Edward Mullins

Prediction of intrapartum fetal compromise using the cerebroumbilical ratio: a prospective observational study

OBJECTIVE To investigate the use of the fetal cerebroumbilical ratio to predict intrapartum compromise in appropriately grown fetuses. STUDY DESIGN A prospective observational study set at Queen Charlottes and Chelsea hospital, London, UK. Fetal biometry and Doppler resistance indices were measured in 400 women immediately before established labor. Labor was then managed according to local protocols and guidelines, and intrapartum and neonatal outcome details recorded. RESULTS Infants delivered by cesarean section for fetal compromise had significantly lower cerebroumbilical ratios than those born by spontaneous vaginal delivery (1.52 vs 1.82, P ≤ .001). Infants with a cerebroumbilical ratio <10th percentile were 6 times more likely to be delivered by cesarean section for fetal compromise than those with a cerebroumbilical ratio ≥10th percentile (odds ratio, 6.1; 95% confidence interval, 3.03-12.75). A cerebroumbilical ratio >90th percentile appears protective of cesarean section for fetal compromise (negative predictive value 100%). CONCLUSION The fetal cerebroumbilical ratio can identify fetuses at high and low risk of a subsequent diagnosis of intrapartum compromise, and may be used to risk stratify pregnancies before labor.

Prediction of fetal compromise in labor

OBJECTIVE: The majority of intrapartum fetal hypoxia occurs in uncomplicated pregnancies. Current intrapartum monitoring techniques have not resulted in a reduction in the incidence of cerebral palsy in term neonates. We report the development of a composite risk score to allow risk stratification of normal pregnancies before labor. METHODS: Six hundred one women were recruited to this prospective observational study. All women underwent an ultrasound examination before active labor, during which fetal biometry and fetal Doppler flow resistance indices were measured. A composite risk score, amalgamating data from the umbilical artery, middle cerebral artery, and umbilical vein, was then developed and correlated with intrapartum outcomes. RESULTS: In cases with the highest composite risk scores, the incidence of fetal compromise (the primary outcome) was 80.0% compared with just 15.3% in cases with the lowest risk scores (relative risk 5.2, 95% confidence interval 2.7–10.1). These cases were also at increased risk of cesarean delivery (53.3% compared with 3.4%, P<.001) and of developing a fetal heart rate pattern considered pathologic by National Institute for Health and Clinical Excellence criteria (P=.003). No significant variation in Apgar scores or umbilical artery pH was observed. CONCLUSION: Intrapartum fetal compromise remains a significant global health issue. The composite risk score reported here can identify fetuses at both high risk and low risk of a subsequent diagnosis of intrapartum fetal compromise. This may enable more judicious use of current intrapartum fetal monitoring techniques, which are hampered by low specificity. LEVEL OF EVIDENCE: II

Sex specific differences in fetal middle cerebral artery and umbilical venous Doppler.

Background The incidence of several adverse pregnancy outcomes including fetal growth restriction are higher in pregnancies where the fetus is male, leading to suggestions that placental insufficiency is more common in these fetuses. Placental insufficiency associated with fetal growth restriction may be identified by multi-vessel Doppler assessment, but little evidence exists regarding sex specific differences in these Doppler indices or placental function. This study aims to investigate sex specific differences in fetal and placental perfusion and to correlate these changes with intra-partum outcome. Methods and Findings This is a prospective cohort study. We measured Doppler indices of 388 term pregnancies immediately prior to the onset of active labour (≤3 cm dilatation). Fetal sex was unknown at the time of the ultrasound assessment. Information from the ultrasound scan was not made available to clinical staff. Case notes and electronic records were reviewed following delivery. We report significantly lower Middle Cerebral artery pulsatility index (1.34 vs. 1.43, p = 0.004), Middle Cerebral artery peak velocity (53.47 cm/s vs. 58.10 cm/s, p = <0.001), and Umbilical venous flow/kg (56 ml/min/kg vs. 61 ml/min/kg, p = 0.02) in male fetuses. These differences however, were not associated with significant differences in intra-partum outcome. Conclusion Sex specific differences in feto-placental perfusion indices exist. Whilst the physiological relevance of these is currently unknown, the identification of these differences adds to our knowledge of the physiology of male and female fetuses in utero. A number of disease processes have now been shown to have an association with changes in fetal haemodynamics in-utero, as well as having a sex bias, making further investigation of the sex specific differences present during fetal life important. Whilst the clinical application of these findings is currently limited, the results from this study do provide further insight into the gender specific circulatory differences present in the fetal period.

Changes in the maternal cytokine profile in pregnancies complicated by fetal growth restriction

Fetal growth restriction (FGR) is an important and poorly understood condition of pregnancy, which results in significant fetal, neonatal and long‐term morbidity and mortality. The aetiology of FGR is unknown and is likely to result from sub‐optimal placental implantation and feto‐maternal immunological interaction. The diagnostic criteria for FGR vary between studies, and the condition often occurs with preeclampsia (PET). We present a review of studies of maternal cytokines in FGR and compare these with studies of Small for Gestational Age and PET pregnancies.

Survival of pregnancies with small for gestational age detected before 24 weeks gestation

OBJECTIVE Counselling women where severe growth abnormalities are detected early in the pregnancy is often difficult due to a paucity of outcome data of this specific subset of early onset disease. This study therefore aimed to assess the outcome of pregnancies where an estimated fetal weight less than the third centile were detected prior to 24 weeks gestation. STUDY DESIGN A retrospective study in two London teaching hospitals, over an eight year period was performed, analysing all pregnancies with an ultrasound estimated fetal weight less than the third centile prior to 24 weeks gestation. Outcome data: intrauterine death, neonatal death, survival to discharge, gestation at delivery and birthweight were collected. RESULTS Out of 20 pregnancies included in the analysis, six died in utero, two died in the neonatal period and 12 (60%) survived until discharge. Of the livebirths, 67% delivered preterm and 100% percent of livebirths were delivered by Caesarean Section. CONCLUSION When severe growth abnormalities were detected before 24 weeks, more than half of pregnancies resulted in survival to neonatal discharge. There was an increased incidence of preterm delivery, caesarean section and neonatal unit admission. This information is useful in counselling parents.

Influence of parity on fetal hemodynamics and amniotic fluid volume at term

Pregnancy complications, particularly those associated with placental dysfunction, occur more frequently in nulliparous than in parous women. This difference may be a consequence of improved trophoblastic invasion and, as a result, improved placental function following previous pregnancy. Placental dysfunction in cases of fetal growth restriction may be identified by ultrasound assessment of fetoplacental hemodynamics and amniotic fluid volume. In this prospective observational study, we investigated whether differences in these measures of placental function exist between nulliparous and parous women, prior to active labor.

Older mothers do not confer greater perinatal risk to dichorionic diamniotic twins.

Advanced maternal age may be associated with adverse maternal and perinatal outcomes in singleton pregnancies. It is unclear whether a similar association exists for dichorionic twins. This objective of this study was to ascertain whether advanced maternal age was associated with increased perinatal morbidity and mortality in a 15 year retrospective review of dichorionic diamniotic (DCDA) twins delivered at Queen Charlottes and Chelsea Hospital, a tertiary referral center in London, UK, between 1994 and 2008. In all, 1 174 DCDA deliveries occurred in the study period. Maternal age was not associated with neonatal unit admission or composite fetal and neonatal mortality. Advanced maternal age appeared to have no deleterious effect on the perinatal outcomes of DCDA twin pregnancies.

Is continuous electronic fetal monitoring useful for all women in labour

Routine monitoring of all women would prevent much neonatal morbidity, argue Edward Mullins and Christoph Lees, but Peter Brocklehurst believes that it will increase the risk of harm from unnecessary caesarean sections

Changes in the Fetal and Neonatal Cytokine Profile in Pregnancies Complicated by Fetal Growth Restriction

Fetal growth restriction (FGR) is a major complication of pregnancy with unknown etiology which results in marked fetal, neonatal and long‐term morbidity, and mortality. FGR is likely to result from suboptimal placental implantation and perturbed immunological interactions. The diagnostic criteria for FGR vary between studies and the condition often occurs with pre‐eclampsia. Here, we review published studies of fetal and neonatal cytokines in FGR and compare these with studies of small for gestational age, pre‐eclampsia and pregnancies delivering pre‐term.

OP30.10: Dichorionic Tri‐Amniotic triplets (DCTA): conservative and interventional management and outcomes

Objectives: Preterm birth is a main contributor for neurodevelopmental impairment in affected infants. The study aimed to evaluate long-term neurodevelopmental outcome of twins following preterm delivery between 2003 and 2008. Methods: Neurodevelopmental outcome of monochorionic (MC) and dichorionic (DC) twins, who were born between 24+0 weeks and 33+6 weeks at the Medical University of Graz, was analyzed retrospectively. Primary outcome was neurodevelopmental impairment at the age of two years. Secondary outcome were pregnancy complications. Results: The population consisted of 264 children (132 twin pregnancies), 94 (71%) were DC and 38 (29%) MC. The most frequent complications (30%) in each group were preterm rupture of membranes and preterm labor. Mean gestational age at delivery was 30+4 and 31+0 weeks for MC and DC twins, respectively. In the MC group 38 (84%) of 66 children had an uneventful outcome, while 7 (16%) had neurodevelopmental impairment [1 (2%) mild, 6 (13%) severe]. 114 (83%) of 138 DC children were healthy, whereas 24 (17%) presented neurologic delay [11 (8%) mild, 4 (3%) moderate, 9 (7%) severe]. Conclusions: The rates for neurodevelopmental impairment of MC and DC twins were comparable. However, severe problems occurred more often in MC twins.