Respiratory outcome in preterm small for gestational age fetuses with or without abnormal umbilical artery Doppler and/or maternal hypertension

Objective.?To study respiratory outcome in preterm small for gestational age (SGA) fetuses with or without signs of intrauterine growth restriction due to placental insufficiency, and with or without maternal hypertension.

Methods.?This was a retrospective study of 187 neonates with birth weight <10^th percentile and gestational age <34 weeks. Results from umbilical artery Doppler velocimetry were used to identify the abnormal Doppler subgroup.

Results.?No significant difference in respiratory outcome between SGA fetuses with normal (SGA-N) or abnormal (SGA-A) umbilical artery Doppler examination was found. Within the SGA-A group, the respiratory distress syndrome (RDS) incidence (OR 5.6, 95% CI 1.7–18.3), RDS grade (OR 6.7, 95% CI 1.2–38.5), and need for surfactant (OR 5.3, 95% CI 1.1–24.4) were higher in infants of women with hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome as compared to those of normotensive mothers.

Conclusions.?Lung maturation is not accelerated with placental insufficiency. SGA-A fetuses of mothers with HELLP syndrome have a significantly poorer respiratory outcome than those with healthy mothers. Possibly, fetuses of mothers with HELLP syndrome are subjected to ‘oxidative stress’ causing lung damage rather than lung maturation.     

Interaction between risk factors for fetal growth retardation associated with abnormal umbilical artery Doppler studies

BACKGROUND: The role of antenatal risk factors associated with the occurrence of fetal growth restriction complicated by abnormal umbilical artery Doppler studies has not yet been studied extensively. We evaluated the role and the interactions of antenatal antecedents of fetal growth restriction complicated by abnormal umbilical artery end-diastolic velocities. METHODS: We compared antenatal variables in 183 pregnancies complicated by fetal growth retardation and abnormal umbilical artery Doppler studies and 549 appropriately grown fetuses with normal end-diastolic velocity waveform in the umbilical artery. Logistic regression was used to evaluate the association between antenatal variables and fetal growth retardation and to test for interaction. RESULTS: In logistic models, increasing maternal age [odds ratio (OR) 1.06, 95% confidence interval (CI) 1.01-1.11], nulliparity (OR 2.2, 95% CI 1.37-3.5), smoking during pregnancy (OR 2.56, 95% CI 1.56-4.22), preeclampsia (OR 27.5, 95% CI 15.1-49.9), first-trimester hemorrhage (OR 2.25, 95% CI 1.32-3.82) and low (< 0.2 kg/week) weight gain in pregnancy (OR 3.48, 95% CI 1.71-3.05) were significantly associated with an increased risk of fetal growth restriction complicated by abnormal Doppler studies. These risk factors were also significantly correlated with the occurrence of absent/reversed end-diastolic blood flow in the umbilical artery. Maternal smoking during pregnancy interacted negatively with preeclampsia but positively with a low weight gain in pregnancy. CONCLUSIONS: The results of this study have shown that antenatal risk factors for intrauterine growth retardation (IUGR) complicated by abnormal Doppler studies are similar to those associated with the birth of a small-for-gestational-age infant. Preeclampsia, maternal smoking and low weight gain in pregnancy play a significant causal role in the origin of fetal growth restriction associated with abnormal uteroplacental blood flow.     

Placental Doppler velocimetry in gestational diabetes mellitus

OBJECTIVE: To evaluate if maternal glucose level and growth of the fetus were related to placental vascular impedance in pregnancy complicated by gestational diabetes mellitus. MATERIAL AND METHODS: A retrospective study of 146 gestational diabetic women of which 117 needed insulin therapy. Glycosylated hemoglobin (HbA1c) was evaluated as well as umbilical and uterine artery Doppler velocimetry. The results were related to adverse outcome of pregnancy including newborn birthweight. RESULTS: Abnormal umbilical artery blood flow velocity was seen in 5% of the cases and abnormal uterine artery flow in 16%. Uterine and umbilical artery vascular impedance was significantly lower in macrosomic newborns. There was a poor correlation between HbA1c, vascular impedance and birthweight. There were 11 cases that developed preeclampsia, all having abnormal uterine artery Doppler and two abnormal umbilical artery Doppler. CONCLUSION: Uterine and umbilical artery vascular impedance in pregnancies complicated by gestational diabetes is related to birthweight and placental weight, but not to maternal HbA1c levels. Placental Doppler ultrasound does not seem to be of clinical value for fetal surveillance in these pregnancies unless the pregnancy is complicated by preeclampsia and/or intrauterine fetal growth restriction.     

Automated auditory brainstem response in preterm newborns with histological chorioamnionitis

Objective: We investigated whether histological chorioamnionitis is associated with an adverse neonatal hearing outcome.

Methods: Two cohorts of very preterm newborns (n?=?548, gestational age ≤ 32.0 weeks) were linked to placental histology and automated auditory brainstem response (AABR) outcome.

Results: In multivariable analyses, an abnormal AABR was not predicted by the presence of histological chorioamnionitis, either with or without fetal involvement (OR 1.4, 95% CI 0.5 – 3.8, p?=?0.54 and OR 1.1, 95% CI 0.4–3.0, p?=?0.79, respectively). Significant predictors of abnormal AABR included, e.g. birth weight (per kg increase: OR 0.2, 95% CI 0.0–0.6, p?=?0.006), umbilical cord artery pH (per 0.1 increase: OR 0.7, 95% CI 0.5–0.9, p?=?0.005) and mechanical ventilation (OR 3.7, 95% CI 1.2–11.6, p?=?0.03).

Conclusions: Histological chorioamnionitis was not associated with an adverse neonatal hearing outcome in two cohorts of very preterm newborns. Indicators of a complicated neonatal clinical course were the most important predictors of an abnormal hearing screening.     

Placental ischemia and changes in umbilical and uteroplacental arterial and venous hemodynamics

Objective: To relate Doppler velocimetry findings in fetoplacental and uteroplacental circulation to placental histomorphology. Material and methods: In 14 uncomplicated and 31 high-risk pregnancies Doppler velocimetry was performed in umbilical artery and vein, and in maternal uterine veins and arteries during the second half of gestation. Histopathology of the placentas was examined, especially for signs of ischemia and inflammation. Results: All fetuses in uncomplicated pregnancies had normal flow velocity waveforms in umbilical artery; in the high-risk group, 18 fetuses had abnormal flow (increased PI or absent/reverse end-diastolic flow). The latter group had more often high ischemic score and infarctions in the placenta than found in pregnancies with normal umbilical artery flow (p?<?0.001 and p?=?0.02, respectively). Similarly, the abnormal uterine artery flow pattern (uterine artery score 3–4) occurred more often with high ischemic score and placenta infarctions (p?<?0.001 and p?<?0.001, respectively). No significant associations were found between the uterine venous flow type and placental ischemia. Conclusion: Placental ischemic morphological changes were associated with Doppler ultrasound signs of increased resistance to arterial blood flow, both on the fetal and maternal sides of the placenta. No significant relation to the uterine venous flow velocities was found.     

Elevated vaginal pH in the absence of current vaginal infection,still a challenging obstetrical problem

Abstract

Objective: To assess the association of vaginal pH?≥?5 in the absence of vaginal infection with systemic inflammation and adverse pregnancy outcome.

Methods: Four-hundred sixty pregnant women completed the study, upon enrollment Vaginal pH was measured for all women, maternal and umbilical sera were obtained for determining C-reactive protein (CRP) and uric acid levels. Umbilical blood was tested for gas parameters, 1 and 5?min Apgar scores, the need for neonatal resuscitation and neonatal intensive care unit (NICU) admission were recorded.

Results: Elevated vaginal pH was significantly associated with preterm birth (odds ratio (OR), 2.23; 95% confidence interval (CI), 1.04–4.76), emergency cesarean section (OR 2.57; 95% CI 1.32–5), neonatal resuscitation in the delivery room (OR 2.85; 95% CI 1.1–7.38), elevated cord base deficit (OR 8.01; 95% CI 1.61–39.81), low cord bicarbonate (OR 4.16, 95% CI 1.33–12.92) and NICU admission (OR 2.02; 95% CI 1.12–3.66). Increased vaginal pH was also significantly associated with maternal leukocytosis, hyperuricemia and elevated CRP levels in maternal and umbilical sera.

Conclusions: Elevated vaginal pH in the absence of current vaginal infection still constitutes a risk for adverse pregnancy outcome which is mediated by systemic inflammatory response.     

Histomorphology of the placenta and the placental bed of growth restricted foetuses and correlation with the Doppler velocimetries of the uterine and umbilical arteries

The aim of the present study was to evaluate the histomorphology of the placenta and the placental bed and to correlate this with the Doppler study of the uterine and umbilical arteries of intrauterine growth restricted pregnancies. The study group consisted of 47 women with intrauterine growth restricted foetuses. Twenty-five uneventful pregnancies with appropriate for gestational age foetuses were selected as controls. Doppler studies of umbilical and uterine arteries were performed within the last week before delivery. Placental bed biopsies were obtained at Caesarean section with direct visualization of the placental site. The incidence of pathologic bed biopsies in control, IUGR with normal uterine artery Doppler velocimetry and IUGR with abnormal uterine artery Doppler velocimetry was 0 per cent, 16.6 per cent and 79.3 per cent respectively (P< 0.001). Placentae from IUGR cases with abnormal umbilical artery Doppler velocimetries had a significantly increased number of villous infarcts, cytotrophoblast proliferation and thickening of the villous trophoblastic basal membrane (P=0.001, P=0.038 and P=0.02 respectively). Abnormal placental bed biopsy pathology was significantly associated with abnormal uterine artery velocimetry (OR 33.7, 6.5-173.6; P< 0.001). Abnormal placental pathology was significantly associated with abnormal umbilical artery Doppler velocimetry (OR 21.04, 3.8-115.9;P< 0.001). Women with both abnormal uterine and umbilical artery Doppler velocimetries were delivered earlier and their babies had lower mean birth and placental weight (P< 0.001). In conclusion, placental bed biopsy and placental pathologies are best reflected by abnormal uterine and umbilical artery velocity waveforms, respectively. The most severe clinical outcomes and perinatal mortality are present when both uterine and umbilical districts are altered.     

Respiratory outcome in preterm small for gestational age fetuses with or without abnormal umbilical artery Doppler and/or maternal hypertension.

OBJECTIVE: To study respiratory outcome in preterm small for gestational age (SGA) fetuses with or without signs of intrauterine growth restriction due to placental insufficiency, and with or without maternal hypertension. METHODS: This was a retrospective study of 187 neonates with birth weight <10(th) percentile and gestational age <34 weeks. Results from umbilical artery Doppler velocimetry were used to identify the abnormal Doppler subgroup. RESULTS: No significant difference in respiratory outcome between SGA fetuses with normal (SGA-N) or abnormal (SGA-A) umbilical artery Doppler examination was found. Within the SGA-A group, the respiratory distress syndrome (RDS) incidence (OR 5.6, 95% CI 1.7-18.3), RDS grade (OR 6.7, 95% CI 1.2-38.5), and need for surfactant (OR 5.3, 95% CI 1.1-24.4) were higher in infants of women with hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome as compared to those of normotensive mothers. CONCLUSIONS: Lung maturation is not accelerated with placental insufficiency. SGA-A fetuses of mothers with HELLP syndrome have a significantly poorer respiratory outcome than those with healthy mothers. Possibly, fetuses of mothers with HELLP syndrome are subjected to 'oxidative stress' causing lung damage rather than lung maturation.     

Risk of Fetal Death Associated With Maternal Drug Dependence and Placental Abruption: A Population-Based Study

ObjectiveSubstance use in pregnancy is associated with placental abruption, but the risk of fetal death independent of abruption remains undetermined. Our objective was to examine the effect of maternal drug dependence on placental abruption and on fetal death in association with abruption and independent of it.MethodsTo examine placental abruption and fetal death, we performed a retrospective population-based study of 1 854 463 consecutive deliveries of liveborn and stillborn infants occurring between January 1, 1995 and March 31, 2001, using the Canadian Institute for Health Information Discharge Abstract Database.ResultsMaternal drug dependence was associated with a tripling of the risk of placental abruption in singleton pregnancies (adjusted odds ratio [OR] 3.1; 95% confidence intervals [CI] 2.6–3.7), but not in multiple gestations (adjusted OR 0.88; 95% CI 0.12–6.4). Maternal drug dependence was associated with an increased risk of fetal death independent of abruption (adjusted OR 1.6: 95% CI 1.1–2.2) in singleton pregnancies, but not in multiples. Risk of fetal death was increased with placental abruption in both singleton and multiple gestations, even after controlling for drug dependence adjusted OR 11.4 in singleton pregnancy; 95% CI 10.6–12.2, and 3.4 in multiple pregnancy; 95% CI 2.4–4.9).ConclusionMaternal drug use is associated with an increased risk of intrauterine fetal death independent of placental abruption. In singleton pregnancies, maternal drug dependence is associated with an increased risk of placental abruption.     

Pregnancy outcomes in liver transplant patients,a population-based study

Objective: To determine the incidence of pregnancy in liver transplant (LT) patients in a large population-based cohort and to determine the maternal and fetal risks associated with these pregnancies.

Methods: We conducted an age-matched cohort study using the US Healthcare and Utilization project–Nationwide Inpatient Sample from 2003–2011. We used unconditional logistic regression, adjusted for baseline characteristics, to estimate the likelihood of common obstetric complications in the LT group compared with age-matched nontransplant patients.

Results: There were 7?288?712 deliveries and an estimated incidence of 2.1 LTs/100?000 deliveries over the nine-year study period. LT patients had higher rates of maternal complications including hypertensive disorders (OR 6.5, 95% CI: 4.4–9.5), gestational diabetes (OR 1.9, 95% CI: 1.0–3.5), anemia (OR 3.2, 95% CI: 2.1–4.9), thrombocytopenia (OR 27.5, 95% CI: 12.7–59.8) and genitourinary tract infections (OR 4.2, 95% CI: 1.8–9.8). Deliveries among women with LT had higher risks of cesarean section (OR 2.9, 95% CI: 2.0–4.1), postpartum hemorrhage (OR 3.2, 95% CI: 1.7–6.2) and blood transfusion (OR 18.7, 95% CI: 8.5–41.0). Fetal complications in LT patients included preterm delivery (OR 4.7, 95% CI: 3.2–7.0), intrauterine growth restriction (OR 4.1, 95% CI: 2.1–7.7) and congenital anomalies (OR 6.0, 95% CI: 1.1–32.0).

Conclusion: Although pregnancies in LT recipients are feasible, they are associated with a high rate of maternal and fetal morbidities. Close antenatal surveillance is recommended.     

To ignore or not to ignore placental calcifications on prenatal ultrasound: a systematic review and meta-analysis

Objective: The human placenta is known to calcify with advancing gestational age, and, in fact, the presence of significant calcifications is one of the components of grade III placenta, typical of late gestation. As such, the presence of significant placental calcifications often prompts obstetric providers to expedite delivery. This practice has been attributed, in part, to the presumed association between grade III placenta and adverse pregnancy outcomes. Such approach, however, can be the source of major anxiety and may lead to unnecessary induction of labor, with its associated predisposition to cesarean delivery as well as a myriad of maternal and neonatal morbidities. The objective of this study was to examine the association between grade III placental calcifications and pregnancy outcomes.

Materials and methods: A systematic review of the literature was performed for studies evaluating the association between grade III placenta and a number of pregnancy outcomes, including labor induction, fetal distress (abnormal fetal heart tracing), low Apgar score (less than 7 at 5?min), need for neonatal resuscitation, admission to the Neonatal Intensive Care Unit, perinatal death, meconium liquor, and low birth weight.

Results: There was a five-fold increase in risk of labor induction with the presence of grade III placenta (OR 5.41; 95% CI 2.98–9.82). There was no association between grade III placenta and the incidence of abnormal fetal heart tracing (OR 1.62; 95% CI 0.94–2.78), low Apgar score of less than 7 at 5?min (OR 1.68; 95% CI 0.84–3.36), need for neonatal resuscitation (OR 1.08; 95% CI 0.67–1.75), and admission to the Neonatal Intensive Care Unit (OR 0.90; 95% CI 0.21–3.74). In turn, the incidence of meconium liquor was higher in the setting of grade III placentae (OR 1.68; 95% CI 1.17–2.39). Similarly, a positive association between grade III placental calcifications and low birth weight (OR 1.63; 95% CI 1.19–2.22) and perinatal death (OR 7.41; 95% CI 4.94–11.09) was identified.

Conclusion: The study alerts us to a significant association between grade 3 placental calcifications and labor induction, although it demonstrates that these sonographic findings do not appear to predispose to fetal distress, low Apgar score, need for neonatal resuscitation, or admission to the NICU.     

Influence of fetal acidemia on fetal heart rate analyzed by computerized cardiotocography in pregnancies with placental insufficiency

Abstract

Objective: To determine the influence of fetal acidemia on fetal heart rate (FHR) parameters analyzed by computerized cardiotocography (cCTG) in pregnancies with placental insufficiency.

Methods: This was a cross-sectional study of 46 pregnancies with placental insufficiency between 26 and 34 weeks gestation by abnormal umbilical artery Doppler [pulsatility index (PI)?>?95th percentile].

Results: Twenty fetuses had acidemia at birth, pH?<?7.20 (43.5%) and 26 had normal pH (56.5%). In the analysis of FHR parameters, fetal movements (FM) per hour was significantly lower in the group with acidemia (median?=?2) when compared with the group with normal pH (median?=?15, p?=?0.019). The values of pH correlated positively with FM (ρ?=?0.35; p?=?0.019, 95% CI: 0.061 to 0.577) and basal FHR (ρ?=?0.37, p?=?0,011, 95% CI: 0.090 to 0.597) and negatively with the ductus venosus (DV) PI for veins (PIV) z-score (ρ?=??0.31, p?=?0,036, 95% CI: ?0.550 to ?0.021). Logistic regression showed that the DV PIV z-score (p?=?0.0232) and basal FHR (p?=?0.0401) were independent variables associated with acidemia at birth.

Conclusions: The present results suggest that cCTG parameters may be useful in the management of cases with early onset placental insufficiency in association with Doppler velocimetry assessment, and that basal FHR and DV-PIV are most clearly in association with acidemia at birth.     

Correlation of fetal DNA levels in maternal plasma with Doppler status in pathological pregnancies

OBJECTIVES: To evaluate whether intrauterine growth restriction (IUGR) as seen in preeclampsia is associated with high levels of fetal DNA in maternal circulation, and whether fetal DNA is related to altered uterine and/or umbilical artery Doppler velocimetry. METHODS: Fetal DNA quantification was performed by real-time PCR on SRY sequences in 64 male-bearing pregnant women with IUGR and/or preeclampsia and 89 controls. RESULTS: Fetal DNA content was significantly elevated in IUGR pregnancies similar to preeclampsia and correlated with altered umbilical Doppler velocimetry, while no correlation was found with uterine Doppler status. CONCLUSION: Increased fetal DNA levels in maternal plasma may be a sign of placental or fetal pathology even in the presence of normal uterine Doppler velocimetry, allowing a more precise diagnostic evaluation. The finding that elevated fetal DNA in IUGR pregnancies correlates with abnormal umbilical Doppler velocimetry suggests that fetal DNA release is associated more with fetal chronic hypoxia than with fetal size.     

Adverse fetal outcome: is first trimester ultrasound and Doppler better predictor than biomarkers?

Aims and objectives: To evaluate the predictive value of first trimester biomarkers and ultrasound in determining adverse fetal outcomes in a low risk Asian population.

Material and method: All low risk, singleton pregnancies between 11 and 14 weeks gestation underwent ultrasound with uterine artery Doppler along with PAPP-A and free β-hCG estimation, and were followed till delivery to observe the outcome. The adverse fetal outcomes detected were structural anomaly, aneuploidy, intrauterine growth restriction, preterm birth and stillbirth (SB).

Results: Out of 3500 women screened, 417 cases had adverse fetal outcome in the absence of maternal complication, 2151 had normal outcome. Major structural anomaly was detected in first trimester in 17/28 (60.7%) cases. The most important markers for adverse fetal outcome were increased uterine artery pulsatility index (UPI) (p?=?0.028, OR 1.5, 95% CI: 1.05–2.38, AUC 0.56) for IUGR, nuchal translucency (p?=?0.001, OR 1.7, 95% CI: 1.11–2.77, AUC 0.60) for major anomaly and low PAPP-A (p?=?0.017, OR ?0.075, 95% CI: 0.87–0.98, AUC 0.621) for SB.

Conclusion: UPI, NT and PAPP-A in the first trimester are significant markers of adverse fetal outcome, although the sensitivity and specificity are not high they have a high negative predictive value.     

The use of angiogenic biomarkers in maternal blood to identify which SGA fetuses will require a preterm delivery and mothers who will develop pre-eclampsia

Objective: To determine (1) whether maternal plasma concentrations of angiogenic and anti-angiogenic factors can predict which mothers diagnosed with “suspected small for gestational age fetuses (sSGA)” will develop pre-eclampsia (PE) or require an indicated early preterm delivery (≤?34 weeks of gestation); and (2) whether risk assessment performance is improved using these proteins in addition to clinical factors and Doppler parameters.

Methods: This prospective cohort study included women with singleton pregnancies diagnosed with sSGA (estimated fetal weight <10th percentile) between 24 and 34 weeks of gestation (n?=?314). Plasma concentrations of soluble vascular endothelial growth factor receptor-1 (sVEGFR-1), soluble endoglin (sEng) and placental growth factor (PlGF) were determined in maternal blood obtained at the time of diagnosis. Doppler velocimetry of the umbilical (Umb) and uterine (UT) arteries was performed. The outcomes were (1) subsequent development of PE; and (2) indicated preterm delivery at ≤34 weeks of gestation (excluding deliveries as a result of spontaneous preterm labor, preterm pre-labor rupture of membranes or chorioamnionitis).

Results: (1) The prevalence of PE and indicated preterm delivery was 9.2% (n?=?29/314) and 7.3% (n?=?23/314), respectively; (2) the area under the receiver operating characteristic curve (AUC) for the identification of patients who developed PE and/or required indicated preterm delivery was greater than 80% for the UT artery pulsatility index (PI) z-score and each biochemical marker (including their ratios) except sVEGFR-1 MoM; (3) using cutoffs at a false positive rate of 15%, women with abnormal plasma concentrations of angiogenic/anti-angiogenic factors were 7–13 times more likely to develop PE, and 12–22 times more likely to require preterm delivery than those with normal plasma MoM concentrations of these factors; (4) sEng, PlGF, PIGF/sEng and PIGF/sVEGFR-1 ratios MoM, each contributed significant information about the risk of PE beyond that provided by clinical factors and/or Doppler parameters: women who had low MoM values for these biomarkers were at 5–9 times greater risk of developing PE than women who had normal values, adjusting for clinical factors and Doppler parameters (adjusted odds ratio for PlGF: 9.1, PlGF/sEng: 5.6); (5) the concentrations of sVEGFR-1 and PlGF/sVEGFR-1 ratio MoM, each contributed significant information about the risk of indicated preterm delivery beyond that provided by clinical factors and/or Doppler parameters: women who had abnormal values were at 8–9 times greater risk for indicated preterm delivery, adjusting for clinical factors and Doppler parameters; and (6) for a two-stage risk assessment (Umb artery Doppler followed by Ut artery Doppler plus biochemical markers), among women who had normal Umb artery Doppler velocimetry (n?=?279), 21 (7.5%) developed PE and 11 (52%) of these women were identified by an abnormal UT artery Doppler mean PI z-score (>2SD): a combination of PlGF/sEng ratio MoM concentration and abnormal UT artery Doppler velocimetry increased the sensitivity of abnormal UT artery Doppler velocimetry to 76% (16/21) at a fixed false-positive rate of 10% (p?=?0.06).

Conclusion: Angiogenic and anti-angiogenic factors measured in maternal blood between 24 and 34 weeks of gestation can identify the majority of mothers diagnosed with “suspected SGA” who subsequently developed PE or those who later required preterm delivery ≤34 weeks of gestation. Moreover, incorporation of these biochemical markers significantly improves risk assessment performance for these outcomes beyond that of clinical factors and uterine and umbilical artery Doppler velocimetry.     

Ultrasound Doppler evaluation of uteroplacental and fetoplacental circulation in pre-eclampsia

Summary Blood flow velocity waveforms (FVW) were recorded weekly from the umbilical and arcuate arteries in 58 hospitalised women with a pregnancy complicated by pre-eclampsia. The maximum velocity waveform was analysed for pulsatility index (PI) and the results from the final antenatal examination were related to the outcome of pregnancy. The umbilical artery FVW was abnormal in 36% of the pre-eclamptic pregnancies, as was the arcuate artery FVW in 42%. No difference in FVW was found between mild and severe pre-eclampsia. Abnormal FVW in the umbilical artery was associated significantly both with intra-uterine growth retardation (IUGR) (P<0.001) and with signs of fetal distress (FD) (P<0.05). Abnormal arcuate artery FVW was associated with FD (P<0.05), but not with IUGR. The outcome of pregnancy was related to Placenta Waveform Class, which was derived from the blood velocity on both maternal and fetal sides of placenta. The results suggest that ultrasound Doppler examination of the umbilical artery is a useful aid in monitoring pregnancies complicated by preeclampsia, but that arcuate artery examination needs further evaluation.     

High placental index and poor pregnancy outcomes: a retrospective study of 18 386 pregnancies

Abstract

Introduction: Our aim was to state the correlation between placental index and pregnancy outcomes or in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) pregnancies.

Materials and methods: We included in this retrospective study all singleton births in a third level clinic during the period 2001–2011 (n?=?18?386). We divided placental index into quartiles and analyzed the differences between the groups in term of pregnancy outcomes. Then, we estimated crude and adjusted odds ratios (ORs) for placental index over the third centile of the distribution to correlate with pregnancy outcomes. We also analyzed the correlation between IVF/ICSI conceived pregnancies and placental index.

Results: Poor pregnancy outcomes were overrepresented in the highest quartile of placental index distribution. Thus, placental index was higher in pregnancies characterized by pregnancy-related hypertensive disorders (PRHDs), small for gestational age infants, newborn needing cardiopulmonary resuscitation or hospitalization in neonatal intensive care unit. These findings were independent of maternal age, length of gestation at delivery, IVF/ICSI conception and ethnicity. For IVF/ICSI pregnancies, the OR for being over the third quartile of placental index distribution was 2.01 (CI.95 1.40–2.90) after adjustment for maternal age, length of gestation, ethnicity, birth weight, parity, fetal sex, alteration of glucose metabolism in pregnancy and PRHDs.

Conclusions: We found a high placental index among pregnancies characterized by poor outcomes and conceived by IVF/ICSI.     

Doppler velocimetry for predicting outcome of pregnancies with decreased fetal movements

AIM: The aim of this study was to evaluate umbilical artery (UA) and uterine artery (Ut.A) Doppler velocimetry in a low-risk pregnancy group with decreased fetal movements. MATERIAL AND METHODS: Eight hundred and eighty-eight women were examined because of decreased fetal movements. All fetuses were alive on maternal admission. In all cases, UA and Ut.A Doppler velocimetries were performed, as well as a nonstress test (NST). The managing clinician was informed only of the UA Doppler. RESULTS: In the group of 135 women who gave birth within 2 days, UA velocimetry was abnormal in seven fetuses. In 11 cases, Ut.A vascular resistance was abnormal and in 18 cases 'notch' was stated. There were 19 emergency sections in this group. Signs of increased placental vascular resistance were correlated with need for operational delivery because of fetal distress. Among the remaining 753 women who delivered after more than 2 days after examination, UA velocimetry showed abnormality in five fetuses. In 42 cases the Ut.A pulsatility index was abnormal and in 118 cases an early end diastolic 'notch' was present. There was one perinatal death in this group. CONCLUSIONS: Decreased fetal movement perception by mothers should be taken seriously. Abnormal placental Doppler was an infrequent finding in these low-risk pregnancies. However, adding UA and Ut.A Doppler velocimetries to conventional NST surveillance might be reassuring for managing clinicians.     

First trimester thyroid stimulating hormone as an independent risk factor for adverse pregnancy outcome

Purpose: Maternal thyroid gland dysfunction may adversely affect pregnancy outcome. We aimed to examine the association between subclinical thyroid dysfunction, both hypothyroidism and hyperthyroidism, to adverse pregnancy outcome.

Materials and methods: Retrospective cohort study of all women with an available first trimester thyroid function testing and known pregnancy outcome, categorized to subclinical hypothyroidism, or hyperthyroidism and evaluated for complication during gestation and delivery.

Results: Four thousand five hundred and four women were included in the final analysis – 3231 were euthyroid, 73 (1.6%) were categorized as subclinical hyperthyroidism and 1200 (26.6%) had subclinical hypothyroidism. Low thyroid-stimulating hormone (TSH) levels, i.e. subclinical hyperthyroidism, correlates with higher rates of placental abruption and extremely low birth weight, below 1500?g. Also, the risk for preterm delivery prior to 34 gestational weeks is higher among women with subclinical hypothyroidism, with greater risk among those with a higher TSH level. (OR 1.81, 95% CI 1.0–3.28 for TSH 2.5–4.0 mIU/L and OR 2.33, 95% CI 1.11–4.42 for those with TSH?>?4 4.0 mIU/L).

Conclusions: Subclinical hypothyroidism is associated with an increased risk for preterm delivery prior to 34 gestational weeks. Additionally, subclinical hyperthyroidism may also have a role in adverse pregnancy outcome – low birth weight and placental abruption – although this needs to be further explored.     

Risk factors for intrauterine fetal death (1988–2009)

Objective.?To determine risk factors for intrauterine fetal death (IUFD).

Study design.?A retrospective population-based study, of all singleton deliveries between the years 1988–2009 was conducted. Intrapartum deaths, postpartum death, and multiple gestations were excluded. A multiple logistic regression model was used to determine independent risk factors.

Results.?During the study period, out of 228,239 singleton births, 1694 IUFD cases were recorded (7.4 per 1000 births). The following independent risk factors were identified in the logistic regression executed: Oligohydramnios (OR 2.6, 95% CI 2.1–3.2, p-value?<?0.001), polyhydramnios (OR 1.8, 95% CI 1.4–2.2, p-value?<?0.001), previous adverse perinatal outcome (OR 1.7, 95% CI 1.5–2.1, p-value?<?0.001), congenital malformations (OR 2.0, 95% CI 1.8–2.3, p-value?<?0.001), true knot of cord (OR 3.7, 95% CI 2.8–4.9, p-value?<?0.001), meconium stained amniotic fluid (OR 2.7, 95% CI 2.3–3.0, p-value<0.001), placental abruption (OR 2.9, 95% CI 2.4–3.5, p-value?<?0.001), advanced maternal age (OR 1.03, 95% CI 1.02–1.04, p-value?<?0.001), and hypertensive disorders (OR 1.24, 95% CI 1.0–1.4, p-value?=?0.026). Jewish ethnicity (versus Bedouin – OR 0.64, 95% CI 0.57–0.72, p-value?<?0.001), gestational diabetes (OR 0.7, 95% CI 0.5–0.8, p-value?=?0.001), previous cesarean section (OR 0.8, 95% CI 0.7–0.97, p-value?=?0.019), and recurrent abortions (OR 0.8, 95% CI 0.6–0.9, p-value?=?0.011) were negatively associated with IUFD.

Conclusion.?Several independent risk factors were identified, suggesting a possible cause of death. Other pathologic conditions that facilitate tighter pregnancy surveillance and active management were found protective, pointing the benefit of such management approaches in high-risk pregnancies.