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1. Core outcome set for studies investigating management of selective fetal growth restriction in twins

Author

Townsend, R., Duffy, J. M. N., Sileo, F., Perry, H., Ganzevoort, W., Reed, K., Baschat, A. A., Deprest, J., Gratacos, E., Hecher, K., Lewi, L., Lopriore, E., Oepkes, D., Papageorghiou, A., Gordijn, S. J., Khalil, A., Baschat, A., Perales-Marin, A., Johnson, A., Silvana, A., Papageorghious, A., Khurana, A., Trinder, B., Combs, C. A., Bailie, C., Huddy, C., Bolch, C., Coutinho, C. M., Skupski, D., Hake, D., Schlembach, D., Lindahl, E., Carreras, E., Mantovani, E., Giallongo, E., Marler, E., Bertucci, E., Prefumo, F., Sileo, F. G., Guy, G., Rizzo, G., King, H., Valensise, H., Samarage, H., Duffy, J., Denton, J., Curado, J., Marsden, J., Tolosa, J. E., Toms, J., Copel, J., Richards, J., Ishii, K., Palmer, K., Watkins, K., Mcgrath, L., Canolini, L., Dhuri, M. V., Kyriakidou, M., Lanna, M., Treadwell, M., Watson, M., Rankin, M., Fenwick, N., Moore, P., O'Brien, P., Cincotta, R., Linton, S., Robinson, S., Mcsorley, T., Fuchs, T., Ghi, T., Omosebi, W., Acheampong, Y., Obstetrics and Gynaecology, Amsterdam Reproduction & Development (AR&D), APH - Digital Health, and APH - Quality of Care

Subjects
Delphi Technique, multiple pregnancy, Delphi method, Obstetric Surgical Procedures, consensus, core outcome set, Delphi consensus, fetal growth restriction, Outcome (game theory), NOMINAL GROUP TECHNIQUE, 0302 clinical medicine, Nominal group technique, Outcome Assessment, Health Care, Birth Weight, 030212 general & internal medicine, 030219 obstetrics & reproductive medicine, Fetal Growth Retardation, Radiological and Ultrasound Technology, Obstetrics and Gynecology, Gestational age, General Medicine, Treatment Outcome, PREGNANCY, Female, Live birth, Live Birth, medicine.medical_specialty, Endpoint Determination, Birth weight, Gestational Age, Likert scale, 03 medical and health sciences, medicine, Humans, Radiology, Nuclear Medicine and imaging, fetal growth restriction, multiple pregnancy, core outcome set, consensus, business.industry, Infant, Newborn, Twins, Monozygotic, Reproductive Medicine, Family medicine, Sonographer, Pregnancy, Twin, Settore MED/40 - Ginecologia e Ostetricia, business
Abstract

OBJECTIVE: Selective fetal growth restriction (sFGR) occurs in monochorionic twin pregnancies when unequal placental sharing leads to restriction in the growth of just one twin. Management options include laser separation of the fetal circulations, selective reduction or expectant management, but what constitutes the best treatment is not yet known. New trials in this area are urgently needed but, in this rare and complex group, maximizing the relevance and utility of clinical research design and outputs is paramount. A core outcome set ensures standardized outcome collection and reporting in future research. The objective of this study was to develop a core outcome set for studies evaluating treatments for sFGR in monochorionic twins. METHODS: An international steering group of clinicians, researchers and patients with experience of sFGR was established to oversee the process of development of a core outcome set for studies investigating the management of sFGR. Outcomes reported in the literature were identified through a systematic review and informed the design of a three-round Delphi survey. Clinicians, researchers, and patients and family representatives participated in the survey. Outcomes were scored on a Likert scale from 1 (limited importance for making a decision) to 9 (critical for making a decision). Consensus was defined a priori as a Likert score of ≥ 8 in the third round of the Delphi survey. Participants were then invited to take part in an international meeting of stakeholders in which the modified nominal group technique was used to consider the consensus outcomes and agree on a final core outcome set. RESULTS: Ninety-six outcomes were identified from 39 studies in the systematic review. One hundred and three participants from 23 countries completed the first round of the Delphi survey, of whom 88 completed all three rounds. Twenty-nine outcomes met the a priori criteria for consensus and, along with six additional outcomes, were prioritized in a consensus development meeting, using the modified nominal group technique. Twenty-five stakeholders participated in this meeting, including researchers (n = 3), fetal medicine specialists (n = 3), obstetricians (n = 2), neonatologists (n = 3), midwives (n = 4), parents and family members (n = 6), patient group representatives (n = 3), and a sonographer. Eleven core outcomes were agreed upon. These were live birth, gestational age at birth, birth weight, intertwin birth-weight discordance, death of surviving twin after death of cotwin, loss during pregnancy or before final hospital discharge, parental stress, procedure-related adverse maternal outcome, length of neonatal stay in hospital, neurological abnormality on postnatal imaging and childhood disability. CONCLUSIONS: This core outcome set for studies investigating the management of sFGR represents the consensus of a large and diverse group of international collaborators. Use of these outcomes in future trials should help to increase the clinical relevance of research on this condition. Consensus agreement on core outcome definitions and measures is now required. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd. ispartof: ULTRASOUND IN OBSTETRICS & GYNECOLOGY vol:55 issue:5 pages:652-660 ispartof: location:England status: published

Published
2020

2. Fetal monitoring indications for delivery and 2-year outcome in 310 infants with fetal growth restriction delivered before 32 weeks' gestation in the TRUFFLE study

Author

Visser, Gha, Bilardo, Cm, Derks, Jb, Ferrazzi, E, Fratelli, N, Frusca, T, Ganzevoort, W, Lees, Cc, Napolitano, R, Todros, T, Wolf, H, Hecher, K, Marlow, N, Arabin, B, Brezinka, C, Diemert, A, Duvekot, Jj, Martinelli, P, Ostermayer, E, Papageorghiou, At, Schlembach, D, Schneider, Ktm, Thilaganathan, B, Valcamonico, A, Aktas, A, Borgione, S, Chaoui, R, Cornette, Jmj, Diehl, T, van Eyck, J, van Haastert, Ic, Kingdom, J, Lobmaier, S, Lopriore, E, Missfelder-Lobos, H, Mansi, G, Martelli, P, Maso, G, Marsal, K, Maurer-Fellbaum, U, Mensing van Charante, N, Mulder-de Tollenaer, S, Oberto, M, Oepkes, D, Ogge, G, van der Post, Jam, Prefumo, F, Preston, L, Raimondi, F, Rattue, H, Reiss, Ikm, Scheepers, Ls, Skabar, A, Spaanderman, M, Thornton, J, Valensise, H, Weisglas-Kuperus, N, and Zimmermann, A

Subjects
Male, cardiotocography, ductus venosus, fetal growth restriction, fetal heart rate variation, preterm delivery, Cardiotocography, Female, Fetal Growth Retardation, Fetus, Gestational Age, Humans, Infant, Newborn, Netherlands, Pregnancy, Pregnancy Outcome, Pulsatile Flow, Survival Analysis, Umbilical Arteries, Delivery, Obstetric, Fetal Monitoring, Ultrasonography, Prenatal, Prenatal, Ultrasonography, Infant, Obstetric, Newborn, Settore MED/40, Delivery
Abstract

In the TRUFFLE (Trial of Randomized Umbilical and Fetal Flow in Europe) study on the outcome of early fetal growth restriction, women were allocated to one of three groups of indication for delivery according to the following monitoring strategies: (1) reduced fetal heart rate (FHR) short-term variation (STV) on cardiotocography (CTG); (2) early changes in fetal ductus venosus (DV) waveform (DV-p95); and (3) late changes in fetal DV waveform (DV-no-A). However, many infants per monitoring protocol were delivered because of safety-net criteria, for maternal or other fetal indications, or after 32 weeks of gestation when the protocol was no longer applied. The objective of the present posthoc subanalysis was to investigate the indications for delivery in relation to 2-year outcome in infants delivered before 32 weeks to further refine management proposals.We included all 310 cases of the TRUFFLE study with known outcome at 2 years' corrected age and seven fetal deaths, excluding seven cases with inevitable perinatal death. Data were analyzed according to the allocated fetal monitoring strategy in combination with the indication for delivery.Overall, only 32% of liveborn infants were delivered according to the specified monitoring parameter for indication for delivery; 38% were delivered because of safety-net criteria, 15% for other fetal reasons and 15% for maternal reasons. In the CTG-STV group, 51% of infants were delivered because of reduced STV. In the DV-p95 group, 34% of infants were delivered because of abnormal DV and, in the DV-no-A group, only 10% of infants were delivered accordingly. The majority of infants in the DV groups were delivered for the safety-net criterion of spontaneous decelerations in FHR. Two-year intact survival was highest in the DV groups combined compared with the CTG-STV group (P = 0.05 for live births only, P = 0.21 including fetal death), with no difference between DV groups. A poorer outcome in the CTG-STV group was restricted to infants delivered because of FHR decelerations in the safety-net subgroup. Infants delivered because of maternal reasons had the highest birth weight and a non-significantly higher intact survival.In this subanalysis of infants delivered before 32 weeks, the majority were delivered for reasons other than the allocated monitoring strategy indication. Since, in the DV group, CTG-STV criteria were used as a safety net but in the CTG-STV group, no DV safety-net criteria were applied, we speculate that the slightly poorer outcome in the CTG-STV group might be explained by the absence of DV data. The optimal timing of delivery of fetuses with early intrauterine growth restriction may therefore be best determined by monitoring them longitudinally, with both DV and CTG monitoring. Copyright © 2016 ISUOG. Published by John WileySons Ltd.

Published
2017

3. Longitudinal study of computerized cardiotocography in early fetal growth restriction.

Author

Wolf, H., Arabin, B., Lees, C. C., Oepkes, D., Prefumo, F., Thilaganathan, B., Todros, T., Visser, G. H. A., Bilardo, C. M., Derks, J. B., Diemert, A., Duvekot, J. J., Ferrazzi, E., Frusca, T., Hecher, K., Marlow, N., Martinelli, P., Ostermayer, E., Papageorghiou, A. T., and Scheepers, H. C. J.

Subjects
FETAL growth retardation, FETAL heart rate monitoring, BIRTH weight, NEUROLOGICAL disorders, GESTATIONAL age, HEALTH outcome assessment, CEREBRAL artery physiology, FETAL heart, CEREBRAL arteries, COMPARATIVE studies, FETAL ultrasonic imaging, LONGITUDINAL method, RESEARCH methodology, EVALUATION of medical care, MEDICAL cooperation, PHYSICS, PREGNANCY, RESEARCH, RESEARCH funding, SURVIVAL analysis (Biometry), EVALUATION research, RANDOMIZED controlled trials, FETAL heart rate, PHYSIOLOGY
Abstract

Objectives: To explore whether, in early fetal growth restriction (FGR), the longitudinal pattern of fetal heart rate (FHR) short-term variation (STV) can be used to identify imminent fetal distress and whether abnormalities of FHR recordings are associated with 2-year infant outcome.Methods: The original TRUFFLE study assessed whether, in early FGR, delivery based on ductus venosus (DV) Doppler pulsatility index (PI), in combination with safety-net criteria of very low STV on cardiotocography (CTG) and/or recurrent FHR decelerations, could improve 2-year infant survival without neurological impairment in comparison with delivery based on CTG monitoring only. This was a secondary analysis of women who delivered before 32 weeks and had consecutive STV data recorded > 3 days before delivery and known infant outcome at 2 years of age. Women who received corticosteroids within 3 days of delivery were excluded. Individual regression line algorithms of all STV values, except the last one before delivery, were calculated. Life tables and Cox regression analysis were used to calculate the daily risk for low STV or very low STV and/or FHR decelerations (below DV group safety-net criteria) and to assess which parameters were associated with this risk. Furthermore, it was assessed whether STV pattern, last STV value or recurrent FHR decelerations were associated with 2-year infant outcome.Results: One hundred and forty-nine women from the original TRUFFLE study met the inclusion criteria. Using the individual STV regression lines, prediction of a last STV below the cut-off used by the CTG monitoring group had sensitivity of 42% and specificity of 91%. For each day after study inclusion, the median risk for low STV (CTG group cut-off) was 4% (interquartile range (IQR), 2-7%) and for very low STV and/or recurrent FHR decelerations (below DV group safety-net criteria) was 5% (IQR, 4-7%). Measures of STV pattern, fetal Doppler (arterial or venous), birth-weight multiples of the median and gestational age did not usefully improve daily risk prediction. There was no association of STV regression coefficients, a low last STV and/or recurrent FHR decelerations with short- or long-term infant outcomes.Conclusion: The TRUFFLE study showed that a strategy of DV monitoring with safety-net criteria of very low STV and/or recurrent FHR decelerations for delivery indication could increase 2-year infant survival without neurological impairment. This post-hoc analysis demonstrates that, in early FGR, the daily risk of abnormal CTG, as defined by the DV group safety-net criteria, is 5%, and that prediction is not possible. This supports the rationale for CTG monitoring more often than daily in these high-risk fetuses. Low STV and/or recurrent FHR decelerations were not associated with adverse infant outcome and it appears safe to delay intervention until such abnormalities occur, as long as DV-PI is within normal range. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

Published
2017
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4. Prediction of single fetal demise after laser therapy for twin-twin transfusion syndrome.

Author

Eschbach, S. J., Boons, L. S. T. M., Wolterbeek, R., Middeldorp, J. M., Klumper, F. J. C. M., Lopriore, E., Oepkes, D., and Haak, M. C.

Subjects
FETOFETAL transfusion, DISEASES in twins, ULTRASONIC imaging, LASER therapy, LASER surgery, PERINATAL death, BLOOD flow measurement, GESTATIONAL age, HEMODYNAMICS, MEDICAL lasers, EVALUATION of medical care, PLACENTA, PREGNANCY, TWINS, CASE-control method, SELECTIVE reduction (Multiple pregnancy), SURGERY, THERAPEUTICS, PREVENTION
Abstract

Objective: Single fetal demise (SFD) occurs in up to 20% of monochorionic pregnancies treated with laser coagulation for twin-twin transfusion syndrome (TTTS). We aimed to determine the independent factors associated with SFD to improve outcome in the care of TTTS pregnancies in the future.Methods: This was a case-control study on twin pregnancies treated for TTTS between 2007 and 2013. Data on ultrasound, laser surgery and outcome were retrieved from our monochorionic twin database. We analyzed separately cases of SFD in donor and recipient twins, and compared them with treated pregnancies that resulted in two live births.Results: Of the 273 TTTS pregnancies treated with laser coagulation, SFD occurred in 30 donors (11.0%) and 27 recipients (9.9%). In 67% of pregnancies with SFD, the death occurred within 1 week after laser treatment. For SFD in donors, absent/reversed end-diastolic flow in the umbilical artery was the strongest predictor (odds ratio (OR), 3.0 (95% CI, 1.1-8.0); P = 0.01), followed by the presence of an arterioarterial anastomosis (OR, 4.2 (95% CI, 1.4-13.1); P = 0.03) and discordance in estimated fetal weight (OR, 1.0 (95% CI, 1.0-1.1); P = 0.04). For SFD in recipients, independent predictors were absent/reversed A-wave in the ductus venosus (OR, 3.6 (95% CI, 1.2-10.5); P = 0.02) and the absence of recipient-to-donor arteriovenous anastomoses (OR, 10.6 (95% CI, 1.8-62.0); P < 0.01).Conclusions: Our findings confirm earlier reports that suggest that abnormal blood flow is associated with SFD after laser treatment for TTTS. The association of SFD with the type of anastomoses is a new finding. We speculate that the type of anastomoses present determines the degree of hemodynamic change during laser therapy. Future strategies should aim at stabilizing fetal circulation before laser therapy to decrease the vulnerability to acute preload and afterload changes. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

Published
2016
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5. Twin-to-twin transfusion syndrome after 26 weeks of gestation: is there a role for fetoscopic laser surgery?

Author

Middeldorp, J. M., Lopriore, E., Sueters, M., Klumper, F. J. C. M., Kanhai, H. H. H., Vandenbussche, F. P. H. A., and Oepkes, D.

Subjects
INFANT mortality, LASER surgery, PREGNANCY, GESTATIONAL age, CHILDBIRTH, SYNDROMES, LASER coagulation
Abstract

Objective To compare fetoscopic laser surgery with amniodrainage in the treatment of twin-to-twin transfusion syndrome (TTTS) diagnosed after 26 weeks of gestation. Design A retrospective cohort study. Setting Leiden University Medical Centre, a tertiary referral hospital for fetal therapy. Population Between January 1991 and February 2006, 21 TTTS cases were diagnosed and treated after 26 weeks of gestation. Methods Treatment of TTTS consisted of either amniodrainage or fetoscopic laser coagulation of vascular anastomoses. Main outcome measures Primary outcome: adverse outcome (intrauterine or neonatal death, major neonatal morbidity and/or severe cerebral injury). Secondary outcome: gestational age at birth. Results Eleven TTTS cases were treated with amniodrainage and ten with laser surgery. Median gestational age at birth in the amniodrainage group and in the laser surgery group was 29 and 31 weeks, respectively ( P = 0.17) All infants were born alive. Major neonatal morbidity occurred more often in the amniodrainage group than in the laser surgery group, 27% (6/22) and 0% (0/20), respectively ( P = 0.02). Severe cerebral injury in the amniodrainage group and in the laser surgery group occurred in 23% (5/22) and 15% (3/20) of infants, respectively ( P = 0.70). Neonatal mortality in the amniodrainage group and in the laser surgery group was 14% (3/22) and 0% (0/20), respectively ( P = 0.23). Overall adverse outcome was 36% (8/22) in the amniodrainage group and 15% (3/20) in the laser surgery group ( P = 0.17). Conclusion In TTTS diagnosed after 26 weeks of gestation, amniodrainage and laser surgery both result in 100% survival. However, infants born after laser surgery have less major neonatal morbidity. [ABSTRACT FROM AUTHOR]

Published
2007
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6. Is middle cerebral artery Doppler related to neonatal and 2-year infant outcome in early fetal growth restriction?

Author

Baskaran Thilaganathan, T. Diehl, A. G. van Wassenaer-Leemhuis, A. Aktas, A T Papageorghiou, Caterina M. Bilardo, Enrico Ferrazzi, R. Chaoui, G. H. A. Visser, Herbert Valensise, J. A. M. van der Post, Jan B. Derks, G. Oggè, J. van Eyck, Neil Marlow, I.K.M. Reiss, Wessel Ganzevoort, Ktm Schneider, M Oberto, A. Skabar, Raffaele Napolitano, U. Maurer-Fellbaum, H. Missfelder-Lobos, John Kingdom, G. Mansi, S. Borgione, Federico Prefumo, Anke Diemert, Tamara Stampalija, E. Lopriore, Gianpaolo Maso, Karel Marsal, Tiziana Frusca, L.S. Scheepers, F. Raimondi, Dietmar Schlembach, Adriana Valcamonico, N. Mensing van Charante, Christoph Lees, Silvia M. Lobmaier, Christoph Brezinka, L. Preston, S. Mulder-de Tollenaer, Pasquale Martinelli, Jim G Thornton, Marc E. A. Spaanderman, J.J. Duvekot, Nicola Fratelli, I.C. van Haastert, N. Weisglas-Kuperus, Dick Oepkes, Kurt Hecher, Hans Wolf, Tullia Todros, E. Ostermayer, Birgit Arabin, A. Zimmermann, Jérôme Cornette, P. Martelli, Other departments, ARD - Amsterdam Reproduction and Development, APH - Quality of Care, Obstetrics and Gynaecology, Other Research, Neonatology, APH - Digital Health, RS: GROW - R4 - Reproductive and Perinatal Medicine, Obstetrie & Gynaecologie, MUMC+: MA Medische Staf Obstetrie Gynaecologie (9), Stampalija, Tamara, Arabin, Birgit, Wolf, Han, Bilardo, Caterina M., Lees, Christoph, Brezinka, C., Derks, J. B., Diemert, A., Duvekot, J. J., Ferrazzi, E., Frusca, T., Ganzevoort, W., Hecher, K., Kingdom, J., Marlow, N., Marsal, K., Martinelli, P., Ostermayer, E., Papageorghiou, A. T., Schlembach, D., Schneider, K. T. M., Thilaganathan, B., Thornton, J., Todros, T., Valcamonico, A., Valensise, H., van Wassenaer-Leemhuis, A., Visser, G. H. A., Aktas, A., Borgione, S., Chaoui, R., Cornette, J. M. J., Diehl, T., van Eyck, J., Fratelli, N., van Haastert, I. C., Lobmaier, S., Lopriore, E., Missfelder-Lobos, H., Mansi, G., Martelli, P., Maso, G., Maurer-Fellbaum, U., Mensing van Charante, N., Mulder-de Tollenaer, S., Napolitano, R., Oberto, M., Oepkes, D., Ogge, G., van der Post, J. A. M., Prefumo, F., Preston, L., Raimondi, F., Reiss, I. K. M., Scheepers, L. S., Skabar, A., Spaanderman, M., Weisglas-Kuperus, N., Zimmermann, A., Bilardo, Caterina M, Raimondi, Francesco, Reproductive Origins of Adult Health and Disease (ROAHD), and Amsterdam Reproduction & Development (AR&D)

Subjects
Middle Cerebral Artery, PREDICTION, Intrauterine growth restriction, Umbilical Arteries, 0302 clinical medicine, Child Development, cerebroplacental ratio, Doppler velocimetry, intrauterine growth restriction, middle cerebral artery, neonatal, umbilicocerebral ratio, Pregnancy, RESISTANCE INDEX RATIO, Obstetrics and Gynaecology, FOR-GESTATIONAL-AGE, 1114 Paediatrics And Reproductive Medicine, Birth Weight, Prenatal, Cardiotocography, 030212 general & internal medicine, Prospective Studies, Child, Ultrasonography, RISK, 030219 obstetrics & reproductive medicine, Fetal Growth Retardation, medicine.diagnostic_test, Obstetrics, Doppler, Gestational age, Obstetrics and Gynecology, Settore MED/40, Child, Preschool, Pulsatile Flow, Middle cerebral artery, BLOOD-FLOW PARAMETERS, Female, Delivery, Ductus venosus, Human, medicine.medical_specialty, Delivery, Obstetric, Gestational Age, Humans, Ultrasonography, Doppler, Ultrasonography, Prenatal, Preschool, Obstetric, 03 medical and health sciences, PULSATILITY INDEX, FETUSES, medicine.artery, SURVEILLANCE, medicine, Journal Article, Obstetrics & Reproductive Medicine, business.industry, Umbilical artery, Odds ratio, medicine.disease, Confidence interval, Prospective Studie, Umbilical Arterie, WEIGHT, business
Abstract

BACKGROUND: Reduced fetal middle cerebral artery Doppler impedance is associated with hypoxemia in fetal growth restriction. It remains unclear as to whether this finding could be useful in timing delivery, especially in the third trimester. In this regard there is a paucity of evidence from prospective studies.OBJECTIVES: The aim of this study was to determine whether there is an association between middle cerebral artery Doppler impedance and its ratio with the umbilical artery in relation to neonatal and 2 year infant outcome in early fetal growth restriction (26(+0) -31(+6) weeks of gestation). Additionally we sought to explore which ratio is more informative for clinical use.STUDY DESIGN: This is a secondary analysis from the Trial of Randomized Umbilical and Fetal Flow in Europe, a prospective, multicenter, randomized management study on different antenatal monitoring strategies (ductus venosus Doppler changes and computerized cardiotocography short-term variation) in fetal growth restriction diagnosed between 26(+0) and 31(+6) weeks. We analyzed women with middle cerebral artery Doppler measurement at study entry and within 1 week before delivery and with complete postnatal follow-up (374 of 503). The primary outcome was survival without neurodevelopmental impairment at 2 years corrected for prematurity. Neonatal outcome was defined as survival until first discharge home without severe neonatal morbidity. Z-scores were calculated for middle cerebral artery pulsatility index and both umbilicocerebral and cerebroplacental ratios. Odds ratios of Doppler parameter Z-scores for neonatal and 2 year infant outcome were calculated by multivariable logistic regression analysis adjusted for gestational age and birthweight p50 ratio.RESULTS: Higher middle cerebral artery pulsatility index at inclusion but not within 1 week before delivery was associated with neonatal survival without severe morbidity (odds ratio, 1.24; 95% confidence interval, 1.02-1.52). Middle cerebral artery pulsatility index Z-score and umbilicocerebral ratio Z-score at inclusion were associated with 2 year survival with normal neurodevelopmental outcome (odds ratio, 1.33; 95% confidence interval, 1.03-1.72, and odds ratio, 0.88; 95% confidence interval, 0.78-0.99, respectively) as were gestation at delivery and birthweight p50 ratio (odds ratio, 1.41; 95% confidence interval, 1.20-1.66, and odds ratio, 1.86; 95% confidence interval, 1.33-2.60, respectively). When comparing cerebroplacental ratio against umbilicocerebral ratio, the incremental range of the cerebroplacental ratio tended toward zero, whereas the umbilicocerebral ratio tended toward infinity as the values became more abnormal.CONCLUSION: In a monitoring protocol based on ductus venosus and cardiotocography in early fetal growth restriction (26(+0) -31(+6) weeks of gestation), the impact of middle cerebral artery Doppler and its ratios on outcome is modest and less marked than birthweight and delivery gestation. It is unlikely that middle cerebral artery Doppler and its ratios are informative in optimizing the timing of delivery in fetal growth restriction before 32 weeks of gestation. The umbilicocerebral ratio allows for a better differentiation in the abnormal range than the cerebroplacental ratio.

Published
2017

7. Epidemiology and management of fetal and neonatal alloimmune thrombocytopenia.

Author

de Vos, T.W., Winkelhorst, D., de Haas, M., Lopriore, E., and Oepkes, D.

Subjects
*EPIDEMIOLOGY, *BLOOD platelet transfusion, *GESTATIONAL age, *BLOOD platelet disorders, *DISABILITIES, *THROMBOCYTOPENIA
Abstract

Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a disease in pregnancy characterized by maternal alloantibodies directed against the human platelet antigen (HPA). These antibodies can cause intracranial hemorrhage (ICH) or other major bleeding resulting in lifelong handicaps or death. Optimal fetal care can be provided by timely identification of pregnancies at risk. However, this can only be done by routinely antenatal screening. Whether nationwide screening is cost-effective is still being debated. HPA-1a alloantibodies are estimated to be found in 1 in 400 pregnancies resulting in severe burden and fetal ICH in 1 in 10.000 pregnancies. Antenatal treatment is focused on the prevention of fetal ICH and consists of weekly maternal IVIg administration. In high-risk FNAIT treatment should be initiated at 12–18 weeks gestational age using high dosage and in standard-risk FNAIT at 20–28 weeks gestational age using a lower dosage. Postnatal prophylactic platelet transfusions are often given in case of severe thrombocytopenia to prevent bleedings. The optimal threshold and product for postnatal transfusion is not known and international consensus is lacking. In this review practical guidelines for antenatal and postnatal management are offered to clinicians that face the challenge of reducing the risk of bleeding in fetuses and infants affected by FNAIT. [ABSTRACT FROM AUTHOR]

Published
2020
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