T. Stampalija

Utero-placental Doppler ultrasound for improving pregnancy outcome

BACKGROUNDnImpaired placentation can cause some of the most important obstetrical complications such as pre-eclampsia and intrauterine growth restriction and has been linked to increased fetal morbidity and mortality. The failure to undergo physiological trophoblastic vascular changes is reflected by the high impedance to the blood flow at the level of the uterine arteries. Doppler ultrasound study of utero-placental blood vessels, using waveform indices or notching, may help to identify the at-risk women in the first and second trimester of pregnancy, such that interventions might be used to reduce maternal and fetal morbidity and/or mortality.nnnOBJECTIVESnTo assess the effects on pregnancy outcome, and obstetric practice, of routine utero-placental Doppler ultrasound in first and second trimester of pregnancy in pregnant women at high and low risk of hypertensive complications.nnnSEARCH STRATEGYnWe searched the Cochrane Pregnancy and Childbirth Groups Trials Register (June 2010) and the reference lists of identified studies.nnnSELECTION CRITERIAnRandomised and quasi-randomised controlled trials of Doppler ultrasound for the investigation of utero-placental vessel waveforms in first and second trimester compared with no Doppler ultrasound. We have excluded studies where uterine vessels have been assessed together with fetal and umbilical vessels.nnnDATA COLLECTION AND ANALYSISnTwo authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. We checked data entry.nnnMAIN RESULTSnWe found two studies involving 4993 participants. The methodological quality of the trials was good. Both studies included women at low risk for hypertensive disorders, with Doppler ultrasound of the uterine arteries performed in the second trimester of pregnancy. In both studies, pathological finding of uterine arteries was followed by low-dose aspirin administration.We identified no difference in short-term maternal and fetal clinical outcomes.We identified no randomised studies assessing the utero-placental vessels in the first trimester or in women at high risk for hypertensive disorders.nnnAUTHORS CONCLUSIONSnPresent evidence failed to show any benefit to either the baby or the mother when utero-placental Doppler ultrasound was used in the second trimester of pregnancy in women at low risk for hypertensive disorders. Nevertheless, this evidence cannot be considered conclusive with only two studies included. There were no randomised studies in the first trimester, or in women at high risk. More research is needed to investigate whether the use of utero-placental Doppler ultrasound may improve pregnancy outcome.

Distinction between fetal growth restriction and small for gestational age newborn weight enhances the prognostic value of low PAPP‐A in the first trimester

Several studies have tested the hypothesis that low maternal serum levels of pregnancy-associated plasma protein A (PAPP-A) may predict adverse pregnancy outcomes other than Down syndrome in first trimester (Dugoff et al., 2004; Krantz et al., 2004; Smith et al., 2006; Barrett et al., 2008; Spencer et al., 2008a,b). Low levels of PAPP-A in maternal blood could become an early marker of obstetrical complications associated with poor placental function, that is small babies, gestational hypertension (GH), pre-eclampsia (PE), stillbirth and even premature delivery. However, contradictory results had been observed in different cohorts (Kavak et al., 2006; Spencer et al., 2008a,b). These findings could result as a consequence of non-homogeneous criteria in the definition of different abnormal obstetrical outcomes. Recently, Poon et al. (2010) showed that low PAPP-A is significantly associated with early PE but not with late PE. This confirmed the need to distinguish among abnormal obstetrical outcomes those based on similar placental damage. Moreover, when considering poor obstetrical outcomes, other environmental factors have to be taken into account. Among these, maternal smoking has been largely studied while it is associated with impaired fetal growth. Therefore, this factor could interfere when evaluating the predictive value of PAPP-A. The aim of this article was to sort out among abnormal obstetrical outcomes those consistently related to an abnormal placental vascular function and to evaluate their association with low levels of maternal serum PAPP-A in early pregnancy.

OP09.01: First trimester uterine artery Doppler velocimetry and arterial tonometry

antral follicles. After the year of observation the ovary volume reduced (6.7 ± 1.2/5.1 ± 1.2 ml) with no significant difference from initial data noted in both groups. At the same period the follicular size was normal in the 1st group, in the 2nd group the maximal size of the follicles exceeded 9 mm (significant difference from the initial data P < 0.05). Initially the hormone level in both groups was normal. In 6 months the level of AMH in both groups reduced, but the difference was insignificant with no changes in FSH and E2 levels. By the end of the observation the hormone level didn’t change in the 1st group, in the 2nd group was registered a reduction of AMH level remaining in the range of age norm, but significantly lower than initial (1.98 ± 0.57/1.02 ± 0.30 ng/ml P < 0.05). Conclusions: The influence of UAE on ovary function of fertile patients cannot be ruled out, the risk of reduction of ovarian reserve increases in the older age group.

C2. Maternal cardiac deceleration capacity: a novel insight into maternal autonomic function.

Abstract Objective: To explore maternal cardiac deceleration capacity (DC), a marker of autonomic function derived from heart rate variability analysis, in pregnancies complicated by intrauterine growth restriction (IUGR) and hypertensive disorders of pregnancy (HDP) associated to IUGR (HDP-IUGR) or to appropriate for gestational age fetuses (HDP-AGAf). Methods: Single-center case-control study conducted at Buzzi Children’s Hospital, Milan. Maternal electrocardiograms were analyzed by Phase-Rectified Signal Averaging (PRSA) to obtain cardiac beat-to-beat DC in women with: HDP-IUGR; HDP-AGAf; severe-IUGR; mild- IUGR; uncomplicated pregnancies. IUGR was defined as abdominal circumference <5th centile; severe-IUGR was associated with umbilical artery Doppler pulsatility index42SD. Results: Two- hundred and sixty-nine women recruited. Women with HDP-IUGR (nu2009=u200935) showed significantly higher cardiac DC compared both to controls (nu2009=u2009141) (pu2009=u20090.003) and women with HDP-AGAf (nu2009=u200918) (pu2009=u20090.01). Women with severe-IUGR (nu2009=u200914) showed significantly higher DC than controls (pu2009=u20090.01). Women with mild-IUGR (nu2009=u200961) as with HDPAGAf showed no differences in DC compared to controls (both pu2009=u20090.3). Conclusion: Elevated cardiac deceleration capacity proves autonomic alterations in mothers with severe placental failure. We present a new bedside approach to explore maternal autonomic cardiovascular regulation that might reflect the severity of placental vascular insufficiency.

Maternal cardiac deceleration capacity: a novel insight into maternal autonomic function in pregnancies complicated by hypertensive disorders and intrauterine growth restriction

OBJECTIVEnTo explore maternal cardiac deceleration capacity (DC), a marker of autonomic function derived from electrocardiographic (ECG) signals, in pregnancies complicated by intrauterine growth restriction (IUGR) and hypertensive disorders of pregnancy (HDP) associated to IUGR (HDP-IUGR) or to appropriate for gestational age fetal growth (HDP-AGAf).nnnMETHODSnProspective single center case-control study conducted at Buzzi Childrens Hospital, Milan. Maternal ECGs were analyzed by Phase Rectified Signal Averaging (PRSA) method to obtain cardiac DC in women with: HDP-IUGR, HDP-AGAf, severe-IUGR, mild-IUGR and uncomplicated pregnancies. IUGR was defined as abdominal circumference <5th centile; severe-IUGR was associated with umbilical artery Doppler pulsatility index >2 standard deviations. Non-parametric tests were adopted.nnnRESULTSn269 women were recruited. Women with HDP-IUGR (n=35) showed significantly higher cardiac DC compared both to controls (n=141) (p=0.003) and women with HDP-AGAf (n=18) (p=0.01). Women with severe-IUGR (n=14) showed significantly higher DC than controls (p=0.01). Women with mild-IUGR (n=61) as well as women with HDP-AGAf showed no differences in DC compared to controls (both p=0.3).nnnCONCLUSIONSnWomen with pregnancy complicated by severe placental failure, such as HDP-IUGR and severe IUGR, show significant autonomic alterations, as indicated by elevated cardiac DC. On the contrary, pregnancy complications such as HDP-AGAf and mild IUGR show no impact on maternal autonomic balance. We present a new approach to explore maternal autonomic cardiovascular regulation that might reflect the severity of placental vascular insufficiency.

OP09.05: Pulse wave analysis: evaluation of arterial stiffness in first trimester for prediction of placental and maternal pre‐eclampsia (PE)

care in a tertiary Brazilian hospital. The base-cohort population was 487 singleton pregnancies, including 9 case subjects who developed PE requiring delivery before 34 weeks (early PE) and 22 with late PE, 47 with gestational hypertension, and 409 cases subjects (84%) who were unaffected by PE or gestational hypertension. Maternal history, body mass index (BMI), mean arterial pressure (MAP), and uterine artery pulsatility index were recorded in all of the cases. Univariate and logistic regression analysis was used to derive algorithms for the prediction of hypertensive disorders. Results: The maternal characteristics selected by regression analysis to be part of the final predictive model were nulliparity, previous personal and family history of PE. MAP was higher (86 versus 78 mmHg) in patients who developed PE (P < 0.01). The uterine artery percentile of mean PI was higher in the PE than in the control group (50.3% ± 31.7% versus 37.4% ± 30.0%; P < 0.01). It was estimated that, with the algorithm for PE, 78%, 45%, and 26% of early PE, late PE, and gestational hypertension, respectively, could be detected with a 10% false-positive rate. Conclusions: The traditional approach to screening for PE, which is based on maternal demographic characteristics and medical history, identifies ∼60% of cases destined to develop early PE for a falsepositive rate of 10%. This study proposes that a combination of maternal risk factors, mean arterial blood pressure, and uterine artery Doppler, for the same false-positive rate of 10%, could identify 78% of cases of early PE.

OP09.06: Hypertensive disorders (HD) of placental and maternal origin: evaluation by applanation tonometry

care in a tertiary Brazilian hospital. The base-cohort population was 487 singleton pregnancies, including 9 case subjects who developed PE requiring delivery before 34 weeks (early PE) and 22 with late PE, 47 with gestational hypertension, and 409 cases subjects (84%) who were unaffected by PE or gestational hypertension. Maternal history, body mass index (BMI), mean arterial pressure (MAP), and uterine artery pulsatility index were recorded in all of the cases. Univariate and logistic regression analysis was used to derive algorithms for the prediction of hypertensive disorders. Results: The maternal characteristics selected by regression analysis to be part of the final predictive model were nulliparity, previous personal and family history of PE. MAP was higher (86 versus 78 mmHg) in patients who developed PE (P < 0.01). The uterine artery percentile of mean PI was higher in the PE than in the control group (50.3% ± 31.7% versus 37.4% ± 30.0%; P < 0.01). It was estimated that, with the algorithm for PE, 78%, 45%, and 26% of early PE, late PE, and gestational hypertension, respectively, could be detected with a 10% false-positive rate. Conclusions: The traditional approach to screening for PE, which is based on maternal demographic characteristics and medical history, identifies ∼60% of cases destined to develop early PE for a falsepositive rate of 10%. This study proposes that a combination of maternal risk factors, mean arterial blood pressure, and uterine artery Doppler, for the same false-positive rate of 10%, could identify 78% of cases of early PE.

OP01.02: Increased cardiovascular risk in hypertensive disorders (HD) of placental origin

Objectives: To determine the incidence of chromosomal abnormalities, syndromic association and fetal defects in second trimester fetal growth restriction (FGR) in a tertiary referral center for prenatal diagnosis. Methods: Retrospective review of all cases referred between 14 and 27 weeks with an abdominal circumference (AC) < 5th centile between 2008 and 2012. The presence of aneuploidy and associated malformations was also assessed. Multiple pregnancies were excluded. Results: A total of 8626 fetuses had ultrasonographic examination between 14 and 27 weeks. Of these, there were 239 cases (2.8%) with evidence of FGR. Thirty-seven fetuses had an abnormal karyotype or an identified syndromic association (15%), 67 had at least one morphological abnormality without aneuploidy or syndromic association (28%), 135 cases were isolated fetal growth retardation (57%). The most common chromosomal defect was Trisomy 18. Most common morphological abnormalities were relative short femur (5%), omphalocele (5%) and gastroschisis (4%). The Maternal age was higher (33 yr ± 5 yr versus 31 yr ± 5, 6 yr, P = 0.007) and the z-score for the AC lower (2.5 ± 1 versus 2.15 ± 0.6) in the group with abnormal karyotype or syndromic association than in the group without malformation. Amniotic fluid was more often increased in the group with an abnormal karyotype or associated malformation (14% and 17%) than in the group without malformations (0%, P = 0.0003 and 0.0001). Conclusions: This study describes abnormalities and outcomes associated with second trimester fetal growth retardation in a large population of patients referred for that purpose. Our results suggest that the degree of growth restriction, maternal age and the amniotic fluid index may help in the prenatal management and counseling of this high risk population.

OP09.02: Placental volume and uterine artery Doppler correlation in first trimester of pregnancy

antral follicles. After the year of observation the ovary volume reduced (6.7 ± 1.2/5.1 ± 1.2 ml) with no significant difference from initial data noted in both groups. At the same period the follicular size was normal in the 1st group, in the 2nd group the maximal size of the follicles exceeded 9 mm (significant difference from the initial data P < 0.05). Initially the hormone level in both groups was normal. In 6 months the level of AMH in both groups reduced, but the difference was insignificant with no changes in FSH and E2 levels. By the end of the observation the hormone level didn’t change in the 1st group, in the 2nd group was registered a reduction of AMH level remaining in the range of age norm, but significantly lower than initial (1.98 ± 0.57/1.02 ± 0.30 ng/ml P < 0.05). Conclusions: The influence of UAE on ovary function of fertile patients cannot be ruled out, the risk of reduction of ovarian reserve increases in the older age group.