12 results on '"Brezinka C"'
Search Results
2. How to monitor pregnancies complicated by fetal growth restriction and delivery before 32 weeks: post-hoc analysis of TRUFFLE study.
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Ganzevoort W, Mensing Van Charante N, Thilaganathan B, Prefumo F, Arabin B, Bilardo CM, Brezinka C, Derks JB, Diemert A, Duvekot JJ, Ferrazzi E, Frusca T, Hecher K, Marlow N, Martinelli P, Ostermayer E, Papageorghiou AT, Schlembach D, Schneider KTM, Todros T, Valcamonico A, Visser GHA, Van Wassenaer-Leemhuis A, Lees CC, and Wolf H
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- Adult, Cardiotocography, Central Nervous System Diseases congenital, Child, Preschool, Female, Gestational Age, Heart Rate, Fetal, Humans, Infant, Infant, Extremely Premature, Male, Middle Cerebral Artery physiology, Pregnancy, Pulsatile Flow, Survival Analysis, Treatment Outcome, Uterine Artery physiology, Central Nervous System Diseases prevention & control, Fetal Growth Retardation diagnostic imaging, Fetal Membranes, Premature Rupture diagnostic imaging, Ultrasonography, Prenatal
- Abstract
Objectives: In the recent TRUFFLE study, it appeared that, in pregnancies complicated by fetal growth restriction (FGR) between 26 and 32 weeks' gestation, monitoring of the fetal ductus venosus (DV) waveform combined with computed cardiotocography (CTG) to determine timing of delivery increased the chance of infant survival without neurological impairment. However, concerns with the interpretation were raised, as DV monitoring appeared to be associated with a non-significant increase in fetal death, and some infants were delivered after 32 weeks, at which time the study protocol no longer applied. This secondary sensitivity analysis of the TRUFFLE study focuses on women who delivered before 32 completed weeks' gestation and analyzes in detail the cases of fetal death., Methods: Monitoring data of 317 pregnancies with FGR that delivered before 32 weeks were analyzed, excluding those with absent outcome data or inevitable perinatal death. Women were allocated randomly to one of three groups of indication for delivery according to the following monitoring strategies: (1) reduced fetal heart rate short-term variation (STV) on CTG; (2) early changes in fetal DV waveform; and (3) late changes in fetal DV waveform. Primary outcome was 2-year survival without neurological impairment. The association of the last monitoring data before delivery and infant outcome was assessed by multivariable analysis., Results: Two-year survival without neurological impairment occurred more often in the two DV groups (both 83%) than in the CTG-STV group (77%), however, the difference was not statistically significant (P = 0.21). Among the surviving infants in the DV groups, 93% were free of neurological impairment vs 85% of surviving infants in the CTG-STV group (P = 0.049). All fetal deaths (n = 7) occurred in the groups with DV monitoring. Of the monitoring parameters obtained shortly before fetal death in these seven cases, an abnormal CTG was observed in only one case. Multivariable regression analysis of factors at study entry demonstrated that a later gestational age, higher estimated fetal weight-to-50
th percentile ratio and lower umbilical artery pulsatility index (PI)/fetal middle cerebral artery-PI ratio were significantly associated with normal outcome. Allocation to DV monitoring had a smaller effect on outcome, but remained in the model (P < 0.1). Abnormal fetal arterial Doppler before delivery was significantly associated with adverse outcome in the CTG-STV group. In contrast, abnormal DV flow was the only monitoring parameter associated with adverse outcome in the DV groups, while fetal arterial Doppler, STV below the cut-off used in the CTG-STV group and recurrent decelerations in fetal heart rate were not., Conclusions: In accordance with the findings of the TRUFFLE study on monitoring and intervention management of very preterm FGR, we found that the proportion of infants surviving without neuroimpairment was not significantly different when the decision for delivery was based on changes in DV waveform vs reduced STV on CTG. The uneven distribution of fetal deaths towards the DV groups was probably a chance effect, and neurological outcome was better among surviving children in these groups. Before 32 weeks, delaying delivery until abnormalities in DV-PI or STV and/or recurrent decelerations in fetal heat rate occur, as defined by the study protocol, is likely to be safe and possibly benefits long-term outcome. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd., (Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.)- Published
- 2017
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3. 2 year neurodevelopmental and intermediate perinatal outcomes in infants with very preterm fetal growth restriction (TRUFFLE): a randomised trial.
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Lees CC, Marlow N, van Wassenaer-Leemhuis A, Arabin B, Bilardo CM, Brezinka C, Calvert S, Derks JB, Diemert A, Duvekot JJ, Ferrazzi E, Frusca T, Ganzevoort W, Hecher K, Martinelli P, Ostermayer E, Papageorghiou AT, Schlembach D, Schneider KT, Thilaganathan B, Todros T, Valcamonico A, Visser GH, and Wolf H
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- Cardiotocography methods, Central Nervous System Diseases prevention & control, Child, Preschool, Europe epidemiology, Female, Gestational Age, Humans, Infant, Newborn, Male, Pregnancy, Pregnancy Outcome, Ultrasonography, Doppler, Pulsed, Ultrasonography, Prenatal, Central Nervous System Diseases epidemiology, Fetal Growth Retardation epidemiology, Heart Rate, Fetal physiology, Infant, Extremely Premature, Umbilical Arteries diagnostic imaging
- Abstract
Background: No consensus exists for the best way to monitor and when to trigger delivery in mothers of babies with fetal growth restriction. We aimed to assess whether changes in the fetal ductus venosus Doppler waveform (DV) could be used as indications for delivery instead of cardiotocography short-term variation (STV)., Methods: In this prospective, European multicentre, unblinded, randomised study, we included women with singleton fetuses at 26-32 weeks of gestation who had very preterm fetal growth restriction (ie, low abdominal circumference [<10th percentile] and a high umbilical artery Doppler pulsatility index [>95th percentile]). We randomly allocated women 1:1:1, with randomly sized blocks and stratified by participating centre and gestational age (<29 weeks vs ≥29 weeks), to three timing of delivery plans, which differed according to antenatal monitoring strategies: reduced cardiotocograph fetal heart rate STV (CTG STV), early DV changes (pulsatility index >95th percentile; DV p95), or late DV changes (A wave [the deflection within the venous waveform signifying atrial contraction] at or below baseline; DV no A). The primary outcome was survival without cerebral palsy or neurosensory impairment, or a Bayley III developmental score of less than 85, at 2 years of age. We assessed outcomes in surviving infants with known outcomes at 2 years. We did an intention to treat study for all participants for whom we had data. Safety outcomes were deaths in utero and neonatal deaths and were assessed in all randomly allocated women. This study is registered with ISRCTN, number 56204499., Findings: Between Jan 1, 2005 and Oct 1, 2010, 503 of 542 eligible women were randomly allocated to monitoring groups (166 to CTG STV, 167 to DV p95, and 170 to DV no A). The median gestational age at delivery was 30·7 weeks (IQR 29·1-32·1) and mean birthweight was 1019 g (SD 322). The proportion of infants surviving without neuroimpairment did not differ between the CTG STV (111 [77%] of 144 infants with known outcome), DV p95 (119 [84%] of 142), and DV no A (133 [85%] of 157) groups (ptrend=0·09). 12 fetuses (2%) died in utero and 27 (6%) neonatal deaths occurred. Of survivors, more infants where women were randomly assigned to delivery according to late ductus changes (133 [95%] of 140, 95%, 95% CI 90-98) were free of neuroimpairment when compared with those randomly assigned to CTG (111 [85%] of 131, 95% CI 78-90; p=0.005), but this was accompanied by a non-significant increase in perinatal and infant mortality., Interpretation: Although the difference in the proportion of infants surviving without neuroimpairment was non-significant at the primary endpoint, timing of delivery based on the study protocol using late changes in the DV waveform might produce an improvement in developmental outcomes at 2 years of age., Funding: ZonMw, The Netherlands and Dr Hans Ludwig Geisenhofer Foundation, Germany., (Copyright © 2015 Elsevier Ltd. All rights reserved.)
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- 2015
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4. Perinatal morbidity and mortality in early-onset fetal growth restriction: cohort outcomes of the trial of randomized umbilical and fetal flow in Europe (TRUFFLE).
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Lees C, Marlow N, Arabin B, Bilardo CM, Brezinka C, Derks JB, Duvekot J, Frusca T, Diemert A, Ferrazzi E, Ganzevoort W, Hecher K, Martinelli P, Ostermayer E, Papageorghiou AT, Schlembach D, Schneider KT, Thilaganathan B, Todros T, van Wassenaer-Leemhuis A, Valcamonico A, Visser GH, and Wolf H
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- Adult, Europe epidemiology, Female, Fetal Growth Retardation physiopathology, Fetal Growth Retardation therapy, Gestational Age, Humans, Kaplan-Meier Estimate, Perinatal Care, Perinatal Mortality, Pregnancy, Pregnancy Outcome, Prospective Studies, Fetal Growth Retardation mortality, Fetus blood supply, Umbilical Arteries physiology
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Objectives: Few data exist for counseling and perinatal management of women after an antenatal diagnosis of early-onset fetal growth restriction. Yet, the consequences of preterm delivery and its attendant morbidity for both mother and baby are far reaching. The objective of this study was to describe perinatal morbidity and mortality following early-onset fetal growth restriction based on time of antenatal diagnosis and delivery., Methods: We report cohort outcomes for a prospective multicenter randomized management study of fetal growth restriction (Trial of Randomized Umbilical and Fetal Flow in Europe (TRUFFLE)) performed in 20 European perinatal centers between 2005 and 2010. Women with a singleton fetus at 26-32 weeks of gestation, with abdominal circumference < 10(th) percentile and umbilical artery Doppler pulsatility index > 95(th) percentile, were recruited. The main outcome measure was a composite of fetal or neonatal death or severe morbidity: survival to discharge with severe brain injury, bronchopulmonary dysplasia, proven neonatal sepsis or necrotizing enterocolitis., Results: Five-hundred and three of 542 eligible women formed the study group. Mean ± SD gestational age at diagnosis was 29 ± 1.6 weeks and mean ± SD estimated fetal weight was 881 ± 217 g; 12 (2.4%) babies died in utero. Gestational age at delivery was 30.7 ± 2.3 weeks, and birth weight was 1013 ± 321 g. Overall, 81% of deliveries were indicated by fetal condition and 97% were by Cesarean section. Of 491 liveborn babies, outcomes were available for 490 amongst whom there were 27 (5.5%) deaths and 118 (24%) babies suffered severe morbidity. These babies were smaller at birth (867 ± 251 g) and born earlier (29.6 ± 2.0 weeks). Death and severe morbidity were significantly related to gestational age, both at study entry and delivery and also with the presence of maternal hypertensive morbidity. The median time to delivery was 13 days for women without hypertension, 8 days for those with gestational hypertension, 4 days for pre-eclampsia and 3 days for HELLP syndrome., Conclusions: Fetal outcome in this study was better than expected from contemporary reports: perinatal death was uncommon (8%) and 70% survived without severe neonatal morbidity. The intervals to delivery, death and severe morbidity were related to the presence and severity of maternal hypertensive conditions., (Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.)
- Published
- 2013
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5. Effects of Antenatal Betamethasone on Fetal Doppler Indices and Short Term Fetal Heart Rate Variation in Early Growth Restricted Fetuses
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Fratelli, N., Prefumo, F., Wolf, H., Hecher, K., Visser, G.H.A., Giussani, D., Derks, J.B., Shaw, C.J., Frusca, T., Ghi, T., Ferrazzi, E., Lees, C.C., Arabin, B., Bilardo, C.M., Brezinka, C., Diemert, A., Duvekot, J.J., Ganzevoort, W., Marlow, N., Martinelli, P., Ostermayer, E., Papageorghiou, A.T., Schlembach, D., Schneider, K.T.M., Thilaganathan, B., Thornton, J., Todros, T., Valcamonico, A., Wassenaer-Leemhuis, A. van, Aktas, A., Borgione, S., Chaoui, R., Cornette, J.M.J., Diehl, T., Eyck, J. van, Haastert, I.C. van, Lobmaier, S., Lopriore, E., Missfelder-Lobos, H., Mansi, G., Martelli, P., Maso, G., Maurer-Fellbaum, U., Charante, N.M. van, Tollenaer, S.M., Napolitano, R., Oberto, M., Oepkes, D., Ogge, G., Post, J.A.M. van der, Preston, L., Raimondi, F., Reiss, I.K.M., Scheepers, L.S., Skabar, A., Spaanderman, M., Weisglas-Kuperus, N., Zimmermann, A., TRUFFLE Grp, TRUFFLE Grp Authors, TRUFFLE Grp Collaborating Authors, Obstetrics & Gynecology, Pediatrics, RS: CAPHRI - R3 - Functioning, Participating and Rehabilitation, Interne Geneeskunde, Neonatology, Amsterdam Reproduction & Development (AR&D), Fratelli, Nicola, Prefumo, Federico, Wolf, Han, Hecher, Kurt, Visser, Gerard H A, Giussani, Dino, Derks, Jan B, Shaw, Caroline J, Frusca, Tiziana, Ghi, Tullio, Ferrazzi, E, Lees, Christoph C, Truffle, Group, and Raimondi, Francesco
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medicine.medical_specialty ,Cardiotocography ,Vascular damage Radboud Institute for Health Sciences [Radboudumc 16] ,betamethasone ,fetal growth restriction ,obstetrics ,Female ,Fetal Heart ,Fetus ,Humans ,Pregnancy ,Pregnancy Outcome ,Prospective Studies ,Betamethasone ,Fetal Growth Retardation ,Glucocorticoids ,Heart Rate, Fetal ,Ultrasonography, Prenatal ,Antenatal steroid ,Fetal ,03 medical and health sciences ,0302 clinical medicine ,All institutes and research themes of the Radboud University Medical Center ,Heart Rate ,Internal medicine ,Heart rate ,medicine ,TRUFFLE Group ,Prenatal ,Radiology, Nuclear Medicine and imaging ,030212 general & internal medicine ,Prospective cohort study ,Ultrasonography ,030219 obstetrics & reproductive medicine ,medicine.diagnostic_test ,business.industry ,Nuclear Medicine & Medical Imaging ,TRUFFLE Group collaborating authors ,TRUFFLE Group authors ,Cardiology ,business ,Lower limbs venous ultrasonography ,Ductus venosus ,medicine.drug - Abstract
To investigate the effects of the antenatal administration of betamethasone on fetal Doppler and short term fetal heart rate variation (CTG-STV) in early growth restricted (FGR) fetuses. Post hoc analysis of data derived from the TRUFFLE study, a prospective, multicenter, randomized management trial of severe early onset FGR. Repeat Doppler and CTG-STV measurements between the last recording within 48 hours before the first dose of betamethasone (baseline value) and for 10 days after were evaluated. Multilevel analysis was performed to analyze the longitudinal course of the umbilico-cerebral ratio (UC ratio), the ductus venosus pulsatility index (DVPIV) and CTG-STV. We included 115 fetuses. A significant increase from baseline in CTG-STV was found on day + 1 (p = 0.019) but no difference thereafter. The DVPIV was not significantly different from baseline in any of the 10 days following the first dose of betamethasone (p = 0.167). Multilevel analysis revealed that, over 10 days, the time elapsed from antenatal administration of betamethasone was significantly associated with a decrease in CTG-STV (p = 0.045) and an increase in the DVPIV (p = 0.001) and UC ratio (p 0.001). Although steroid administration in early FGR has a minimal effect on increasing CTG-STV one day afterwards, the effects on Doppler parameters were extremely slight with regression coefficients of small magnitude suggesting no clinical significance, and were most likely related to the deterioration with time in FGR. Hence, arterial and venous Doppler assessment of fetal health remains informative following antenatal steroid administration to accelerate fetal lung maturation.ZIEL: Untersuchung des Effekts der antenatalen Gabe von Betamethason auf den fetalen Doppler und die Kurzzeitvariation der fetalen Herzfrequenz (CTG-STV) bei Föten mit früher Wachstumsrestriktion (FGR). Post-hoc-Analyse von Daten der TRUFFLE-Studie, einer prospektiven, multizentrischen, randomisierten Managementstudie bei schwerer, früh einsetzender FGR. Wiederholte Doppler- und CTG-STV-Messungen zwischen der letzten Aufnahme innerhalb von 48 Stunden vor der ersten Betamethason-Dosis (Ausgangswert) und über 10 Tage wurden bewertet. Eine mehrstufige Analyse erfolgte, um den longitudinalen Verlauf der umbilikal-zerebralen Ratio (UC-Ratio), des Pulsatilitätsindex des Ductus venosus (DVPIV) und der CTG-STV zu analysieren. Wir haben 115 Föten eingeschlossen. Ein signifikanter Anstieg der CTG-STV gegenüber dem Ausgangswert wurde am Tag + 1 (p = 0,019) ermittelt, danach gab es keinen Unterschied. Der DVPIV unterschied sich an keinem der 10 Tage nach erster Betamethason-Dosis signifikant vom Ausgangswert (p = 0,167). Eine mehrstufige Analyse ergab, dass die verstrichene Zeit nach der antenatalen Betamethason-Gabe über 10 Tage hinweg signifikant mit der Abnahme der CTG-STV (p = 0,045) und der Zunahme des DVPIV (p = 0,001) und der UC-Ratio (p 0,001) assoziiert war. Obwohl die Steroidverabreichung bei früher FGR eine kleine Auswirkung auf den Anstieg der CTG-STV 1 Tag darauf hatte, waren die Effekte auf die Doppler-Parameter äußerst gering mit Regressionskoeffizienten von geringer Höhe, die nicht auf klinische Signifikanz schließen lassen. Sie stehen höchstwahrscheinlich in Zusammenhang mit der Verschlechterung bei FGR im Laufe der Zeit. Daher bleibt die Beurteilung der arteriellen und venösen Doppler bezüglich des Gesundheitszustandes des Fötus aussagekräftig, nachdem diesem zur Beschleunigung der fetalen Lungenreifung antenatal Steroide verabreicht wurden.
- Published
- 2021
6. Fetal cerebral Doppler changes and outcome in late preterm fetal growth restriction : prospective cohort study
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Stampalija, T., Thornton, J., Marlow, N., Napolitano, R., Bhide, A., Pickles, T., Bilardo, C. M., Gordijn, S. J., Gyselaers, W., Valensise, H., Hecher, K., Sande, R. K., Lindgren, P., Bergman, E., Arabin, B., Breeze, A. C., Wee, L., Ganzevoort, W., Richter, J., Berger, A., Brodszki, J., Derks, J., Mecacci, F., Maruotti, G. M., Myklestad, K., Lobmaier, S. M., Prefumo, F., Klaritsch, P., Calda, P., Ebbing, C., Frusca, T., Raio, L., Visser, G. H. A., Krofta, L., Cetin, I., Ferrazzi, E., Cesari, E., Wolf, H., Lees, C. C., Brezinka, C., Casagrandi, D., Cerny, A., Dall'Asta, A., Devlieger, R., Duvekot, J., Eggebo, T. M., Fantasia, I., Ferrari, F., Fratelli, N., Ghi, T., Graupner, O., Greimel, P., Hofstaetter, C., Presti, D. Lo, Georg, M., Macsali, F., Marsal, K., Martinelli, P., Mylrea-Foley, B., Mullins, E., Ostermayer, E., Papageorghiou, A., Peasley, R., Ramoni, A., Sarno, L., Seikku, L., Simeone, S., Thilaganathan, B., Tiralongo, G., Valcamonico, A., van Holsbeke, C., Vietheer, A., APH - Quality of Care, ARD - Amsterdam Reproduction and Development, Obstetrics and Gynaecology, APH - Digital Health, Stampalija, T., Thornton, J., Marlow, N., Napolitano, R., Bhide, A., Pickles, T., Bilardo, C. M., Gordijn, S. J., Gyselaers, W., Valensise, H., Hecher, K., Sande, R. K., Lindgren, P., Bergman, E., Arabin, B., Breeze, A. C., Wee, L., Ganzevoort, W., Richter, J., Berger, A., Brodszki, J., Derks, J., Mecacci, F., Maruotti, G. M., Myklestad, K., Lobmaier, S. M., Prefumo, F., Klaritsch, P., Calda, P., Ebbing, C., Frusca, T., Raio, L., Visser, G. H. A., Krofta, L., Cetin, I., Ferrazzi, E., Cesari, E., Wolf, H., Lees, C. C., Brezinka, C., Casagrandi, D., Cerny, A., Dall'Asta, A., Devlieger, R., Duvekot, J., Eggebo, T. M., Fantasia, I., Ferrari, F., Fratelli, N., Ghi, T., Graupner, O., Greimel, P., Hofstaetter, C., Presti, D. L., Georg, M., Macsali, F., Marsal, K., Martinelli, P., Mylrea-Foley, B., Mullins, E., Ostermayer, E., Papageorghiou, A., Peasley, R., Ramoni, A., Sarno, L., Seikku, L., Simeone, S., Thilaganathan, B., Tiralongo, G., Valcamonico, A., Van Holsbeke, C., Vietheer, A., and HUS Gynecology and Obstetrics
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Technology ,adverse outcome ,umbilical-cerebral ratio ,Umbilical Arteries ,umbilical artery ,TRUFFLE-2 Group ,Fetal Development ,0302 clinical medicine ,Obstetrics and gynaecology ,Pregnancy ,Reference Values ,3123 Gynaecology and paediatrics ,Interquartile range ,Birth Weight ,Prospective Studies ,030212 general & internal medicine ,Prospective cohort study ,Fetal Growth Retardation ,030219 obstetrics & reproductive medicine ,Radiological and Ultrasound Technology ,Obstetrics ,Radiology, Nuclear Medicine & Medical Imaging ,Doppler ,Obstetrics & Gynecology ,Obstetrics and Gynecology ,Gestational age ,General Medicine ,Stillbirth ,3. Good health ,ddc ,Europe ,Fetal Weight ,Pulsatile Flow ,Infant, Small for Gestational Age ,Female ,Waist Circumference ,Rheology ,Life Sciences & Biomedicine ,Live Birth ,middle cerebral artery ,neonatal ,umbilicocerebral ratio ,Radiology, Nuclear Medicine and Medical Imaging ,Adult ,medicine.medical_specialty ,Birth weight ,education ,610 Medicine & health ,Gestational Age ,Reproduktionsmedicin och gynekologi ,DIAGNOSIS ,Ultrasonography, Prenatal ,03 medical and health sciences ,Fetus ,Obstetrics, Gynecology and Reproductive Medicine ,medicine ,MANAGEMENT ,Humans ,Radiology, Nuclear Medicine and imaging ,Risk factor ,Obstetrics & Reproductive Medicine ,Science & Technology ,business.industry ,CEREBROPLACENTAL RATIO ,Infant, Newborn ,Ultrasonography, Doppler ,Acoustics ,Reproductive Medicine ,Relative risk ,1114 Paediatrics and Reproductive Medicine ,Radiologi och bildbehandling ,business - Abstract
OBJECTIVES: To explore the association between fetal umbilical and middle cerebral artery (MCA) Doppler abnormalities and outcome in late preterm pregnancies at risk of fetal growth restriction. METHODS: This was a prospective cohort study of singleton pregnancies at risk of fetal growth restriction at 32 + 0 to 36 + 6 weeks of gestation, enrolled in 33 European centers between 2017 and 2018, in which umbilical and fetal MCA Doppler velocimetry was performed. Pregnancies were considered at risk of fetal growth restriction if they had estimated fetal weight and/or abdominal circumference (AC)
- Published
- 2020
7. Severe fetal growth restriction at 26–32 weeks : key messages from the TRUFFLE study
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Bilardo, Cm, Hecher, K, Visser, Gha, Papageorghiou, At, Marlow, N, Thilaganathan, B, Van Wassenaer-Leemhuis, A, Todros, T, Marsal, K, Frusca, T, Arabin, B, Brezinka, C, Derks, Jb, Diemert, A, Duvekot, Jj, Ferrazzi, E, Ganzevoort, W, Martinelli, P, Ostermayer, E, Schlembach, D, Valensise, H, Thornton, J, Wolf, H, Lees, C, Calda, P, Gordjin, S, Gyselaers, W, Klaritsch, P, Lobmaier, S, Manz, M, Napolitano, R, Prefumo, F, Schild, R, Stampalija, T, von Holsbeke, C, von Kaisenberg, C, Bilardo, C. M., Hecher, K., Visser, G. H. A., Papageorghiou, A. T., Marlow, N., Thilaganathan, B., Van Wassenaer-Leemhuis, A., Todros, T., Marsal, K., Frusca, T., Arabin, B., Brezinka, C., Derks, J. B., Diemert, A., Duvekot, J. J., Ferrazzi, E., Ganzevoort, W., Martinelli, P., Ostermayer, E., Schlembach, D., Valensise, H., Thornton, J., Wolf, H., Lees, C., Calda, P., Gordjin, S., Gyselaers, W., Klaritsch, P., Lobmaier, S., Manz, M., Napolitano, R., Prefumo, F., Schild, R., Stampalija, T., von Holsbeke, C., and von Kaisenberg, C.
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Fetal Growth Retardation ,Radiological and Ultrasound Technology ,Obstetrics and Gynecology ,Gestational Age ,Fetal ,Heart Rate, Fetal ,Humans ,Heart Rate ,Reproductive Medicine ,Radiology ,Nuclear Medicine and Imaging ,Settore MED/40 ,Human - Abstract
What was the TRUFFLE study? The Trial of Randomized Umbilical and Fetal Flow in Europe (TRUFFLE) was a prospective, multicenter, unblinded, randomized trial that ran between 1 January 2005 and 1 October 2010 in 20 European centers 1 . It studied singleton pregnancies at 26–32 weeks of gestation with a diagnosis of fetal growth restriction (FGR), defined as abdominal circumference < 10th percentile and high umbilical artery Doppler pulsatility index (PI) (> 95th percentile). In order to assess whether changes in the fetal ductus venosus (DV) Doppler waveform or short-term variation (STV) on cardiotocography (CTG) should be used as a trigger for delivery in these pregnancies, the 503 included women were randomly allocated to one of three ‘timing-of-delivery’ plans (with 1 : 1 : 1 randomization).
- Published
- 2017
8. 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
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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
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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.
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- 2017
9. Perinatal morbidity and mortality in early-onset fetal growth restriction: cohort outcomes of the trial of randomized umbilical and fetal flow in Europe (TRUFFLE)
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Lees, C., Marlow, N., Arabin, B., Bilardo, C. M., Brezinka, C., Derks, J. B., Duvekot, J., Frusca, Tiziana, Diemert, A., Ferrazzi, E., Ganzevoort, W., Hecher, K., Martinelli, P., Ostermayer, E., Papageorghiou, A. T., Schlembach, D., Schneider, K. T., Thilaganathan, B., Todros, T., van Wassenaer Leemhuis, A., Valcamonico, A., Visser, G. H., Wolf, H., Truffle, Group, Lees, C, Marlow, N, Arabin, B, Bilardo, Cm, Brezinka, C, Derks, Jb, Duvekot, J, Frusca, T, Diemert, A, Ferrazzi, E, Ganzevoort, W, Hecher, K, Martinelli, Pasquale, Ostermayer, E, Papageorghiou, At, Schlembach, D, Schneider, Kt, Thilaganathan, B, Todros, T, van Wassenaer Leemhuis, A, Valcamonico, A, Visser, Gh, Wolf, H, and Truffle, Group
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Adult ,Fetal Growth Retardation ,Pregnancy Outcome ,Gestational Age ,Kaplan-Meier Estimate ,Umbilical Arteries ,Europe ,Perinatal Care ,Fetus ,Pregnancy ,Humans ,Female ,Prospective Studies ,Perinatal Mortality - Abstract
OBJECTIVES: Few data exist for counseling and perinatal management of women after an antenatal diagnosis of early-onset fetal growth restriction. Yet, the consequences of preterm delivery and its attendant morbidity for both mother and baby are far reaching. The objective of this study was to describe perinatal morbidity and mortality following early-onset fetal growth restriction based on time of antenatal diagnosis and delivery. METHODS: We report cohort outcomes for a prospective multicenter randomized management study of fetal growth restriction (Trial of Randomized Umbilical and Fetal Flow in Europe (TRUFFLE)) performed in 20 European perinatal centers between 2005 and 2010. Women with a singleton fetus at 26-32 weeks of gestation, with abdominal circumference < 10(th) percentile and umbilical artery Doppler pulsatility index > 95(th) percentile, were recruited. The main outcome measure was a composite of fetal or neonatal death or severe morbidity: survival to discharge with severe brain injury, bronchopulmonary dysplasia, proven neonatal sepsis or necrotizing enterocolitis. RESULTS: Five-hundred and three of 542 eligible women formed the study group. Mean ± SD gestational age at diagnosis was 29 ± 1.6 weeks and mean ± SD estimated fetal weight was 881 ± 217 g; 12 (2.4%) babies died in utero. Gestational age at delivery was 30.7 ± 2.3 weeks, and birth weight was 1013 ± 321 g. Overall, 81% of deliveries were indicated by fetal condition and 97% were by Cesarean section. Of 491 liveborn babies, outcomes were available for 490 amongst whom there were 27 (5.5%) deaths and 118 (24%) babies suffered severe morbidity. These babies were smaller at birth (867 ± 251 g) and born earlier (29.6 ± 2.0 weeks). Death and severe morbidity were significantly related to gestational age, both at study entry and delivery and also with the presence of maternal hypertensive morbidity. The median time to delivery was 13 days for women without hypertension, 8 days for those with gestational hypertension, 4 days for pre-eclampsia and 3 days for HELLP syndrome. CONCLUSIONS: Fetal outcome in this study was better than expected from contemporary reports: perinatal death was uncommon (8%) and 70% survived without severe neonatal morbidity. The intervals to delivery, death and severe morbidity were related to the presence and severity of maternal hypertensive conditions.
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- 2013
10. 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.
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Visser, G. H. A., Bilardo, C. M., Derks, J. B., Ferrazzi, E., Fratelli, N., Frusca, T., Ganzevoort, W., Lees, C. C., Napolitano, R., Todros, T., Wolf, H., Hecher, K., Marlow, N., Arabin, B., Brezinka, C., Diemert, A., Duvekot, J. J., Martinelli, P., Ostermayer, E., and Papageorghiou, A. T.
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FETAL growth retardation ,FETAL monitoring ,GESTATIONAL age ,HEALTH outcome assessment ,PERINATAL death ,COMPARATIVE studies ,DELIVERY (Obstetrics) ,FETAL heart rate monitoring ,FETAL ultrasonic imaging ,RESEARCH methodology ,EVALUATION of medical care ,MEDICAL cooperation ,PHYSICS ,PREGNANCY ,RESEARCH ,SURVIVAL analysis (Biometry) ,EVALUATION research ,UMBILICAL arteries - Abstract
Objective: 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.Methods: 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.Results: 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.Conclusions: 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 Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]- Published
- 2017
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11. How to monitor pregnancies complicated by fetal growth restriction and delivery before 32 weeks: post-hoc analysis of TRUFFLE study
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W, Ganzevoort, N, Mensing Van Charante, B, Thilaganathan, F, Prefumo, B, Arabin, C M, Bilardo, C, Brezinka, J B, Derks, A, Diemert, J J, Duvekot, E, Ferrazzi, T, Frusca, K, Hecher, N, Marlow, P, Martinelli, E, Ostermayer, A T, Papageorghiou, D, Schlembach, K T M, Schneider, T, Todros, A, Valcamonico, G H A, Visser, A, Van Wassenaer-Leemhuis, C C, Lees, H, Wolf, A, Zimmermann, RS: GROW - R4 - Reproductive and Perinatal Medicine, Obstetrie & Gynaecologie, MUMC+: MA Medische Staf Obstetrie Gynaecologie (9), Ganzevoort, W, Mensing Van Charante, N, Thilaganathan, B, Prefumo, F, Arabin, B, Bilardo, C M, Brezinka, C, Derks, J B, Diemert, A, Duvekot, J J, Ferrazzi, E, Frusca, T, Hecher, K, Marlow, N, Martinelli, P, Ostermayer, E, Papageorghiou, A T, Schlembach, D, Schneider, K T M, Todros, T, Valcamonico, A, Visser, G H A, Van Wassenaer-Leemhuis, A, Lees, C C, Wolf, H, and Raimondi, F.
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Adult ,Male ,Fetal Membranes, Premature Rupture ,Middle Cerebral Artery ,intrauterine growth restriction ,ductus venosu ,FLOW ,Gestational Age ,PLACENTAL INSUFFICIENCY ,Ultrasonography, Prenatal ,fetal growth restriction ,Central Nervous System Diseases ,Pregnancy ,Humans ,OUTCOMES ,Fetal Growth Retardation ,Infant ,Heart Rate, Fetal ,Survival Analysis ,ductus venosus ,DOPPLER ,Uterine Artery ,Treatment Outcome ,Central Nervous System Disease ,Child, Preschool ,Infant, Extremely Premature ,Pulsatile Flow ,Female ,TRIAL ,Survival Analysi ,cardiotocography ,Human - Abstract
Objectives In the recent TRUFFLE study, it appeared that, in pregnancies complicated by fetal growth restriction (FGR) between 26 and 32 weeks' gestation, monitoring of the fetal ductus venosus (DV) waveform combined with computed cardiotocography (CTG) to determine timing of delivery increased the chance of infant survival without neurological impairment. However, concerns with the interpretation were raised, as DV monitoring appeared to be associated with a non-significant increase in fetal death, and some infants were delivered after 32 weeks, at which time the study protocol no longer applied. This secondary sensitivity analysis of the TRUFFLE study focuses on women who delivered before 32 completed weeks' gestation and analyzes in detail the cases of fetal death. Methods Monitoring data of 317 pregnancies with FGR that delivered before 32 weeks were analyzed, excluding those with absent outcome data or inevitable perinatal death. Women were allocated randomly to one of three groups of indication for delivery according to the following monitoring strategies: (1) reduced fetal heart rate short-term variation (STV) on CTG; (2) early changes in fetal DV waveform; and (3) late changes in fetal DV waveform. Primary outcome was 2-year survival without neurological impairment. The association of the last monitoring data before delivery and infant outcome was assessed by multivariable analysis. Results Two-year survival without neurological impairment occurred more often in the two DV groups (both 83%) than in the CTG-STV group (77%), however, the difference was not statistically significant (P=0.21). Among the surviving infants in the DV groups, 93% were free of neurological impairment vs 85% of surviving infants in the CTG-STV group (P=0.049). All fetal deaths (n=7) occurred in the groups withDVmonitoring. Of the monitoring parameters obtained shortly before fetal death in these seven cases, an abnormal CTG was observed in only one case. Multivariable regression analysis of factors at study entry demonstrated that a later gestational age, higher estimated fetal weight-to-50th percentile ratio and lower umbilical artery pulsatility index (PI)/fetal middle cerebral artery-PI ratio were significantly associated with normal outcome. Allocation to DV monitoring had a smaller effect on outcome, but remained in the model (P
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- 2017
12. Is middle cerebral artery Doppler related to neonatal and 2-year infant outcome in early fetal growth restriction?
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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)
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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
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