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Objective: To identify specific estimates and predictors of neonatal morbidity and mortality in early onset fetal growth restriction due to placental dysfunction., Methods: Prospective multicenter study of prenatally diagnosed growth-restricted liveborn neonates of less than 33 weeks of gestational age. Relationships between perinatal variables (arterial and venous Dopplers, gestational age, birth weight, acid-base status, and Apgar scores) and major neonatal complications, neonatal death, and intact survival were analyzed by logistic regression. Predictive cutoffs were determined by receiver operating characteristic curves., Results: Major morbidity occurred in 35.9% of 604 neonates: bronchopulmonary dysplasia in 23.2% (n=140), intraventricular hemorrhage in 15.2% (n=92), and necrotizing enterocolitis in 12.4% (n=75). Total mortality was 21.5 % (n=130), and 58.3% survived without complication (n=352). From 24 to 32 weeks, major morbidity declined (56.6% to 10.5%), coinciding with survival that exceeded 50% after 26 weeks. Gestational age was the most significant determinant (P<.005) of total survival until 26(6/7) weeks (r(2)=0.27), and intact survival until 29(2/7) weeks (r(2)=0.42). Beyond these gestational-age cutoffs, and above birth weight of 600 g, ductus venosus Doppler and cord artery pH predicted neonatal mortality (P<.001, r(2)=0.38), and ductus venosus Doppler alone predicted intact survival (P<.001, r(2)=0.34)., Conclusion: This study provides neonatal outcomes specific for early-onset placenta-based fetal growth restriction quantifying the impact of gestational age, birth weight, and fetal cardiovascular parameters. Early gestational age and birth weight are the primary quantifying parameters. Beyond these thresholds, ductus venosus Doppler parameters emerge as the primary cardiovascular factor in predicting neonatal outcome., Level of Evidence: II.

Objective: This study was undertaken to test which venous Doppler parameter offers the best prediction of acid-base status at birth in pregnancies complicated by intrauterine growth restriction (IUGR) caused by placental dysfunction., Study Design: A prospective cross-sectional Doppler study of IUGR fetuses with abnormal umbilical artery Doppler and birth weight less than the 10th percentile. Absence of atrial systolic forward velocities in the ductus venosus (DV) (DV-RAV) and umbilical vein (UV) pulsations were noted and multiple venous indices were calculated for the inferior vena cava (IVC) and DV (IVC and DV preload index, peak velocity index [PVIV] and pulsatility index [PIV] and the DV S/a ratio). Doppler indices, UV pulsations, and DV- RAV were related to an umbilical artery cord pH <7.20, and a pH <7.00 and/or base deficit greater than -13 (severe metabolic compromise) in neonates delivered by cesarean section without labor., Results: In 122 fetuses all venous Doppler indices were equally predictive of a pH <7.20, with the exception of the IVC PVIV. No Doppler index predicted severe metabolic compromise. Bayesian analysis of individual Doppler parameters showed comparable outcome prediction with the highest sensitivity for the IVC PIV (76%) and the highest specificity for DV-RAV (96%). Combined assessment of the IVC, DV, and UV provided the most accurate outcome prediction. Doppler abnormality in either vessel identified 89% of neonates with pH <7.20 (negative predictive value 92%) and 10 of 11 neonates with severe metabolic compromise. Prediction was most specific (84%) when Doppler parameters were abnormal in all 3 vessels., Conclusion: IVC, DV, and UV Doppler parameters correctly predict acid-base status in a significant proportion of IUGR neonates. Combination, rather than single vessel assessment provides the best predictive accuracy. While the choice of Doppler index can be guided by operator preference, familiarity with the examination technique of all 3 vessels is encouraged to offer the highest flexibility in clinical practice.

Purpose of Review: Doppler applications in pregnancy are expanding exponentially. Flow velocity waveforms provide important information 12 weeks to term, from maternal vessels, placental circulation and fetal systemic vessels, with implications for both mother and fetus. As applications proliferate, awareness of the complexity of fetal and placental circulations, in normal pregnancy and in sequential responses to compromise, has also grown. The necessary data are now available to establish core values in Doppler evaluation for at-risk pregnancies., Recent Findings: Uterine arteries depict maternal vascular effects of the invading placenta, predicting the frequency and severity of pre-eclampsia and intrauterine growth restriction. New evidence suggests early treatment based on this principle, significantly reduces these impacts. Umbilical artery Doppler reflects downstream placental vascular resistance, strongly correlated with intrauterine growth restriction and the multisystem effects of placental deficiency. Abnormalities are progressive, with reduction, loss, and finally a reversal of diastolic flow. When umbilical arteries become abnormal, the differentiation of fetal status requires Doppler information from systemic vessels. Middle cerebral artery changes begin when the redistribution of cardiac output reflects rising placental resistance, demonstrating 'brain sparing' when cerebrovascular dilation occurs. In the compromised intrauterine growth retarded fetus, precordial veins illustrate fetal cardiac function, changing as the respiratory status declines. This Doppler information is combined with biophysical profile scoring to determine the need for and timing of intervention., Summary: Doppler evaluation of at-risk pregnancies provides crucial prognostic and diagnostic detail about placentation and fetal adaptation. What has been research detail is now becoming the standard of care, in comprehensive fetal-maternal assessment.

Aims: To study relationships between nucleated red blood cell count (NRBC), persistence of NRBC count elevation and neonatal complications in growth restricted fetuses (IUGR)., Methods: Observational study of IUGR neonates (birthweight < 10th percentile). NRBC's/100 WBC were ascertained in a peripheral blood sample. Subsequent daily samples were analyzed until NRBC's fell < 10/100 WBC. NRBC count and days of NRBC elevation were related to complications (respiratory distress syndrome (RDS), bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), necrotising enterocolitis (NEC), circulatory insufficiency (CI), day 28 oxygen requirement, mortality)., Results: 157/298 IUGR neonates (52.7%) had complications, which were associated with a higher NRBC count and persistence of NRBC elevation (12 vs. 189 NRBC's and 1 vs. 4 days; p < 0.0001 respectively). This relationship applied to each complication. Prematurity was the main determinant of RDS, BPD and mortality, while IVH was related to mechanical ventilation, CI to birthweight percentile and NEC to degree of acidemia. Persistence of NRBC count elevation was a statistical contributor for RDS, CI and mortality and the NRBC count to day 28 oxygen requirement., Conclusion: NRBC count elevation and persistent NRBC count elevation are associated with perinatal complications in IUGR. Wide ranges in numbers, complex relationships between triggering factors and impacts of other perinatal variables limit the use of NRBC parameters as predictors of complications.