E. Hernandez‐Andrade

The University of Texas Health Science Center at Houston

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E. Gratacós

Consorci Institut D'Investigacions Biomediques August Pi I Sunyer

F. Figueras

Hospital Sant Joan de Déu Barcelona

H. Figueroa

Universidad de Los Andes

F. Crispi

Hospital Sant Joan de Déu Barcelona

L. Cabero

Universitat Autònoma de Barcelona

O. Moreno‐Alvarez

Mexican Social Security Institute

K. H. Nicolaides

King's College Hospital

Ruthy Acosta‐Rojas

Centre for Biomedical Network Research on Rare Diseases

Karel Maršál

Lund University

E. Eixarch

Consorci Institut D'Investigacions Biomediques August Pi I Sunyer

Cooperative Institutions

Universitat de Barcelona

Hospital Clínic de Barcelona

Consorci Institut D'Investigacions Biomediques August Pi I Sunyer

The University of Texas Health Science Center at Houston

Centre for Biomedical Network Research on Rare Diseases

Centro de Investigación Biomédica en Red

Universitat Autònoma de Barcelona

Instituto de Salud Carlos III

Hospital Sant Joan de Déu Barcelona

Memorial Hermann

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Contribution of the myocardial performance index and aortic isthmus blood flow index to predicting mortality in preterm growth‐restricted fetuses

Ultrasound in Obstetrics and Gynecology (2009)

E. Hernandez‐Andrade F. Crispi Jesús Andrés Benavides-Serralde W. Plasencia H. Figueroa

Abstract Objectives To evaluate the predictive value for perinatal death of the myocardial performance index (MPI) and aortic isthmus flow index (IFI), as isolated parameters and in a combined model including currently used Doppler indices, in preterm growth restricted (IUGR) fetuses. Methods Umbilical artery, fetal middle cerebral artery (MCA) and ductus venosus (DV) pulsatility indices (PIs) were recorded, along with IFI and MPI, in a cohort of 97 preterm (delivered at between 24 and 34 weeks) IUGR fetuses. Logistic regression analysis was performed to identify those variables that were independently associated with perinatal mortality, and an algorithm to estimate probability of death was constructed including the best combination of parameters. Results With the exception of MCA, all Doppler indices were significantly associated with perinatal death as isolated parameters, but only DV‐PI and MPI were found to be independent predictors on multivariate analysis. An algorithm combining DV atrial flow (positive or absent/reversed) and MPI (normal or above 95 th percentile) had a better predictive accuracy than did any single parameter. The risk for death in IUGR fetuses below 28 weeks' gestation with present atrial flow in the DV and normal MPI was 18%, with either characteristic abnormal it was 70–73%, and with both abnormal it was 97%. The risk for death in IUGR fetuses above 28 weeks with present atrial flow in the DV and normal MPI was 0.1%, with either abnormal it was 6–7%, and with both abnormal it was 45%. Conclusions MPI is an independent predictor of perinatal death in preterm IUGR fetuses with accuracy similar to that of DV flow. A combination of DV flow with MPI may better stratify the estimated probability of death. IFI does not add to the prediction of perinatal death when used in combination with DV flow. Copyright © 2009 ISUOG. Published by John Wiley & Sons, Ltd.

Perinatal mortality

Fetal growth

10.1002/uog.7347

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Citations (87)

EP15.05: Fetal growth restriction between 18 and 24 weeks: outcomes and risk factors

Ultrasound in Obstetrics and Gynecology (2023)

Ghamar Bitar Keya Lee Hailie Ciomperlik Shobha Natarajan Edith Miller

To assess risk factors and associated outcomes with persistent fetal growth restriction (FGR) after mid-trimester diagnosis. Retrospective study of fetuses with FGR by estimated weight (EFW) < 10th percentile or abdominal circumference (AC) < 10th percentile identified between 18 – 24 weeks of gestation without structural or chromosomal anomalies. We compared pregnancies that had persistent FGR (at last scan prior to delivery) to those with resolved FGR. Primary outcome was small for gestational age (SGA) defined as birthweight < 10th percentile by WHO criteria. Secondary outcomes were preterm delivery < 37 weeks of gestation, stillbirth/neonatal death, and maternal outcomes. 398 singleton gestations were diagnosed with FGR between 18.0 – 24.0 weeks of gestation. After exclusion criteria, 161 patients (50.5%) were included for analysis; 69 (42.9%) had resolved FGR and 92 (57.1%) were persistent FGR. Maternal characteristics were similar between groups. Gestational age at diagnostic ultrasound were similar between groups (21 ± 1.4 weeks' gestation vs. 21 ± 1.4 weeks' gestation, p = 0.9). As compared to resolved FGR, pregnancies with persistent FGR were more likely to have: EFW ≤ 3% at initial diagnosis (62% persistent FGR vs. 26.1 resolved FGR%, p < 0.0001), have a trend towards abnormal Doppler studies (27% vs. 15.4% p = 0.17), more likely to be SGA at delivery (72.5% vs. 23.2%; p < 0.001), higher frequency of stillbirth/neonatal death (16.3% vs. 1.5%; p = .001), delivery prior 37 weeks of gestation (46.7% vs. 5.8% p < 0.0001), higher prevalence of maternal hypertensive disorders of pregnancy (41.3% vs. 20.2%; p = 0.006), and prolonged maternal hospital stay following delivery (3.6 ± 3.0 days vs. 2.5 ± 1.1 days; p = 0.004). Fetuses diagnosed with FGR at 18-24 weeks having an EFW ≤ 3rd percentile were likely to have persistent FGR. Those pregnancies for whom FGR persisted were more likely to be SGA at birth and have a higher frequency of fetal demise.

Fetal growth

Intrauterine growth restriction

10.1002/uog.26874

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OC71: Fetal cardiac function evaluated with the modified myocardial performance index in twin–twin transfusion syndrome and impact of laser therapy

Ultrasound in Obstetrics and Gynecology (2006)

E. Gratacós H. Figueroa B. Muñoz O. Moreno L. Cabero

To evaluate the fetal cardiac function as measured by the modified myocardial performance index (Mod-MPI), in twin-to twin transfusion syndrome (TTS) before and after laser surgery. Mod-MPI was measured in the left cardiac chambers of donors and recipients from 20 pregnancies affected with TTS one day before and 3–6 days after laser surgery. The isovolumetric contraction (ICT), relaxation (IRT) and ejection (ET) times were measured using the Doppler signals of the aperture and closure (clicks) of the mitral and aortic valves as landmarks. Mod-MPI was calculated as IVT + IVT/ET and a value above 0.42 (P95) was considered abnormal. Before laser, recipients had a Mod-MPI of (Mean, SD) 0.48 (0.11) and donors of 0.36 (0.06) and (p = 0.0001). Three donors had a Mod-MPI above 0.42. After laser, the recipients decreased the Mod-MPI to 0.41 (0.05) (versus pre-treatment values p = 0.0001), whereas in donors it increased to 0.39 (0.06) (p = 0.007), and the differences between recipient and donor observed before laser became non-significant. Of the 3 donors with increased Mod-MPI before therapy, two died afterwards. Alterations in the Mod-MPI reflect the hemodynamic disturbances of TTS and its modification after laser therapy. An increased Mod-MPI before treatment in the donor might further indicate a poor prognosis after laser, but this observation must be confirmed in larger studies.

Isovolumetric contraction

Mod

10.1002/uog.2931

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Learning curve for lung area to head circumference ratio measurement in fetuses with congenital diaphragmatic hernia

Ultrasound in Obstetrics and Gynecology (2010)

R. Cruz‐Martinez F. Figueras O. Moreno‐Alvarez J. Martı́nez O. Gómez

To assess the learning curve for the fetal lung area to head circumference ratio (LHR) calculation in fetuses with congenital diaphragmatic hernia (CDH).Three trainees with the theoretical knowledge, but without prior experience in the LHR measurement, were selected. Each trainee and one experienced examiner measured the observed to expected (O/E)-LHR in the lung contralateral to the side of the hernia by two methods-manual tracing of lung borders and multiplication of the longest diameters-in a cohort of 95 consecutive CDH fetuses. The average difference between the three trainees and the expert in the O/E-LHR measurement was calculated. A difference below 10% was considered to indicate an accurate measurement. The average learning curve was delineated using cumulative sum analysis (CUSUM).The CUSUM plots demonstrate that the learning curve was achieved by 77 and 72 tests performed for the area obtained by the manual-tracing and multiplication-of-the-longest-diameter methods, respectively.The minimum number of scans required for an inexperienced trainee to become competent in examining the LHR is on average 70.

CUSUM

Learning curve

Fetal head

10.1002/uog.7577

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Monitoring of fetuses with intrauterine growth restriction: longitudinal changes in ductus venosus and aortic isthmus flow

Ultrasound in Obstetrics and Gynecology (2008)

F. Figueras A Benavides M. del Río F. Crispi E. Eixarch

Abstract Objectives To explore in growth‐restricted fetuses the sequence of changes in aortic isthmus and ductus venosus blood flow in relation to other arterial Doppler parameters commonly used to evaluate fetal wellbeing. Methods Umbilical and middle cerebral arteries, ductus venosus and aortic isthmus were explored serially by means of pulsed Doppler in a cohort of singleton small‐for‐gestational age fetuses requiring delivery before 34 weeks. Longitudinal changes in the last 30 days before delivery were modeled by multilevel analysis. Individual regression lines for each variable were calculated for each fetus and from these the regression lines for the whole group were derived, in order to estimate the mean time point at which each Doppler parameter became abnormal (outside the 5 th –95 th centile range). A survival analysis was performed during the monitoring period, in which the endpoint was an abnormal Doppler pulsatility index. Results A total of 162 observations were performed on 46 fetuses (median, 3; range, 2–10). The median gestational age at inclusion was 28.9 (range, 23.6–33.4) weeks and delivery occurred at a median gestational age of 30.5 (range, 25.9–33.9) weeks. Six (13%) cases of perinatal mortality occurred. Umbilical and middle cerebral artery Doppler showed an almost linear deterioration throughout monitoring, becoming abnormal on average 24 days and 20 days before delivery, respectively. Aortic isthmus Doppler became abnormal on average 13 days before delivery, while ductus venosus Doppler did so within the last week before delivery. Conclusions In preterm growth‐restricted fetuses, aortic isthmus blood flow becomes abnormal on average 1 week earlier than does that in the ductus venosus. This could provide a sound basis to better define management protocols aimed to improve intact fetal survival. Copyright © 2008 ISUOG. Published by John Wiley & Sons, Ltd.

Ductus venosus

Intrauterine growth restriction

Umbilical artery

10.1002/uog.6278

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Lung tissue perfusion in congenital diaphragmatic hernia and association with the lung‐to‐head ratio and intrapulmonary artery pulsed Doppler

Ultrasound in Obstetrics and Gynecology (2010)

O. Moreno‐Alvarez R. Cruz‐Martinez E. Hernandez‐Andrade Elisa Doné O. Gómez

To evaluate lung tissue perfusion in fetuses with congenital diaphragmatic hernia (CDH) and to explore the association of lung tissue perfusion with the lung area to head circumference ratio (LHR) and intrapulmonary artery pulsed Doppler.Fetuses with isolated left CDH were evaluated and compared with a group of fetuses without CDH, which were sampled from our general population and matched by gestational age at inclusion. Lung tissue perfusion measured using fractional moving blood volume (FMBV), the observed to expected (O/E) LHR and pulsed Doppler of the proximal intrapulmonary artery were evaluated in the lung contralateral to the side of the hernia. Doppler waveform analysis included the pulsatility index (PI), the peak early diastolic reversed flow (PEDRF) and the peak systolic velocity (PSV). All Doppler parameters were converted into Z-scores for gestational age. The associations between FMBV and O/E-LHR and between FMBV and intrapulmonary arterial Doppler parameters were analyzed using multiple linear regression, adjusted by gestational age.A total of 190 fetuses (95 with CDH and 95 controls) were evaluated. Fetuses with CDH showed significantly lower lung FMBV (26.8 (SD 8.4) vs. 37.9 (SD 8.1)%; P < 0.001) than controls. Lung tissue perfusion correlated positively with O/E-LHR (r = 0.37; P < 0.001) and negatively with intrapulmonary artery PI (r = - 0.31; P < 0.001), PEDRF (r = - 0.43; P < 0.001) and PSV (r = - 0.18; P = 0.03).Fetuses with CDH have decreased lung tissue perfusion, which is associated with decreased lung growth and increased intrapulmonary artery impedance.

10.1002/uog.7592

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Citations (38)

OC138: Power Doppler and fetal organ perfusion

Ultrasound in Obstetrics and Gynecology (2004)

Karel Maršál E. Hernandez‐Andrade

To develop a standardized method for quantification of the power Doppler signals recorded from fetal organs, compensating for factors (instrument settings, depth, and attenuation) that can affect the results. The method by Rubin et al. has been modified and fractional moving blood volume (FMBV) was estimated within the standardized region of interest within the fetal lung The method was evaluated in an in vitro model and then applied in an animal experimental model. In fetal sheep, the measurements of FMBV were compared with blood perfusion measurements using radioactive labeled microspheres. A test of the reproducibility of the FMBV estimation was performed by two independent operators in the lungs of 20 human fetuses. Then the method was applied on a clinical material. FMBV was estimated in the lung of 47 normally grown and 25 growth restricted (IUGR) fetuses after 32 weeks of gestation. 1) A high correlation was found between the FMBV and radioactive labeled microspheres in measurement of fetal adrenal gland perfusion (r = 0.90). 2) The reproducibility test gave satisfactory results: Intraclass correlation coefficient 0.92 (95% confidence interval [CI] 0.78–0.96); interclass correlation coefficient 0.70 (95%CI 0.56–0.76), Kappa index 0.82 (95%CI 0.51–0.93). 3) The normal fetuses showed a higher lung FMBV values than the IUGR fetuses (P = 0.003). There was no association between the FMBV and respiratory complications during neonatal period. The power Doppler FMBV method proved to give an estimate of fetal organ blood perfusion. A standardized and reproducible method of examining fetal lung circulation has been developed. The clinical potential of the power Doppler FMBV method, e.g., for prediction of lung hypoplasia, remains to be established.

Coefficient of variation

10.1002/uog.1256

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Neurodevelopmental outcome in 2‐year‐old infants who were small‐for‐gestational age term fetuses with cerebral blood flow redistribution

Ultrasound in Obstetrics and Gynecology (2008)

E. Eixarch E. Meler A. Iraola M. Illa F. Crispi

Abstract Objective To assess the neurodevelopmental outcome at 2 years of age of children who had been small‐for‐gestational‐age (SGA) term babies with cerebral blood flow redistribution. Methods Perinatal outcome was assessed in a cohort of 97 term singleton appropriate‐for‐gestational‐age and 125 term singleton SGA fetuses with normal umbilical artery Doppler, stratified according to the presence of cerebral blood flow redistribution. Neurodevelopmental outcome was assessed prospectively at 2 years of age by means of the 24‐month Age & Stage Questionnaire (ASQ). Results Of the 125 SGA fetuses, 25 had redistribution of the cerebral blood flow, and 100 did not. There were no significant differences in perinatal outcome between these two SGA groups. At 2 years of age, children who had been SGA fetuses with middle cerebral artery (MCA) pulsatility index (PI) < 5 th centile had a higher incidence of suboptimal neurodevelopmental outcome compared with those with normal MCA‐PI (52% vs. 31%; P = 0.049) and a lower mean centile in communication (53.1 vs. 67.4; P = 0.006) and problem‐solving (39.7 vs. 47.4; P = 0.04) areas. Conclusion SGA fetuses with cerebral blood flow redistribution have a higher risk of subtle neurodevelopmental deficits at 2 years of age. This challenges the concept that fetal cerebral redistribution is an entirely protective mechanism and suggests MCA‐PI as a risk stratifying factor for adverse neurodevelopmental outcome. Copyright © 2008 ISUOG. Published by John Wiley & Sons, Ltd.

10.1002/uog.6249

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Gestational‐age‐adjusted reference values for the modified myocardial performance index for evaluation of fetal left cardiac function

Ultrasound in Obstetrics and Gynecology (2007)

E. Hernandez‐Andrade H. Figueroa C. Kottman Sebastián E. Illanes J Arraztoa

Abstract Objective It has been shown that the modified myocardial performance index (Mod‐MPI) is associated with higher reproducibility than conventional MPI because it uses mitral and aortic valve ‘clicks’ to calculate each time period. We aimed to construct normal reference values for the Mod‐MPI after 19 weeks' gestation. Methods The Mod‐MPI was calculated in the left ventricle of 557 normal fetuses at 19–39 weeks' gestation. The isovolumetric contraction time (ICT), isovolumetric relaxation time (IRT) and ejection time (ET) were measured using the Doppler signals (clicks) of the opening and closing of the mitral and aortic valves as landmarks. Mod‐MPI was calculated as (ICT + IRT)/ET. Results Throughout gestation, there was a small increase in the Mod‐MPI (at 19 weeks it was 0.35 ± 0.027 (mean ± SD); at 39 weeks, 0.37 ± 0.029; Mod‐MPI = 0.33 + 0.001× gestational age (GA) (weeks), r 2 = 0.017). Of the three components, ICT remained constant, IRT increased (IRT = 0.028 + 2.52 × GA (weeks)), and ET slightly decreased (ET = 0.184 − 3.65 × GA (weeks)). Fetal heart rate (FHR) had no effect on the Mod‐MPI, but the duration of IRT, ICT and ET decreased by 13–15% when FHR increased from 130 to 160 beats per minute. Conclusion The GA‐adjusted reference values for the Mod‐MPI and the three time periods used for its calculation can be applied to fetal cardiac evaluation in the presence of pregnancy‐associated complications. Copyright © 2007 ISUOG. Published by John Wiley & Sons, Ltd.

Isovolumetric contraction

10.1002/uog.3947

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Prediction of fetal anemia in rhesus disease by measurement of fetal middle cerebral artery peak systolic velocity

Ultrasound in Obstetrics and Gynecology (2004)

M Scheier E. Hernandez‐Andrade A. V. Carmo V. Dezerega K. H. Nicolaides

Abstract Objective In red blood cell (RBC) isoimmunized pregnancies fetal anemia is associated with a hyperdynamic circulation. The aim of the present study was to examine further the possible value of fetal middle cerebral artery peak systolic velocity (MCA‐PSV) in the management of affected pregnancies. Methods A reference range of fetal MCA‐PSV with gestation was constructed from the study of 813 normal singleton pregnancies at 20–40 weeks' gestation. Fetal MCA‐PSV was also measured in 58 fetuses from RBC isoimmunized pregnancies, with maternal hemolytic antibody concentration of >15 IU/mL at 19–38 weeks' gestation and within 10 days of measurement of fetal hemoglobin concentration in blood obtained either by cordocentesis ( n = 43) or at delivery ( n = 15). In the RBC isoimmunized pregnancies each of the measured MCA‐PSV and hemoglobin concentrations was expressed as a delta value (difference in SDs from the normal mean for gestation). Regression analysis was used to determine the significance of the association between delta MCA‐PSV and delta fetal hemoglobin concentration. Results In the normal pregnancies there was a significant increase in fetal MCA‐PSV with gestation (mean MCA‐PSV = 10 0.0223 × GA + 0.963 ). In RBC isoimmunized pregnancies the fetal MCA‐PSV was increased and there was a significant association between delta MCA‐PSV and delta hemoglobin concentration (delta hemoglobin = (delta MCA‐PSV + 0.093)/−0.356; R 2 = 0.638, P < 0.0001). An MCA‐PSV of mean + 1.5 SDs detected 96% of severely anemic fetuses, with a hemoglobin deficit of at least 6 SDs, for a false‐positive rate of 14%. Conclusion Measurement of fetal MCA‐PSV is a useful method of assessing fetal anemia. In the clinical management of isoimmunized pregnancies a cut‐off in MCA‐PSV of mean + 1.5 SDs can identify nearly all severely anemic fetuses with a low false‐positive rate. Copyright © 2004 ISUOG. Published by John Wiley & Sons, Ltd.

10.1002/uog.1010

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Citations (94)