Albana Cerekja

Computerized cardiotocography in the management of intrauterine growth restriction associated with Doppler velocimetry alterations

Objective: To verify the reliability of computerized cardiotocography (cCTG) in the prediction of the oxygen metabolism status of fetuses with growth restriction and Doppler velocimetry alterations. Methods: From 24 third‐trimester cesarean section performed because of intrauterine growth restriction (IUGR) and Doppler velocimetry alterations, there were 11 cases of fetal heart rate alterations (Dawes–Redman criteria were not satisfied) and 13 cases of reactive cCTG. Fetal lung maturity was detected by amniocentesis and blood samples for umbilical blood gas analysis (UBGA) were collected before the first neonatal breath from the umbilical artery in a double‐clamped segment of the cord. Results: Umbilical cord gas analysis showed arterial cord blood pH to be 7.20 or less in 11 newborns (45.8%), 7.10 or less in 6 (25%), and 7.00 or less in 3 (12.5%). Linear regression analysis showed short‐term variation (STV) in the fetal heart rate to be significantly correlated with umbilical artery pH (r=0.49; P=0.01) and pCO2 (r=−0.50; P=0.01). There were no significant correlations between cCTG and the other UBGA parameters considered. Receiver operator curves permitted to calculate the STV values at which pathological neonatal UBGA values can be expected (pH<7.00 and pCO2>80 mmHg). A short‐term variation less than 4.5 ms was found to predict acidemia with a sensitivity of 100% and a specificity of 70% (positive predictive value, 33%; negative predictive value, 100%), and hypercarbia with a sensitivity of 100% and a specificity of 77.8% (positive predictive value, 55.6%; negative predictive value, 100%). Conclusion: In view of the results of this study, 4.5 ms for STV may be a threshold below which timing of delivery should be decided in cases of fetal growth restriction.

Prognostic value of umbilical-middle cerebral artery pulsatility index ratio in fetuses with growth restriction

Objective: To study the utility of Doppler velocimetry and computerized cardiotocography in the management of intrauterine growth restriction and prediction of neonatal outcome. Patients and methods: Seventy‐two pregnant women with fetuses showing growth restriction and delivered within 48 h of their last Doppler velocimetry evaluation. The last computerized cardiotocographic trace from these fetuses was used for statistical analysis, and the last trace from the healthy fetuses of 93 consecutive women undergoing cesarean section was used as control. Umbilical artery pulsatility index (UA PI), middle cerebral artery pulsatility index (MCA PI), UA PI / MCA PI ratio, and uterine artery resistance index (Ut RI) were assessed. Results: Among women with growth‐restricted fetuses, all parameters were significantly higher in those who had hypertension; and in those who had diabetes, only the UA PI / MCA ratio was significantly higher. Umbilical artery PI values and the UA PI / MCA ratio were higher in those who had a nonreassuring result to computerized nonstress test immediately before delivery. A multiple logistic analysis showed that the UA PI / MCA ratio was the only Doppler velocimetry parameter predicting cardiotocographic nonreactivity; furthermore, the predictivity of extended newborn hospitalization (longer than 15 days) was verified, with a sensitivity of 56% and a specificity of 92% when the ratio was higher than 1.26. Conclusion: The MCA PI of fetuses with growth restriction should be assessed. The UA PI / MCA ratio is predictive of a nonreactive computerized cardiotocography trace and of prolonged neonatal hospitalization.

Mean platelet volume: Association with adverse neonatal outcome

The aim of the study was to investigate on a possible association between maternal mean platelet volume (MPV) and oxygen-metabolic changes in pregnancies affected by altered maternal-fetal Doppler velocimetry. We considered the altered maternal-fetal Doppler velocimetry group (n = 57) pregnant women admitted to our Institution for a pregnancy complication associated to the event Pre-eclampsia (PE) and intrauterine growth retardation (IUGR), with altered Doppler velocimetry in the umbilical artery ( UA) (high pulsatility index, absence or reverse end diastolic flow (ARED), blood flow cephalisation) and/or bilateral increased resistance in uterine arteries. Out of these cases, 25 pregnancies were complicated by PE and 32 pregnancies were complicated by IUGR. We included 145 normotensive third trimester pregnant women as a normal maternal-fetal Doppler velocimetry control group. From all women, 20 ml of whole venous blood was obtained from the antecubital vein soon after Doppler velocimetry evaluation. MPV was significantly higher in women with abnormal Doppler velocimetry compared to those with normal Doppler velocimetry (8.0 fl [7.0–8.7] vs. 9.1 fl [8.0–10.6], <0.001. Values are median [interquartiles]). We performed a ROC curve in order to find an MPV cut-off able to predict an uneventful event in Doppler velocimetry compromised fetuses (neonatal O2 support > 48 hrs or intubation and/or pH < 7.2 at umbilical blood gas analysis (UBGA)). An MPV ≥ 10 fl was significantly related to the former diagnostic endpoints compared to that of non-compromised fetuses (sensitivity: 45%, specificity: 89.7%, 95 CI: 18.8–66, p < 0.01). Our study suggests that pregnancies affected by Doppler velocimetry alterations, an MPV value ≥ 10 fl may be associated with severe oxygen support and/or low UA ph at birth.

Efficacy of three different antithrombotic regimens on pregnancy outcome in pregnant women affected by recurrent pregnancy loss

Introduction: Recurrent pregnancy loss (RPL) is a common health problem affecting 1–5% of women at reproductive age. Aim of the study: Evaluation of three different antithrombotic treatments in women with antecedent of RPL, comparing the results in negative and positive to thrombophilic screening pregnant women. Materials and methods: We recruited 361 women with an antecedent of two or more pregnancy losses. From this group, 167 women became pregnant and considered for the study. The evaluated pregnant women were divided as negative/positive to thrombofilic screening: (a) 80 (48%) with negative thrombophilic screening, (b) 87 (52%) positive to thrombophilic screening. Pregnant women included in the study and considered negative or positive for thrombophilic screening, were randomized into three different therapy groups: (a) group 1: Acetil salicylic acid (ASA) 100 mg daily until third month of pregnancy, (b) group 2: low molecular-weight heparin (LMWH) – enoxaparine 40 mg daily until third month of pregnancy, (c) group 3: ASA 100 mg plus LMWH 40 mg daily until third month of pregnancy. Results: In 80 negative to thrombophilic screening pregnant women, the comparison of efficacy of the three treatments, shows that all three treatment regimens were significantly effective comparing live births against fetal losses. In 87 positive to thrombophilic screening pregnant women, the comparison of efficacy for the three regimens, shows that the therapy with LMWH or LMWH plus ASA are significantly protective against fetal losses with respect to ASA, which showed a high number of fetal losses (11 live births, 18 fetal losses). Comment: We suggest that thromboprophylaxis is indicated in women with RPL independently from positiveness to thrombophilic markers.

Association between maternal-fetal Doppler velocimetry and fetal lung maturity.

Abstract Aims: To correlate maternal-fetal Doppler velocimetry parameters to indices of fetal lung maturity (FLM). Methods: Fifty-five consecutive third trimester pregnancies in which a pulsed-wave Doppler study, including uterine resistance index (Ut RI), umbilical artery pulsatility index (UA PI), middle cerebral artery pulsatility index (MCA PI) and the UA/MCA ratio was performed within 24 hours before amniocentesis and within a week from birth. FLM was determined by amniotic fluid lamellar bodies count (LBs). Results: A positive correlation between MCA PI and LBs (p < 0.007, r = 0.44) was found. MCA PI showed a trend to lower values in fetuses that developed RDS at birth (1.3±0.5 vs. 1.7±0.4, NS). LBs significantly decreased as Ut RI increased (O.R.: 0.98, C.I. 0.97–0.99, p < 0.05). A mean Ut RI > 0.64 was correlated to delayed FLM (LBs < 20,000/μl; sensitivity: 90.9%, specificity: 90.3%; positive predictive value: 76.9%, negative predictive value: 96.6%). Comment: In third trimester pregnancies abnormal uterine artery waveforms may be associated to a delayed FLM, as expressed by decreased amniotic fluid LBs.

Doppler velocimetry alterations related to platelet changes in third trimester pregnancies

The aim of this study was to evaluate the correlations between the haematological parameter mean platelet volume and Doppler velocimetry parameters in order to improve clinical management in third trimester complicated pregnancies (pre-eclampsia, PE, and IUGR) affected by altered uterine resistances. Fifty-one patients were included in the abnormal uterine arteries Doppler velocimetry group (25 pregnancies were complicated by PE, 26 pregnancies were complicated by IUGR). Ninety-nine normotensive pregnant women taking no drugs for at least 2 weeks prior to testing and with no difference in gestational age at evaluation, with normal Doppler velocimetry profiles at routine screen, were used as controls. From all pregnant women, 20 mL of whole blood were obtained into citrate tubes after Doppler velocimetry evaluation and analysed for red blood cell counts (RBC), mean corpuscular volume (MCV), haemoglobin (HGB), haematocrit level (HCT), white blood cells count (WBC), platelet counts (PLT), mean platelets volume (MPV) and other biochemical parameters. From all blood parameters studied, MPV was significantly higher in women with altered uterine artery Doppler velocimetry compared with those with normal Doppler profiles (9.4 ± 1.0 vs. 8.05 ± 1.2 fL, P < 0.001). In the group with altered uterine artery Doppler velocimetry, pregnancies complicated by PE showed a MPV value higher than pregnancies affected by IUGR (9.5 ± 1.6 vs. 8.9 ± 1.1, P < 0.001). Finally, mean uterine arteries RI values were significantly related to MPV (fL) in both PE and IUGR groups (P < 0.01, r = 0.37 and P < 0.01, r = 0.38, respectively). Our study shows that a periodical monitoring of haematological parameters such as MPV can be associated to Doppler velocimetry in order to improve the management of pregnancies with uterine arteries Doppler velocimetry alterations.

Computerized cardiotocography parameters in pregnant women affected by pregestational diabetes mellitus.

Abstract Aim: To evaluate whether computerized CTG (cCTG) is a reliable method of predicting neonatal outcome in pregnancies complicated by pregestational diabetes at term. Patients and methods: We considered 27 pregnant women affected by pregestational diabetes and 46 normal pregnancies as controls that fulfilled the following criteria: singleton, Caucasian, euglycemic pregnancies at term (>37 weeks gestational age). All women delivered by cesarean section (CS), with an antepartum cCTG performed within one hour before the CS and an UBGA available at birth. No patient was in labor during FHR monitoring. Results: Among cCTG parameters, accelerations 15 bpm, HV min, HV ms and STV were significantly lower in comparison to controls. We observed that in the diabetic pregnant women the parameter STV was not able to predict or to linearly regress with the most important UBGA parameters: pH and pCO2. Contrarily, in normal pregnancies, the STV linearly regressed with both the pH (p < 0.03) and pCO2 (p < 0.04). Conclusions: Computerized FHR criteria may not be applicable to fetuses in pregestational diabetic pregnancies at term. Therefore some criteria should perhaps be modified for a correct interpretation of cCTG in these pregnancies.

Oral contraceptives and clinical recurrence of human papillomavirus lesions and cervical intraepithelial neoplasia following treatment

To evaluate the effect of oral contraceptive use on the recurrence rate of human papillomavirus (HPV) lesions and cervical intraepithelial neoplasia (CIN) following ablative or excisional procedures in a long‐term follow‐up.

Improvement of uterine artery Doppler velocimetry indices after metroplasty in arcuate uteri

OBJECTIVE Our study aimed to evaluate the effect of metroplasty performed in arcuate uteri on uterine artery Doppler velocimetry. STUDY DESIGN We performed uterine artery Doppler velocimetry transvaginally before and after metroplasty in 36 women with arcuate uteri. Pulsatility indexes (PI) of uterine arteries were calculated and the presence or absence of a protodiastolic notch was evaluated. RESULTS Comparing Doppler indexes before and after metroplasty, we found that uterine artery impedance improves as assessed by lower mean PI. We observed that PI after intervention was significantly lower compared with indexes before for mean Doppler index evaluations (mean uterine PI pre: 2.07+/-0.61 and post: 1.49+/-0.24 [p<0.03]). No differences were observed as regards bilateral protodiastolic notch absence or presence. A protodiastolic notch was present in 22 out of 36 women before metroplasty (61%), and a notch was observed in 19 out of 36 (52%) after metroplasty. CONCLUSIONS Our results suggest that, metroplasty, as well as making the uterine cavity wider, leads to better uterine perfusion.

Betamethasone effects on umbilical arteries and ductus venosus Doppler velocity waveforms in growth-restricted fetuses

We studied intrauterine-growth-restricted (IUGR) fetuses with absent or reversed umbilical artery end-diastolic flow (EDF) velocity in order to evaluate the benefit of antenatal steroid therapy. Perinatal outcomes after betamethasone were evaluated where end diastolic flow returned (group I), compared with data from fetuses with persistent absent-reverse end diastolic(ARED) flow (group II). Objectives/methods: We recruited sixty-four IUGR fetuses, 28–32 weeks’ gestation, whose umbilical artery spectral tracings showed ARED flow and positive a-wave in the ductus venosus at admission. Results: Group I, 21 cases of restored EDF after betamethasone: Significant, persistent return of umbilical artery EDF flow and persistent ductus venosus a-wave were documented. Group II, 43 cases of persistent ARED flow: Persistent ARED flow in umbilical arteries and deterioration of ductus venosus waveform with significant, increasing pulsatility index and/or a-wave disappearance were documented. In group I, cardiotocographic alterations were delayed contrasted with group II, (p = 0.03). Neonatal complications in group II were eight cases of intraventricular hemorrhage; two cases of retinopathy of prematurity; three neonatal deaths, one fetal demise; and a higher incidence of neonatal respiratory distress syndrome. Conclusions: Betamethasone treatment may have beneficial effects on restoring end-diastolic umbilical artery velocimetry and precordial waveforms. These spectral Doppler changes are related to delayed cardiotocographic alterations and to better perinatal outcomes.