C. Mastroianni

Distinction between fetal growth restriction and small for gestational age newborn weight enhances the prognostic value of low PAPP‐A in the first trimester

Several studies have tested the hypothesis that low maternal serum levels of pregnancy-associated plasma protein A (PAPP-A) may predict adverse pregnancy outcomes other than Down syndrome in first trimester (Dugoff et al., 2004; Krantz et al., 2004; Smith et al., 2006; Barrett et al., 2008; Spencer et al., 2008a,b). Low levels of PAPP-A in maternal blood could become an early marker of obstetrical complications associated with poor placental function, that is small babies, gestational hypertension (GH), pre-eclampsia (PE), stillbirth and even premature delivery. However, contradictory results had been observed in different cohorts (Kavak et al., 2006; Spencer et al., 2008a,b). These findings could result as a consequence of non-homogeneous criteria in the definition of different abnormal obstetrical outcomes. Recently, Poon et al. (2010) showed that low PAPP-A is significantly associated with early PE but not with late PE. This confirmed the need to distinguish among abnormal obstetrical outcomes those based on similar placental damage. Moreover, when considering poor obstetrical outcomes, other environmental factors have to be taken into account. Among these, maternal smoking has been largely studied while it is associated with impaired fetal growth. Therefore, this factor could interfere when evaluating the predictive value of PAPP-A. The aim of this article was to sort out among abnormal obstetrical outcomes those consistently related to an abnormal placental vascular function and to evaluate their association with low levels of maternal serum PAPP-A in early pregnancy.

Assessment of coupling between trans-abdominally acquired fetal ECG and uterine activity by bivariate phase-rectified signal averaging analysis

Couplings between uterine contractions (UC) and fetal heart rate (fHR) provide important information on fetal condition during labor. At present, couplings between UC and fHR are assessed by visual analysis and interpretation of cardiotocography. The application of computerized approaches is restricted due to the non-stationarity of the signal, missing data and noise, typical for fHR. Herein, we propose a novel approach to assess couplings between UC and fHR, based on a signal-processing algorithm termed bivariate phase-rectified signal averaging (BPRSA). Methods Electrohysterogram (EHG) and fetal electrocardiogram (fECG) were recorded non-invasively by a trans-abdominal device in 73 women at term with uneventful singleton pregnancy during the first stage of labor. Coupling between UC and fHR was analyzed by BPRSA and by conventional cross power spectral density analysis (CPSD). For both methods, degree of coupling was assessed by the maximum coefficient of coherence (CPRSA and CRAW, respectively) in the UC frequency domain. Coherence values greater than 0.50 were consider significant. CPRSA and CRAW were compared by Wilcoxon test. Results At visual inspection BPRSA analysis identified coupled periodicities in 86.3% (63/73) of the cases. 11/73 (15%) cases were excluded from further analysis because no 30 minutes of fECG recording without signal loss was available for spectral analysis. Significant coupling was found in 90.3% (56/62) of the cases analyzed by BPRSA, and in 24.2% (15/62) of the cases analyzed by CPSD, respectively. The difference between median value of CPRSA and CRAW was highly significant (0.79 [IQR 0.69–0.90] and 0.29 [IQR 0.17–0.47], respectively; p<0.0001). Conclusion BPRSA is a novel computer-based approach that can be reliably applied to trans-abdominally acquired EHG-fECG. It allows the assessment of correlations between UC and fHR patterns in the majority of labors, overcoming the limitations of non-stationarity and artifacts. Compared to standard techniques of cross-correlations, such as CPSD, BPRSA is significantly superior.

OP09.01: First trimester uterine artery Doppler velocimetry and arterial tonometry

antral follicles. After the year of observation the ovary volume reduced (6.7 ± 1.2/5.1 ± 1.2 ml) with no significant difference from initial data noted in both groups. At the same period the follicular size was normal in the 1st group, in the 2nd group the maximal size of the follicles exceeded 9 mm (significant difference from the initial data P < 0.05). Initially the hormone level in both groups was normal. In 6 months the level of AMH in both groups reduced, but the difference was insignificant with no changes in FSH and E2 levels. By the end of the observation the hormone level didn’t change in the 1st group, in the 2nd group was registered a reduction of AMH level remaining in the range of age norm, but significantly lower than initial (1.98 ± 0.57/1.02 ± 0.30 ng/ml P < 0.05). Conclusions: The influence of UAE on ovary function of fertile patients cannot be ruled out, the risk of reduction of ovarian reserve increases in the older age group.

Bedside cardiovascular maternal interrogation in the first trimester to predict different phenotypes of hypertensive disorders in pregnancy

OBJECTIVE The aim is to evaluate if maternal cardiovascular indices, in the first trimester of pregnancy, might be useful to differentiate women who develop different hypertensive disorders of pregnancy (HDP). STUDY DESIGN Method: 1399 pregnant women attending screening for chromosomal aneuploidies were recruited. The following parameters were measured: Doppler Velocimetry of uterine arteries; Peripheral blood pressure; Aortic Pressure derived from applanation tonometry. Primary outcome were: women who developed HDP associated with newborns with an appropriate weight for local gestational age standards (AGA) and women that developed HDP associated with a newborn weight below the 10th centile (SGA). RESULTS Mean UtA PI was significantly higher in the HDP-SGA compared with controls. HDP-AGA showed a higher rate of family history of hypertension and a higher BMI. In HDP-AGA Brachial and Aortic mean pressure were higher than controls. The most significant contributors for all forms of HDP were mean UtA PI for HDP-SGA and mean arterial blood pressure for HDP-AGA. The multivariate logistic regression for HDP-SGA shows an AUC 0.88, whereas the AUC for the prediction of HDP-AGA group was 0.71. CONCLUSION HDP-SGA were characterized by significantly higher values of UtA-PI, whereas HDP-AGA by mean aortic and brachial pressure and risk factors for endothelial dysfunction.

Prenatal diagnosis of extrahepatic umbilicosystemic shunt: a new variant?

Extrahepatic umbilicosystemic shunts are a rare occurence, caused when critical anastomoses fail to form between the three major pairs of veins in the fetal venous system: umbilical, cardinal and vitelline veins1,2. Various anastomoses of the umbilical vein with extrahepatic veins have been reported, e.g. with the iliac vein, the inferior vena cava, the right or left atrium or the coronary sinus2–4. We report a case of extrahepatic umbilicosystemic shunt formed by an aberrant vessel, which, bypassing the portal veins, branches into two vessels and simultaneously connects the umbilical system with the superior vena cava (SVC) and the inferior vena cava (IVC). To our knowledge, this is the first report of such a variant.

OP09.05: Pulse wave analysis: evaluation of arterial stiffness in first trimester for prediction of placental and maternal pre‐eclampsia (PE)

care in a tertiary Brazilian hospital. The base-cohort population was 487 singleton pregnancies, including 9 case subjects who developed PE requiring delivery before 34 weeks (early PE) and 22 with late PE, 47 with gestational hypertension, and 409 cases subjects (84%) who were unaffected by PE or gestational hypertension. Maternal history, body mass index (BMI), mean arterial pressure (MAP), and uterine artery pulsatility index were recorded in all of the cases. Univariate and logistic regression analysis was used to derive algorithms for the prediction of hypertensive disorders. Results: The maternal characteristics selected by regression analysis to be part of the final predictive model were nulliparity, previous personal and family history of PE. MAP was higher (86 versus 78 mmHg) in patients who developed PE (P < 0.01). The uterine artery percentile of mean PI was higher in the PE than in the control group (50.3% ± 31.7% versus 37.4% ± 30.0%; P < 0.01). It was estimated that, with the algorithm for PE, 78%, 45%, and 26% of early PE, late PE, and gestational hypertension, respectively, could be detected with a 10% false-positive rate. Conclusions: The traditional approach to screening for PE, which is based on maternal demographic characteristics and medical history, identifies ∼60% of cases destined to develop early PE for a falsepositive rate of 10%. This study proposes that a combination of maternal risk factors, mean arterial blood pressure, and uterine artery Doppler, for the same false-positive rate of 10%, could identify 78% of cases of early PE.

OP09.06: Hypertensive disorders (HD) of placental and maternal origin: evaluation by applanation tonometry

care in a tertiary Brazilian hospital. The base-cohort population was 487 singleton pregnancies, including 9 case subjects who developed PE requiring delivery before 34 weeks (early PE) and 22 with late PE, 47 with gestational hypertension, and 409 cases subjects (84%) who were unaffected by PE or gestational hypertension. Maternal history, body mass index (BMI), mean arterial pressure (MAP), and uterine artery pulsatility index were recorded in all of the cases. Univariate and logistic regression analysis was used to derive algorithms for the prediction of hypertensive disorders. Results: The maternal characteristics selected by regression analysis to be part of the final predictive model were nulliparity, previous personal and family history of PE. MAP was higher (86 versus 78 mmHg) in patients who developed PE (P < 0.01). The uterine artery percentile of mean PI was higher in the PE than in the control group (50.3% ± 31.7% versus 37.4% ± 30.0%; P < 0.01). It was estimated that, with the algorithm for PE, 78%, 45%, and 26% of early PE, late PE, and gestational hypertension, respectively, could be detected with a 10% false-positive rate. Conclusions: The traditional approach to screening for PE, which is based on maternal demographic characteristics and medical history, identifies ∼60% of cases destined to develop early PE for a falsepositive rate of 10%. This study proposes that a combination of maternal risk factors, mean arterial blood pressure, and uterine artery Doppler, for the same false-positive rate of 10%, could identify 78% of cases of early PE.

OP01.02: Increased cardiovascular risk in hypertensive disorders (HD) of placental origin

Objectives: To determine the incidence of chromosomal abnormalities, syndromic association and fetal defects in second trimester fetal growth restriction (FGR) in a tertiary referral center for prenatal diagnosis. Methods: Retrospective review of all cases referred between 14 and 27 weeks with an abdominal circumference (AC) < 5th centile between 2008 and 2012. The presence of aneuploidy and associated malformations was also assessed. Multiple pregnancies were excluded. Results: A total of 8626 fetuses had ultrasonographic examination between 14 and 27 weeks. Of these, there were 239 cases (2.8%) with evidence of FGR. Thirty-seven fetuses had an abnormal karyotype or an identified syndromic association (15%), 67 had at least one morphological abnormality without aneuploidy or syndromic association (28%), 135 cases were isolated fetal growth retardation (57%). The most common chromosomal defect was Trisomy 18. Most common morphological abnormalities were relative short femur (5%), omphalocele (5%) and gastroschisis (4%). The Maternal age was higher (33 yr ± 5 yr versus 31 yr ± 5, 6 yr, P = 0.007) and the z-score for the AC lower (2.5 ± 1 versus 2.15 ± 0.6) in the group with abnormal karyotype or syndromic association than in the group without malformation. Amniotic fluid was more often increased in the group with an abnormal karyotype or associated malformation (14% and 17%) than in the group without malformations (0%, P = 0.0003 and 0.0001). Conclusions: This study describes abnormalities and outcomes associated with second trimester fetal growth retardation in a large population of patients referred for that purpose. Our results suggest that the degree of growth restriction, maternal age and the amniotic fluid index may help in the prenatal management and counseling of this high risk population.

OP09.02: Placental volume and uterine artery Doppler correlation in first trimester of pregnancy

antral follicles. After the year of observation the ovary volume reduced (6.7 ± 1.2/5.1 ± 1.2 ml) with no significant difference from initial data noted in both groups. At the same period the follicular size was normal in the 1st group, in the 2nd group the maximal size of the follicles exceeded 9 mm (significant difference from the initial data P < 0.05). Initially the hormone level in both groups was normal. In 6 months the level of AMH in both groups reduced, but the difference was insignificant with no changes in FSH and E2 levels. By the end of the observation the hormone level didn’t change in the 1st group, in the 2nd group was registered a reduction of AMH level remaining in the range of age norm, but significantly lower than initial (1.98 ± 0.57/1.02 ± 0.30 ng/ml P < 0.05). Conclusions: The influence of UAE on ovary function of fertile patients cannot be ruled out, the risk of reduction of ovarian reserve increases in the older age group.