Well-being In High-risk Pregnancies Research Articles

Doppler Ultrasound for Fetal Assessment in High Risk Pregnancies

Background When it comes to the provision of antenatal care or research, pregnant women tend to be divided into low- and high-risk populations; however, the boundaries between the groups are often blurred. For most researchers, ‘high-risk status’ includes maternal conditions associated with increased perinatal mortality and morbidity such as diabetes, hypertensive disorders (chronic hypertension and pre-eclampsia) and cardiac disorders. The waveform analysis of the feto- maternal circulation by Doppler ultrasound has become a quick and a simple way for the assessment of fetal well-being in high-risk pregnancies. It helps identify fetuses at risk of hypoxia and acidaemia, when the results are applied clinically; they contribute to reduced perinatal mortality rates. Objectives The main objective of this study is to evaluate Doppler flow indices as an index for assessing fetal wellbeing in high-risk pregnancies. Methods A total of 40 pregnant women with singleton pregnancies at a gestational age ≥3234 weeks were included in this study, 30 of them had a high risk factor were selected as 10 preeclampsia patient, 10 gestational diabetes patient, 10 cardiac patient, the remaining 10 women had no obstetric disorder or any risk factor were selected as control. All pregnant women underwent uniform antenatal assessment protocol that includes an Ultrasound examination and Doppler evaluation of fetoplacental circulation: umbilical artery (UA), middle cerebral artery (MCA) and ductus venosus (DV) Doppler ultrasound studies. Results Our findings showed no statistically significant difference in the Doppler indices between gestational diabetes group and control group. There was only a considerable change in DV Doppler waveform in this study that is also insignificant. At preeclampsia group, it was found that there was statistically significant difference regarding UA RI, MCA RI, and MCA RI/UA RI ratio compared to control group. In the cardiac group, fetal Doppler indices were comparable to those of the control group. Conclusion The result of the present study suggest that Doppler indices in the third trimester may be useful markers of fetal well-being in high risk pregnancy. Hypertensive disorders with pregnancy can be considered the most important indication for third trimester Doppler examination. Two-vessel examination in these cases seems a good practice.

UMBILICAL ARTERY DOPPLER VERSUS NON-STRESS TEST IN HIGH RISK PREGNANCIES

Background: Maternal monitoring of fetal movement is a mean of screening fetal status. The rationale is based on the assumption that early recognition of decreased fetal movement (DFM) makes it possible for the clinician to intervene at a stage when the fetus is still compensated, and thus prevent progression to fetal or neonatal injury or death. Objective: To evaluate the role of non-stress test and umbilical artery Doppler measurements as an antenatal screening test for assessment of fetal well-being in high risk pregnancies affected by decreased fetal movements. Patients and methods: The current study enrolled 200 patients complaining of decreased fetal movements came for ante natal care in ante natal care clinic of Al Azhar Assiut University Hospital. Enrolled women were randomly allocated in two equal groups, the study continued for 1 year (from January 2019 – December 2019). Results: This study shows that the use of umbilical artery Doppler ultrasound assessment as an antenatal screening test was associated with a reduction in the incidence of cesarean delivery for fetal distress, more successful induction of labor, less admissions to NICU and better APGAR score in high risk pregnant population complaining of decreased fetal movement compared to non-stress test. Conclusion: Umbilical artery Doppler ultrasound assessment of the fetus in conjunction with a policy of directed intervention resulted in a decrease in the rate of cesarean delivery for fetal distress in a high-risk pregnancy, when compared with the NST.

UMBILICAL ARTERY DOPPLER VERSUS NON-STRESS TEST IN HIGH RISK PREGNANCIES

Background: Maternal monitoring of fetal movement is a mean of screening fetal status. The rationale is based on the assumption that early recognition of decreased fetal movement (DFM) makes it possible for the clinician to intervene at a stage when the fetus is still compensated, and thus prevent progression to fetal or neonatal injury or death. Objective: To evaluate the role of non-stress test and umbilical artery Doppler measurements as an antenatal screening test for assessment of fetal well-being in high risk pregnancies affected by decreased fetal movements. Patients and methods: The current study enrolled 200 patients complaining of decreased fetal movements came for ante natal care in ante natal care clinic of Al Azhar Assiut University Hospital. Enrolled women were randomly allocated in two equal groups, the study continued for 1 year (from January 2019 – December 2019). Results: This study shows that the use of umbilical artery Doppler ultrasound assessment as an antenatal screening test was associated with a reduction in the incidence of cesarean delivery for fetal distress, more successful induction of labor, less admissions to NICU and better APGAR score in high risk pregnant population complaining of decreased fetal movement compared to non-stress test. Conclusion: Umbilical artery Doppler ultrasound assessment of the fetus in conjunction with a policy of directed intervention resulted in a decrease in the rate of cesarean delivery for fetal distress in a high-risk pregnancy, when compared with the NST.

Is umbilical Doppler ultrasound helpful in assessing fetal well-being in high-risk pregnancies?

Sea Mar Marysville FMR, Marysville, WA Central Washington FMR, Yakima, WA The authors declare no conflicts of interest.

Fetal and umbilical Doppler ultrasound in high-risk pregnancies.

Abnormal blood flow patterns in fetal circulation detected by Doppler ultrasound may indicate poor fetal prognosis. It is also possible that false positive Doppler ultrasound findings could lead to adverse outcomes from unnecessary interventions, including preterm delivery. The objective of this review was to assess the effects of Doppler ultrasound used to assess fetal well-being in high-risk pregnancies on obstetric care and fetal outcomes. We updated the search of Cochrane Pregnancy and Childbirth's Trials Register on 31 March 2017 and checked reference lists of retrieved studies. Randomised and quasi-randomised controlled trials of Doppler ultrasound for the investigation of umbilical and fetal vessels waveforms in high-risk pregnancies compared with no Doppler ultrasound. Cluster-randomised trials were eligible for inclusion but none were identified. Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked. We assessed the quality of evidence using the GRADE approach. Nineteen trials involving 10,667 women were included. Risk of bias in trials was difficult to assess accurately due to incomplete reporting. None of the evidence relating to our main outcomes was graded as high quality. The quality of evidence was downgraded due to missing information on trial methods, imprecision in risk estimates and heterogeneity. Eighteen of these studies compared the use of Doppler ultrasound of the umbilical artery of the unborn baby with no Doppler or with cardiotocography (CTG). One more recent trial compared Doppler examination of other fetal blood vessels (ductus venosus) with computerised CTG.The use of Doppler ultrasound of the umbilical artery in high-risk pregnancy was associated with fewer perinatal deaths (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.52 to 0.98, 16 studies, 10,225 babies, 1.2% versus 1.7 %, number needed to treat (NNT) = 203; 95% CI 103 to 4352, evidence graded moderate). The results for stillbirths were consistent with the overall rate of perinatal deaths, although there was no clear difference between groups for this outcome (RR 0.65, 95% CI 0.41 to 1.04; 15 studies, 9560 babies, evidence graded low). Where Doppler ultrasound was used, there were fewer inductions of labour (average RR 0.89, 95% CI 0.80 to 0.99, 10 studies, 5633 women, random-effects, evidence graded moderate) and fewer caesarean sections (RR 0.90, 95% CI 0.84 to 0.97, 14 studies, 7918 women, evidence graded moderate). There was no comparative long-term follow-up of babies exposed to Doppler ultrasound in pregnancy in women at increased risk of complications.No difference was found in operative vaginal births (RR 0.95, 95% CI 0.80 to 1.14, four studies, 2813 women), nor in Apgar scores less than seven at five minutes (RR 0.92, 95% CI 0.69 to 1.24, seven studies, 6321 babies, evidence graded low). Data for serious neonatal morbidity were not pooled due to high heterogeneity between the three studies that reported it (1098 babies) (evidence graded very low).The use of Doppler to evaluate early and late changes in ductus venosus in early fetal growth restriction was not associated with significant differences in any perinatal death after randomisation. However, there was an improvement in long-term neurological outcome in the cohort of babies in whom the trigger for delivery was either late changes in ductus venosus or abnormalities seen on computerised CTG. Current evidence suggests that the use of Doppler ultrasound on the umbilical artery in high-risk pregnancies reduces the risk of perinatal deaths and may result in fewer obstetric interventions. The results should be interpreted with caution, as the evidence is not of high quality. Serial monitoring of Doppler changes in ductus venosus may be beneficial, but more studies of high quality with follow-up including neurological development are needed for evidence to be conclusive.

Fetal and umbilical Doppler ultrasound in high-risk pregnancies.

Abnormal blood flow patterns in fetal circulation detected by Doppler ultrasound may indicate poor fetal prognosis. It is also possible false positive Doppler ultrasound findings could encourage inappropriate early delivery. The objective of this review was to assess the effects of Doppler ultrasound used to assess fetal well-being in high-risk pregnancies on obstetric care and fetal outcomes. We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 30 September 2013. Randomised and quasi-randomised controlled trials of Doppler ultrasound for the investigation of umbilical and fetal vessels waveforms in high-risk pregnancies compared with no Doppler ultrasound. Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked. Eighteen completed studies involving just over 10,000 women were included. The trials were generally of unclear quality with some evidence of possible publication bias. The use of Doppler ultrasound in high-risk pregnancy was associated with a reduction in perinatal deaths (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.52 to 0.98, 16 studies, 10,225 babies, 1.2% versus 1.7 %, number needed to treat (NNT) = 203; 95% CI 103 to 4352). There were also fewer inductions of labour (average RR 0.89, 95% CI 0.80 to 0.99, 10 studies, 5633 women, random-effects) and fewer caesarean sections (RR 0.90, 95% CI 0.84 to 0.97, 14 studies, 7918 women). No difference was found in operative vaginal births (RR 0.95, 95% CI 0.80 to 1.14, four studies, 2813 women), nor in Apgar scores less than seven at five minutes (RR 0.92, 95% CI 0.69 to 1.24, seven studies, 6321 babies). Current evidence suggests that the use of Doppler ultrasound in high-risk pregnancies reduced the risk of perinatal deaths and resulted in less obstetric interventions. The quality of the current evidence was not of high quality, therefore, the results should be interpreted with some caution. Studies of high quality with follow-up studies on neurological development are needed.

Systematic review and meta-analysis of the test accuracy of ductus venosus Doppler to predict compromise of fetal/neonatal wellbeing in high risk pregnancies with placental insufficiency

Objective To evaluate the test accuracy of ductus venosus Doppler for prediction of compromise of fetal/neonatal wellbeing. Study design The search strategy employed searching of electronic databases (Medline, Embase, Cochrane library, Medion) from inception to May 2009, hand searching of journal and reference lists, contact with experts. Two reviewers independently selected articles in which the results of ductus venosus Doppler were associated with the occurrence of compromise of fetal/neonatal wellbeing. There were no language restrictions applied. Data were extracted on study characteristics, quality and results to construct 2 × 2 tables. Likelihood ratios for positive and negative test results, sensitivity, specificity and their 95% confidence intervals were generated for the different indices and thresholds. Results Eighteen studies, testing 2267 fetuses met the selection criteria, all performed in a high risk population with placental insufficiency in second/third trimester. Meta-analysis showed moderate predictive accuracy. The best result was for the prediction of perinatal mortality, positive likelihood ratio 4.21 (95% CI 1.98–8.96) and negative likelihood ratio 0.43 (95% CI 0.30–0.61). For prediction of adverse perinatal outcome the results were positive likelihood ratio 3.15 (95% CI 2.19–4.54) and negative likelihood ratio 0.49 (95% CI 0.40–0.59). Conclusion Abnormal ductus venosus Doppler showed moderate predictive accuracy for compromise of fetal/neonatal wellbeing overall and perinatal mortality in high risk pregnancies with placental insufficiency.

Fetal and umbilical Doppler ultrasound in high-risk pregnancies.

Abnormal blood flow patterns in fetal circulation detected by Doppler ultrasound may indicate poor fetal prognosis. It is also possible false positive Doppler ultrasound findings could encourage inappropriate early delivery. The objective of this review was to assess the effects of Doppler ultrasound used to assess fetal well-being in high-risk pregnancies on obstetric care and fetal outcomes. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2009) and the reference lists of identified studies. Randomised and quasi-randomised controlled trials of Doppler ultrasound for the investigation of umbilical and fetal vessels waveforms in high-risk pregnancies compared to no Doppler ultrasound. Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked. Eighteen completed studies involving just over 10,000 women were included. The trials were generally of unclear quality with some evidence of possible publication bias. The use of Doppler ultrasound in high-risk pregnancy was associated a reduction in perinatal deaths (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.52 to 0.98, 16 studies, 10,225 babies, 1.2% versus 1.7 %, numbers needed to treat = 203; 95%CI 103 to 4352). There were also fewer inductions of labour (average RR 0.89, 95% CI 0.80 to 0.99, 10 studies, 5633 women, random effects) and fewer caesarean sections (RR 0.90, 95% CI 0.84 to 0.97, 14 studies, 7918 women). No difference was found in operative vaginal births (RR 0.95, 95% CI 0.80 to 1.14, four studies, 2813 women) nor in Apgar scores less than seven at five minutes (RR 0.92, 95% CI 0.69 to 1.24, seven studies, 6321 babies). Current evidence suggests that the use of Doppler ultrasound in high-risk pregnancies reduced the risk of perinatal deaths and resulted in less obstetric interventions. The quality of the current evidence was not of high quality, therefore, the results should be interpreted with some caution. Studies of high quality with follow-up studies on neurological development are needed.

Biophysical profile for fetal assessment in high risk pregnancies.

A biophysical profile (BPP) includes ultrasound monitoring of fetal movements, fetal tone and fetal breathing, ultrasound assessment of liquor volume with or without assessment of the fetal heart rate. The BPP is performed in an effort to identify babies that may be at risk of poor pregnancy outcome, so that additional assessments of wellbeing may be performed, or labour may be induced or a caesarean section performed to expedite birth. To assess the effects of the BPP when compared with conventional monitoring (CTG only or MBPP) on pregnancy outcome in high-risk pregnancies. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2007), CENTRAL (The Cochrane Library 2006, Issue 4), MEDLINE (1966 to November 2006), EMBASE (1974 to November 2006) and CINAHL (1980 to November 2006). Randomised and quasi-randomised controlled trials involving a comparison of fetal BPP with other forms of antepartum fetal assessment in women with high-risk pregnancies. Two authors independently assessed eligibility, quality and extracted data. We included five trials, involving 2974 women. Most trials were not of high quality. Although the overall incidence of adverse outcomes was low, available evidence from randomised controlled trials does not support the use of BPP as a test of fetal wellbeing in high-risk pregnancies. We found no significant differences between the groups in perinatal deaths (relative risk (RR) 1.33, 95% confidence interval (CI) 0.60 to 2.98) or in Apgar score less than seven at five minutes (RR 1.27, 95% CI 0.85 to 1.92). Combined data from the two high-quality trials suggest an increased risk of caesarean section in the BPP group RR 1.60, 95% CI 1.05 to 2.44, n = 280, interaction test P = 0.03. However, the number of participating women was relatively small (n = 280). Therefore, additional evidence is required in order to be definitive regarding the efficacy of this test in high-risk pregnancies. Furthermore, the impact of the BPP on other interventions, length of hospitalisation, serious short-term and long-term neonatal morbidity and parental satisfaction requires further evaluation. At present, there is insufficient evidence from randomised trials to support the use of BPP as a test of fetal wellbeing in high-risk pregnancies.

Einsatz von Nabelschnur-Doppler bei vorzeitiger Plazentalösung: zwei klinische Fallberichte

Hintergrund: Die dopplersonografische Untersuchung der A. umbilicalis ist eine etablierte Methode zur Überwachung von Hochrisikoschwangerschaften. Daten über dessen Einsatz in Akutsituationen, wie bei vorzeitiger Plazentalösung, sind allerdings rar und kontrovers. Fallberichte: Wir berichten von zwei Patientinnen, die in der 31 + 2 und 34 + 2 Schwangerschaftswoche (SSW) mit Status post vaginaler Blutung in unsere Klinik eingewiesen wurden. Bei der Aufnahme konnte keine Blutung festgestellt werden und sowohl klinisch als auch ultrasonografisch konnte kein Hinweis für eine Plazentalösung gefunden werden. Beide Patientinnen zeigten einen normalen Blutfluss (positiver enddiastolischer Fluss) in den Nabelschnurarterien bei pathologischem CTG. Eine zusätzliche Wachstumsrestriktion ergab bei einem Feten weitere Hinweise auf eine vorbestehende chronische fetale Asphyxie. In beiden Fällen wurden asphyktische Kinder mittels Kaiserschnitt entbunden. Die histologischen Endbefunde der Plazenten zeigten deutliche retroplazentare Hämatome und bestätigten die postpartale Diagnose der vorzeitigen Placentalösung. Schlussfolgerung: Die dopplersonografische Untersuchung der A. umbilicalis bei vorzeitiger Plazentalösung bringt keine zusätzliche Information zur Diagnoseerstellung bei Verdacht auf vorzeitige Plazentalösung. Sie kann darüber hinaus falsch unauffällige Befunde liefern.

Serial assessment of amniotic fluid index in uncomplicated term pregnancies: prognostic value of amniotic fluid reduction

Objective: Assessment of amniotic fluid volume in association with a non-stress test is a commonly used method to monitor fetal well-being in high-risk pregnancies. The aims of our study were to determine whether oligohydramnios and the trend in amniotic fluid volume have prognostic significance in low-risk pregnancies between 40.0 and 41.6 weeks' gestation.Methods: Between January 1997 and December 2000, all uncomplicated gestations with a singleton non-anomalous fetus reaching 40.0 weeks' gestation underwent semi-weekly monitoring of amniotic fluid index (AFI) until delivery. Oligohydramnios was defined as an AFI of ⩽ 5 cm. Changes in AFI were expressed as centimeters per day, and were calculated as: [(last AFI before delivery minus first AFI at 40.0 weeks) / interval in days between the two scans]. Adverse outcome was considered the occurrence of 5-min Apgar score < 7; umbilical artery pH < 7.0; Cesarean section for fetal distress; or fetal death. Comparisons between the groups with favorable and adverse outcomes was performed with χ2 or Fisher's exact test for categorical variables, and Student's t test for continuous variables. A two-tailed p value < 0.05 was considered significant.Results: A total of 3050 women met the study criteria, and underwent a median number of two (range 1–7) sonographic assessments of AFI after 40.0 weeks, with oligohydramnios detected in 341 women. In 1466 women at least two serial AFI determinations were obtained, allowing computation of an AFI trend. Gestations resulting in adverse perinatal outcome (n = 167, 5.5%) had a significantly higher rate of oligohydramnios (33/167, 19.8% vs. 308/2883, 10.7%, p = 0.001), but a similar rate of reduction in AFI ( − 0.65 ± 0.64 vs. – 0.66 ± 0.66 cm/day; p = 0.85) than those with favorable outcome. The difference in rate of reduction of AFI between the two groups was not significant, even in the subset of gestations that developed oligohydramnios ( − 1.08 ± 0.87 vs. – 1.26 ± 0.89 cm/day; p = 0.27).Conclusion: A sonographic diagnosis of oligohydramnios carries an increased risk of adverse perinatal outcome, even in low-risk pregnancies after 40 weeks. The trend in amniotic fluid volume reduction does not seem to have prognostic significance.

Biophysical profile for fetal assessment in high risk pregnancies.

Biophysical profile usually includes ultrasound monitoring of fetal movements, fetal tone and fetal breathing, ultrasound assessment of amniotic fluid volume and assessment of fetal heart rate by electronic monitoring. The objective of this review was to assess the effects of biophysical profile tests on pregnancy outcome in high risk pregnancies. We searched the Cochrane Pregnancy and Childbirth trials register. Date of last search: October 1998. Randomised trials comparing fetal biophysical profile with other forms of fetal assessment in women with high risk pregnancies. Trial quality was assessed. Four studies were included. Most trials were not of high quality. No difference was found between biophysical profile and other forms of fetal assessment over a range of fetal and neonatal measures. At present, there is not enough evidence from randomised trials to evaluate the use of biophysical profile as a test of fetal well-being in high risk pregnancies.

Scanning in late pregnancy

This article explains the importance of ultrasound scanning in late pregnancy for assessing fetal growth and wellbeing. It differentiates between normal, symmetrical and asymmetrical growth retardation and discusses the use of the biophysical profile. The role of the midwife in the ultrasound unit and the use of Doppler ultrasound to assess fetal wellbeing in high-risk pregnancies are also covered.

Predictive value of antepartum fetal heart rate non-stress test in high-risk pregnancy.

For antepartum evaluation of high-risk pregnancies the non-stress test (NST) was performed in order to predict favorable or adverse fetal outcome. Between January 1, 1980 and December 31, 1980, 4078 NSTs were performed on 454 women with high-risk pregnancies. The NSTs were evaluated for pathology by a CTG pathology score. The NST interpretation were normal 95%, slight pathological 4% and severe pathological 1%. The group of women in whom all NST results were normal gave birth to healthy babies. In tact with an increasing number of pathologica-NSTs and with worsening CTG pathology score, a significant increase was found for cesarean section rate, acute operative delivery, low Apgar score, low umbilical cord artery pH and infants born small for gestational age or clinically dysmature. The frequence of perinatal morbidity was almost the same, irrespective of whether the NSTs showed accelarations or not on one or more occasions. To identify fetuses suffering from retarded intra-uterine growth the predictive value of normal NST was 97.3% and the predictive value of pathological NST was 34.8%. To identify perinatal morbidity the predictive values were 87.4% and 55.1% respectively. The NST appears to be a reliable test for antepartum assessment of fetal well-being in high-risk pregnancies.