J. A. Benavides‐Serralde

Cardiac dysfunction and cell damage across clinical stages of severity in growth-restricted fetuses

OBJECTIVE The purpose of this study was to assess cardiac function and cell damage in intrauterine growth-restricted (IUGR) fetuses across clinical Doppler stages of deterioration. STUDY DESIGN One hundred twenty appropriate-for-gestational-age and 81 IUGR fetuses were classified in stages 1/2/3 according umbilical artery present/absent/reversed end-diastolic blood flow, respectively. Cardiac function was assessed by modified-myocardial performance index, early-to-late diastolic filling ratios, cardiac output, and cord blood B-type natriuretic peptide; myocardial cell damage was assessed by heart fatty acid-binding protein, troponin-I, and high-sensitivity C-reactive protein. RESULTS Modified-myocardial performance index, blood B-type natriuretic peptide, and early-to-late diastolic filling ratios were increased in a stage-dependent manner in IUGR fetuses, compared with appropriate-for-gestational-age fetuses. Heart fatty acid-binding protein levels were higher in IUGR fetuses at stage 3, compared with control fetuses. Cardiac output, troponin-I, and high-sensitivity C-reactive protein did not increase in IUGR fetuses at any stage. CONCLUSION IUGR fetuses showed signs of cardiac dysfunction from early stages. Cardiac dysfunction deteriorates further with the progression of fetal compromise, together with the appearance of biochemical signs of cell damage.

Evaluation of conventional Doppler fetal cardiac function parameters: E/A ratios, outflow tracts, and myocardial performance index.

Structural evaluation of the fetal heart is well established. Functional evaluation using pulsed-wave Doppler may also be performed. E/A ratios express the relationship between the maximal velocities of the E and A waveforms of ventricular filling. In normal fetuses, E/A ratios are usually <1 but show a constant increment during gestation, mainly related to the increment of the E wave. In intrauterine growth restriction (IUGR) fetuses, E/A ratios are lower compared to values in normally grown fetuses at the same gestational age. Cardiac outflows provide information on the time-velocity integral that, combined with the vessel area, allows calculation of the left and right cardiac outputs. In normal fetuses there is a predominance of the right ventricle (55–60%) in contributing to the combined cardiac output. In IUGR fetuses this predominance shifts to the left ventricle in order to increase the flow to the upper part of the fetal body and brain. The myocardial performance index (MPI) also provides information on systolic and diastolic cardiac function. The MPI is an early and consistent marker of cardiac dysfunction which becomes altered in early stages of chronic hypoxia or in cases with cardiac overload such as in twin-to-twin transfusion syndrome.

Contribution of the myocardial performance index and aortic isthmus blood flow index to predicting mortality in preterm growth-restricted fetuses

To evaluate the predictive value for perinatal death of the myocardial performance index (MPI) and aortic isthmus flow index (IFI), as isolated parameters and in a combined model including currently used Doppler indices, in preterm growth restricted (IUGR) fetuses.

Automatic segmentation of the fetal cerebellum on ultrasound volumes, using a 3D statistical shape model

Previous work has shown that the segmentation of anatomical structures on 3D ultrasound data sets provides an important tool for the assessment of the fetal health. In this work, we present an algorithm based on a 3D statistical shape model to segment the fetal cerebellum on 3D ultrasound volumes. This model is adjusted using an ad hoc objective function which is in turn optimized using the Nelder–Mead simplex algorithm. Our algorithm was tested on ultrasound volumes of the fetal brain taken from 20 pregnant women, between 18 and 24 gestational weeks. An intraclass correlation coefficient of 0.8528 and a mean Dice coefficient of 0.8 between cerebellar volumes measured using manual techniques and the volumes calculated using our algorithm were obtained. As far as we know, this is the first effort to automatically segment fetal intracranial structures on 3D ultrasound data.

Reference Values for Doppler Parameters of the Fetal Anterior Cerebral Artery throughout Gestation

Aim: To construct normal reference values for Doppler parameters in 2 anatomical segments of the fetal anterior cerebral artery (ACA) throughout pregnancy. Methods: The ACA was evaluated in 373 normally growing fetuses from 20 to 40 weeks of gestation. The first segment of the ACA (ACA-S1) was recorded just after its origin from the internal carotid artery in the same plane as the middle cerebral artery (MCA). The second segment (ACA-S2) was recorded distal to the outlet of the anterior communicating artery. Results: The ACA pulsatility index (PI) behaved similarly in both segments, with a constant increase until 28 weeks followed by a decrease until the end of pregnancy [ACA-S1 PI = 3.49 – 0.37 × gestational age (GA) – (0.0063 × GA2), SD = 0.6 – 0.061 × GA – (0.001 × GA2); ACA-S2 PI = 1.54 – 0.22 × GA – (0.0037 × GA2), SD = 0.206 + (0.0037 × GA)]. Peak systolic velocities in both segments showed a constant increase from 20 to 40 weeks of gestation. No significant differences were found between the 2 segments with regard to any Doppler parameter. However, the angle of insonation and the time spent on examination were significantly lower and reproducibility was better for ACA-S1. Conclusion: Despite showing similar Doppler values, ACA-S1 has a higher reliability than ACA-S2 and can be recorded in the same anatomical projection as the MCA.

Doppler evaluation of the posterior cerebral artery in normally grown and growth restricted fetuses

To evaluate Doppler parameters of the two segments of the posterior cerebral artery (PCA) in normally grown and growth restricted (IUGR) fetuses.

OP20.08: The use of a cardiac profile improves detection of heart dysfunction and prediction of poor perinatal outcome as compared with ductus venosus alone

n 75 37 48 68 23 Echocardiography Aortic isthmus flow index −0.5 (1.3) −0.9 (1.5) −1.3 (4) −2.5 (6.5)** −11.8 (4.2)** Aortic peak velocity −0.04 (1.3) −0.9 (1.3)* −0.8 (1.7)* −0.9 (1.4)* −1.3 (1.8)** Pulmonary peak velocity −0.6 (1.1) −1.3 (1.7)* −1.5 (1.1)* −1.3 (1.4)* −1.5 (1.2)* Aortic valve diameter 0.8 (1.6) 0.1 (1.9)* 0.2 (2.5) 0.7 (2.4) 0.3 (2) Pulmonary valve diameter 0.1 (1.4) −0.3 (2.4) −1.5 (2.4)* 0.1 (1.6) −1.4 (1.1)* Left shortening fraction −1.5 (1.2) −2 (1.6) −1.2 (1.6) −1.7 (3.1) 0.03 (4.3)* Right shortening fraction −0.8 (3) −2.7 (4.3)* −1.2 (3.8) −1.2 (4.7) −0.3 (7.5) Isovolumetric contraction time −0.05 (1.3) 0 (1.9) 0 (1.7) 0.3 (1.8) 0.5 (2.5) Ejection time 0 (1.3) −0.8 (1.8)* −1.3 (1.4)* −1.5 (1.7)* −1.6 (1.2)* Cardiothoracic ratio 0.4 (1.2) 0.3 (1.5) 0.6 (1.8) 1.1 (1)* 2.2 (1)** Left E/A ratio −0.3 (1.4) −0.1 (1.8) 0.4 (1.4)* 0.5 (2.2)* 1.6 (2.7)** Right E/A ratio 0.2 (0.9) 0.3 (1.7) 0.7 (1.5)* 0.6 (1.9)* 1.2 (2.2)* Isovolumetric relaxation time 0.05 (1.3) 0.3 (1.7) 0.5 (2.1) 0.5 (2.6) 1.2 (3.4)** Modified-myocardial performance index −0.1 (1.2) 0.6 (2.3)* 1.1 (2.1)* 1.1 (2.4)* 1.9 (2.1)** Normalized left cardiac output 235 (147) 295 (67)* 344 (155)* 351 (219)* 298 (184)* Normalized right cardiac output 343 (113) 308 (162) 429 (212)* 463 (245)* 554 (119)** Normalized combined cardiac output 570 (166) 512 (180) 749 (318)* 881 (289)* 722 (225)* Biochemical evaluation Cord blood BNP (pg/mL) 20 (26) 48 (51)* 92 (164)* 70 (83)* 410 (340)**

Social and Economic Factors Influencing a Fetal Surgery Program for Complicated Monochorionic Twin Pregnancies in a Developing Country

Objective: To analyze social and economic factors affecting the implementation of a fetal surgery program in a developing country. Materials and Methods: During an 18-month period, 30 women with complicated monochorionic diamniotic twin pregnancies were evaluated. 27 women had twin-to-twin transfusion syndrome (TTTS), 2 women had a selective intrauterine growth restriction, and 1 a discordant twin pregnancy with 1 fetus with a severe open neural tube defect. The TTTS cases were treated with fetoscopic laser ablation of the interplacental vascular communications and the remaining 3 cases with bipolar cord occlusion of the affected twin. The patients were evaluated using family income levels (very low, low, median, and high income). Demographic characteristics, gestational age at referral, the prevalence of infections, tocolysis care with hospital readmission, prolonged hospital stay until delivery, and gestational age at delivery were evaluated. Results: The overall survival rate of fetuses treated with laser ablation was 60% (32/54). Survival of at least 1 twin was achieved in 21/27 pregnancies (77%), and survival of both twins in 12/27 pregnancies (44%). The 3 pregnancies treated with cord occlusion had survival of the normal twin. Patients with low and very low family income showed a significantly higher prevalence of vaginal infections, increased periods of tocolysis requiring hospitalization, prolonged hospital stay until the end of pregnancy, and lower gestational age at delivery. Conclusion: When a fetal surgery program is implemented in a developing country, social and economic factors will influence the overall healthcare costs and treatment outcomes.

OC212: Risk assessment of pre-eclampsia and IUGR in patients with normalization of the uterine artery Doppler study between 20 and 24 weeks

although the NDI was defined as zero in the absence of a notch. The averaged values of resistance index (RI) and NDI from the right and left uterine artery were used for statistical analysis. We measured the serum levels of PlGF and sFlt-1 during both 16–23 and 27–29 weeks of gestation. The cut-off values for RI, NDI, sFlt-1 and sFlt-1/PlGF ratio were set at the 90th percentile, and the cut-off value for PlGF at the 10th percentile. Results: Pre-eclampsia occurred in 5.0%. The area under the curve (AUC) of NDI for pre-eclampsia was larger than that of RI (0.777 vs. 0.687), and the AUC of PlGF was larger than that of sFlt-1 in the second trimester (0.672 vs. 0.561). Therefore, we selected the NDI and PlGF as the appropriate risk factors for the occurrence of pre-eclampsia. In women with both normal (Group 1, n = 221), only abnormal PlGF (Group 2, n = 14), only abnormal NDI (Group 3, n = 16), and both abnormal (Group 4, n = 9), the frequencies of high sFlt-1/PlGF ratio in the early third trimester were 6.8%, 21.4%, 0%, and 100%, respectively (P < 0.001), and the frequencies of pre-eclampsia were 2.7%, 0%, 6.3% and 66.7%, respectively (P < 0.001). Conclusions: A high sFlt-1/PlGF ratio in the early third trimester and pre-eclampsia may frequently occur in women with both a high NDI and low PlGF levels in the second trimester.

OC42: Evaluation of the impact of the presence or absence of pre‐eclampsia on fetal cardiac function in intrauterine growth restricted fetuses

abdominal circumference and femur length, as well as 3D ultrasound of the femur and of the humerus were performed. Measurements of subcutaneous fat were taken at the inferior border of the scapula. Ultrasound images were saved on to a DVD and analyzed offline with the Philips Q-LAB program. The birth weight was customized using the GROW software for New Zealand. The definitions used were IUGR < 5th centile and macrosomia > 95th centile. Vol is the volume of limb measured over 50% of diaphyseal length. Fat vol is the vol minus volume lean muscle mass over 50% of diaphyseal length. Fat circ is the circumference at mid-diaphyseal point minus lean mass circumference. Results: Volume measurements relate to 50% of limb length. They can be compared with FL/AC of fetuses with different ethnic characteristics. Thigh measurements are better than humeral or fat at differentiating growth abnormalities (Table).