Michelle Kush

Doppler and biophysical assessment in growth restricted fetuses: distribution of test results

Multi‐vessel Doppler ultrasonography and biophysical profile scoring (BPS) are used in the surveillance of growth restricted fetuses (IUGR). The interpretation of both tests performed concurrently may be complex. This study examines the relationship between Doppler ultrasonography and biophysical test results in IUGR fetuses.

Predictors of necrotizing enterocolitis in preterm growth-restricted neonates

OBJECTIVE The purpose of this study was to test the hypothesis that multivessel fetal Doppler imaging provides enhanced prediction of necrotizing enterocolitis (NEC) in preterm placental insufficiency. STUDY DESIGN Placental-based growth-restricted fetuses (abdominal circumference <5%, abnormal umbilical artery [UA] Doppler imaging) were examined. UA, middle cerebral artery, ductus venosus, and umbilical vein (UV) were evaluated prenatally and were assessed for their ability to predict NEC in neonates who were delivered at <37 weeks of gestation. RESULTS Thirty-nine of 404 neonates (9.7%) experienced NEC. Among these, the mortality rate was 15.4% (6/39 neonates; odds ratio, 2.7; 95% CI, 1.03-7.11). NEC cases had higher UA Doppler indices prenatally (P = .023), lower gestational ages and birthweight at delivery (P < .0001, respectively), 5-minute Apgar scores of <7, and higher umbilical cord artery base deficit (P < .01, respectively). NEC was more likely after prenatal UV pulsations (odds ratio, 2.4; 95% CI, 1.13-5.14; P = .028) and severe cardiovascular abnormality (composite variable incorporating UA- absent or reversed end diastolic velocity, absent or reversed ductus venosus a-wave, or UV pulsations; odds ratio, 2.1; 95% CI, 1.06-4.05; P = .029) Logistic regression revealed birthweight and base deficit as the main contributors of NEC (r(2) = 0.20; P < .0001). Receiver operating characteristic analyses revealed birthweight of <790 g (sensitivity, 74.4%; specificity, 72.9%; P < .0001) and gestational age of < or =32.2 weeks (sensitivity, 94.9%; specificity, 45.8%; P < .0001) as optimal cut-offs that provide an odds ratio for NEC of 8.2 (95% CI, 3.9-17.6; P < .0001). CONCLUSION Placental disease predisposes the severely growth-restricted neonate to necrotizing enterocolitis. Even when arterial and venous Doppler variables are taken into consideration, birthweight remains the predominant risk factor for NEC. Further research should focus on the critical transition to neonatal life to identify relevant triggers in predisposed neonates.

Persistent fetal hemoglobin in maternal circulation complicating the diagnosis of fetomaternal hemorrhage.

BACKGROUND: Transplacental hemorrhage can be life threatening to a fetus and has important maternal treatment implications. In contrast, hereditary persistence of fetal hemoglobin is a condition that has little consequence. The Kleihauer-Betke test, which is routinely used to document transplacental hemorrhage, will be positive in either case. CASES: We report two cases in which maternal persistence of fetal hemoglobin was unknown and led to the erroneous diagnosis of fetomaternal hemorrhage. These cases highlight both the limitations of the Kleihauer-Betke test and the role of flow cytometry in diagnosing fetomaternal hemorrhage. CONCLUSION: The use of flow cytometry can clarify Kleihauer-Betke test results when there is known maternal persistence of fetal hemoglobin and can more precisely quantify a fetomaternal hemorrhage for accurate Rh immune globulin dosing.

Variable umbilical artery end-diastolic velocity: a possible sign of velamentous cord insertion in monochorionic gestation

1. Haimov-Kochman R, Sciaky-Tamir Y, Yanai N, Yagel S. Conservative management of two cases of ectopic scar pregnancies implanted in previous uterine scars. Ultrasound Obstet Gynecol 2002; 19: 616–619. 2. Seow K-M, Hwang J-L, Tsai Y-L. Ultrasound diagnosis of a pregnancy in Cesarean section scar (Letter). Ultrasound Obstet Gynecol 2001; 18: 547–548. 3. Jurkovic D, Hacket E, Campbell S. Diagnosis and treatment of early cervical pregnancy: a review and a report of two cases treated conservatively. Ultrasound Obstet Gynecol 1996; 8: 373–380.

Lethal Progression of a Fetal Intracranial Arteriovenous Malformation

Fetal intracranial vascular tumors present unique clinical challenges. Accurate diagnosis of the lesion, as well as an understanding of the local and systemic impacts, will guide the antenatal surveillance and the treatment plan and will determine the prognosis. Management will be altered by and dependent on intrauterine progression, gestational age, and fetal condition at birth. In addition, large vascular tumors can lead to the development of the Kasabach-Merritt sequence in the fetus and to either fetal or maternal hemodynamic impairment. Vascular tumors are either malformations or neoplasms. Color and pulsed wave Doppler sonography are useful for the identification of vascular lesions and help narrow the differential diagnosis. Once a vascular malformation is identified, a comprehensive anatomic survey is mandatory to determine whether there are coexistent malformations that impact either the diagnosis or prognosis. These lesions can have local mass effects, systemic hemodynamic effects, or both. Therefore, longitudinal assessment of the fetus is focused on the detection of lesion progression and on any fetal or maternal status changes. We report the prenatal diagnosis of an intracranial arteriovenous malformation (AVM) with a dramatic progression affecting both mother and fetus.

First-trimester detection of fetal anomalies in pregestational diabetes using nuchal translucency, ductus venosus Doppler, and maternal glycosylated hemoglobin.

OBJECTIVE The frequency of fetal anomalies in women with pregestational diabetes correlates with their glycemic control. This study aimed to assess the predictive performance of first-trimester fetal nuchal translucency (NT), ductus venosus (DV) Doppler, and hemoglobin A1c (HbA1c) to predict fetal anomalies in women with pregestational diabetes. STUDY DESIGN This was a prospective observational study of patients undergoing first-trimester NT with DV Doppler. Screening performance was tested for first-trimester parameters to detect fetal anomalies. RESULTS Of 293 patients, 17 had fetal anomalies (11 cardiac, 7 major, 3 multisystem). All anomalous fetuses were suspected prenatally. One had NT >95th centile, 2 had reversed DV a-wave, and 13 had HbA1c >7.0%. The HbA1c was the primary determinant of anomalies (r(2), 0.15; P < .001) and >8.35% was the optimal cutoff for prediction of anomalies with an area under the curve of 0.72 (95% confidence interval, 0.57-0.88). Therefore, first-trimester prediction of anomalies was best in women with increased NT or HbA1c >8.3% (sensitivity 70.6%, specificity 77.4%, positive predictive value 16.2%, negative predictive value 97.7%, P < .001). CONCLUSION In women with pregestational diabetes and poor glycemic control, an increased NT increases risks for major fetal anomalies. Second-trimester follow-up is required to achieve accurate prenatal diagnosis.

Hematologic profile of neonates with growth restriction is associated with rate and degree of prenatal Doppler deterioration

To examine the relationship between hematologic parameters at birth and prenatal progression of Doppler abnormalities in fetal growth restriction (FGR).

OC27.04: Intervention thresholds for severe early onset growth restriction (IUGR)

intraventricular hemorrhagia and elevated nucleated red blood cell counts at delivery. Results: 8 stillbirths (10.7%), 12 perinatal (16%) and 2 neonatal death (2%) occurred among 74 fetuses. Logistic regression analysis confirmed that abnormal Ductus venosus waveforms (R2 = 0.57, p < 0.001) together with gestational age (R2 = 0.57, p < 0.001) showed the strongest association with perinatal death, whereas gestational age only was significantly related with neonatal death (R2 = 0.67, p < 0.05). Abnormal ductus venosus Doppler waveforms (R2 = 0.86, p < 0.001) and gestation age (R2 = 0.49, p < 0.05) were strongly associated with adverse outcome. Abnormal venous Doppler flow patterns performed better in the prediction of fetal or perinatal demise than died ARED flow or brain sparing. Conclusion: Abnormal Ductus venosus waveforms in preterm growth-related fetuses with ARED flow are strongly relates to adverse fetal and perinatal outcomes below 32 weeks of gestational age. The possible benefit of these pregnancies to be prolonged can only be evaluated in a prospective randomized study.

P10.06: The relationship of Doppler and biophysical parameters in growth restricted fetuses (IUGR)

Objective: Adding NO donors to the antihypertensive treatment in gestational hypertensive patients complicated by fetal growth restriction. Methods: Fifty moderate to severe gestational hypertensive patients (27–30 weeks of gestation) with fetal abdominal circumference < 10th percentile for gestational age and normal fetal Doppler parameters, were submitted to maternal echocardiographic exam before and 14 days after treatment was started. Patients were randomised in two treatment groups: (1) 25 patients underwent Calcium antagonists and Bed Rest; (2) 25 patients underwent Calcium antagonists and Bed Rest + Transdermal glyceryl trinitrate (5–10 mg released in 24 hours administrated for 12–14 hours) + intravenous fluid infusion with 2000 mL over 24 hours. Results: Are shown in the table. Conclusions: Nitrates and fluid therapy added to standard antihypertensive treatment improve maternal hemodinamics and fetal growth more than standard antihypertensive treatment alone.

OC24.04: Relationship between prenatal Doppler findings and neurodevelopmental outcome at 2 years of age in intrauterine growth restriction (IUGR)

Comment: In CHD fetuses, increased DV Index, associated with reduced forward ductal flow to the right atrium, well correlates with increased right atrial pressure occurring in right outflow tract obstruction or in hypoplastic left ventricle. On the contrary in IUGR fetuses with increased DV Index and compensatory ductal dilatation, normal left cardiac output suggests normal myocardial function due to a maintained or even increased forward flow through the DV to right atrium.