Mario Girard

Association between first-trimester placental volume and birth weight

OBJECTIVE To estimate the correlation between first-trimester placental volume, birth weight, small-for-gestational-age (SGA), and preeclampsia. METHODS A prospective study of women with singleton pregnancy at 11-13 weeks of gestation was conducted. First-trimester placental volume was measured using three-dimensional ultrasound and reported as multiple of median (MoM) for gestational age. Participants were followed until delivery where birth weight, placental weight, and occurrence of preeclampsia were collected. Non-parametric analyses were performed. RESULTS We reached a complete follow-up for 543 eligible women. First-trimester placental volume was significantly correlated with birth weight (correlation coefficient: 0.18; p < 0.0001) and placental weight (cc: 0.22; p < 0.0001) adjusted for gestational age. First-trimester placental volume was smaller in women who delivered SGA neonates (median MoM: 0.79; interquartile range: 0.62-1.00; p < 0.001) and greater in women who delivered large-for-gestational-age neonates (median MoM: 1.13; 0.95-1.49; p < 0.001) when compared to women with neonates between the 10th and 90th percentile (median MoM: 1.00; 0.81-1.25). First-trimester placental volume was not associated with the risk of preeclampsia (cc: 0.01; p = 0.87). CONCLUSION First-trimester placental volume is strongly associated with fetal and placental growth. However, we did not observe a correlation between placental volume and the risk of preeclampsia.

Lower uterine segment thickness to prevent uterine rupture and adverse perinatal outcomes: a multicenter prospective study

BACKGROUND Choice of delivery route after previous cesarean delivery can be difficult because both trial of labor after cesarean delivery and elective repeat cesarean delivery are associated with risks. The major risk that is associated with trial of labor after cesarean delivery is uterine rupture that requires emergency laparotomy. OBJECTIVE This study aimed to estimate the occurrence of uterine rupture during trial of labor after cesarean delivery when lower uterine segment thickness measurement is included in the decision-making process about the route of delivery. STUDY DESIGN In 4 tertiary-care centers, we prospectively recruited women between 34 and 38 weeks of gestation who were contemplating a vaginal birth after a previous single low-transverse cesarean delivery. Lower uterine segment thickness was measured by ultrasound imaging and integrated in the decision of delivery route. According to lower uterine segment thickness, women were classified in 3 risk categories for uterine rupture: high risk (<2.0 mm), intermediate risk (2.0-2.4 mm), and low risk (≥2.5 mm). Our primary outcome was symptomatic uterine rupture, which was defined as requiring urgent laparotomy. We calculated that 942 women who were undergoing a trial of labor after cesarean delivery should be included to be able to show a risk of uterine rupture <0.8%. RESULTS We recruited 1856 women, of whom 1849 (99%) had a complete follow-up data. Lower uterine segment thickness was <2.0 mm in 194 women (11%), 2.0-2.4 mm in 217 women (12%), and ≥2.5 mm in 1438 women (78%). Rate of trial of labor was 9%, 42%, and 61% in the 3 categories, respectively (P<.0001). Of 984 trials of labor, there were no symptomatic uterine ruptures, which is a rate that was lower than the 0.8% expected rate (P=.0001). CONCLUSION The inclusion of lower uterine segment thickness measurement in the decision of the route of delivery allows a low risk of uterine rupture during trial of labor after cesarean delivery.

Reliability of Two-Dimensional Transvaginal Sonographic Measurement of Lower Uterine Segment Thickness Using Video Sequences

OBJECTIVES To report the intra- and interobserver reliability of measurement of the lower uterine segment (LUS) thickness using transvaginal sonographic videos. METHODS A prospective study of 60 women with previous, low-transverse cesarean undergoing LUS examination (36 to 39 weeks) was performed. Two observers independently measured full LUS thickness using transvaginal sonography. A video of the LUS was recorded and analyzed more than 2 months later by both observers. Intra- and interobserver reliability was assessed with median absolute differences and interquartile range (IQR), nonparametric limits of agreement, intraclass correlation coefficients (ICC) with 95% confidence interval (95% CI), and kappa coefficients. RESULTS Median full LUS thickness was 3.6 mm (range: 0.9 to 8.0 mm). Intraobserver repeatability was excellent (median difference: 0.2 mm, IQR: 0.1 to 0.4; ICC: 0.94, 95% CI: 0.90 to 0.96; kappa: 1.00). Interobserver (median difference: 0.3 mm, IQR: 0.2 to 1.3; ICC: 0.91, 95% CI: 0.86 to 0.95; kappa: 0.76, 95% CI: 0.54 to 0.98) and intermethod reproducibility (median difference: 0.4 mm, IQR: 0.2 to 0.8; ICC: 0.82, 95% CI: 0.72 to 0.89; kappa: 0.69, 95% CI: 0.43 to 0.94) were good. However, both interobserver and intermethod reproducibility were improved when LUS thickness was below 3 mm. CONCLUSION Full LUS thickness measured from transvaginal sonographic videos has excellent intra- and interobserver reproducibility and good reproducibility with live transvaginal ultrasound.

Association between physical activity in early pregnancy and markers of placental growth and function.

OBJECTIVES It has been suggested that physical activity (PA) can influence the development of the placenta and the risk of placenta-mediated complications of pregnancy. We evaluated the association between PA and early markers of placental development. METHODS Ninety-four nulliparous women were invited to participate in a prospective observational cohort study. Assessment included measurement of placental growth factor (PlGF) and pregnancy-associated plasma protein-A (PAPP-A) concentrations (expressed in multiples of the median), an ultrasound at 11 to 13 weeks for measurement of placental volume and the mean uterine artery (UtA) pulsatility index, and a questionnaire on PA. The association between PA and these markers was evaluated using univariate and multivariate regression analyses. RESULTS We found a significantly lower concentration of PlGF and a trend towards lower placenta volume and lower PAPP-A concentration with increased PA frequency. The negative association between PA frequency and PlGF concentration remained significant after adjustment for potential confounding factors. CONCLUSION Our results suggest that PA in early pregnancy could negatively affect placental development. This finding could explain the association between PA and severe preeclampsia. This finding deserves confirmation in a larger cohort.

Reliability of 3-Dimensional Transvaginal Sonographic Measurement of Lower Uterine Segment Thickness

The purpose of this study was to report the intraobserver and interobserver reliability of transvaginal 3‐dimensional (3D) sonographic measurement of lower uterine segment thickness.

Labour Before a Caesarean Section and the Morphology of the Lower Uterine Segment in the Next Pregnancy

T women with a single previous Caesarean section underwent ultrasonographic measurement of the lower uterine segment (LUS) between 35 and 38 weeks. While the first woman had a previous CS before labour for breech presentation, the second had a CS for arrested cervical dilatation at 8 cm. In the first woman, visualization of a defect in the uterine scar (full thickness of 1.8 mm) was possible only through a transabdominal approach, approximately 9 cm from cervical os (Figure 1A). In the second woman, the presence of a defect inside the cervical tissue was visible only through a transvaginal approach (Figure 1B).

High-flavanol and high-theobromine versus low-flavanol and low-theobromine chocolate to improve uterine artery pulsatility index: a double blind randomized clinical trial

Abstract Objective: To evaluate the impact of high-flavanol and high-theobromine (HFHT) chocolate in women at risk of preeclampsia (PE). Study design: We conducted a single-center randomized controlled trial including women with singleton pregnancy between 11 and 14 weeks gestation who had bilateral abnormal uterine artery (UtA) waveforms (notching) and elevated pulsatility index (PI). Participants were randomized to either HFHT or low-flavanol and low-theobromine (LFLT) chocolate (30 grams daily for a total of 12 weeks). UtA PI, reported as multiple of medians (MoM) adjusted for gestational age, was assessed at baseline and 12 weeks after randomization. Results: One hundred thirty-one women were randomized with mean gestational age of 12.4 ± 0.6 weeks and a mean UtA PI of 1.39 ± 0.31 MoM. UtA PI adjusted for gestational age significantly decreased from baseline to the second visit (12 weeks later) in the two groups (p < 0.0001) but no significant difference was observed between the groups (p = 0.16). Conclusions: Compared with LFLT chocolate, daily intake of HFHT chocolate was not associated with significant changes of UtA PI. Nevertheless, the improvement observed in both groups suggests that chocolate could improve placental function independently of flavanol and/or theobromine content.

OP15.08: Comparison between transvaginal and abdominal sonography of lower uterine segment thickness near term

(UtR), and estimate the fraction of CO distributed to the uteroplacental circulation during the second half of pregnancy. Methods: Fifty-three low risk-pregnancies were evaluated longitudinally at approximately 4-weekly intervals from 22 weeks until term (a total of 253 observations). Mean arterial blood pressure (MAP), CO and SVR were measured using impedance cardiography, and the uterine artery blood flow velocities and diameter using Doppler and B-mode ultrasonography, respectively. Quta of both uterine arteries was estimated as the product of time-averaged intensity weighted mean velocity and cross-sectional area of the uterine artery. UtR was calculated as: MAP/sum of right and left Quta. Results: CO increased from 5.5 to 5.8 L/min (p = 0.006) despite a significant increase in SVR from 1046 to 1135 dyne s cm-5 (p = 0.0077) during 22–40 weeks. The UtR decreased from 0.26 to 0.13 mmHg/mL/min (p < 0.00001) and the total utero-placental blood flow more than doubled during the same period increasing from 299 ml/min to 673 ml/min which represented 5.6% to 11.7% of the maternal CO. Conclusion: We have established longitudinal reference intervals for the fraction of maternal CO distributed to the utero-placental circulation at 22–40 weeks of gestation. Increments in uteroplacental blood flow are relatively higher than that of the CO in the second half of pregnancy suggesting redistribution of maternal circulation due to continuous reduction in UtR.

OP21.03: Inter-acquisition reliability of 11–13 weeks sub-placental myometrium vasculature obtained by 3D ultrasound

Mean CRL was 63.03 ± 8.30 mm. Mean gestational age was 12.55 ± 0.63 weeks. Fetal placental sites and ratios were as following; Anterior location 48.1%, Posterior location 40.9%, Lateral location 5.4% and fundal location 3.6%. Left and right uterine artery PI values according to placental sites are shown in the Table 1. There were no statistical significant differences among placental sites. Unilateral or bilateral uterine artery notch was present in 350 pregnant women (19%). Uterine artery notch laterality ratios according to placental sites are as following; in anterior location (n = 168) 65% bilateral, 24% left sided, 11% right sided; in posterior (n = 122) 68% bilateral, 18% left sided, 13% right sided; in lateral (n = 39) 62% bilateral, 28% left sided, 10% right sided and in fundus (n = 21) 58% bilateral, 28% left sided, 14% right sided. The ratios did not show significant difference. Conclusions: The placental site does not seem to have effect on uterine artery PI values and the laterality of uterine artery notch.

Intra-Amniotic Sludge in a Woman With Asymptomatic Cervical Dilatation

Awoman presented for spotting at 23 weeks’ gestation. She had had transient vaginal bleeding during the first trimester and irregular abdominal cramping for the previous two weeks. She was afebrile, had no regular uterine contractions, and her abdomen was not tender. Pelvic examination revealed a dilated cervix (3 to 4 cm) with protruding amniotic membranes. With a diagnosis of suspected incompetent cervix, rescue cervical cerclage was considered.