Fetuses with diagnosed growth restriction are increasingly delivered by Caesarean section (CS). We hypothesised that an attempt of vaginal delivery is feasible and aimed to evaluate the maternal and neonatal outcome in fetal growth restriction (FGR) according to prenatal blood flow measurements. Retrospective observational study on singleton pregnancies with gestational age ≥ 36 + 0 weeks and a birthweight ≤ 5th centile during a five year period. The blood flow pulsatility index (PI) was measured in the umbilical (UA) and middle cerebral (MCA) arteries and the cerebral placental ratio (CPR) was calculated. A CPR < 5th centile were defined as abnormal. Neonates with a birthweight between the 10th and 90th centile constituted the reference population (n = 17861). Out of 1157 growth restricted neonates, 370 (32%) were identified prenatally. In this group 281/370 (77%) had a vaginal delivery, while 18 (5%) and 71 (19%) were delivered by elective and emergency CS, respectively. The perinatal mortality in prenatally diagnosed FGR was 7/370 (1.9%), including 4 cases with lethal malformations and 3 cases of antepartum stillbirth. Cord artery metabolic acidosis occurred in 3/211 (1.4%). There were no cases of moderate or severe neonatal encephalopathy. An abnormal CPR was calculated in 87/225 (39%). A total of 36/87 (41%) of FGR fetuses with abnormal CPR had a CS compared to 30/138 (22%) with normal CPR and 8% in the reference population. There was a positive linear relationship between CPR z scores and oxygen partial pressure (p) of the UA and vein at delivery and a negative relationship between CPR z scores and p CO2 of the umbilical vein. An abnormal CPR was associated with increased risk of emergency CS (OR 8.1 95% CI 5.2–12.7) and transfer to NICU (OR 6.7, 95% CI 3.9–11.5). Provided careful fetal monitoring vaginal delivery could be achieved in the majority of cases without risk of severe neonatal morbidity. Prenatal diagnosis of FGR at ≥ 36 weeks of gestation allowed for further risk-assessment by Doppler ultrasound.
To test the hypothesis that clinically relevant vessels can be visualized and interrogated with Doppler recording during the second half of pregnancy at an output energy below the currently advocated limits without loss of information.Observational cross-sectional study.Tertiary fetal medicine center.Based on a power calculation for equivalence studies, we recruited 65 pregnant women.Ultrasound examination was performed at 18, 24 or 36 weeks of gestation. The umbilical artery, middle cerebral artery, ductus venosus, and both uterine arteries were identified using color Doppler, and the blood velocities were measured using pulsed wave Doppler at a thermal index for bone (TIB) of 1.0. This procedure was repeated at TIB values of 0.5 and 0.1. The depth of Doppler recording was noted.Visualization of the vessels by color Doppler at all power levels and any systematic changes or increased variance of the recorded parameters with decreasing power level.All vessels could be visualized by color Doppler and their flow velocities measured using pulsed wave Doppler in all participants and at all power levels. There were no systematic changes or increased parameter variance when reducing the power level, despite the insonation depth being significantly greater than in early pregnancy.Reducing the ultrasound power from TIB 1.0 to 0.1 does not alter color Doppler visualization or pulsed wave Doppler measurements in the second half of pregnancy. The lower power level can be recommended as a starting point for clinical examinations throughout pregnancy.
Abstract Introduction Fetal biometry is used for determining gestational age and estimated date of delivery (EDD). However, the accuracy of the EDD depends on the assumed length of pregnancy included in the calculation. This study aimed at assessing the actual pregnancy length and accuracy of EDD prediction based on fetal head circumference measured at the second trimester. Material and methods This was a population‐based observational study with the following inclusion criteria: singleton pregnancy, head circumference dating in the second trimester, spontaneous onset or induction of delivery ≥ 294 days of gestation, live birth. The EDD was set anticipating a pregnancy length of 282 days. Bias in the prediction of EDD was defined as the difference between the actual date of birth and the EDD. Results Head circumference measurements were available for 21 451 pregnancies. Ultrasound‐dated pregnancies had a median pregnancy length of 283.03 days, corresponding to a method bias of 1.03 days (95% CI; 0.89‐1.16). This bias was dependent on the head circumference at dating, ranging from −1.58 days (95% CI; −3.54 to 1.12) to 3.42 days (95% CI; 1.98‐4.31). The median pregnancy length, based on the last menstrual period of women with a regular menstrual cycle (n = 12 985), was 283.15 days (95% CI; 282.91‐283.31). A total of 5685 (22.9%, 95% CI; 22.4% to 23.4%) and 886 women (3.6%, 95% CI; 3.3%‐3.8%) were still pregnant 7 and 14 days after the EDD, respectively. Conclusions Second trimester head circumference measurements can be safely used to predict EDD. A revision of the pregnancy length to 283 days will reduce the bias of EDD prediction to a level comparable with other methods.
OBJECTIVE. Fetal liver blood supply is an important determinant of fetal growth and adaptation. Most fetal liver blood supply is from the umbilical vein, but the portal vein contributes 14-20% and studies of low-risk pregnancies suggest the splanchnic arteries are also involved in the homeostasis of fetal liver perfusion. Here we determine the circulatory pattern of the fetal liver in intrauterine growth restriction (IUGR). DESIGN. Cross-sectional study. POPULATION. Thirty-one IUGR fetuses (estimated fetal weight <5th centile). METHODS. Pulsatility index (PI) measurements of the umbilical, middle cerebral, splenic, hepatic, and superior mesenteric arteries were compared with a reference population and related to umbilical venous flow, umbilico-caval pressure gradient (assessed by ductus venosus peak velocity) and venous distribution within the liver (assessed by flow velocity in the left portal vein). RESULTS. Thirteen of 31 IUGR fetuses had umbilical artery PI > 97.5 centile and 13 showed a middle cerebral artery brain-sparing pattern (PI Z-score < - 2). In IUGR, umbilical venous flow was lower and less umbilical blood was distributed to the right liver lobe, while the umbilico-caval pressure gradient was kept normal. The hepatic and splenic arteries, but not the superior mesenteric artery, had low PI compared with the reference population. CONCLUSIONS. IUGR fetuses with increased or normal umbilical artery PI maintained venous perfusion pressure to the liver while distributing less umbilical blood to the right liver lobe. They showed regional splanchnic arterial redistribution with low splenic and hepatic artery PI, implying increased portal venous flow and direct arterial contribution to hepatic perfusion, respectively.
Abstract Background The African population is composed of a variety of ethnic groups, which differ considerably from each other. Some studies suggest that ethnic variation may influence dating. The aim of the present study was to establish reference values for fetal age assessment in Cameroon using two different ethnic groups (Fulani and Kirdi). Methods This was a prospective cross sectional study of 200 healthy pregnant women from Cameroon. The participants had regular menstrual periods and singleton uncomplicated pregnancies, and were recruited after informed consent. The head circumference (HC), outer-outer biparietal diameter (BPDoo), outer-inner biparietal diameter and femur length (FL), also called femur diaphysis length, were measured using ultrasound at 12–22 weeks of gestation. Differences in demographic factors and fetal biometry between ethnic groups were assessed by t- and Chi-square tests. Results Compared with Fulani women (N = 96), the Kirdi (N = 104) were 2 years older (p = 0.005), 3 cm taller (p = 0.001), 6 kg heavier (p < 0.0001), had a higher body mass index (BMI) (p = 0.001), but were not different with regard to parity. Ethnicity had no effect on BPDoo (p = 0.82), HC (p = 0.89) or FL (p = 00.24). Weight, height, maternal age and BMI had no effect on HC, BPDoo and FL (p = 0.2–0.58, 0.1–0.83, and 0.17–0.6, respectively). When comparing with relevant European charts based on similar design and statistics, we found overlapping 95% CI for BPD (Norway & UK) and a 0–4 day difference for FL and HC. Conclusion Significant ethnic differences between mothers were not reflected in fetal biometry at second trimester. The results support the recommendation that ultrasound in practical health care can be used to assess gestational age in various populations with little risk of error due to ethnic variation.
Obstetric fistula is essentially a result of pelvic injury caused by prolonged obstructed labour. Foot drop and walking difficulties in some of these women signify that the injury may extend beyond the loss of tissue that led to the fistula. However, these aspects of the pelvic injury are scarcely addressed in the literature. Here we specifically aimed at assessing musculoskeletal function in women with obstetric fistula to appreciate the extent of the sequelae of their pelvic injury.This case-control study compared 70 patients with obstetric fistula with 100 controls matched for age and years since delivery. The following was recorded: height, weight, past and present walking difficulties, pain, muscle strength and joint range of motion, circumference and reflexes. Differences between groups were analysed using independent sample t-test and chi-square test for independence.A history of leg pain was more common among cases compared to controls, 20% versus 7% (p = 0.02), and 29% of the cases had difficulties walking following the injuring delivery compared to none of the controls (p ≤ 0.001). Of these, four women reported spontaneous recovery. Cases had 7° less range of motion in ankle dorsal flexion (95%CI: -8.1, -4.8), 8° less ankle plantar flexion (95%CI: -10.6, -6.5), 12° less knee flexion (95%CI: -14.1, -8.9), and 4° less knee extension (95%CI: 2.9, 5.0) compared to controls. Twelve % of the cases had lower ankle dorsal flexion strength (p = 0.009). Foot drop was present in three (4.3%) compared with none among controls. Women with fistula had 4° greater movement in hip extension (95%CI: -5.9, -3.1), 2° greater hip lateral rotation (95%CI: 0.7, 3.3) and 9° greater hip abduction (95%CI: 6.4, 10.7). Twelve % of the cases had stronger medial rotation in the hip (p = 0.04), 20% had stronger hip lateral rotation (p ≤ 0.001), 29% had stronger hip extension (p ≤ 0.001), and 15% had stronger hip abduction (p = 0.04) than controls.Women with obstetric fistula commonly experienced walking difficulties after the delivery, had often leg pain and reduced function in the ankle and knee joints that may have been compensated by increased motion and strength in the hip.
