Publications
396 results found
Shaw C, Rivens I, Civale J, et al., 2019, O-077 Novel and non-invasive high intensity focused ultrasound treatment of twin-twin transfusion syndrome, SRI 2019: Annual Meeting of the Society for Reproductive Investigation, Publisher: Elsevier, ISSN: 1071-5576
Tay J, Masini G, McEniery CM, et al., 2019, Uterine and fetal placental Doppler indices are associated with maternal cardiovascular function, American Journal of Obstetrics and Gynecology, Vol: 220, Pages: 96.e1-96.e8, ISSN: 0002-9378
BackgroundThe mechanism underlying fetal-placental Doppler index changes in preeclampsia and/or fetal growth restriction are unknown, although both are associated with maternal cardiovascular dysfunction.ObjectiveWe sought to investigate whether there was a relationship between maternal cardiac output and vascular resistance and fetoplacental Doppler findings in healthy and complicated pregnancy.Study DesignWomen with healthy pregnancies (n=62), preeclamptic pregnancies (n=13), preeclamptic pregnancies with fetal growth restriction (n=15), or fetal growth restricted pregnancies (n=17) from 24–40 weeks gestation were included. All of them underwent measurement of cardiac output with the use of an inert gas rebreathing technique and derivation of peripheral vascular resistance. Uterine and fetal Doppler indices were recorded; the latter were z scored to account for gestation. Associations were determined by polynomial regression analyses.ResultsMean uterine artery pulsatility index was higher in fetal growth restriction (1.37; P=.026) and preeclampsia+fetal growth restriction (1.63; P=.001) but not preeclampsia (0.92; P=1) compared with control subjects (0.8). There was a negative relationship between uterine pulsatility index and cardiac output (r2=0.101; P=.025) and umbilical pulsatility index z score and cardiac output (r2=0.078; P=.0015), and there were positive associations between uterine pulsatility index and peripheral vascular resistance (r2=0.150; P=.003) and umbilical pulsatility index z score and peripheral vascular resistance (r2= 0.145; P=.001). There was no significant relationship between cardiac output and peripheral vascular resistance with cerebral Doppler indices.ConclusionUterine artery Doppler change is abnormally elevated in fetal growth restriction with and without preeclampsia, but not in preeclampsia, which may explain the limited sensitivity of uterine artery Doppler changes for all these complications when considered in aggregate. Fur
Lees C, Usman S, 2018, Response to: Vaginal examination and fear of childbirth, AUSTRALIAN & NEW ZEALAND JOURNAL OF OBSTETRICS & GYNAECOLOGY, Vol: 58, Pages: E25-E25, ISSN: 0004-8666
Shaw CJ, Allison BJ, Itani N, et al., 2018, Altered autonomic control of heart rate variability in the chronically hypoxic fetus, The Journal of Physiological, Vol: 596, Pages: 6105-6119, ISSN: 1469-7793
Although fetal heart rate variability (FHRV) has long been recognised as a powerful predictor of fetal wellbeing, the mechanisms by which it is reduced in the chronically hypoxic fetus have yet to be established. In particular, the physiological mechanism underlying the reduction of short term variation (STV) in fetal compromise remains unclear. In this study, we present a longitudinal study of the development of autonomic control of FHRV, assessed by indirect indices, time domain (SDNN, RMSSD) and power spectral analysis (LF, HF, LF/HF), in normoxic and chronically hypoxic, chronically catheterised, singleton fetal sheep over the last third of gestation. We used isobaric chambers able to maintain pregnant sheep for prolonged periods in hypoxic conditions (stable fetal femoral arterial PO2 10-12 mmHg), and a customised wireless data acquisition system to record beat-to-beat variation in the fetal heart rate. We determined in vivo longitudinal changes in overall FHRV and the sympathetic and parasympathetic contribution to FHRV in hypoxic (n = 6) and normoxic (n = 6) ovine fetuses with advancing gestational age. Normoxic fetuses show gestational age-related increases in overall indices of FHRV, and in the sympathetic nervous system contribution to FHRV (P < 0.001). Conversely, gestational-age related increases in overall FHRV were impaired by exposure to chronic hypoxia, and there was evidence of suppression of the sympathetic nervous system control of FHRV after 72 h of exposure to hypoxia (P < 0.001). This demonstrates that exposure to late gestation isolated chronical fetal hypoxia has the potential to alter the development of the autonomic nervous system control of FHRV in sheep. This presents a potential mechanism by which a reduction in indices of FHRV in human fetuses affected by uteroplacental dysfunction can predict fetuses at increased risk. This article is protected by copyright. All rights reserved.
Lees C, Tay J, Wilkinson I, 2018, Reply to: Early and late preeclampsia are characterized by high cardiac output, but in the presence of fetal growth restriction, cardiac output is low: insights from a prospective study, American Journal of Obstetrics and Gynecology, Vol: 219, Pages: 627-628, ISSN: 0002-9378
Usman S, Van Calster B, Barton H, et al., 2018, P06.08 Prediction of emergency caesarean sections; which variables are important, ISUOG World Congress 2018, Publisher: Wiley, Pages: 157-157, ISSN: 1469-0705
Wilkinson M, Usman S, Barton H, et al., 2018, OP17.03: The views of pregnant women, midwives and a women's panel on intrapartum ultrasound research: a pilot study, ISUOG World Congress 2018, Publisher: Wiley, Pages: 116-116, ISSN: 1469-0705
Usman S, Barton H, Van Calster B, et al., 2018, P06.10 Prediction of emergency caesarean sections; does umbilical cerebral ratio have an important role to play?, ISUOG World Congress 2018, Publisher: Wiley, Pages: 158-158, ISSN: 1469-0705
Usman S, Kahrs B, Barton H, et al., 2018, OP17.04 Using the intrapartum app on a new population, ISUOG World Congress 2018, Publisher: Wiley, Pages: 116-116, ISSN: 1469-0705
Usman S, Lees C, Khars BH, et al., 2018, P06.07: Time to delivery based on sonographic assessment prior to forceps and vacuum: a pilot study, ISUOG World Congress 2018, Publisher: Wiley, Pages: 157-157, ISSN: 0960-7692
Prior T, Lees C, 2018, Control and monitoring of fetal growth, Encyclopedia of Endocrine Diseases Vol 5, Editors: Huhtaniemi, Martini, Publisher: Academic Press, Pages: 1-9, ISBN: 9780128121993
Encyclopedia of Endocrine Diseases, Second Edition, comprehensively reviews the extensive spectrum of diseases and disorders that can occur within the endocrine system.
Shaw CJ, Rivens I, Civale J, et al., 2018, Trans-abdominal in vivo placental vessel occlusion using High Intensity Focused Ultrasound., Scientific Reports, Vol: 8, Pages: 13631-13631, ISSN: 2045-2322
Pre-clinically, High Intensity Focused Ultrasound (HIFU) has been shown to safely and effectively occlude placental blood vessels in the acute setting, when applied through the uterus. However, further development of the technique to overcome the technical challenges of targeting and occluding blood vessels through intact skin remains essential to translation into human studies. So too does the assessment of fetal wellbeing following this procedure, and demonstration of the persistence of vascular occlusion. At 115 ± 10 d gestational age (term~147 days) 12 pregnant sheep were exposed to HIFU (n = 6), or to a sham (n = 6) therapy through intact abdominal skin (1.66 MHz, 5 s duration, in situ ISPTA 1.3-4.4 kW.cm-2). Treatment success was defined as undetectable colour Doppler signal in the target placental vessel following HIFU exposures. Pregnancies were monitored for 21 days using diagnostic ultrasound from one day before HIFU exposure until term, when post-mortem examination was performed. Placental vessels were examined histologically for evidence of persistent vascular occlusion. HIFU occluded 31/34 (91%) of placental vessels targeted, with persistent vascular occlusion evident on histological examination 20 days after treatment. The mean diameter of occluded vessels was 1.4 mm (range 0.3-3.3 mm). All pregnancies survived until post mortem without evidence of significant maternal or fetal iatrogenic harm, preterm labour, maternal or fetal haemorrhage or infection. Three of six ewes exposed to HIFU experienced abdominal skin burns, which healed without intervention within 21 days. Mean fetal weight, fetal growth velocity and other measures of fetal biometry were not affected by exposure to HIFU. Fetal Doppler studies indicated a transient increase in the umbilical artery pulsatility index (PI) and a decrease in middle cerebral artery PI as a result of general anaesthesia, which was
Dall'Asta A, Shah H, Masini G, et al., 2018, Evaluation of the tramline sign for abnormally invasive placenta using three-dimensional ultrasound and Crystal Vue rendering technology, Ultrasound in Obstetrics and Gynecology, Vol: 52, Pages: 403-404, ISSN: 0960-7692
Prenatal diagnosis of abnormally invasive placenta (AIP) and accurate characterization of its variants can contribute to reducing maternal morbidity and mortality by allowing optimal management in terms of timing and planning of delivery (1,2).
Dall'Asta A, Paramasivam G, Lees CC, 2018, Reply: Artifacts in 3D rendering: secondary palate concealed in acoustic shadow and use of edge-detection filters, Ultrasound in Obstetrics and Gynecology, Vol: 52, Pages: 408-411, ISSN: 0960-7692
Kahrs BH, Usman S, Ghi T, et al., 2018, Fetal rotation during vacuum extractions for prolonged labor: a prospective cohort study, Acta Obstet Gynecol Scand, Vol: 97, Pages: 998-1005
INTRODUCTION: The aim of the study was to investigate fetal head rotation during vacuum extraction. MATERIAL AND METHODS: We conducted a prospective cohort study from November 2013 to July 2016 in seven European hospitals. Fetal head position was determined with transabdominal or transperineal ultrasound and categorized as occiput anterior (OA), occiput transverse (OT) or occiput posterior (OP) position. Main outcome was the proportion of fetuses rotating during vacuum extraction. Secondary outcomes were conversion of delivery method, duration of vacuum extraction, umbilical artery pH <7.10 and agreement between clinical and ultrasound assessments. RESULTS: The study population comprised 165 women. During vacuum extraction 117/119 (98%) remained in OA and two fetuses rotated to OP position. Rotation from OT to OA position occurred in 14/19 (74%) and to OP position in 5/19 (26%). Rotation from OP to OA position occurred in 15/25 (60%), and 10/25 (40%) fetuses remained in OP position. Delivery information was missing in two cases. The conversion rate from vacuum extraction to cesarean section or forceps was 10% in the OA group vs. 23% in the non-OA group; p < 0.05. The estimated duration of vacuum extraction was significantly shorter in OA fetuses, 7 min vs. 10 min (log rank test p < 0.01). There was no significant difference in umbilical artery pH < 7.10 between OA and non-OA position. Cohens Kappa of agreement between clinical and ultrasound assessments was 0.42 (95% CI 0.26-0.57). CONCLUSION: Most fetuses in OP or OT positions rotated to OA position during vacuum extraction, but the proportion of failed vacuum extractions remained high.
Foo F, Mahendru A, Masini G, et al., 2018, Association between prepregnancy cardiovascular function and subsequent preeclampsia or fetal growth restriction, Hypertension, Vol: 72, Pages: 442-450, ISSN: 0194-911X
Preeclampsia and fetal growth restriction during pregnancy are associated with increased risk of maternal cardiovascular disease later in life. It is unclear whether this association is causal or driven by similar antecedent risk factors. Clarification requires recruitment before conception which is methodologically difficult with high attrition rates and loss of outcome numbers to nonconception/miscarriage. Few prospective studies have, therefore, been adequately powered to address these questions. We recruited 530 healthy women (mean age: 35.0 years) intending to conceive and assessed cardiac output, cardiac index, stroke volume, total peripheral resistance, mean arterial pressure, and heart rate before pregnancy. Participants were followed to completion of subsequent pregnancy with repeat longitudinal assessments. Of 356 spontaneously conceived pregnancies, 15 (4.2%) were affected by preeclampsia and fetal growth restriction. Women who subsequently developed preeclampsia/fetal growth restriction had lower preconception cardiac output (4.9 versus 5.8 L/min; P=0.002) and cardiac index (2.9 versus 3.3 L/min per meter2; P=0.031) while mean arterial pressure (87.1 versus 82.3 mm Hg; P=0.05) and total peripheral resistance (1396.4 versus 1156.1 dynes sec cm−5; P<0.001) were higher. Longitudinal trajectories for cardiac output and total peripheral resistance were similar between affected and healthy pregnancies, but the former group showed a more exaggerated fall in mean arterial pressure in the first trimester, followed by a steeper rise and a steeper fall to postpartum values. Significant relationships were observed between cardiac output, total peripheral resistance, and mean arterial pressure and gestational epoch. We conclude that in healthy women, an altered prepregnancy hemodynamic phenotype is associated with the subsequent development of preeclampsia/fetal growth restriction.
Gyselaers W, Spaanderman M, International Working Group on Maternal Hemodynamics, 2018, Assessment of venous hemodynamics and volume homeostasis during pregnancy: recommendations of the International Working Group on Maternal Hemodynamics, Ultrasound in Obstetrics and Gynecology, Vol: 52, Pages: 174-185, ISSN: 0960-7692
Venous hemodynamics and volume homeostasis are important aspects of cardiovascular physiology. However, today their relevance is still very much underappreciated. Their most important role is maintenance and control of venous return and, as such, cardiac output. A high-flow/low-resistance circulation, remaining constant under physiological circumstances, is mandatory for an uncomplicated course of pregnancy. In this article, characteristics of normal and abnormal venous and volume regulating functions are discussed with respect to normal and pathologic outcomes of pregnancy, and current (non-invasive) methods to assess these functions are summarized. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
Lees C, 2018, Prenatal ultrasonography and autism spectrum disorder, JAMA Pediatrics, Vol: 172, Pages: 786-786, ISSN: 2168-6203
Dall'Asta A, van Oostrum NH, Basheer SN, et al., 2018, Etiology and prognosis of severe ventriculomegaly diagnosed at late gestation., European Journal of Ultrasound / Ultraschall in der Medizin, Vol: 39, Pages: 675-689, ISSN: 0172-4614
OBJECTIVES: We sought to assess the causes and outcomes of severe VM diagnosed de novo after 24 weeks of gestation where a mid-trimester anomaly scan was described as normal. METHODS: Multicenter retrospective study of five European fetal medicine centers. The inclusion criteria were normal anatomy at the mid-trimester scan, uni/bilateral finding of posterior ventricle measuring ≥ 15 mm after 24 weeks with neonatal and postnatal pediatric and/or neurological assessment data. RESULTS: Of 74 potentially eligible cases, 10 underwent termination, the outcome was missing in 19 cases and there was 1 neonatal death. Therefore, 44 formed the study cohort with a median gestation at diagnosis of 32 + 0 weeks (25 + 6 - 40 + 5). VM was unilateral in five cases. Agenesis of the corpus callosum (ACC) and grade III/IV intraventricular hemorrhage (IVH) accounted for 14 cases each. ACC was isolated in 9 fetuses. Obstructive abnormalities included 5 arachnoid and 1 cavum velum interpositum cyst. Four fetuses had an associated suspected or confirmed genetic condition, 2 congenital infections, 1 abnormal cortical development and the etiology was unknown in 3/44. Postnatal assessment at median 20 months (3 - 96) showed 22/44 (50 %) normal, 7 (16 %) mildly abnormal and 15 (34 %) severely abnormal neurodevelopmental outcomes. CONCLUSION: One half of babies with severe VM diagnosed after 24 weeks have normal infant outcome with ACC and IVH representing the most common causes. Etiology is the most important factor affecting the prognosis of fetuses with severe VM diagnosed at late gestation.
Tay J, Costanzi A, Basello K, et al., 2018, Maternal Serum B Cell activating factor in hypertensive and normotensive pregnancies, Pregnancy Hypertension, Vol: 13, Pages: 58-61, ISSN: 2210-7789
ObjectivesThe objective of this study was the analysis of B-Cell Activating Factor (BAFF) levels in pregnancies affected by PE, and in pregnancies affected by fetal growth restriction without Hypertensive disorders and its possible correlation with pulse wave velocity and cardiac output.Study designProspective study of 69 women at 24–40 weeks gestation. Haemodynamic function was assessed in those with Pre-eclampsia (PE, n = 19), fetal growth restriction (FGR, n = 10) and healthy pregnancies (n = 40). Maternal venous BAFF levels at recruitment were measured using ELISA. We analysed the relationship between BAFF and cardiac output (CO), and BAFF and PWV (pulse wave velocity); the gold standard for assessing arterial stiffness. PWV was measured with an oscillometric device and CO using inert gas rebreathing technique. PWV and CO were converted to gestation adjusted indices (z scores).Main outcome measuresThe association between BAFF levels in PE and FGR, and the relationship of BAFF with PWV and CO.ResultsBAFF was higher in PE (p = 0.03) but not in FGR (p = 0.83) when compared to healthy pregnancies. There was a positive correlation between BAFF levels and z score PWV (r = 0.25, p = 0.04), but not CO (r = −0.01, p = 0.91). BAFF levels did not change with gestational age. (r = 0.012, p = 0.925).ConclusionsThese findings provide evidence of a possible contribution of BAFF to both maternal inflammation and arterial dysfunction associated with PE. Though no relationship was found with another disorder of placentation: normotensive FGR, this condition is not thought to be associated with maternal inflammation.
Lai J, Woodward R, Alexandrov Y, et al., 2018, Performance of a wearable acoustic system for fetal movement discrimination, PLoS One, Vol: 13, Pages: 1-14, ISSN: 1932-6203
Fetal movements (FM) are a key factor in clinical management of high-risk pregnancies such as fetal growth restriction. While maternal perception of reduced FM can trigger self-referral to obstetric services, maternal sensation is highly subjective. Objective, reliable monitoring of fetal movement patterns outside clinical environs is not currently possible. A wearable and non-transmitting system capable of sensing fetal movements over extended periods of time would be extremely valuable, not only for monitoring individual fetal health, but also for establishing normal levels of movement in the population at large. Wearable monitors based on accelerometers have previously been proposed as a means of tracking FM, but such systems have difficulty separating maternal and fetal activity and have not matured to the level of clinical use. We introduce a new wearable system based on a novel combination of accelerometers and bespoke acoustic sensors as well as an advanced signal processing architecture to identify and discriminate between types of fetal movements. We validate the system with concurrent ultrasound tests on a cohort of 44 pregnant women and demonstrate that the garment is capable of both detecting and discriminating the vigorous, whole-body ‘startle’ movements of a fetus. These results demonstrate the promise of multimodal sensing for the development of a low-cost, non-transmitting wearable monitor for fetal movements.
Tay J, Foo L, Masini G, et al., 2018, Cardiac output in pre eclampsia is associated with the presence of fetal growth restriction, not gestation at onset: a prospective cohort study, American Journal of Obstetrics and Gynecology, Vol: 218, Pages: 517.e1-517.e12, ISSN: 0002-9378
BACKGROUND AND OBJECTIVES: Pre-eclampsia (PE) and fetal growth restriction (FGR) are considered to be placentally-mediated disorders. The clinical manifestations are widely held to relate to gestation age at onset with early- and late-onset PE considered to be phenotypically distinct. Recent studies have reported conflicting findings in relation to cardiovascular function, and in particular cardiac output, in PE and FGR. STUDY DESIGN: We investigated maternal cardiovascular function in relation to clinical subtype in 45 pathological pregnancies (14 'PE only', 16 'FGR only', 15 'PE and FGR') and compared these with 107 healthy person observations. Cardiac output (CO) was the primary outcome measure, and was assessed using an inert gas rebreathing method (Innocor®), from which peripheral vascular resistance was derived (PVR); arterial function was assessed by Vicorder ®, a cuff-based oscillometric device. Cardiovascular parameters were normalised for gestational age in relation to healthy pregnancies using Z scores, thus allowing for comparison across the gestational range 24-40 weeks. RESULTS: Compared with healthy control pregnancies, women with PE had higher CO Z scores (1.87 ± 1.35; p=0.0001) and lower PVR Z scores (-0.76± 0.89; p=0.025); those with FGR had higher PVR Z scores (0.57± 1.18; p=0.04) and those with both PE and FGR had lower CO Z scores (-0.80 ± 1.3; p= 0.007) and higher PVR Z scores (2.16 ± 1.96; p=0.0001). These changes were not related to gestational age of onset. All those affected by PE and/or FGR had abnormally raised augmentation index (AIx) and pulse wave velocity (PWV). Furthermore, in PE, low CO was associated with low birthweight and high CO with high birthweight. (r=0.42, p=0.03). CONCLUSIONS: PE is associated with high CO, but if PE presents with FGR, the opposite is true; both conditions are, nevertheless, defined by hypertension. FGR without PE is associated with high PVR. Though 'early' and 'l
Lees C, 2018, Assessment of arterial function in pregnancy: what about peripheral arterial tonometry? Reply, ULTRASOUND IN OBSTETRICS & GYNECOLOGY, Vol: 51, Pages: 703-703, ISSN: 0960-7692
Usman S, Wilkinson M, Barton H, et al., 2018, The feasibility and accuracy of ultrasound assessment in the labor room, Journal of Maternal-Fetal and Neonatal Medicine, Vol: 32, Pages: 3442-3451, ISSN: 1476-4954
OBJECTIVE: Vaginal examination is widely used to assess the progress of labor; however, it is subjective and poorly reproducible. We aim to assess the feasibility and accuracy of transabdominal and transperineal ultrasound compared to vaginal examination in the assessment of labor and its progress. METHODS: Women were recruited as they presented for assessment of labor to a tertiary inner city maternity service. Paired vaginal and ultrasound assessments were performed in 192 women at 24-42 weeks. Fetal head position was assessed by transabdominal ultrasound defined in relation to the occiput position transformed to a 12-hour clock face; fetal head station defined as head-perineum distance by transperineal ultrasound; cervical dilatation by anterior to posterior cervical rim measurement and caput succedaneum by skin-skull distance on transperineal ultrasound. RESULTS: Fetal head position was recorded in 99.7% (298/299) of US and 51.5% (154/299) on vaginal examination (p < .0001 1 ). Bland-Altman analysis showed 95% limits of agreement, -5.31 to 4.84 clock hours. Head station was recorded in 96.3% (308/320) on vaginal examination (VE) and 95.9% (307/320) on US (p = .79 1 ). Head station and head perineum distance were negatively correlated (Spearman's r = -.57, p < .0001). 54.4% (178/327) of cervical dilatation measurements were determined using US and 100% on VE/speculum (p < .0001). Bland-Altman analysis showed 95% limits of agreement -2.51-2.16 cm. The presence of caput could be assessed in 98.4% (315/320) of US and was commented in 95.3% (305/320) of VEs, with agreement for the presence of caput of 76% (p < .05). Fetuses with caput greater than 10 mm had significantly lower head station (p < .0001). CONCLUSIONS: We describe comprehensive ultrasound assessments in the labor room that could be translated to the assessment of women in labor.
DallʼAsta A, Lees C, 2018, Early Second-Trimester Fetal Growth Restriction and Adverse Perinatal Outcomes., Obstetrics and Gynecology, Vol: 131, Pages: 739-740, ISSN: 0029-7844
Meah VL, Backx K, Davenport MH, et al., 2018, Functional hemodynamic testing in pregnancy: recommendations of the International Working Group on Maternal Hemodynamics, Ultrasound in Obstetrics and Gynecology, Vol: 51, Pages: 331-340, ISSN: 0960-7692
In the general population, functional hemodynamic testing, such as that during submaximal aerobic exercise and isometric handgrip, and the cold pressor test, has long been utilized to unmask abnormalities in cardiovascular function. During pregnancy, functional hemodynamic testing places additional demands on an already stressed maternal cardiovascular system. Dysfunctional responses to such tests in early pregnancy may predict the development of hypertensive disorders that develop later in gestation. For each of the above functional hemodynamic tests, these recommendations provide a description of the test, test protocol and equipment required, and an overview of the current understanding of clinical application during pregnancy.
Foo L, Mahendry A, McEniery C, et al., 2018, Pre-conception maternal haemodynamics is associated with subsequent development of pre-eclampsia (PE) or fetal growth restriction (FGR), RCOG World Congress, Publisher: WILEY, Pages: 12-12, ISSN: 1470-0328
Dall'Asta A, Paramasivam G, Lees CC, 2018, Reply: 3D to boldly go where no 2D has gone before? Pitfalls in 3D reconstruction of the fetal palate, Ultrasound in Obstetrics and Gynecology, Vol: 51, Pages: 416-+, ISSN: 0960-7692
Frusca T, Todros T, Lees C, et al., 2018, Outcome in early-onset fetal growth restriction is best combining computerized fetal heart rate analysis with ductus venosus Doppler: insights from the Trial of Umbilical and Fetal Flow in Europe, American Journal of Obstetrics and Gynecology, Vol: 218, Pages: S783-S789, ISSN: 0002-9378
BACKGROUND: Early-onset fetal growth restriction represents a particular dilemma in clinical management balancing the risk of iatrogenic prematurity with waiting for the fetus to gain more maturity, while being exposed to the risk of intrauterine death or the sequelae of acidosis. OBJECTIVE: The Trial of Umbilical and Fetal Flow in Europe was a European, multicenter, randomized trial aimed to determine according to which criteria delivery should be triggered in early fetal growth restriction. We present the key findings of the primary and secondary analyses. STUDY DESIGN: Women with fetal abdominal circumference <10th percentile and umbilical pulsatility index >95th percentile between 26-32 weeks were randomized to 1 of 3 monitoring and delivery protocols. These were: fetal heart rate variability based on computerized cardiotocography; and early or late ductus venosus Doppler changes. A safety net based on fetal heart rate abnormalities or umbilical Doppler changes mandated delivery irrespective of randomized group. The primary outcome was normal neurodevelopmental outcome at 2 years. RESULTS: Among 511 women randomized, 362/503 (72%) had associated hypertensive conditions. In all, 463/503 (92%) of fetuses survived and cerebral palsy occurred in 6/443 (1%) with known outcome. Among all women there was no difference in outcome based on randomized group; however, of survivors, significantly more fetuses randomized to the late ductus venosus group had a normal outcome (133/144; 95%) than those randomized to computerized cardiotocography alone (111/131; 85%). In 118/310 (38%) of babies delivered <32 weeks, the indication was safety-net criteria: 55/106 (52%) in late ductus venosus, 37/99 (37%) in early ductus venosus, and 26/105 (25%) in computerized cardiotocography groups. Higher middle cerebral artery impedance adjusted for gestation was associated with neonatal survival without severe morbidity (odds ratio, 1.24; 95% confidence interval, 1.02-1.52) and infa
Lees C, 2018, Maintaining public confidence in doctors-at what cost?, BMJ-BRITISH MEDICAL JOURNAL, Vol: 360, ISSN: 1756-1833
This data is extracted from the Web of Science and reproduced under a licence from Thomson Reuters. You may not copy or re-distribute this data in whole or in part without the written consent of the Science business of Thomson Reuters.