Publications by authors named "Amar Bhide"

44 Publications

Is Cardiomegaly an Indication of "Heart-Sparing Effect" in Small Fetuses?

Fetal Diagn Ther 2021 Oct 15:1-7. Epub 2021 Oct 15.

Fetal Medicine Unit, St. George's University Hospitals NHS Foundation Trust, London, United Kingdom.

Introduction: This study aimed to test the hypothesis that cardiac size is maintained in small fetuses presenting with cardiomegaly.

Materials And Methods: We identified singleton fetuses with estimated fetal weight <10th centile and with cardiomegaly without another more likely cardiac or extra-cardiac cause. We used Z-scores for cardiac and thoracic circumferences normalized for gestational age (GA), biparietal diameter (BPD), head circumference (HC), and femur length (FL), obtained from 188 normally grown fetuses.

Results: When comparing chest size, small fetuses had significantly lower thoracic circumferences median Z-scores (IQR) for GA = -4.82 (-6.15 to -3.51), BPD = -2.42 (-4.04 to -1.48), HC = -2.72 (-4.53 to -1.90), and FL = -1.60 (-2.87 to -0.71); p < 0.001 for all. When comparing heart size, small fetuses showed lower cardiac circumferences median Z-scores (IQR) for GA = -1.59 (-2.79 to -0.16); p < 0.001, similar cardiac circumferences Z-scores for BPD = 0.29 (-0.65 to 1.28); p = 0.284 and HC = 0.11 (-1.13 to 0.96); p = 0.953, and higher cardiac circumferences Z-scores for FL = 0.94 (-0.05 to 2.13); p < 0.001.

Conclusions: Our results show that in small fetuses with cardiomegaly, the heart maintains normal dimensions when normalized to cranial diameters and higher dimensions when normalized to long bones. This provides insight into cardiac adaptation to adverse intrauterine environment.
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http://dx.doi.org/10.1159/000519059DOI Listing
October 2021

Placenta Accreta Spectrum Disorders and Cesarean Scar Pregnancy Screening: Are we Asking the Right Questions?

Rev Bras Ginecol Obstet 2021 May 28;43(5):347-350. Epub 2021 Jun 28.

Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, United Kingdom.

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http://dx.doi.org/10.1055/s-0041-1731301DOI Listing
May 2021

Perinatal outcomes of twin pregnancies complicated by late twin-twin transfusion syndrome: A systematic review and meta-analysis.

Acta Obstet Gynecol Scand 2021 05 12;100(5):832-842. Epub 2021 Jan 12.

Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK.

Introduction: Untreated twin-to-twin transfusion syndrome (TTTS) is associated with a high risk of perinatal mortality and morbidity. Laser surgery is recommended before 26 weeks of gestation. However, the optimal management in case of late TTTS (occurring after 26 weeks of gestation) is yet to be established.

Material And Methods: We conducted a systematic review and meta-analysis to evaluate the outcomes of monochorionic-diamniotic twin pregnancies complicated by late TTTS according to different management options (expectant, laser therapy, amnioreduction, or delivery). The primary outcome was mortality, including single and double intrauterine, neonatal, and perinatal death. Secondary outcomes were composite morbidity, neuromorbidity, respiratory distress syndrome, admission to neonatal intensive care unit, intact survival (ie, free from neurological complications), and preterm birth before <32 weeks of gestation. Outcomes were reviewed according to the management and reported for the overall population of twins and disease status (ie, donor and recipient separately). Random-effect meta-analyses of proportions were used to analyze the data.

Results: Nine studies including 796 twin pregnancies affected by TTTS were included. No randomized controlled trials were available for inclusion. TTTS occurred at ≥26 weeks of gestation in 8.7% (95% CI 6.9%-10.9%; 67/769) of cases reporting TTTS at all gestations. Intrauterine death occurred in 17.7% (95% CI 4.9%-36.2%) of pregnancies managed expectantly, 5.3% (95% CI 0.9%-12.9%) of pregnancies treated with laser, and 0% (95% CI 0%-9%) after amnioreduction. Neonatal death occurred in 42.5% (95% CI 17.5%-69.7%) of pregnancies managed expectantly, in 2.8% (95% CI 0.3%-7.7%) of cases treated with laser, and in 20.2% (95% CI 6%-40%) after amnioreduction. Only one study (10 cases) reported data on immediate delivery after diagnosis with no perinatal deaths. Perinatal death incidence was 55.7% (95% CI 31.4%-78.6%) in twin pregnancies managed expectantly, 5.6% (95% CI 0.5%-15.3%) in those treated with laser, and 20.2% (95% CI 6%-40%) in those after amnioreduction. Intact survival was reported in 44.4%, 96.4%, and 78% of fetuses managed expectantly, with laser or amnioreduction, respectively.

Conclusions: Evidence regarding perinatal mortality and morbidity in twin pregnancies complicated by late TTTS according to the different managements was of very low quality. Therefore further high-quality research in this field is needed to elucidate the optimal management of these pregnancies.
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http://dx.doi.org/10.1111/aogs.14066DOI Listing
May 2021

Are Twin Pregnancies Complicated by Weight Discordance or Fetal Growth Restriction at Higher Risk of Preeclampsia?

J Clin Med 2020 Oct 13;9(10). Epub 2020 Oct 13.

Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London SW17 0RE, UK.

Studies have reported controversial findings on the association between fetal growth restriction (FGR) or intertwin weight discordance and the risk of hypertensive disorders of pregnancy (HDP) in twin pregnancies. The aim of this study was to investigate the association between twin growth disorders and HDP. Twin pregnancies resulting in two live births at St George's Hospital between 2000 and 2019 were included. FGR or small-for-gestational-age (SGA) at birth was assessed using singleton and twin reference charts. Intertwin discordance [(large birthweight - small birthweight)/(large birthweight) × 100%)] was calculated. Logistic regression models were performed. SGA (aOR 2.34, 95% CI 1.60-3.44, < 0.001), intertwin discordance ≥25% (aOR 2.10, 95% CI 1.26-3.49, = 0.004) and their co-existence (aOR 2.03, 95% CI 1.16-3.54, = 0.013) were significantly associated with HDP. After adjusting for the known maternal risk factors of HDP and the intertwin discordance, SGA (using the twin charts) was the strongest independent risk factor associated with HDP (aOR 2.12, 95% CI 1.40-3.22, < 0.001) and preeclampsia (aOR 2.34, 95% CI 1.45-3.76, < 0.001). This study highlights that the presence of at least one SGA twin is significantly associated with HDP during pregnancy. Therefore, maternal blood pressure should be closely monitored in twin pregnancies complicated by SGA with or without intertwin discordance.
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http://dx.doi.org/10.3390/jcm9103276DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7600839PMC
October 2020

Performance of Antenatal Diagnostic Criteria of Twin-Anemia-Polycythemia Sequence.

J Clin Med 2020 Aug 26;9(9). Epub 2020 Aug 26.

Fetal Medicine Unit, St George's University Hospitals, Blackshaw Road, London SW17 0QT, UK.

This study aims to elicit the validation performance of different diagnostic criteria and to evaluate the disease course and perinatal outcomes of pregnancies complicated by twin anemia polycythemia sequence (TAPS). Monochorionic diamniotic (MCDA) twin pregnancies who received serial middle cerebral artery (MCA) peak systolic velocity (PSV) measurements without non-TAPS-related demise or major anomalies were included. Course of disease, antenatal intervention, additional ultrasound features, and perinatal outcomes were compared between each criteria and onset. Forty-nine cases of TAPS and 203 non-TAPS controls were identified. The incidence of TAPS was 19.2%, 15.7%, 7.8%, and 6.3% for ΔPSV MoM > 0.373, ΔPSV MoM > 0.5, traditional, and Delphi consensus criteria, respectively ( < 0.001). The incidence of antenatal intervention was 55.1, 62.5, 75.0, and 87.5%, respectively. Furthermore, cases detected according to the Delphi consensus criteria had a higher rate of progression or intervention compared to cases detected with ΔPSV MoM > 0.373 (87.0 vs. 59.0%, = 0.037). TAPS had a significantly higher birth weight discordance than uncomplicated MCDA twins (25.3 vs. 7.3%, < 0.001). Application of four different diagnostic criteria for TAPS leads to significant differences in the incidence, severity, and antenatal intervention. The Delphi criteria identified more severe cases likely to require intervention, and the delta PSV > 0.373 criteria identified milder cases, without a significant impact on neonatal outcomes.
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http://dx.doi.org/10.3390/jcm9092754DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7563169PMC
August 2020

The Association Between Hypertension in Pregnancy and Preterm Birth with Fetal Growth Restriction in Singleton and Twin Pregnancy: Use of Twin Versus Singleton Charts.

J Clin Med 2020 Aug 5;9(8). Epub 2020 Aug 5.

Fetal Medicine Unit, St George's Hospital, St George's University of London, Cranmer Terrace, London SW17 0RE, UK.

Objective: To compare the rates of fetal growth restriction (FGR) in singleton and twin pregnancies using singleton and twin-specific birthweight standards.

Methods: The study included liveborn twin and singleton pregnancies between January 2000 and January 2019. Hypertensive disorders of pregnancy (HDP) included gestational hypertension and pre-eclampsia. The study outcomes were FGR or small-for-gestational-age (SGA) at birth as assessed using singleton and twin reference charts.

Results: The analysis included 1473 twin and 62,432 singleton pregnancies. In singleton pregnancies the risk of PTB <34 weeks without HDP (OR 2.82, < 0.001), delivery ≥34 weeks with HDP (OR 2.38, < 0.001), and PTB <34 weeks with HDP (OR 13.65, < 0.001) were significantly higher in the pregnancies complicated by FGR compared to those without. When selective fetal growth restriction (sFGR) was assessed using the singleton standard, the risk of PTB <34 weeks without HDP (OR 1.03, = 0.872), delivery ≥34 weeks with HDP (OR 1.36, = 0.160) were similar in the pregnancies complicated by sFGR compared to those without, while the risk of PTB <34 weeks with HDP (OR 2.41, = 0.025) was significantly higher in the pregnancies complicated by sFGR compared to those without. When sFGR was assessed using the twin-specific chart, the risk of PTB <34 weeks without HDP (OR 3.55, < 0.001), delivery ≥34 weeks with HDP (OR 3.17, = 0.004), and PTB <34 weeks with HDP (OR 5.69, < 0.001) were significantly higher in the pregnancies complicated by sFGR compared to those without. The stronger and more consistent association persisted in the subgroup analyses according to chorionicity. The strength of association in dichorionic twin pregnancies resembles that of the singletons more closely and consistently when the FGR was diagnosed using the twin-specific charts.

Conclusion: FGR in twin pregnancies has a stronger and more consistent association with HDP and PTB when using twin-specific rather than singleton charts. This study provides further evidence supporting the use of twin-specific charts when assessing fetal growth in twin pregnancies.
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http://dx.doi.org/10.3390/jcm9082518DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7464003PMC
August 2020

Ductus venosus Doppler waveform pattern in fetuses with early growth restriction.

Acta Obstet Gynecol Scand 2020 05 22;99(5):608-614. Epub 2019 Dec 22.

Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust and Molecular & Clinical Sciences Research Institute, St George's University, London, UK.

Introduction: We aimed to assess if maximum velocities of the ductus venosus flow velocity waveform are associated with adverse outcomes in early-onset fetal growth restriction.

Material And Methods: Retrospective cohort study from two tertiary referral units, including singleton fetuses with estimated birthweight or fetal abdominal circumference ≤10th centile and absent or reversed end-diastolic velocity in the umbilical artery delivered between 26 and 34  weeks of gestation. Pulsatility index for veins, and maximum velocities of S-, D-, v- and a-waves, were measured in the ductus venosus within 24 hours of birth. Logistic regression was used to describe the relation between severe neonatal morbidity or neonatal death and clinical independent predictors.

Results: The study population included 132 early-onset fetal growth restriction fetuses. Newborns with neonatal morbidity or neonatal death had significantly lower values of v/D maximum velocity ratio multiples of the median (0.86 vs 095; P = 0.006) within 24 hours of birth. The v/D ratio remained a significant predictor of neonatal death or severe neonatal morbidity after adjusting for gestational age and birthweight (adjusted odds ratio 0.065, 95% confidence interval 0.004-0.957).

Conclusions: Assessment of ductus venosus v/D maximum velocity ratio might help to identify fetal growth restriction fetuses at increased risk for neonatal death or severe neonatal morbidity. Confirmation in prospective studies is necessary.
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http://dx.doi.org/10.1111/aogs.13782DOI Listing
May 2020

Pregnancy outcomes following home blood pressure monitoring in gestational hypertension.

Pregnancy Hypertens 2019 Oct 15;18:14-20. Epub 2019 Jul 15.

Middle East Technical University, Department of Statistics, Ankara, Turkey; Molecular & Clinical Sciences Research Institute, St. George's University of London, London, UK. Electronic address:

Objectives: To assess the safety and efficacy of home blood pressure monitoring (HBPM) and office (traditional) blood pressure measurements in a cohort of pregnant women with gestational hypertension (GH).

Study Design: This was a cohort study at St. George's Hospital, University of London conducted between December 2013 and August 2018. The inclusion criteria was pregnant women with a diagnosis of GH. Eligible patients were counseled and trained by a specialist midwife and were provided with an automated Microlife® "WatchBP Home" BP machine. Each patient followed an individualised schedule of hospital visits and BP measurements based on the HBPM pathway or standard hospital protocol which was based on the National Institute of Health and Care Excellence (NICE) guideline.

Main Outcome Measures: Adverse fetal, neonatal and maternal outcomes as well as number of antenatal hospital visits were recorded and compared between HBPM and office (traditional) pathways.

Results: 143 women with GH were included in the study (80 HBPM vs 63 standard care). There were no significant difference between the two groups in maternal high-dependency unit admission (P = 0.999), birth weight centile (P = 0.803), fetal growth restriction (p = 0.999), neonatal intensive care unit admissions (p = 0.507) and composite neonatal (p = 0.654), maternal (p = 0.999) or fetal adverse outcomes (p = 0.999). The number of Day Assessment Unit (DAU) visits was significantly lower in the HBPM group than the traditional pathway (median 4.0 vs. 5.0, P = 0.009). The difference was greater when the number of visits were adjusted for the duration of monitoring in weeks (median: 1.0 vs 1.5, P < 0.001). There were no significant difference between the two groups in the total number of outpatient (P = 0.357) and triage visits (p = 0.237). However, the total number of antenatal visits adjusted for the duration of monitoring was significantly lower for the HBPM group compared to the traditional pathway (median 1.4 vs 1.8, P = 0.020).

Conclusions: HBPM in women with GH results in significantly less antenatal visits compared to women on a standard pathway of care. The two groups had comparable fetal, neonatal and maternal adverse outcomes. Large multicentre studies are needed to ascertain the safety of rare adverse pregnancy outcomes.
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http://dx.doi.org/10.1016/j.preghy.2019.07.006DOI Listing
October 2019

Who should write and endorse clinical practice guidelines if our patients are to benefit from them?

Acta Obstet Gynecol Scand 2018 12;97(12):1413-1414

Women's Health and Perinatology Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway.

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http://dx.doi.org/10.1111/aogs.13490DOI Listing
December 2018

Sex differences in fetal heart rate and variability assessed by antenatal computerized cardiotocography.

Acta Obstet Gynecol Scand 2018 Dec 14;97(12):1486-1490. Epub 2018 Sep 14.

Women's Health & Perinatal Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, Tromsø, Norway.

Introduction: The aim of the current study is to explore the effect of fetal sex on the fetal heart rate and variability.

Material And Methods: This is a retrospective cross-sectional study. We analyzed fetal heart rate (FHR) traces of pregnant women that were recorded antenatally using a commercially available computerized cardiotocograph (cCTG; Oxford system). Fetal sex was ascertained after birth. Baseline FHR and short-term heart rate variation (STV) were compared between male and female fetuses. Expected mean values for baseline FHR and STV were computed and multiples of the mean (MOMean) of males and females were compared.

Results: Information on 9259 cases is reported in this study. Baseline FHR of female fetuses was significantly higher (P < 0.001) and STV lower (P < 0.001) than that of male fetuses. This difference remained even after the effects of gestational age and diurnal variation were eliminated by computation of MOMean, but the absolute differences in the baseline FHR (0.9 beats/min [bpm]) and STV (0.246 ms) between male and female fetuses were small. A significant negative correlation was found between baseline FHR and STV (r = -0.518, P < 0.001). Similarly, a significant negative correlation was found between the MoMean of baseline FHR and MoMean STV (r = -0.481, P < 0.001).

Conclusions: Using the Oxford cCTG, male fetuses show a significantly lower baseline FHR and greater variability as compared with female fetuses. However, the absolute differences are small and may not be of major clinical significance.
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http://dx.doi.org/10.1111/aogs.13437DOI Listing
December 2018

Fertility treatment: Getting stressed about stress.

Authors:
Amar Bhide

Acta Obstet Gynecol Scand 2018 03;97(3):233-234

St George's Hospital, London, UK.

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http://dx.doi.org/10.1111/aogs.13302DOI Listing
March 2018

FIGO consensus guidelines on placenta accreta spectrum disorders: Prenatal diagnosis and screening.

Int J Gynaecol Obstet 2018 Mar;140(3):274-280

Nuffield Department of Obstetrics and Gynecology, University of Oxford, John Radcliffe Hospital, Oxford, UK.

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http://dx.doi.org/10.1002/ijgo.12408DOI Listing
March 2018

A simplified guide to randomized controlled trials.

Acta Obstet Gynecol Scand 2018 Apr 27;97(4):380-387. Epub 2018 Feb 27.

Department of Clinical Science, Intervention and Technology, Karolinska Institute and Center for Fetal Medicine, Karolinska University Hospital, Stockholm, Sweden.

A randomized controlled trial is a prospective, comparative, quantitative study/experiment performed under controlled conditions with random allocation of interventions to comparison groups. The randomized controlled trial is the most rigorous and robust research method of determining whether a cause-effect relation exists between an intervention and an outcome. High-quality evidence can be generated by performing an randomized controlled trial when evaluating the effectiveness and safety of an intervention. Furthermore, randomized controlled trials yield themselves well to systematic review and meta-analysis providing a solid base for synthesizing evidence generated by such studies. Evidence-based clinical practice improves patient outcomes and safety, and is generally cost-effective. Therefore, randomized controlled trials are becoming increasingly popular in all areas of clinical medicine including perinatology. However, designing and conducting an randomized controlled trial, analyzing data, interpreting findings and disseminating results can be challenging as there are several practicalities to be considered. In this review, we provide simple descriptive guidance on planning, conducting, analyzing and reporting randomized controlled trials.
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http://dx.doi.org/10.1111/aogs.13309DOI Listing
April 2018

Prenatal ultrasound diagnosis and outcome of placenta previa accreta after cesarean delivery: a systematic review and meta-analysis.

Am J Obstet Gynecol 2017 07 6;217(1):27-36. Epub 2017 Mar 6.

Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's Hospital, London, United Kingdom.

Background: Women with a history of previous cesarean delivery, presenting with a placenta previa, have become the largest group with the highest risk for placenta previa accreta.

Objective: The objective of the study was to evaluate the accuracy of ultrasound imaging in the prenatal diagnosis of placenta accreta and the impact of the depth of villous invasion on management in women presenting with placenta previa or low-lying placenta and with 1 or more prior cesarean deliveries.

Study Design And Data Sources: We searched PubMed, Google Scholar, clinicalTrials.gov, and MEDLINE for studies published between 1982 and November 2016.

Study Eligibility Criteria: Criteria for the study were cohort studies that provided data on previous mode of delivery, placenta previa, or low-lying placenta on prenatal ultrasound imaging and pregnancy outcome. The initial search identified 171 records, of which 5 retrospective and 9 prospective cohort studies were eligible for inclusion in the quantitative analysis.

Study Appraisal And Synthesis Methods: The studies were scored on methodological quality using the Quality Assessment of Diagnostic Accuracy Studies tool.

Results: The 14 cohort studies included 3889 pregnancies presenting with placenta previa or low-lying placenta and 1 or more prior cesarean deliveries screened for placenta accreta. There were 328 cases of placenta previa accreta (8.4%), of which 298 (90.9%) were diagnosed prenatally by ultrasound. The incidence of placenta previa accreta was 4.1% in women with 1 prior cesarean and 13.3% in women with ≥2 previous cesarean deliveries. The pooled performance of ultrasound for the antenatal detection of placenta previa accreta was higher in prospective than retrospective studies, with a diagnostic odds ratios of 228.5 (95% confidence interval, 67.2-776.9) and 80.8 (95% confidence interval, 13.0-501.4), respectively. Only 2 studies provided detailed data on the relationship between the depth of villous invasion and the number of previous cesarean deliveries, independently of the depth of the villous invasion. A cesarean hysterectomy was performed in 208 of 232 cases (89.7%) for which detailed data on management were available. Positive correlations were found in the largest prospective studies between the cumulative rates of the more invasive forms of accreta placentation and the sensitivity and specificity of ultrasound imaging but not with diagnostic odds ratio values. We found no data on the ultrasound screening of placenta accreta at the routine midtrimester ultrasound examination from the nonexpert ultrasound units.

Conclusion: Planning individual management for delivery is possible only with accurate evaluation of prenatal risk of accreta placentation in women presenting with a low-lying placenta/previa and a history of prior cesarean delivery. Ultrasound is highly sensitive and specific in the prenatal diagnosis of accreta placentation when performed by skilled operators. Developing a prenatal screening protocol is now essential to further improve the outcome of this increasingly more common major obstetric complication.
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http://dx.doi.org/10.1016/j.ajog.2017.02.050DOI Listing
July 2017

Is cerebroplacental ratio a marker of impaired fetal growth velocity and adverse pregnancy outcome?

Am J Obstet Gynecol 2017 06 8;216(6):606.e1-606.e10. Epub 2017 Feb 8.

St George's Hospital, St George's University of London, St George's University Hospitals NHS Foundation Trust, Molecular and Clinical Sciences Research Institute, London, United Kingdom.

Background: The cerebroplacental ratio has been proposed as a marker of failure to reach growth potential near term. Low cerebroplacental ratio, regardless of the fetal size, is independently associated with the need for operative delivery for presumed fetal compromise and with neonatal unit admission at term.

Objective: The main aim of this study was to evaluate whether the cerebroplacental ratio at term is a marker of reduced fetal growth rate. The secondary aim was to investigate the relationship between a low cerebroplacental ratio at term, reduced fetal growth velocity, and adverse pregnancy outcome.

Study Design: This was a retrospective cohort study of singleton pregnancies in a tertiary referral center. The abdominal circumference was measured at 20-24 weeks' gestation and both abdominal circumference and fetal Dopplers recorded at or beyond 35 weeks, within 2 weeks of delivery. Abdominal circumference and birthweight values were converted into Z scores and centiles, respectively, and fetal Doppler parameters into multiples of median, adjusting for gestational age. Abdominal circumference growth velocity was quantified using the difference in the abdominal circumference Z score, comparing the scan at or beyond 35 weeks with the scan at 20-24 weeks. Both univariable and multivariable logistic regression analyses were performed to investigate the association between low cerebroplacental ratio and the low abdominal circumference growth velocity (in the lowest decile) and to identify and adjust for potential confounders. As a sensitivity analysis, we refitted the model excluding the data on pregnancies with small-for-gestational-age neonates.

Results: The study included 7944 pregnancies. Low cerebroplacental ratio multiples of median was significantly associated with both low abdominal circumference growth velocity (adjusted odds ratio, 2.10; 95% confidence interval, 1.71-2.57, P <0.001) and small for gestational age (adjusted odds ratio, 3.60; 95% confidence interval, 3.04-4.25, P < .001). After the exclusion of pregnancies resulting in small-for-gestational-age neonates, a low cerebroplacental ratio multiples of the median remained significantly associated with both low abdominal circumference growth velocity (adjusted odds ratio, 1.76; 95% confidence interval, 1.34-2.30, P < .001) and birthweight centile (adjusted odds ratio, 0.99; 95% confidence interval, 0.998-0.995, P < .001). The need for operative delivery for fetal compromise was significantly associated with a low cerebroplacental ratio (adjusted odds ratio, 1.40; 95% confidence interval, 1.10-1.78, P = .006), even after adjusting for both the umbilical artery pulsatility index multiples of the median and middle cerebral artery pulsatility index multiples of median. The results were similar, even after the exclusion of pregnancies resulting in small-for-gestational-age neonates (adjusted odds ratio, 1.39; 95% confidence interval, 1.06-1.84, P = .018). Low cerebroplacental ratio multiples of the median remained significantly associated with the risk of operative delivery for presumed fetal compromise (P < .001), even after adjusting for the known antenatal and intrapartum risk factors. These associations persisted, even after the exclusion of small-for-gestational-age births. In appropriate-for-gestational-age-sized fetuses, abdominal circumference growth velocity was significantly lower in those with a low cerebroplacental ratio multiples of the median than in those with normal cerebroplacental ratio multiples of the median (P < .001).

Conclusion: The cerebroplacental ratio is a marker of impaired fetal growth velocity and adverse pregnancy outcome, even in fetuses whose size is considered appropriate using conventional biometry.
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http://dx.doi.org/10.1016/j.ajog.2017.02.005DOI Listing
June 2017

Sensitivity of first-trimester ultrasound in the detection of congenital anomalies in twin pregnancies: population study and systematic review.

Acta Obstet Gynecol Scand 2016 Dec 20;95(12):1359-1367. Epub 2016 Oct 20.

Fetal Medicine Unit, Division of Developmental Sciences, St George's University of London, London, UK.

Introduction: The first aim of this study was to ascertain the diagnostic performance of first-trimester ultrasound in detecting congenital anomalies in twins. The secondary aim was to explore the strength of association between different pregnancy characteristics and early detection of structural anomalies in a large unselected population of twin pregnancies. A systematic review of the published literature was also carried out.

Material And Methods: Retrospective analysis of prospectively collected data from consecutive twin pregnancies booked for antenatal care between 1996 and 2014. Predictive accuracy of those covariates independently associated with the occurrence of fetal anomalies was assessed with logistic regression analysis and receiver operating characteristics curves.

Results: In all, 1064 twin pregnancies (820 dichorionic and 264 monochorionic) were included in the analysis. Forty-two pregnancies had one or more fetuses with structural abnormalities. Detection of structural abnormalities using ultrasound was possible in the first trimester in 27.3% (95% confidence interval 15.0-42.8) of twin pregnancies. Monochorionicity (odds ratio 2.3, 95% confidence interval 1.1-4.7) and discordance in crown-rump length and nuchal translucency were associated with an increased risk of fetal anomalies. However, their predictive accuracy was only moderate (areas under the curve 0.67, 95% confidence interval 0.6-0.8 and 0.68, 95% confidence interval 0.6-0.8, for crown-rump length and nuchal translucency discrepancy, respectively).

Conclusions: First-trimester detection of structural abnormalities in twin pregnancies is possible in 27.3% (95% confidence interval 15.0-42.8) of cases. The likelihood for first-trimester detection of structural anomalies in twins was maximum for cranial vault, midline brain and abdominal wall defects. Monochorionicity and increasing discrepancy in crown-rump length and nuchal translucency were associated with fetal structural abnormalities, although their predictive performance was only moderately good.
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http://dx.doi.org/10.1111/aogs.13017DOI Listing
December 2016

Mid-pregnancy fetal growth, uteroplacental Doppler indices and maternal demographic characteristics: role in prediction of stillbirth.

Acta Obstet Gynecol Scand 2016 Nov;95(11):1313-1318

Fetal Medicine Unit, Academic Department of Obstetrics and Gynecology, St George's University of London, London, UK.

Introduction: To evaluate the relative value of mid trimester fetal growth, uterine artery Doppler indices and maternal demographics in prediction of stillbirth.

Material And Methods: Retrospective cohort study; 23 894 singleton pregnancies routinely scanned between 19 and 24 weeks' gestation. Maternal characteristics included age, body mass index, ethnicity and medical history. Fetal biometry indices, birthweight and uterine artery pulsatility index values were converted to percentiles and multivariable logistic regression analysis was performed. The predictive accuracy was assessed using receiver operating characteristic curves analysis. The main outcome was prediction of preterm and term stillbirths.

Results: Non-Caucasian ethnicity, femur length centile and uterine artery pulsatility index were significantly associated with the risk of stillbirth (all p < 0.01). The detection rate of screening by maternal factors alone was 19% for all stillbirths, and 12 and 14% for term and preterm stillbirth at a 10% false positive rate, respectively. Using femur length centile alone, the detection rates were 27 and 23%, respectively. Uterine artery pulsatility index alone was able to predict 24 and 31% of term and preterm stillbirths. Screening by combining maternal factors, femur length centile and uterine artery Doppler detected 27 and 35% of term and preterm stillbirths at a 10% false positive rate.

Conclusions: Second trimester ultrasound assessment offers an opportunity to identify pregnancies at the highest risk of stillbirth occurring as a consequence of placental dysfunction. This information may be useful to improve pregnancy outcome by identifying women who may benefit from increased ultrasound surveillance and/or timely intervention.
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http://dx.doi.org/10.1111/aogs.13012DOI Listing
November 2016

Outcomes Associated With Isolated Agenesis of the Corpus Callosum: A Meta-analysis.

Pediatrics 2016 Sep;138(3)

Department of Obstetrics and Gynaecology, University of Brescia, Brescia, Italy.

Context: Antenatal counseling in cases of agenesis of the corpus callosum (ACC) is challenging.

Objectives: To ascertain the outcome in fetuses with isolated complete ACC and partial ACC.

Data Sources: Medline, Embase, CINAHL, and Cochrane databases.

Study Selection: Studies reporting a prenatal diagnosis of ACC. The outcomes observed were: chromosomal abnormalities at standard karyotype and chromosomal microarray (CMA) analysis, additional anomalies detected only at prenatal MRI and at postnatal imaging or clinical evaluation, concordance between prenatal and postnatal diagnosis and neurodevelopmental outcome.

Data Extraction: Meta-analyses of proportions were used to combine data.

Results: Twenty-seven studies were included. In cACC, chromosomal anomalies occurred in 4.81% (95% confidence interval [CI], 2.2-8.4) of the cases. Gross and fine motor control were abnormal in 4.40% (95% CI, 0.6-11.3) and 10.98% (95% CI, 4.1-20.6) of the cases, respectively, whereas 6.80% (95% CI, 1.7-14.9) presented with epilepsy. Abnormal cognitive status occurred in 15.16% (95% CI, 6.9-25.9) of cases. In partial ACC, the rate of chromosomal anomalies was 7.45% (95% CI, 2.0-15.9). Fine motor control was affected in 11.74% (95% CI, 0.9-32.1) of the cases, and 16.11% (95% CI, 2.5-38.2) presented with epilepsy. Cognitive status was affected in 17.25% (95% CI, 3.0-39.7) of cases.

Limitations: Different neurodevelopmental tools and time of follow-up of the included studies.

Conclusions: Children wih a prenatal diagnosis of isolated ACC show several degrees of impairment in motor control, coordination, language, and cognitive status. However, in view of the large heterogeneity in outcomes measures, time at follow-up, and neurodevelopmental tools used, large prospective studies are needed to ascertain the actual occurrence of neuropsychological morbidity of children with isolated ACC.
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http://dx.doi.org/10.1542/peds.2016-0445DOI Listing
September 2016

Effect of Hypoxemia with or without Increased Placental Vascular Resistance on Fetal Left and Right Ventricular Myocardial Performance Index in Chronically Instrumented Sheep.

Ultrasound Med Biol 2016 11 17;42(11):2589-2598. Epub 2016 Aug 17.

Women's Health & Perinatal Research Group, UiT-The Arctic University of Norway, Tromsø, Norway; Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway; Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden.

Myocardial performance index (MPI) is increased in growth-restricted fetuses with placental insufficiency, but it is unknown if this is due to fetal hypoxemia or increased placental vascular resistance (R). We used chronically instrumented sheep fetuses (n = 24). In 12 fetuses, placental embolization was performed 24 h before experiments. On the day of the experiment, left (LV) and right (RV) ventricular MPIs were obtained by pulsed Doppler at baseline and in the hypoxemia and recovery phases. At baseline, R was greater and fetal pO lower in the placental embolization group, but RV and LV MPIs were comparable to those of the control group. During hypoxemia, mean LV MPI increased significantly only in fetuses with an intact placenta (0.34 vs. 0.46), returning to baseline during the recovery phase. Right ventricular MPI was unaffected. We conclude that fetal LV function is sensitive to acute hypoxemia. Exposure to chronic hypoxemia could pre-condition the fetal heart and protect its function with worsening hypoxemia.
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http://dx.doi.org/10.1016/j.ultrasmedbio.2016.07.006DOI Listing
November 2016

Fetal monitoring in labor: Implications of evidence generated by new systematic review.

Acta Obstet Gynecol Scand 2016 Jan;95(1):5-8

Department of Clinical Medicine, UiT- The Arctic University of Norway, Tromsø, Norway.

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http://dx.doi.org/10.1111/aogs.12830DOI Listing
January 2016

Mid-pregnancy fetal biometry, uterine artery Doppler indices and maternal demographic characteristics: role in prediction of small-for-gestational-age birth.

Acta Obstet Gynecol Scand 2016 Feb 8;95(2):238-44. Epub 2015 Nov 8.

Fetal Medicine Unit, Academic Department of Obstetrics and Gynaecology, St George's University of London, London, UK.

Introduction: The aim of this study was to evaluate the role of mid-trimester fetal biometry, uterine artery Doppler indices and maternal demographics in prediction of small-for-gestational-age (SGA) birth.

Materials And Methods: We conducted a retrospective cohort study in a single referral center. The study included 23 894 singleton pregnancies scanned between 19 and 24 weeks of gestation. Maternal demographics included age, body mass index and ethnicity. Fetal biometry, birthweight and uterine artery pulsatility index values were converted into centiles. Multivariable logistic regression analysis was performed and the predictive accuracy was assessed using receiver operating characteristic curve analysis. The main outcome measure was prediction of delivery of preterm and term SGA neonates defined as a birthweight in the lowest centile groups (<10th, <5th and <3rd centiles).

Results: Maternal ethnicity, fetal biometry and uterine artery Doppler indices were significantly associated with the risk of SGA <5th centile (p < 0.01). Maternal factors or fetal biometry alone showed poor to moderate performance in prediction of term and preterm SGA <5th centile at a 10% false-positive rate. Uterine artery pulsatility index alone was able to predict 25, 60 and 77% of SGA <5th centile delivering at >37, <37 and <32 weeks of gestation respectively at a 10% false-positive rate; maternal factors, fetal biometry and uterine artery Doppler combined detected 40, 66 and 89% of term, preterm and very preterm SGA <5th centile at a 10% false-positive rate.

Conclusions: Second-trimester screening can identify the majority of pregnancies at high risk of SGA birth and showed a higher performance for earlier gestational ages at birth and lower birthweight centiles.
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http://dx.doi.org/10.1111/aogs.12804DOI Listing
February 2016

Reliability of Doppler Assessment of the Middle Cerebral Artery in the Near and Far Fields in Healthy and Anemic Fetuses.

J Ultrasound Med 2015 Nov 2;34(11):2037-42. Epub 2015 Oct 2.

Fetal Medicine Unit, Academic Department of Obstetrics and Gynecology, St George's University of London, London, England (S.S., A.Bh.); Department of Obstetrics, Gynecology and Pediatrics, Catholic University of Sacred Heart, Rome, Italy (S.S.); and Chikitsa, Center for Excellence in Ultrasound, Mumbai, India (A.Ba., K.K.).

Objectives: The purpose of this study was to assess the reliability of the middle cerebral artery pulsatility index (PI) and peak systolic velocity (PSV) at the proximal portions of the near- and far-field vessel sites in healthy and anemic fetuses.

Methods: The middle cerebral artery PSV and PI were prospectively assessed in 50 normal singleton pregnancies. The Doppler waveforms for the middle cerebral artery PI and the PSV were recorded independently by 2 operators at the most proximal portions of the near- and far-field sites. Data for the PSV and PI at the proximal portions of both the near- and the far-field sites were also retrospectively collected in 7 anemic fetuses.

Results: No significant difference between the operators was detected for the middle cerebral artery PSV (P = .60) and PI (P = .88) measured in the conventionally used near-field proximal site in the 50 healthy fetuses. No significant difference between the proximal portions of the near- and far-field sites was detected for the PSV (P = .53) and PI (P = .23) in healthy or anemic fetuses.

Conclusions: The findings of this study suggest that the use of the far-field vessel is an acceptable alternative for measurement of the middle cerebral artery PI and PSV when investigation of the near-field vessel is technically difficult.
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http://dx.doi.org/10.7863/ultra.14.11078DOI Listing
November 2015

A pilot study of the impact of a novel compression belt on pelvic blood flow in healthy postpartum women.

Int J Gynaecol Obstet 2015 Nov 6;131(2):208. Epub 2015 Aug 6.

Department of Obstetrics and Gynaecology, St. George's Hospital and University of London, London, UK.

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http://dx.doi.org/10.1016/j.ijgo.2015.05.022DOI Listing
November 2015

Number of episodes of reduced fetal movement at term: association with adverse perinatal outcome.

Am J Obstet Gynecol 2015 Nov 20;213(5):678.e1-6. Epub 2015 Jul 20.

Fetal Medicine Unit, St George's Hospital, St George's University of London, London, United Kingdom.

Objective: The aims of this study were evaluation of the association of reduced fetal movements (RFM) and small-for-gestational-age (SGA) birth at term and to explore if fetal and maternal outcomes are different with single vs repeated episodes of RFM and normal fetal assessment test results.

Study Design: This was a retrospective cohort study of all singleton pregnancies referred for RFMs at a tertiary fetal medicine unit from January 2008 through September 2014. Ultrasound and Doppler indices were obtained from a computerized ultrasound database and pregnancy outcome was collected from hospital records.

Results: Of the 21,944 women with a singleton pregnancy booked for maternity care during the study period, 1234 women (5.62%) reported RFMs >36+0 weeks. Of these, 1029 women (83.4%) reported a single episode of RFM and 205 (16.6%) had ≥2 presentations for RFM. Women with repeated RFMs had a significantly higher mean uterine artery pulsatility index in the second trimester. The prevalence of SGA baby at birth in women presenting with a single episode as compared to repeated episodes of RFM was 9.8% and 44.2%, respectively (odds ratio, 7.3; 95% confidence interval, 5.1-10.4; P < .05).

Conclusion: Repeated episodes of RFMs at term are more likely to occur in women with high second-trimester uterine artery Doppler resistance indices and are strongly associated with the birth of SGA infants. Women presenting with repeated episodes of RFM should be treated as being at high risk of placental dysfunction irrespective of the results of prenatal ultrasound and Doppler assessment.
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http://dx.doi.org/10.1016/j.ajog.2015.07.015DOI Listing
November 2015

Estimation of Detection Rates of Aneuploidy in High-Risk Pregnancy Using an Approach Based on Nuchal Translucency and Non-Invasive Prenatal Testing: A Cohort Study.

Fetal Diagn Ther 2015 30;38(4):254-61. Epub 2015 Apr 30.

Fetal Medicine Unit, Academic Department of Obstetrics and Gynaecology, St George's University of London, London, UK.

Objectives: The aim was to investigate aneuploidy detection using an approach based on nuchal translucency (NT) and non-invasive prenatal testing (NIPT).

Methods: This was a cohort study including 5,306 high-risk pregnancies with NT measurements and chorionic villus samples (CVS) tested for full karyotype.

Results: The fetal karyotype was normal in 4,172 (78.6%) cases and abnormal in 1,134 (21.4%), including 1,009 with a likely clinically significant adverse outcome. Universal CVS with full karyotyping would lead to the diagnosis of all clinically significant abnormalities. A policy of relying solely on NIPT would have led to the diagnosis of 88.9% of clinically significant abnormalities. A strategy whereby NIPT is the main method, with CVS reserved for cases with NT ≥3.0 mm, would require CVS in 21.7% of cases, identify 94.8% of significant abnormalities and avoid miscarriage in 41 pregnancies compared to CVS for all.

Conclusions: A policy of NIPT for increased-risk cases and CVS with full karyotype if the NT was ≥3.0 mm reduced the risk of miscarriage yet still identified 95% of clinically significant aneuploidy.
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http://dx.doi.org/10.1159/000381182DOI Listing
October 2016

The value of the urinary protein:creatinine ratio for the detection of significant proteinuria in women with suspected preeclampsia.

Acta Obstet Gynecol Scand 2015 May 25;94(5):542-6. Epub 2015 Mar 25.

Fetal Assessment Unit, St George's Hospital, London, UK.

To explore the correlation between urinary protein:creatinine ratio and 24-h excretion of protein, we studied 149 women referred to a day assessment unit for investigations for suspected preeclampsia. Paired samples were obtained for measurement of urinary protein:creatinine ratio and 24-h protein excretion. Collection of a 24-h urine sample was validated by the daily creatinine excretion. The outcome measure was proteinuria of 300 mg/day or more. Inaccurate 24-h collection was observed in 17% of women. All women (n = 56) with a protein:creatinine ratio >60 mg/mM had significant proteinuria. No woman with protein:creatinine ratio <18 mg/mM (n = 20) had significant proteinuria. We recommend that a dual cut-off should be used for excluding and "ruling in" the diagnosis of significant proteinuria. A 24-h urine collection should be used only for urinary protein:creatinine ratio values between 18 and 60 mg/mM in the detection of significant proteinuria.
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http://dx.doi.org/10.1111/aogs.12624DOI Listing
May 2015

Discordance in fetal biometry and Doppler are independent predictors of the risk of perinatal loss in twin pregnancies.

Am J Obstet Gynecol 2015 Aug 28;213(2):222.e1-222.e10. Epub 2015 Feb 28.

Fetal Medicine Unit, St George's Hospital, St George's University of London, London, England, UK.

Objective: Impaired fetal growth might be better evaluated in twin pregnancies by assessing the intertwin discordance rather than the individual fetal size. The aim of this study was to investigate the prediction of perinatal loss in twin pregnancy using discordance in fetal biometry and Doppler.

Study Design: This was a retrospective cohort study in a tertiary referral center. The estimated fetal weight (EFW), umbilical artery (UA) pulsatility index (PI), middle cerebral artery (MCA) PI, cerebroplacental ratio (CPR), and their discordance recorded at the last ultrasound assessment before delivery or demise of one or both fetuses were converted into centiles or multiples of the median (MoM). The discordance was calculated as the larger value-smaller value/larger value. A logistic regression analysis was performed to identify, and adjust for, potential confounders. The predictive accuracy was assessed using receiver-operating characteristic curve analysis.

Results: The analysis included 620 (464 dichorionic diamniotic and 156 monochorionic diamniotic) twin pregnancies (1240 fetuses). Perinatal loss of one or both fetuses complicated 16 pregnancies (2.6%). The combination of EFW discordance and CPR discordance had the best predictive performance (area under the curve, 0.96; 95% confidence interval, 0.92-1.00) for perinatal mortality. The detection rate, false-positive rate, positive likelihood ratio, and negative likelihood ratio were 87.5%, 6.7%, 13.08, and 0.13, respectively. The EFW centile, EFW below the 10th centile (small for gestational age), UA PI discordance, MCA PI discordance, and MCA PI MoM were significantly associated with the risk of perinatal loss on univariate analysis, but these associations became nonsignificant after adjusting for other confounders (P = .097, P = .090, P = .687, P = .360, and P = .074, respectively). The UA PI MoM, CPR MoM, EFW discordance, and CPR discordance were all independent predictors of the risk of perinatal loss, even after adjusting for potential confounders (P = .022, P = .002, P < .001, and P = .010, respectively).

Conclusion: EFW discordance and CPR discordance are independent predictors of the risk of perinatal loss in twin pregnancies. Their combination could identify the majority of twin pregnancies at risk of perinatal loss. These findings highlight the importance of discordance in Doppler indices of fetal hypoxia, as well as fetal size, in assessing the risk of perinatal mortality.
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http://dx.doi.org/10.1016/j.ajog.2015.02.024DOI Listing
August 2015

Neonatal Acid-Base Status in Term Fetuses: Mathematical Models Investigating Cerebroplacental Ratio and Birth Weight.

Fetal Diagn Ther 2015 3;38(1):55-60. Epub 2015 Feb 3.

Fetal Medicine Unit, St George Hospital, London, UK.

Objective: Cerebroplacental ratio (CPR) is emerging as a marker of fetal hypoxia at term. The aim of this study was to demonstrate graphically the interrelationships among CPR, birthweight (BW), and neonatal pH, and construct 2D and 3D representations of the areas with potential low pH.

Methods: This was a retrospective study of 2,927 term fetuses evaluated according to BW and CPR. The outcome was the acid-base status at birth. Multivariate relationships among CPR, BW, and arterial and venous pH were depicted in 3D scattergrams. Subsequently, trend surfaces were calculated and represented in 2D contour graphs. Finally, 3D representations were constructed by smothering pH data using moving average filters.

Results: The trend surfaces and the 2D and 3D contour graphs showed the complex association among the three variables. Although pH changed with CPR and BW, the influence of the BW was smaller than the influence of the CPR, with this effect being more evident in the venous than in the arterial pH.

Conclusions: Two scenarios threaten fetal well-being at term: a very low birth weight and a very low fetal CPR. Our findings suggest that the importance of fetal hemodynamics in determining the acid-base status at birth surpasses that of fetal weight.
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http://dx.doi.org/10.1159/000368829DOI Listing
May 2016

The association between fetal Doppler and admission to neonatal unit at term.

Am J Obstet Gynecol 2015 Jul 15;213(1):57.e1-57.e7. Epub 2014 Oct 15.

Fetal Medicine Unit, St George's Hospital, St George's University of London, London, England, UK.

Objective: Fetal cerebroplacental ratio is emerging as a better proxy than birthweight for placental insufficiency and as a marker of fetal compromise at term. The extent to which these fetal Doppler changes are related to neonatal outcomes has not been systematically assessed. The main aim of this study was to evaluate the association between estimated fetal weight percentile, cerebroplacental ratio recorded at 34(+0)-35(+6) weeks' gestation, and neonatal unit admission at term.

Study Design: This was a retrospective cohort study in a tertiary referral center over an 11 year period from 2002 to 2012. The umbilical artery pulsatility index (PI), middle cerebral artery PI, and cerebroplacental ratio were recorded at 34(+0)-35(+6) weeks. Weight values were converted into percentiles and Doppler parameters into multiples of the median (MoM), adjusting for gestational age. Logistic regression analysis was performed to identify, and adjust for, potential confounders.

Results: We identified 2518 pregnancies in which a scan was performed at 34(+0)-35(+6) weeks and delivery occurred at or beyond 37 weeks. In the 2485 pregnancies included in the analysis, the umbilical artery PI MoM was significantly higher, and the middle cerebral artery PI and cerebroplacental ratio MoM significantly lower in the babies requiring neonatal unit admission (P < .05). However, the estimated fetal weight percentile was not significantly different between those who required neonatal unit admission and those who did not (P = .087). According to multivariate logistic regression, cerebroplacental ratio MoM (odds ratio, 0.39; 95% confidence interval, 0.19-0.79; P = .008) and gestational age at delivery (odds ratio, 0.70; 95% confidence interval, 0.61-0.80; P < .001) were significantly associated with the risk of neonatal unit admission, whereas maternal age and birthweight percentile were not (P = .183 and P = .460, respectively). Irrespective of birthweight or estimated fetal weight percentile, the fetal cerebroplacental ratio appears to be a better predictor of the need for neonatal unit admission (P < .001).

Conclusion: Lower cerebroplacental ratio and gestational age at delivery, but not fetal size, were independently associated with the need for admission to the neonatal unit at term in a high-risk patient group. The extent to which fetal hemodynamic assessment could be used to predict perinatal morbidity and optimize the timing of delivery merits further investigation.
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http://dx.doi.org/10.1016/j.ajog.2014.10.013DOI Listing
July 2015

Is fetal cerebroplacental ratio an independent predictor of intrapartum fetal compromise and neonatal unit admission?

Am J Obstet Gynecol 2015 Jul 18;213(1):54.e1-54.e10. Epub 2014 Oct 18.

Fetal Medicine Unit, St. George's Hospital, St. George's University of London, London, United Kingdom.

Objective: We sought to evaluate the association between fetal cerebroplacental ratio (CPR) and intrapartum fetal compromise and admission to the neonatal unit (NNU) in term pregnancies.

Study Design: This was a retrospective cohort study in a single tertiary referral center over a 14-year period from 2000 through 2013. The umbilical artery pulsatility index, middle cerebral artery pulsatility index, and CPR were recorded within 2 weeks of delivery. The birthweight (BW) values were converted into centiles and Doppler parameters converted into multiples of median (MoM), adjusting for gestational age using reference ranges. Logistic regression analysis was performed to identify, and adjust for, potential confounders.

Results: The study cohort included 9772 singleton pregnancies. The rates of operative delivery for presumed fetal compromise and neonatal admission were 17.2% and 3.9%, respectively. Doppler CPR MoM was significantly lower in pregnancies requiring operative delivery or admission to NNU for presumed fetal compromise (P < .01). On multivariate logistic regression, both CPR MoM and BW centile were independently associated with the risk of operative delivery for presumed fetal compromise (adjusted odds ratio [OR], 0.67; 95% confidence interval [CI], 0.52-0.87; P = .003 and adjusted OR, 0.994; 95% CI, 0.992-0.997; P < .001, respectively). The latter associations persisted even after exclusion of small-for-gestational-age cases from the cohort. Multivariate logistic regression also demonstrated that CPR MoM was an independent predictor for NNU admission at term (adjusted OR, 0.55; 95% CI, 0.33-0.92; P = .021), while BW centile was not (adjusted OR, 1.00; 95% CI, 0.99-1.00; P = .794). The rates of operative delivery for presumed fetal compromise were significantly higher for appropriate-for-gestational-age fetuses with low CPR MoM (22.3%) compared to small-for-gestational-age fetuses with normal CPR MoM (17.3%).

Conclusion: Lower fetal CPR, regardless of the fetal size, was independently associated with the need for operative delivery for presumed fetal compromise and with NNU admission at term. The extent to which fetal hemodynamic status could be used to predict perinatal morbidity and optimize the mode of delivery merits further investigation.
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http://dx.doi.org/10.1016/j.ajog.2014.10.024DOI Listing
July 2015
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