Publications by authors named "M Litwinska"

13 Publications

Stratification of pregnancy care based on risk of pre-eclampsia derived from biophysical and biochemical markers at 19-24 weeks' gestation.

Ultrasound Obstet Gynecol 2021 Apr 1. Epub 2021 Apr 1.

Harris Birthright Research Centre for Fetal Medicine, King's College, London, UK.

Objective: We have previously proposed that all pregnant women should have assessment of risk for preeclampsia (PE) at 20 and 36 weeks' gestation and that the 20 weeks assessment should be used to define subgroups requiring additional monitoring and reassessment at 28 and 32 weeks. The objective of this study is to examine the potential improvement in screening for PE with delivery at <28, <32, <36 and ≥36 weeks' gestation at 19-24 weeks' gestation by the addition of serum placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFLT-1) to the combination of maternal demographic characteristics and medical history, uterine artery pulsatility index (UtA-PI) and mean arterial pressure (MAP).

Methods: This was a prospective, non-intervention study in women attending for an ultrasound scan at 19-24 weeks as part of routine pregnancy care. Patient-specific risks of delivery with PE at <36 weeks' gestation were calculated using the competing risks model to combine the prior distribution of the gestational age at delivery with PE, obtained from maternal characteristics and medical history, with multiple of the median (MoM) values of UtA-PI, MAP, PlGF and sFLT-1. Different risk cut-offs were used to vary the proportion of the population stratified into each of four risk categories (very high-risk, high-risk, intermediate-risk and low-risk) with the intention of detecting about 80%, 85%, 90% and 95% of the cases of delivery with PE at <28, <32 and <36 weeks' gestation. The performance of screening was assessed by plotting the detection rate against the screen positive rate and calculating the areas under these curves and by proportion stratified to a given group for fixed detection rates. Model based estimates of screening performance for these various combinations of markers were also produced.

Results: In the study population of 37886 singleton pregnancies there were 1130 (3.0%) that subsequently developed PE, including 160 (0.4%) that delivered at <36 weeks' gestation. In both the modelled and empirical results there was incremental improvement in the performance of screening with the addition of PlGF and sFLT-1 to the combination of maternal factors, UtA-PI and MAP. If the objective of screening was to identify about 90% of cases of PE with delivery at <28, <32 and <36 weeks and the method of screening was a combination of maternal factors, UtA-PI and MAP, the respective screen positive rates would be 3.1%, 8.5%, and 19.1%. The respective values for screening by maternal factors, UtA-PI, MAP and PlGF were 0.2%, 0.7% and 10.6% and for screening by maternal factors, UtA-PI, MAP, PlGF and sFLT-1 were 0.1%, 0.4% and 9.5%. The empirical results were consistent with the modelled ones. There was good agreement between the predicted risk and observed incidence of PE <36 weeks' gestation with all three strategies of screening.

Conclusion: The performance of screening for PE with delivery at <28, <32 and <36 weeks' gestation at 19-24 weeks' gestation achieved by a combination of maternal demographic characteristics and medical history, UtA-PI and MAP is improved by the addition of serum PlGF and sFLT-1. The performance of screening for PE at ≥36 weeks' gestation is poor irrespective of the method of screening at 19-24 weeks. This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1002/uog.23640DOI Listing
April 2021

Stratification of pregnancy care based on risk of pre-eclampsia derived from uterine artery Doppler at 19-24 weeks' gestation.

Ultrasound Obstet Gynecol 2021 Mar 1. Epub 2021 Mar 1.

Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK.

Objectives: There were two objectives of this study. First, to examine the value of uterine artery pulsatility index (UtA-PI) at 19-24 weeks' gestation in the prediction of subsequent development of pre-eclampsia (PE) and to compare the performance of screening between the use of, first, fixed cut-offs of UtA-PI, second, percentile cut-offs of UtA-PI adjusted for gestational age, third, a competing-risks model combining maternal demographic characteristics and medical history with UtA-PI, and, fourth, a competing-risks model combining maternal factors with UtA-PI and mean arterial pressure (MAP). Second, to stratify pregnancy care based on the estimated risk of PE at 19-24 weeks' gestation from UtA-PI and combinations of maternal factors with UtA-PI and MAP.

Methods: This was a prospective, non-intervention study in women attending for an ultrasound scan at 19-24 weeks as part of routine pregnancy care. Patient-specific risks of delivery with PE at < 36 weeks' gestation were calculated using the competing-risks model to combine the prior distribution of the gestational age at delivery with PE, obtained from maternal characteristics and medical history, with multiples of the median (MoM) values of UtA-PI and MAP. Different risk cut-offs were used to vary the proportion of the population stratified into each risk category (very high risk, high risk, intermediate risk and low risk) with the intention of detecting about 80%, 85%, 90% and 95% of cases of delivery with PE at < 28, < 32 and < 36 weeks' gestation. We also examined the performance of screening by maternal factors and UtA-PI MoM, fixed cut-offs of UtA-PI and percentile cut-offs of UtA-PI adjusted for gestational age. Calibration for risks for PE < 36 weeks' gestation by the combination of maternal factors, UtA-PI MoM and MAP MoM was assessed by plotting the observed incidence of PE against the predicted incidence. Additionally, we developed reference ranges of transabdominal and transvaginal measurement of UtA-PI according to gestational age.

Results: In the study population of 96 678 singleton pregnancies, there were 2866 (3.0%) that subsequently developed PE, including 467 (0.5%) that delivered at < 36 weeks' gestation. If the objective of screening was to identify about 90% of cases of delivery with PE at < 28, < 32 and < 36 weeks and the method of screening was a combination of maternal factors, UtA-PI MoM and MAP MoM, the proportion of the population stratified into very high-risk, high-risk, intermediate-risk and low-risk groups would be 2.4%, 3.9%, 17.8% and 75.9%, respectively; the respective values were 6.0%, 3.0%, 21.0% and 70.0% if screening was by maternal factors and UtA-PI MoM, 5.7%, 7.5%, 49.8% and 37.0% if screening was by fixed cut-offs of UtA-PI and 6.9%, 5.2%, 49.0% and 38.9% if screening was by percentile cut-offs of UtA-PI. In the validation of the prediction model based on a combination of maternal factors and MoM values of UtA-PI and MAP, calibration plots demonstrated good agreement between the predicted risk and the observed incidence of PE.

Conclusions: All pregnant women should have screening for PE at 20 and 36 weeks' gestation. The findings at 20 weeks can be used to identify the subgroups that require additional monitoring and reassessment at 28 and 32 weeks. The performance of screening by a combination of maternal factors and MoM values of UtA-PI and MAP at 19-24 weeks for delivery with PE at < 28, < 32 and < 36 weeks' gestation is superior to that of screening by a combination of maternal factors and UtA-PI MoM, by fixed cut-offs of UtA-PI or by percentile cut-offs of UtA-PI. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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http://dx.doi.org/10.1002/uog.23623DOI Listing
March 2021

Neonatal survival and kidney function after prenatal interventions for obstructive uropathies.

Ginekol Pol 2019 ;90(7):416-422

Department of Gynecology, Fertility and Fetal Therapy, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland.

Objectives: Prenatal interventions in LUTO (lower urinary tract obstruction) usually are still question of a debate between gynaecologist and paediatric nephrologist. We aimed the study to assess the early survival rate and renal outcome in LUTO foetuses.

Material And Methods: The study was a prospective data analysis of 39 foetuses from singleton pregnancies. All pregnant women with LUTO in the foetus were qualified for VAS based on a local practice. The mean time of first urine analysis ranged between 13-30 weeks of pregnancy. Primary end-point analysis included live birth, 28d-survival, pulmonary and renal function assessment in neonatal period.

Results: From initial number of 39, six patients miscarried before the procedure was performed. Overall, 33 VAS were performer at the mean 21 week of pregnancy (range 14-30 weeks). 25/39 foetuses survived until delivery. Three neonates died in first 3 days of life. In the first month 3 children required peritoneal dialysis, but at 28 day all children were dialysis-free. Overall survival rate at 28 day was 56%. Renal function preservation of the initial group (39) turned out to be low - 18% (7/39).

Conclusions: Our study showed average survival curves and complications. LUTO in the foetus had mostly unfavourable outcome in the neonatal period. The prenatal intervention did not increase it significantly and did not guarantee the preservation of normal kidney function.
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http://dx.doi.org/10.5603/GP.2019.0071DOI Listing
March 2020

Percutaneous Intratumor Laser Ablation for Fetal Sacrococcygeal Teratoma.

Fetal Diagn Ther 2020 10;47(2):138-144. Epub 2019 Jul 10.

Department of Gynecology, Fertility, and Fetal Surgery, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland.

Objective: To evaluate the efficiency of percutaneous intratumor laser ablation for fetal solid sacrococcygeal teratoma (SCT).

Subjects And Methods: We carried out percutaneous ultrasound-guided intratumor laser ablation through a 17-gauge needle using an output of 40 W in 7 fetuses with large solid SCT and reviewed the literature for minimally invasive therapy for this condition.

Results: Laser ablation was carried out at a median gestational age of 20 (range 19-23) weeks, and in all cases there was elimination of obvious vascularization within the tumor and improvement in cardiac function. Three (43%) babies survived and had surgical excision of the tumor within 2 days of birth, 3 liveborn babies died within 5 days of birth and before surgery, and 1 fetus died within 2 weeks after the procedure. In previous series of various percutaneous interventions for predominantly solid SCT the survival rate was 33% (2/6) (95% CI 9.7-70%) for endoscopic laser to superficial vessels, 57% (4/7) (95% CI 25-84%) for intratumor laser, 67% (8/12) (95% CI 39-86%) for intratumor radiofrequency ablation, and 20% (1/5) (95% CI 3.6-62%) for intratumor injection of alcohol.

Conclusions: In solid SCT, the reported survival from intratumor laser or radiofrequency ablation is about 50%, but survival does not mean success, and it remains uncertain whether such interventions are beneficial or not because the number of fetuses is small and there were no controls that were managed expectantly.
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http://dx.doi.org/10.1159/000500775DOI Listing
November 2020

Ventriculo-amniotic shunting for severe fetal ventriculomegaly.

Acta Obstet Gynecol Scand 2019 09 9;98(9):1172-1177. Epub 2019 May 9.

Department of Gynecology, Fertility and Fetal Therapy, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland.

Introduction: Severe fetal cerebral ventriculomegaly, observed in about 1 in 1000 newborns, is associated with a high risk of perinatal death and neurodevelopmental delay in survivors. The objective of this study was to evaluate the efficiency of ventriculo-amniotic shunting for drainage of severe fetal cerebral ventriculomegaly and the neurodevelopment of survivors at the age of 2 years.

Material And Methods: This was a retrospective study of 44 fetuses with severe bilateral ventriculomegaly treated with ventriculo-amniotic shunting in a tertiary fetal therapy center between 2010 and 2015.

Results: Shunt insertion was successfully carried out at a median gestational age of 25 weeks (range 20-33 weeks). There were three fetal deaths within 24 hours of the procedure and 41 live births at a median gestational age of 37 weeks (range 28-39 weeks). Neurodevelopment at 2 years of age was evaluated using the Bayley scale in the 38 survivors. In the 27 cases with isolated ventriculomegaly 19 (70.4%; 95% confidence interval [95% CI] 51.5%-84.2%) had normal or mild neurodevelopmental delay and 8 (29.6%; 95% CI 15.6%-48.5%) were moderately or severely delayed. In the 11 with non-isolated ventriculomegaly 2 (18.2%; 95% CI 5.1%-4.8%) had normal or mild neurodevelopmental delay and 9 (81.8%; 95% CI 52.3%-94.9%) babies were moderately or severely delayed.

Conclusions: Ventriculo-amniotic shunting is an option for the management of severe ventriculomegaly and results in normalization of the ventricular diameter. However, a high proportion of survivors have neurodevelopmental delay and the possible beneficial effect of ventriculo-amniotic shunting needs to be assessed by randomized studies.
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http://dx.doi.org/10.1111/aogs.13622DOI Listing
September 2019