Jason Picconi

Biophysical profile in the treatment of intrauterine growth-restricted fetuses who weigh <1000 g

OBJECTIVE The aim of this study was to determine the biophysical profile (BPP) usefulness in the prediction of cord pH, base excess, and guidance regarding the timing of delivery in preterm intrauterine growth-restricted (IUGR) fetuses. STUDY DESIGN A BPP was performed daily in 48 IUGR fetuses and was considered abnormal when it was 2/10 on 1 single occasion or 4/10 on 2 consecutive occasions 2 hours apart. RESULTS The median gestational age and fetal weight for the total population was 27.6 weeks and 632 g, respectively. In 13 fetuses with a BPP of 6, there were 3 deaths, and 7 fetuses were acidemic. In 27 fetuses with a BPP of 8, there were 3 deaths, and 12 fetuses were acidemic. CONCLUSION BPP alone is not a reliable test in the treatment of preterm IUGR fetuses, because of high false-positive and -negative results. The common notion of a good BPP providing reassurance for at least 24 hours is not applicable in severely preterm IUGR fetuses who weigh <1000 g.

Doppler Vascular Changes in Intrauterine Growth Restriction

Intrauterine growth restriction (IUGR) secondary to placental insufficiency is a major cause of perinatal morbidity and mortality in the United States. Historically, Doppler changes occurring in IUGR fetuses play an important role in the diagnosis and management of these fetuses, and now, based on these changes, we have proposed a staging system for IUGR fetuses that demonstrates prognostic value. This manuscript also summarizes a practical classification for IUGR fetuses. We believe that future studies should differentiate among the different types of IUGR fetuses.

The Transitional Phase of Ductus Venosus Reversed Flow in Severely Premature IUGR Fetuses

The guiding hypothesis for this work is that in severe intrauterine growth-restricted (IUGR) fetuses, the time from ductus venosus (DV) reversed flow (RF) appearance to intrauterine fetal demise (IUFD) or nonreassuring fetal testing is variable. As such, there must be a transitional phase between the presence of end-diastolic forward flow (FF) and absent or reversed end-diastolic flow (A/REDF). Ductus venosus Doppler was serially studied in 19 IUGR fetuses (estimated fetal weight < 10th percentile and umbilical artery pulsatility index > 95th percentile) from diagnosis until demise or delivery occurring for nonreassuring fetal testing. Ductus venosus waveforms were assessed qualitatively: forward flow versus absent or reversed flow in diastole. Two sets of at least 30 consecutive ductus venosus waveforms were obtained at each examination. If the waveforms differed between the two sets, they were defined as alternating. Cord arterial pH and base excess (BE) were obtained at birth. In 14 cases, DVRF occurred intermittently between periods of FF during the same clinical visit. Intermittent DVRF was present from 2 to 57 days (median, 13 days) and became continuous from 1 to 23 days (median, 7 days) before the occurrence of delivery for nonreassuring fetal testing or fetal demise. One fetus had an abnormal arterial pH (< 7.0) and one had an abnormal BE (< -12). These data show that (1) there is a transitional phase in which DV alternates FF and A/RF before RF becomes persistent; (2) the time from the appearance of DVRF to delivery or IUFD is variable, and (3) not all very preterm IUGR fetuses with continuous DVRF are acidemic. Because of these findings, the decision of delivery regarding early severe IUGR fetuses should be individualized, and the DVRF Doppler information has to be integrated with other antenatal fetal parameters.

Ductus venosus S-wave/isovolumetric A-wave (SIA) index and A-wave reversed flow in severely premature growth-restricted fetuses

Objective. Ductus venosus (DV) Doppler waveforms show 2 periods of decreased velocity during iso‐volumetric relaxation (isovolumetric relaxation velocity [IRV]) and atrial contraction (A wave or end‐diastolic velocity [EDV]). In intrauterine growth‐restricted (IUGR) fetuses, both may become abnormal. The hypothesis for this study was that in severely premature IUGR fetuses, Doppler assessment of both the IRV and EDV allows a more accurate prediction of fetal outcome than absent/reversed end‐diastolic flow (A/REDF) alone. Methods. Ductus venosus Doppler waveforms were serially studied in 49 severely premature IUGR fetuses from diagnosis until death or delivery. The DV waveforms were assessed for peak systolic velocity (PSV), IRV, and EDV and qualitatively for forward end‐diastolic flow or A/REDF. The S‐wave/isovolumetric A‐wave (SIA) index [PSV/(IRV + EDV)] for each fetus was compared to fetal/neonatal outcomes. Results. There were 8 cases of fetal death (FD), 9 cases of neonatal death (ND), and 32 cases of neonatal survival (NS). A receiver operating characteristic (ROC) curve for the SIA index in all cases showed that values less than −1.25 correlated with FD and those greater than −1.25 correlated with live birth, with 100% sensitivity and 100% specificity. A second ROC curve of live births showed that values less than 2.07 correlated with NS and those greater than 2.07 correlated with ND with 67% sensitivity and 94% specificity. Ductus venosus A/REDF correlated with FD, ND, and NS with sensitivity values of 88%, 78%, and 32%, respectively. Of the 32 NSs, 11 (34%) had A/REDF with a median of 11 days before delivery. Conclusions. The SIA index is a novel Doppler parameter for assessment of severely premature IUGR fetuses that allows a much more accurate prediction of fetal outcome compared to A/REDF alone.

OC116: Ductus venosus SIA Index and a‐wave reversed flow in severely premature growth‐restricted fetuses

test. Results: There were 8 fetal demises (FD), 9 neonatal demises (ND), and 32 neonates survived (NS) at the time of hospital discharge. An ROC curve for the SIA Index in all cases showed less than −1.25 correlated with FD and greater than −1.25 correlated with live birth with 100% sensitivity and 100% specificity. A second ROC curve of live births showed less than 2.07 correlated with NS and greater than 2.07 correlated with ND with a sensitivity of 67% and a specificity of 94%. DV A/REDF correlated with FD and ND with sensitivities of 88% and 78%, respectively, and with NS 32%. Of the 32 NS, 11 (34%) possessed A/REDF at some time, with a median of 11 days before delivery. Conclusions: The SIA Index is a novel Doppler parameter in the assessment of severely premature IUGR fetuses that allows a much more accurate prediction of fetal outcome compared to A/REDF alone. Assessment of the SIA Index should therefore be considered part of the evaluation of IUGR fetuses.

OC117: Are double pulsations in the umbilical vein equivalent to a-wave reversal in the ductus venosus in the management of IUGR?

Objectives: Doppler waveforms of the Ductus Venosus (DV) demonstrate two periods of decreased blood velocity. These occur during isovolumetric relaxation at the end of ventricular systole and during atrial contraction at the end of ventricular diastole (a wave). In IUGR fetuses, both the isovolumetric relaxation velocity (IRV) and the end-diastolic velocity (EDV) may become abnormal. The hypothesis of this study is that in severely premature IUGR fetuses, Doppler assessment of both the IRV and the EDV allows a more accurate prediction of fetal outcome than A/REDF alone. Methods: DV Doppler was serially studied in 49 severely premature IUGR fetuses from diagnosis until demise or delivery. DV waveforms were assessed quantitatively for peak systolic velocity (PSV), IRV, and EDV and qualitatively for forward or A/REDF. The SIA Index [PSV/(IRV+EDV)] was calculated for each fetus and compared to fetal/neonatal outcomes. Data was analyzed by Kruskal-Wallis non-parametric one-way ANOVA with post-hoc Mann-Whitney U test. Results: There were 8 fetal demises (FD), 9 neonatal demises (ND), and 32 neonates survived (NS) at the time of hospital discharge. An ROC curve for the SIA Index in all cases showed less than −1.25 correlated with FD and greater than −1.25 correlated with live birth with 100% sensitivity and 100% specificity. A second ROC curve of live births showed less than 2.07 correlated with NS and greater than 2.07 correlated with ND with a sensitivity of 67% and a specificity of 94%. DV A/REDF correlated with FD and ND with sensitivities of 88% and 78%, respectively, and with NS 32%. Of the 32 NS, 11 (34%) possessed A/REDF at some time, with a median of 11 days before delivery. Conclusions: The SIA Index is a novel Doppler parameter in the assessment of severely premature IUGR fetuses that allows a much more accurate prediction of fetal outcome compared to A/REDF alone. Assessment of the SIA Index should therefore be considered part of the evaluation of IUGR fetuses.