prediction of gestational diabetes mellitus and hypertensive disorders in pregnancy using insulin resistance at 11-14 weeks of gestation. To evaluate if combined maternal markers (insulin resistance, mean arterial pressure and uterine artery Doppler pulsatility index) in first trimester of pregnancy (11-14 weeks) is more effective in predicting the same. Methodology: The study is a prospective observational study carried out from December 2015 to November 2016, in the Department of Obstetrics and Gynaecology at Dr. T.M.A. Pai Hospital, Udupi. The study population consists of pregnant women booked between 11-14 weeks of gestation with viable pregnancy, who are willing for blood investigation to determine insulin resistance and also those women who gave consent to do uterine artery Doppler. Total 165 patients are included in the study. Out of them 118 patients gave consent to do uterine artery Doppler during NT scan. All patients are followed up for presence of development of gestational diabetes mellitus and hypertensive disorders of pregnancy with mode of delivery, intrapartum and postpartum complications. Results: Likelihood ratio by taking HOMA-IR cut off as 1.87 at 11-14 weeks of gestation was 2.5 stating that with HOMA-IR value as 1.87, pregnant women were 2.5 times more likely to develop gestational diabetes mellitus or hypertensive disorders of pregnancy with advancing gestation. It was observed that HOMA-IR values increased with increase in BMI in present study with p value-0.013, thus was found statistically significant. Out of 72 patients having HOMA-IR ≥ 1.87, 32 patients developed either GDM/HTN which accounted for 45% of women who developed gestational diabetes mellitus or hypertensive disorders in pregnancy. There was an increasing trend in HOMA-IR at 11-14 weeks period of gestation in women who later developed gestational diabetes mellitus or hypertensive disorders in pregnancy. Out of 9 patients having gestational hypertension, 7 patients were having HOMA-IR ≥ 1.87, which accounted for 78% of patients developing gestational hypertension (HTN) in pregnancy. HOMA-IR was a useful marker in predictive gestational hypertension (p value &lt;0.01). Out of 32 patients having gestational diabetes mellitus, 26 patients were having HOMA-IR ≥ 1.87, which accounted for 81% of patients developing gestational diabetes mellitus (GDM) in pregnancy. HOMA-IR was a useful marker in predicting gestational diabetes mellitus (P value &lt;0.01). The combined parameters of study showed 100% sensitivity and 100% negative predictive value for predictability of GDM/HTN in pregnancy. Conclusion: HOMA-IR can be used to predict GDM/Hypertensive disorders of pregnancy at 11-14 weeks gestation with reasonable accuracy. Combined screening algorithm with HOMA-IR, MAP and uterine artery Doppler has limited role and may help only in select high risk population. The prospect of screen positive women being given low dose aspirin (75mg) and advice regarding appropriate dietary management to help prevent the development of hypertensive disorders/GDM in later gestation needs to be explored by larger trials.

A trial of positive airway pressure for the treatment of sleep apnea in pregnancy

The pathophysiology of obstructive sleep apnea in pregnancy remains poorly understood and studies examining the effect of treatment with positive airway pressure on pregnancy have been limited. This study aimed to perform a randomized controlled trial of positive airway pressure treatment for obstructive sleep apnea in pregnancy. Participants with a body mass index ≥30 kg/m2 underwent polysomnography at 14 to 20 weeks' gestation (visit 1) and those with obstructive sleep apnea (apnea-hypopnea index ≥5 but <50) were enrolled. In phase 1, participants were randomized to autotitrating positive airway pressure vs sham positive airway pressure; in phase 2, the sham arm was replaced with a sleep hygiene control. Participants returned at 28 to 31 weeks' gestation (visit 2). The mean arterial blood pressure, uterine artery Doppler pulsatility index, endoglin, soluble FMS-like tyrosine kinase 1 levels, and placental growth factor levels were measured, as well as fasting glucose and insulin to calculate insulin resistance (homeostatic model assessment for insulin resistance). The primary outcome was a composite of the uterine artery Doppler pulsatility index, soluble FMS-like tyrosine kinase 1 to placental growth factor ratio, and the homeostatic model assessment for insulin resistance. For secondary analyses, each outcome variable was analyzed independently. Adherence to treatment was examined. A total of 241 participants completed visit 1, and 89 (37%) had an apnea-hypopnea index between 5 and 50. Of the those, 51 participants were randomized in phase 1 and 38 in phase 2. There was no significant difference in our primary outcome by treatment group. In secondary analyses, the uterine artery Doppler pulsatility index was lower in participants on autotitrating positive airway pressure when compared with sleep hygiene controls. Otherwise, there were no differences in the mean arterial blood pressure, angiogenic markers, or metabolic markers in phase 1, phase 2, or across the entire study. The overall adherence to autotitrating positive airway pressure therapy was low, but the mean use was greater in phase 2 (0.3±0.6 hours/night vs 1.3±2.3 hours/night; P=.10). For those on active therapy, fasting glucose values decreased as adherence increased. This randomized controlled trial of autotitrating positive airway pressure in pregnancy did not find any differences in a composite primary cardiometabolic risk profile between the treatment groups. Higher autotitrating positive airway pressure adherence was associated with lower fasting glucose levels. The use of a sham positive airway pressure control arm in phase1 may have negatively impacted adherence to active treatment.

Quality assessment of first-trimester screening for preterm pre-eclampsia.

To assess the performance and impact of first-trimester preterm pre-eclampsia screening in a single center. This was a single-center study of women with a singleton pregnancy who were screened prospectively for preterm pre-eclampsia (i.e. delivery before 37 weeks' gestation) using maternal characteristics, mean arterial pressure (MAP), uterine artery Doppler pulsatility index, maternal serum pregnancy-associated plasma protein-A and placental growth factor. The individual risk for preterm pre-eclampsia was estimated from a published model, and those with a risk above 1 in 200 were recommended to take 150 mg soluble aspirin per day until 34 weeks. Information on the incidence of pre-eclampsia was obtained from the hospital register of adverse pregnancy outcomes. Screening performance indicators, including detection and false-positive rates, were estimated from the distribution of risks. Screening impact was estimated by dividing the observed prevalence by the expected prevalence, which was derived from the distribution of risks. The distributions of MAP, uterine artery Doppler pulsatility index and serum markers were consistent with the risk model parameters. The estimated detection and false-positive rates were 79.7% and 16.2%, respectively. There were six cases of preterm pre-eclampsia, four of which occurred in women with a positive screening result. The prevalence was 62% of that expected, but the 95% CI of 23-140% indicated that the study was underpowered to assess the impact. This study demonstrates that the performance of preterm pre-eclampsia screening can be estimated in a single center with fewer than 2000 women screened. However, in order to assess the impact of screening on the prevalence of the condition, a much larger cohort is needed. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

The Implementation of Preeclampsia Screening and Prevention (IMPRESS) Study

Preeclampsia affects between 2% and 5% of pregnancies and is one of the leading causes of perinatal morbidity and mortality worldwide. Despite strong evidence that the combination of systematic preeclampsia screening based on the Fetal Medicine Foundation preeclampsia risk calculation algorithm with treatment of high-risk patients with low-dose aspirin reduces the incidence of preterm preeclampsia more than currently used risk-factor-based screening, real-world implementation studies have not yet been done in Canada. This study aimed to assess the operational feasibility of implementing first-trimester screening and prevention of preterm preeclampsia (<37 weeks) alongside a publicly funded first-trimester combined screening program for aneuploidies. This was a prospective implementation study. Consecutive pregnant patients referred for first-trimester combined screening (11-13+6 weeks) were offered screening for preeclampsia based on the Fetal Medicine Foundation algorithm concomitantly with their aneuploidy screen. Consenting participants were screened using maternal risk factors, mean arterial pressure, uterine artery Doppler pulsatility index, pregnancy-associated plasma protein-A, and placental growth factor. Risk for preterm preeclampsia (<37 weeks) was calculated using the Fetal Medicine Foundation algorithm, and individuals with a risk score ≥1 per 100 were recommended to use aspirin (162 mg once daily at bedtime, <16-36 weeks). Implementation metrics assessed included: acceptability, operational impact, proportion of aspirin initiation, quality and safety measures, and screen performance. Between December 1, 2020 and April 23, 2021, 1124 patients consented to preeclampsia screening (98.3% uptake), and 92 (8.2%) screened positive. Appointments for patients receiving first-trimester combined screening aneuploidy and preeclampsia screening averaged 6 minutes longer than first-trimester combined screening alone, and adding uterine artery Doppler pulsatility index averaged 2 minutes. Of the 92 patients who screened as high-risk for preeclampsia, 72 (78.3%) were successfully contacted before 16 weeks' gestation. Of these, 62 (86.1%) initiated aspirin, and 10 (13.9%) did not. Performance audit identified a consistent negative bias with mean arterial pressure measurements (median multiple of the median <1 in 10%); other variables were satisfactory. There were 7 cases of preterm preeclampsia (0.69%): 5 and 2 in the high- and low-risk groups, respectively. Screening detected 5 of 7 (71.4 %) preterm preeclampsia cases, with improved performance after adjustment for aspirin treatment effect. This study confirms the operational feasibility of implementing an evidence-based preeclampsia screening and prevention program in a publicly funded Canadian setting. This will facilitate implementation into clinical service and the scaling up of this program at a regional and provincial level.

Role of Routine Mid-Trimester Uterine Artery Doppler for Surveillance of Placental Mediated Disorders in a Low-Risk Population.

Abnormalities in the placentation process can increase pregnancy-related complications like pre-eclampsia, placental abruption, intrauterine-fetal death (IUFD) or foetal-growth restriction (FGR). Our objective was to investigate the feasibility of utilising the mid-trimester uterine artery Doppler Pulsatility Index (PI), a non-invasive and effective screening tool, as a diagnostic measure to predict adverse pregnancy outcomes in a low-risk population in South India. This prospective cohort study was done in the Obstetrics and Gynaecology unit at Amrita Institute of Medical Sciences, South India, between August 2018 and January 2020. Uterine artery Doppler was performed along with the targeted anomaly scan between 18 and 24 weeks of gestation and a relationship was established with pregnancy outcome. Of 100 participants, abnormal uterine artery PI (PI > 90th centile) was found in 13 pregnancies, of which statistically significant association was found with hypertensive disorders (P=0.001), FGR (P=0.064) and preterm birth before 37 weeks (P=0.051). No association was found between abnormal uterine artery PI and neonatal birth weight (P=-0.3), APGAR score (P=0.35) and NICU admission (P=0.078). An early abnormal finding in the doppler study can modify the level of antenatal surveillance required along with appropriate timely interventions, thereby significantly reducing the associated maternal and neonatal morbidity and mortality. When combined with routine ultrasound in pregnancy, such an affordable and straightforward diagnostic modality can improve antenatal care by reducing complications even in a low-risk population.

Ophthalmic artery Doppler for pre-eclampsia prediction at the first trimester: a Bayesian survival-time model.

To develop a Bayesian survival-time model for the prediction of pre-eclampsia (PE) at the first trimester using a combination of established biomarkers including maternal characteristics and history, mean arterial pressure (MAP), uterine artery Doppler pulsatility index (UtA-PI), and Placental Growth Factor (PlGF)) with an ophthalmic artery Doppler peak ratio (PR) analysis. The receiving operator curve (ROC) analysis was used to determine the area under the curve (AUC), detection rate (DR), and positive screening cut-off value of the model in predicting the occurrence of early-onset PE (< 34weeks' gestation) and preterm PE (< 37weeks' gestation). Of the 946 eligible participants, 71 (7.49%) subjects were affected by PE. The incidences of early-onset and preterm PE were 1% and 2.2%, respectively. At a 10% false-positive rate, using the high-risk cut-off 1:49, with AUC 0.981 and 95%CI 0.965-0.998, this model had an 100% of DR in predicting early-onset PE. The DR of this model in predicting preterm PE is 71% when using 1:13 as the cut-off, with AUC 0.919 and 95%CI 0.875-0.963. Combination ophthalmic artery Doppler PR with the previously established biomarkers could improve the accuracy of early and preterm PE prediction at the first trimester screening.

First-Trimester Sequential Screening for Preeclampsia Using Angiogenic Factors: Study Protocol for a Prospective, Multicenter, Real Clinical Setting Study.

IntroductionThe incidence of preeclampsia (PE) is about 2–8%, making it one of the leading causes of perinatal morbidity and maternal mortality in the world. Early prophylactic low dose administration (150 mg) of acetylsalicylic acid is associated with a significant reduction in the incidence of early-onset PE, intrauterine growth restriction (IUGR), and neonatal mean stay in the intensive care unit (ICU). Universal implementation of a first-trimester screening system including angiogenic and antiangiogenic markers [the Placental Growth Factor (PlGF) and/or soluble fms-like Tyrosine Kinase-1 (sFlt-1)] has shown a prediction rate of 90% for early-onset PE but entails a high financial cost. The aim of this study is to determine the predictive and preventive capacity of a universal PE first-trimester two-step sequential screening model, determining the PlGF only in patients previously classified as intermediate risk by means of a multivariate model based on resources already used in the standard pregnancy control, in a real clinical setting. We hypothesize that this screening model will achieve similar diagnostic performance as the universal determination of PlGF but at a lower economic cost.Methods and AnalysisThis is a prospective, multicentric, cohort study in a real-world clinical setting. Every singleton pregnancy will be recruited at the routine first pregnancy visit. In a first step, the first-trimester risk of PE will be calculated using a multivariate Gaussian distribution model, based on medical history, mean blood pressure, Pregnancy-Associated Plasma Protein A (PAPP-A), and Uterine Artery Doppler Pulsatility Index (UTPI). Patients will be classified into three risk groups for PE: (1) risk ≥ 1/50, high-risk with no further testing (blinded PlGF); (2) risk between 1/51 and 1/500, medium-risk requiring further testing; and (3) risk ≤ 1/501, low-risk with no further testing. In a second step, the PlGF will only be determined in those patients classified as intermediate risk after this first step, and then reclassified into high- or low-risk groups. Prophylactic administration of aspirin (150 mg/day) will be prescribed only in high risk patients. As a secondary objective, sFlt-1 values will be blindly determined in patients with high and intermediate risk to assess its potential performance in the screening for PE.Ethics and DisseminationThe study will be conducted in accordance with the principles of Good Clinical Practice. This study is approved by the Aragon Research Ethics Committee (CEICA) on 3 July 2020 (15/2020).Clinical Trial RegistrationClinicalTrials.gov, identifier: NCT04767438.

A Comparative Study of Uterine Artery Doppler Parameters and Endometrial Characteristics in Women with Unexplained Infertility and Fertile Women at a Nigerian Teaching Hospital

Objectives: To investigate the uterine artery Doppler parameters and endometrial characteristics in women with unexplained infertility.&#x0D; Methods: A prospective case-control study of 42 women with unexplained infertility and 42 fertile controls. Their mid-luteal phase transvaginal Doppler parameters of both uterine arteries and endometrial characteristics (endometrial blood flow, thickness and volume) were investigated and analysed. P values &lt; 0.05 was statistically significant.&#x0D; Results: The mean uterine artery pulsatility index (PI) and resistivity index (RI) of the cases (women with unexplained infertility) were significantly higher compared to the values in the fertile controls (PI = 2.81±0.61 vs 2.15±0.65; p=0.001) (RI= 0.87±0.08 vs 0.82±0.07; p=0.003). In addition, the end-diastolic volume (EDV) (6.12±4.17 vs 9.37±5.14; p=0.007) and endometrial-subendometrial blood flow (p=0.036) were significantly lower in the cases compared to the controls. Multivariate logistics analysis showed that PI was independently associated with infertile status (p=0.006). There was no significant difference in the mean PSV (48.69±10.9 vs 50.58±11.30; p=0.602), endometrial thickness (10.30+3.13 vs 10.72+3.10; p=0.544), endometrial volume (7.82+1.56 vs 8.23+1.71; p=0.323), mean age (32.28±4.062 vs 31.91±3.58 years; p=0.502), body mass index (26.15±2.71kg/m2 vs 25.24±2.85 kg/m2; p=0.18) menstrual bleeding days (4.07±0.89 days vs 4.02±0.95 days; p=0.481) duration of menstrual cycle (28.02±1.09 days vs 27.64±1.36 days; p= 0.162), smoking history (p=0.909) and alcohol intake (p=0.507) of the infertile women compared with the fertile controls, respectively.&#x0D; Conclusion: Women with unexplained infertility have increased uterine artery Doppler PI and RI and reduced endometrial-subendometrial perfusion compared with fertile controls.&#x0D; Authors&#x0D; A E Smart 1, G O Obajimi 2, A J Adekanmi 3 4, M O Obajimi 3