M. Gómez Roig

Crecimiento intrauterino restringido: ¿problema de definición o de contenido?

El crecimiento es un proceso continuo que se inicia con la fecundación y termina al final de la adolescencia. El feto experimenta de forma conjunta el crecimiento y el desarrollo, y no lo hace de una forma uniforme ni paralela. La facilidad o la dificultad en uno de estos procesos no implican la alteración positiva o negativa en el otro. Los genomas parentales marcan una huella genómica o genoma imprinting desde la gametogénesis y explican entre un 35 y un 40% de las variaciones observadas en el peso al nacer. Este regulador genético viene modulado por otros reguladores de crecimiento externo: el regulador hormonal de naturaleza fetal y estimulante, y el regulador ambiental de naturaleza materna y casi siempre restrictivo. Las principales hormonas implicadas en el control del crecimiento fetal parecen ser diferentes de las relacionadas con el crecimiento posnatal. Actualmente es conocido el control fetal en orden a dos sistemas endocrinos: la insulina y el sistema de los insuline-like growth factor (IGF). En los casos de crecimiento intrauterino restringido (CIR), existe una alteración de la sensibilidad, con una relativa resistencia a la insulina, IGF-I y hormona del crecimiento (GH). La regulación de las proteínas transportadoras de IGF también parece estar alterada. La interacción entre el aporte de nutrientes y el eje endocrino somatotrópico (IGF-I, IGF-II, GH, insulina) es esencial en el control del crecimiento fetal.

P07.17: The use of first trimester biochemical markers for crown-rump length quality control

Methods: Ten ultrasound images demonstrating CRL measurements taken from routine obstetric ultrasound departments were evaluated by a group of 11 experienced ultrasound practitioners, including the nine Regional Obstetric Ultrasound Screening Coordinators for England. The RAG (red/amber/green) flag system was used to score each image as good (green), acceptable (amber) or poor (red). The main components of the image were identified. The constituent parts of each component were then indentified and defined using objective criteria. The images were then rescored using the agreed criteria and the criteria refined until consensus was reached and the correct RAG flag assigned. A suite of 10 scored images, each with a detailed breakdown of how its score was assigned, was produced and piloted as an audit tool for individuals and a teaching tool for staff teams. Results: Six CRL image components, of magnification, end points, horizontal position, rotation, flexion and calliper placement, are identified. Magnification and horizontal position are both defined by one criterion, end points by four, rotation by five, flexion by four and calliper placement by three criteria. A green flag is scored when all 18 criteria are achieved. Failure to achieve specific combinations scores an amber flag while other specific combinations score a red flag. The sonographer response to the tool is that it is daunting to use initially but once familiar with its principles, it is logical, quick to apply and clinically useful. Conclusions: The CRL image can be broken down into 18 defined criteria that can be used to produce an objective image assessment tool.

OP39.10: Comparative corporal composition at twelve and twenty‐four months of life for babies with: intrauterine growth restriction (IUGR), small for gestational age (SGA) and appropriate for gestational age (AGA)

Objectives: Placental insufficiency and fetal growth restriction may lead to fetal hypoxia and acidemia, which result in fetal cardiac injury. The aim was to compare the levels of fetal cardiac troponin T (cTnT) at birth according to fetal gender in pregnancies complicated by placental insufficiency before 34 weeks gestation. Methods: Between March 2007 and Feb 2010, 45 singleton pregnancies with placental insufficiency characterized by abnormal umbilical artery Doppler were prospectively studied. All the patients delivered by Cesarean section and the Doppler exams were performed at the same day. Immediately after delivery, UA blood samples were obtained for fetal cTNT measurements. Fetal cardiac injury was characterized by abnormal level of fetal cTnT at birth (>=0.10 ng/mL). Results: Fetal cardiac TnT at birth was significantly higher in the group of male fetuses (n = 20, 44.4%) when compared with female fetuses (mean = 0.137, SD = 0.095 ng/mL vs. mean = 0.082, SD = 0.077 ng/mL, P = 0.041). In the group of male fetuses, Doppler results of ductus venosus (DV) showed values of DV PIV > 1.0 in 14 cases (70%), and in the group of female fetuses 12 cases (48%, P = 0.237). Conclusions: Fetal gender was associated with cTnT level at birth in pregnancies complicated by placental insufficiency before 34th weeks gestation. The fetal cardiac compromise and cardiac injury may be influenced by fetal gender, suggesting differences in the cardiovascular response to fetal hypoxia.

Associations between neural injury markers of intrauterine growth-restricted infants and neurodevelopment at 2 years of age

Abstract Objectives: The aim of this study was to evaluate the relationships between brain injury biomarkers in intrauterine growth-restricted (IUGR) infants (S100B and neuron-specific enolase (NSE)) and neurodevelopment at 2 years of age. Methods: This prospective case-control study was a cooperative effort among Spanish Maternal and Child Health Network (Retic SAMID) hospitals. At inclusion, biometry for estimated fetal weight and feto-placental Doppler variables were measured for each infant. Maternal venous blood and fetal umbilical arterial blood samples were collected at the time of delivery and neural injury markers S100B and NSE concentrations were measured. Neurodevelopment was evaluated at 2 years of age using the Bayley Scales of Infant and Toddler Development, third edition (Bayley-III). Results: Fifty six pregnancies were included. Thirty-one infants were classified as IUGR and 25 as non-IUGR. Neurodevelopmental evaluation at 2 years of age indicated that there were no between-group differences for any of the tests. For all patients in both groups, we found statistically significant inverse relationships between the concentrations of NSE in the cord blood and the results of the cognitive test (r = −271, p = .042), fine motor subtest (r = −280, p = .036), and social-emotional test (r = −349, p = .015). We also found statistically significant differences between the concentrations of S100B in the cord blood and the results of the cognitive test (r = −306, p = .022) and expressive communication subtest (r = −304, p = .023). For the IUGR group, we found a significant inverse relationship between the concentrations of S100B in the maternal serum and the results of adaptive behavior test (p < .05). In the non-IUGR group, we found statistically significant inverse relationships between the concentration of NSE in the cord blood and the results of the fine motor subtest (r = −446, p = .025) and social-emotional test (r = −489, p = .021). The difference between the concentration of S100B in the cord blood and the language composite score was also statistically significant (p = .038). Conclusions: At 2 years of age, the concentrations of NSE and S100B were higher in the non-IUGR and IUGR groups with the worst scores for some areas of neurodevelopmental evaluation. The value of these biomarkers for prognostic neurodevelopmental use requires further investigation for both non-IUGR and IUGR infants.

P08.19: Perinatal results comparing small for gestational age (SGA) fetuses and intrauterine growth restriction (IUGR) fetuses

Objectives: To detect the hemodynamics characteristics of moternal fetal doppler blood flow surveillance in congenital heart disease (CHD). Methods: This is a retrospective study of 132 singleton pregnancy women due to fetal CHD. Detailed maternal fetal Doppler were performed after fetal echocardiography. We noted the PI of fetal venous duct (DV), free segment of umbilical vein (UV) and intra-abdominal segment, middle cerebral artery (MCA), umbilical artery (UA) and bilateral uterine artery (AU) and congenital heart malformations. According to PI of these vessels, the umbilical artery blood flow classification (BFC), uterine artery score (UAS), placental score (PLS) are done. Results: 1. 27 cases with simple septal defect fetus and 51 cases with complex CHD fetus have normal PI fetal UA, DV and MCA (BFC = 0) compared with normal fetus. 2. 38 cases of complex CHD with cardiothoracic ratio >0.35, TV and MV regurgitation, have significantly increased PI of UA, DV, and PI of MCA reduced. BFC and PLS both >0 (P 0 and PLS >0. Conclusions: The fetal venous system Doppler is the first change, Which give a further demonstration that the abnormality of CHD fetus circulation will cause the fetal-placental circulation corresponding changes, and make the placental function reduce and fetus damage.

OP22.06: Systolic dysfunction in intrauterine growth restriction fetuses with abnormal uterine artery Doppler evaluated by TAPSE and MAPSE

Gestational age at scan (weeks) 35.4 ± 2.9 36.7 ± 3.0 36.2 ± 3.2 0.094 Feto-placental Doppler (z-scores) Umbilical artery pulsatility index −0.02 ± 0.54 −0.02 ± 0.60 0.16 ± 0.53 0.166 Middle cerebral artery pulsatility index 0.54 ± 0.97 0.18 ± 0.71 0.44 ± 0.94 0.146 Cerebroplacental ratio 0.21 ± 1.21 −0.06 ± 1.13 −0.06 ± 1.23 0.362 Fetal cardiac morphometry Cardiothoracic Ratio 0.28 ± 0.05 0.32 ± 0.06* 0.34 ± 0.06* <0.001 Left Sphericity Index 1.83 ± 0.32 1.67 ± 0.25* 1.59 ± 0.33* <0.001 Fetal cardiac function (z-scores) Left myocardial performance Index 0.04 ± 0.59 0.99 ± 1.09* 1.25 ± 1.09* <0.001 Tricuspid annular plane systolic excursion −0.74 ± 0.79 −1.53 ± 0.94* −1.59 ± 0.85* <0.001 Septal annular early diastolic peak velocity (E’) 0.79 ± 1.07 −0.49 ± 1.18* −0.51 ± 1.23* <0.001 Septal annular systolic peak velocity (S’) 0.88 ± 1.11 −0.33 ± 0.98* −0.39 ± 1.06* <0.001

OP01.09: Perinatal outcomes in gestations with intrauterine growth restriction and small for gestational age foetuses, admitted to neonatal unit

vs 11% in NA), in neonatal weight (1800gr in A vs 2500gr in NA) and in IUGR/SGA (83% of IUGR/ 54% of SGA were A vs. 17% of IUGR/46% of SGA were NA). These differences were not observed in maternal age, maternal parity, alterations of uterine arteries Doppler, amniotic fluid, induction of delivery, gestational age at diagnostic, neonatal gender, umbilical artery pH at birth or Apgar score at 1 and 5 minutes. Important neonatal complications were observed all in those newborn admitted to neonatal unit (16 respiratory distress syndromes, 9 pathological cerebral scans, 7 hyaline membrane diseases, 7 mechanical ventilation, 5 inotropic drugs, 3 sepsis, 3 renal insufficiencies, 1 cerebral hemorrhage, 1 neonatal death and 1 enterocolitis). Conclusions: As our study corroborates, obstetrical complications (hypertension, Doppler alterations, non-reassuring fetal heart rate status during labor, Caesarean section, prematurity) in foetuses with an EFW below 10th percentile are predictors of lower fetal weight, of admission to neonatal unit at birth and of neonatal complications.

OP01.10: Intrauterine growth restriction (IUGR), small for gestational age (SGA) and postnatal growth at twelve and twenty four months of life

vs 11% in NA), in neonatal weight (1800gr in A vs 2500gr in NA) and in IUGR/SGA (83% of IUGR/ 54% of SGA were A vs. 17% of IUGR/46% of SGA were NA). These differences were not observed in maternal age, maternal parity, alterations of uterine arteries Doppler, amniotic fluid, induction of delivery, gestational age at diagnostic, neonatal gender, umbilical artery pH at birth or Apgar score at 1 and 5 minutes. Important neonatal complications were observed all in those newborn admitted to neonatal unit (16 respiratory distress syndromes, 9 pathological cerebral scans, 7 hyaline membrane diseases, 7 mechanical ventilation, 5 inotropic drugs, 3 sepsis, 3 renal insufficiencies, 1 cerebral hemorrhage, 1 neonatal death and 1 enterocolitis). Conclusions: As our study corroborates, obstetrical complications (hypertension, Doppler alterations, non-reassuring fetal heart rate status during labor, Caesarean section, prematurity) in foetuses with an EFW below 10th percentile are predictors of lower fetal weight, of admission to neonatal unit at birth and of neonatal complications.

OP36.04: Perinatal outcome after prenatal diagnosis of Ebstein's anomaly

Y. Mivelaz1, K. I. Lim2, C. Templeton1, C. I. Andrew3, J. E. Potts1, G. G. Sandor1 1Division of Cardiology, Department of Pediatrics, BC Children’s Hospital, The University of British Columbia, Vancouver, BC, Canada; 2Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, BC Women’s Hospital, The University of British Columbia, Vancouver, BC, Canada; 3Division of Cardiac Surgery, Department of Surgery, BC Children’s Hospital, The University of British Columbia, Vancouver, BC, Canada

OP17.09: Use of CUSUM method in nuchal translucency audit

Objectives: To determine whether the type of test used for trisomy 21 screening significantly alters the effect that nuchal translucency (NT) variability has on the result. Methods: Our case series included women who underwent aneuploidy screening at a single maternal fetal medicine practice from July 2004 through September 2009. The NT measurements used in each screen were altered to reflect discrepancies in measurement based on an analysis of our unit’s average variation over a nine month period. This mean variation was derived by averaging 500 sets of 3 NT measurements from consecutive patients in our unit from January 2009 through September 2009. Results were then analyzed to identify subjects for whom the variance in NT measurement affected interpretation of risk according to unit cutoffs for each type of screen (1 : 230 for first-trimester and 1 : 110 for integrated). Descriptive and Pearson’s chi-square statistics were used. Results: Of 13,633 total subjects, 6,314 had integrated screening, and 7,319 had first-trimester combined. Each screen’s original NT measurement was re-calculated to reflect our unit’s average variation (0.2 mm). The results were modeled based on a 0.4 mm total range to account for the possibility of an increase or decrease in measurement. The overall number of patients whose results were affected by a change in risk interpretation was 496 (6.8%) for first-trimester and 141 (2.2%) for integrated screening. A comparison of the overall number of subjects affected by each type of screen was statistically significant (P < 0.0001). Conclusions: The effect of variation in NT measurement can be minimized by using integrated screening as compared to firsttrimester combined.