B. Thilaganathan

Placental syndromes: getting to the heart of the matter

Human placentation is uniquely associated with physiological remodeling of the spiral arteries, with deep placentation involving their almost complete transformation. Defective deep placentation has been associated with the development of pre-eclampsia (PE) and fetal growth restriction (FGR), collectively termed ‘placental syndromes’1. The clinical significance of PE and FGR and their deleterious effect on maternal, fetal and neonatal health are well accepted. This article attempts to highlight the importance of maternal hemodynamics and their relevance to placental syndromes.

Non-invasive cardiac output monitoring in pregnancy: comparison to echocardiographic assessment.

To compare non‐invasive hemodynamic measurements obtained in pregnant and postpartum women using two automated cardiac output monitors against those obtained by two‐dimensional (2D) transthoracic echocardiography (TTE).

Placental histopathology associated with pre‐eclampsia: systematic review and meta‐analysis

Pre‐eclampsia (PE) is associated with impaired trophoblastic invasion and typical villous and vascular placental lesions. The primary aim of this study was to quantify the prevalence of placental histopathological lesions in pregnancies complicated by PE.

Perinatal and long-term outcomes in fetuses diagnosed with isolated unilateral ventriculomegaly: systematic review and meta-analysis.

The majority of studies on fetal ventriculomegaly have focused on the perinatal and long‐term outcomes in fetuses with an antenatal diagnosis of bilateral ventriculomegaly. The aim of this study was to undertake a systematic review and meta‐analysis to quantify the perinatal and long‐term outcomes in fetuses diagnosed in the second or third trimester of pregnancy with isolated unilateral ventriculomegaly.

Longitudinal study of computerized cardiotocography in early fetal growth restriction

To explore whether, in early fetal growth restriction (FGR), the longitudinal pattern of fetal heart rate (FHR) short‐term variation (STV) can be used to identify imminent fetal distress and whether abnormalities of FHR recordings are associated with 2‐year infant outcome.

How to monitor pregnancies complicated by fetal growth restriction and delivery before 32 weeks : post-hoc analysis of TRUFFLE study

In the recent TRUFFLE study, it appeared that, in pregnancies complicated by fetal growth restriction (FGR) between 26 and 32 weeks gestation, monitoring of the fetal ductus venosus (DV) waveform combined with computed cardiotocography (CTG) to determine timing of delivery increased the chance of infant survival without neurological impairment. However, concerns with the interpretation were raised, as DV monitoring appeared to be associated with a non‐significant increase in fetal death, and some infants were delivered after 32 weeks, at which time the study protocol no longer applied. This secondary sensitivity analysis of the TRUFFLE study focuses on women who delivered before 32 completed weeks gestation and analyzes in detail the cases of fetal death.

Is middle cerebral artery Doppler related to neonatal and 2-year infant outcome in early fetal growth restriction?

BACKGROUND: Reduced fetal middle cerebral artery Doppler impedance is associated with hypoxemia in fetal growth restriction. It remains unclear as to whether this finding could be useful in timing delivery, especially in the third trimester. In this regard there is a paucity of evidence from prospective studies. OBJECTIVES: The aim of this study was to determine whether there is an association between middle cerebral artery Doppler impedance and its ratio with the umbilical artery in relation to neonatal and 2 year infant outcome in early fetal growth restriction (26+0–31+6 weeks of gestation). Additionally we sought to explore which ratio is more informative for clinical use. STUDY DESIGN: This is a secondary analysis from the Trial of Randomized Umbilical and Fetal Flow in Europe, a prospective, multicenter, randomized management study on different antenatal monitoring strategies (ductus venosus Doppler changes and computerized cardiotocography short‐term variation) in fetal growth restriction diagnosed between 26+0 and 31+6 weeks. We analyzed women with middle cerebral artery Doppler measurement at study entry and within 1 week before delivery and with complete postnatal follow‐up (374 of 503). The primary outcome was survival without neurodevelopmental impairment at 2 years corrected for prematurity. Neonatal outcome was defined as survival until first discharge home without severe neonatal morbidity. Z‐scores were calculated for middle cerebral artery pulsatility index and both umbilicocerebral and cerebroplacental ratios. Odds ratios of Doppler parameter Z‐scores for neonatal and 2 year infant outcome were calculated by multivariable logistic regression analysis adjusted for gestational age and birthweight p50 ratio. RESULTS: Higher middle cerebral artery pulsatility index at inclusion but not within 1 week before delivery was associated with neonatal survival without severe morbidity (odds ratio, 1.24; 95% confidence interval, 1.02–1.52). Middle cerebral artery pulsatility index Z‐score and umbilicocerebral ratio Z‐score at inclusion were associated with 2 year survival with normal neurodevelopmental outcome (odds ratio, 1.33; 95% confidence interval, 1.03–1.72, and odds ratio, 0.88; 95% confidence interval, 0.78–0.99, respectively) as were gestation at delivery and birthweight p50 ratio (odds ratio, 1.41; 95% confidence interval, 1.20–1.66, and odds ratio, 1.86; 95% confidence interval, 1.33–2.60, respectively). When comparing cerebroplacental ratio against umbilicocerebral ratio, the incremental range of the cerebroplacental ratio tended toward zero, whereas the umbilicocerebral ratio tended toward infinity as the values became more abnormal. CONCLUSION: In a monitoring protocol based on ductus venosus and cardiotocography in early fetal growth restriction (26+0–31+6 weeks of gestation), the impact of middle cerebral artery Doppler and its ratios on outcome is modest and less marked than birthweight and delivery gestation. It is unlikely that middle cerebral artery Doppler and its ratios are informative in optimizing the timing of delivery in fetal growth restriction before 32 weeks of gestation. The umbilicocerebral ratio allows for a better differentiation in the abnormal range than the cerebroplacental ratio.

Maternal Hemodynamics in Normal Pregnancies: Reference ranges and the Role of Maternal Characteristics

The main aim of this study was to construct reference ranges of maternal central hemodynamic parameters during pregnancy. The second aim was to determine the maternal and pregnancy characteristics that influence these hemodynamic parameters.

How to monitor pregnancies complicated by fetal growth restriction and delivery below 32 weeks: a post-hoc sensitivity analysis of the TRUFFLE-study.

In the recent TRUFFLE study, it appeared that, in pregnancies complicated by fetal growth restriction (FGR) between 26 and 32 weeks gestation, monitoring of the fetal ductus venosus (DV) waveform combined with computed cardiotocography (CTG) to determine timing of delivery increased the chance of infant survival without neurological impairment. However, concerns with the interpretation were raised, as DV monitoring appeared to be associated with a non‐significant increase in fetal death, and some infants were delivered after 32 weeks, at which time the study protocol no longer applied. This secondary sensitivity analysis of the TRUFFLE study focuses on women who delivered before 32 completed weeks gestation and analyzes in detail the cases of fetal death.

Severe fetal growth restriction at 26–32 weeks : key messages from the TRUFFLE study

C. M. BILARDO1 , K. HECHER2, G. H. A. VISSER3, A. T. PAPAGEORGHIOU4, N. MARLOW5, B. THILAGANATHAN4, A. VAN WASSENAER-LEEMHUIS6, T. TODROS7, K. MARSAL8, T. FRUSCA9, B. ARABIN10, C. BREZINKA11, J. B. DERKS12, A. DIEMERT2, J. J. DUVEKOT13, E. FERRAZZI14, W. GANZEVOORT15, P. MARTINELLI16, E. OSTERMAYER17, D. SCHLEMBACH18, H. VALENSISE19, J. THORNTON20, H. WOLF15 and C. LEES21* , on behalf of the TRUFFLE Group# 1Fetal Medicine Unit, Department of Obstetrics and Gynecology, Vrije Universiteit Medical Center, Amsterdam, The Netherlands; 2Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; 3University Medical Center, Division of Woman and Baby, Utrecht, The Netherlands; 4St George’s, University of London and St George’s University Hospitals NHS Foundation Trust, Molecular and Clinical Sciences Research Institute, London, UK; 5Department of Academic Neonatology, UCL Institute for Women’s Health, London, UK; 6Department of Neonatology, Emma Children’s Hospital Academic Medical Centre, Amsterdam, The Netherlands; 7Department of Obstetrics & Gynecology, University of Turin, Turin, Italy; 8Department of Obstetrics and Gynecology, Lund University, University Hospital, Lund, Sweden; 9Maternal-Fetal Medicine Unit, University of Parma, Parma, Italy; 10Department of Perinatology, Isala Clinics, Zwolle, The Netherlands, and Center for Mother and Child of the Philipps University, Marburg, Germany; 11Department of Obstetrics and Gynecology, Medical University Innsbruck, Innsbruck, Austria; 12Perinatal Center, Wilhelmina Children’s Hospital, Utrecht, The Netherlands; 13Division of Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC, Rotterdam, The Netherlands; 14Buzzi Children’s Hospital, University of Milan, Milan, Italy; 15Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam, The Netherlands; 16Department of Gynecology and Obstetrics, University Federico II of Naples, Naples, Italy; 17Section of Perinatal Medicine, Department of Obstetrics and Gynecology, Technical University, Munich, Germany; 18Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria; 19Department of Biomedicine, Tor Vergata University, Policlinico Casilino, Rome, Italy; 20Department of Obstetrics and Gynaecology, City Hospital, Nottingham, UK; 21Department of Surgery and Cancer, Imperial College London, London, UK, and Department of Development and Regeneration, KU Leuven, Leuven, Belgium ∗Correspondence. (e-mail: christoph.lees@nhs.net)