Publications
396 results found
Lees C, Visser GHA, Hecher K, 2018, Placental–Fetal Growth Restriction, ISBN: 9781107101395
Master the effective evaluation, analysis and management of placental-fetal growth restriction (PFGR), developing strategies to reduce the risk of perinatal mortality and morbidity in patients worldwide. Extensively researched by international experts, this manual provides practitioners with a detailed, hands-on approach to the practical 'pearls' for direct patient management. This authoritative volume advises on matters such as the correct evaluation and management of high-risk patients in danger of PFGR through to delivery. Extensive and wide-ranging, this book is an invaluable companion to the developing research interest and clinical applications in PFGR, including developmental outcomes in early childhood. Featuring a critical evaluation of a variety of abnormal conditions, such as fetal hypoxia and extreme prematurity, which are clearly displayed through extensive illustrations, this essential toolkit ensures that practitioners at all levels can effectively limit adverse outcome and reach the correct diagnosis.
Lees C, Gyselaers W, 2018, Maternal Hemodynamics, Pages: 1-256, ISBN: 9781107157378
Discover new concepts in cardiovascular and hemodynamic functionality during pregnancy, with international experts in feto-maternal medicine. During the early stages of pregnancy, the maternal heart and circulation are subject to major gestational adaptive changes that allow for a normal course and outcome for both mother and baby. Any disruption to these processes can precipitate the onset of severe maternal and fetal complications such as preeclampsia, or intrauterine growth restriction. This invaluable reference work provides a comprehensive discussion of each aspect of the circulation. With a focus on the physiologic and pathophysiologic aspects of maternal cardiovascular function, this guide supports non-invasive assessment, management and prevention techniques for cardiovascular disease, for all stages of fetal and neonatal life. This text supports researchers and specialists in maternal-fetal medicine, whilst providing a key grounding in the topic, for trainees wishing to be at the cutting edge of theories and research.
Everett TR, Johal T, Lees C, 2018, Nitric Oxide Donors in Preeclampsia, Maternal Hemodynamics, Pages: 181-192, ISBN: 9781107157378
Despite the fact that the mechanisms underlying the disease process are more and more understood, preeclampsia remains a significant cause of maternal and neonatal morbidity andmortality worldwide. The mainstay of current therapies is targeted at treatment of hypertension and seizure control rather than aiming to normalize the underlying endothelial function. While targeting the root cause of preeclampsia should be the ultimate goal for therapy and prevention, however, these processes remain elusive and poorly understood. Until such time as this is feasible, NOdonors, or alteration of the NO pathways, either by precursor supplementation (e.g. L-arginine) or through augmentation of downstream effects (e.g. sildenafil), are logical candidates for the treatment of preeclampsia. This chapter summarizes the current evidence underlining the relevance of exploring NO donors in prevention and treatment of preeclampsia.
Usman S, Lawin-O'Brien A, Lees C, 2018, Differential Diagnosis of Fetal Growth Restriction, PLACENTAL-FETAL GROWTH RESTRICTION, Editors: Lees, Visser, Hecher, Publisher: CAMBRIDGE UNIV PRESS, Pages: 14-30
, 2018, Dewhurst's Textbook of Obstetrics and Gynaecology, Publisher: Wiley Blackwell, ISBN: 978-1-119-21142-6
The definitive textbook on the subject
Mullins E, Lees C, Brocklehurst P, 2017, Is continuous electronic fetal monitoring useful for all women in labour?, BMJ, Vol: 359, ISSN: 0959-8138
Routine monitoring of all women would prevent much neonatal morbidity, argue Edward Mullins and Christoph Lees, but Peter Brocklehurst believes that it will increase the risk of harm from unnecessary caesarean sections.
Lees C, 2017, Difficult behaviour can protect patients., BMJ, Vol: 359, Pages: j5314-j5314
Frusca T, Parolini S, Dall'Asta A, et al., 2017, Fetal size and growth velocity in chronic hypertension, Pregnancy Hypertension, Vol: 10, Pages: 101-106, ISSN: 2210-7789
ObjectiveTo investigate longitudinal fetal growth and growth velocity for commonly measured biometric parameters in women with chronic hypertension.MethodsTwo centre retrospective European study of women with chronic hypertension ascertained at pregnancy booking. Ultrasound measurements of head circumference (HC), abdominal circumference (AC) and femur length (FL) were used to derive longitudinal fetal growth charts derived using functional linear discriminant analysis (FLDA). These were compared to existing cross sectional and longitudinal charts, as was birthweight.Results282 women with a median of 3 third trimester ultrasound examinations were included. Gestation at delivery was 37.5 weeks (SD 2.68), birthweight 3049 g (SD 785). Birthweight <10th percentile found in 15.6% deliveries, >90th percentile 20.2%. Fetal size curves derived from women with chronic hypertension were no different to cross sectional and longitudinal charts for a normal population. Compared to a standard longitudinal biometry chart, growth velocity (mm/day) in chronic hypertension was higher for AC and FL at 30–32 weeks (AC 1.447 vs 1.357 p < 0.05; FL 0.296 vs 0.269 p < 0.01) and 34–36 weeks (AC 1.325 vs 1.140 p < 0.01; FL 0.248 vs 0.198 p < 0.01).ConclusionsIn women with chronic hypertension there is an excess of both SGA and LGA babies compared to population standards. Growth velocity of the AC and FL was greater after 30 weeks compared to a normal population.
Usman S, Barton H, Wilhelm-Benartzi C, et al., 2017, P13.07 Acceptability of trasabdominal and transperineal ultrasound compared to vaginal examinations prior to delivery, ISUOG World Congress 2017, Publisher: Wiley, Pages: 196-196, ISSN: 0960-7692
Wilkinson M, Usman S, Barton H, et al., 2017, OP19.07 Transabdominal ultrasound to assess fetal position in labour: a gold standard?, ISUOG World Congress 2017, Publisher: Wiley, Pages: 111-111, ISSN: 0960-7692
Usman S, Wilkinson M, Barton H, et al., 2017, OP19.10 Transperineal ultrasound to assess fetal head station in labour: a more objective assessment of labour?, ISUOG World Congress 2017, Publisher: Wiley, Pages: 112-112, ISSN: 0960-7692
Foo FL, Masini G, Mceniery C, et al., 2017, OC07.01 Pre-conception maternal haemodynamics is associated with subsequent development of pre-eclampsia (PE) or fetal growth restriction (FGR), ISUOG World Congress 2017, Publisher: Wiley, Pages: 12-13, ISSN: 0960-7692
Wilkinson M, Usman S, Barton H, et al., 2017, EP 19.07 Transperineal ultrasound to assess caput succedaneum in labour: a more objective assessment compared to digital vaginal examinations?, ISUOG World Congress 2017, Publisher: Wiley, Pages: 349-349, ISSN: 0960-7692
Mylrea-Lowndes B, Legg S, Shaw C, et al., 2017, OP26.01 A case series of the characteristics, course and outcomes for twin-twin transfusion syndrome (TTTS) diagnosed before 18 weeks' gestation, ISUOG World Congress 2017, Publisher: Wiley, Pages: 132-132, ISSN: 0960-7692
Mylrea-Lowndes B, Harikumar N, Shaw C, et al., 2017, OP26.02 A systematic review of diagnosis, management and outcomes for twin-twin transfusion syndrome (TTTS) diagnosed before 18 weeks' gestation, ISUOG World Congress 2017, Publisher: Wiley, Pages: 132-132, ISSN: 0960-7692
Usman S, Lees C, 2017, P04.03 What is the relationship between the cerebro-umbilical ratio, operative delivery for fetal distress and time to delivery in nulliparous women?, ISUOG World Congress 2017, Publisher: Wiley, Pages: 162-163, ISSN: 0960-7692
Bilardo CM, Hecher K, Visser GHA, et al., 2017, Severe fetal growth restriction at 26-32 weeks: key messages from the TRUFFLE study, Ultrasound in Obstetrics and Gynecology, Vol: 50, Pages: 285-290, ISSN: 0960-7692
Foo FL, McEniery CM, Lees C, et al., 2017, Assessment of arterial function in pregnancy: recommendations of the International Working Group on Maternal Haemodynamics., Ultrasound in Obstetrics and Gynecology, Vol: 50, Pages: 324-331, ISSN: 0960-7692
There is strong evidence supporting the role of maternal arterial dysfunction in pregnancy-specific disorders such as pre-eclampsia and intrauterine growth restriction. As more work is focused towards this field, it is important that methods and interpretation of arterial function assessment are applied appropriately. Here, we summarize techniques and devices commonly used in maternal health studies, with consideration of their technical application in pregnant cohorts.
Visser GHA, Bilardo CM, Derks JB, et al., 2017, 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, Ultrasound in Obstetrics and Gynaecology, Vol: 50, Pages: 347-352, ISSN: 0960-7692
ObjectiveIn 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.MethodsWe 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.ResultsOverall, 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 grou
Lees C, Ferrazzi E, 2017, Relevance of Haemodynamics in Treating Pre-eclampsia, CURRENT HYPERTENSION REPORTS, Vol: 19, ISSN: 1522-6417
Blood pressure is a way of describing the end result of changes in cardiac output, intravascular volume and peripheral resistance. It has certain advantages in that it is a reproducible and easily measured parameter, but in itself, it offers only a limited understanding of the underlying haemodynamics. In pregnancy, profound haemodynamic changes occur and in hypertensive diseases of pregnancy defining a condition by blood pressure alone risks missing the underlying cause. Partly, this has been a problem of ascribing the cause of hypertensive syndromes to the placenta which has inhibited rigorous research into other possible causes of haemodynamic dysfunction. It is becoming increasingly evident that hypertension in pregnancy may be associated with primarily high cardiac output or high peripheral resistance. A knowledge of the underlying type of hypertension may allow more rational treatment of these conditions in pregnancy rather than therapeutic attempts at controlling blood pressure by any means possible as an end in itself.
Dall'Asta A, Paramasivam G, Lees CC, 2017, Reply: 3D ultrasound and the fetal palate. Re: Qualitative evaluation of Crystal Vue rendering technology in assessment of fetal lip and palate, Ultrasound in Obstetrics and Gynecology, Vol: 50, Pages: 276-277, ISSN: 0960-7692
Wolf H, Arabin B, Lees CC, et al., 2017, A longitudinal study of computerised cardiotocography in early fetal growth restriction, Ultrasound in Obstetrics and Gynecology, Vol: 50, Pages: 71-78, ISSN: 1469-0705
ObjectivesTo explore if in early fetal growth restriction (FGR) the longitudinal pattern of short-term fetal heart rate (FHR) variation (STV) can be used for identifying imminent fetal distress and if abnormalities of FHR registration associate with two-year infant outcome.MethodsThe original TRUFFLE study assessed if in early FGR the use of ductus venosus Doppler pulsatility index (DVPI), in combination with a safety-net of very low STV and / or recurrent decelerations, could improve two-year infant survival without neurological impairment in comparison to computerised cardiotocography (cCTG) with STV calculation only. For this secondary analysis we selected women, who delivered before 32 weeks, and who had consecutive STV data for more than 3 days before delivery, and known infant two-year outcome data. Women who received corticosteroids within 3 days of delivery were excluded. Individual regression line algorithms of all STV values except the last one were calculated. Life table analysis and Cox regression analysis were used to calculate the day by day risk for a low STV or very low STV and / or FHR decelerations (DVPI group safety-net) and to assess which parameters were associated to this risk. Furthermore, it was assessed if STV pattern, lowest STV value or recurrent FHR decelerations were associated with two-year infant outcome.ResultsOne hundred and fourty-nine women matched the inclusion criteria. Using the individual STV regression lines prediction of a last STV below the cCTG-group cut-off had a sensitivity of 0.42 and specificity of 0.91. For each day after inclusion the median risk for a low STV(cCTG criteria) was 4% (Interquartile range (IQR) 2% to 7%) and for a very low STV and / or recurrent decelerations (DVPI safety-net criteria) 5% (IQR 4 to 7%). Measures of STV pattern, fetal Doppler (arterial or venous), birthweight MoM or gestational age did not improve daily risk prediction usefully. There was no association of STV regression coefficients, a l
Usman S, Foo L, Tay J, et al., 2017, Authors' reply [Use of magnesium sulfate in preterm deliveries for neuroprotection of the neonate], Obstetrician and Gynaecologist, Vol: 19, Pages: 255-256, ISSN: 1744-4667
Diderholm B, Beardsall K, Murgatroyd P, et al., 2017, Maternal rates of lipolysis and glucose production in late pregnancy are independently related to foetal weight., Clinical Endocrinology, Vol: 87, Pages: 272-278, ISSN: 1365-2265
OBJECTIVE: Associations between maternal glucose levels and increased foetal growth are well established, and independent relationships with maternal weight, weight gain and insulin resistance are also observed. The relative roles of lipolysis and glucose production in the determination of these observations remain unclear. DESIGN: We examined, through detailed physiological studies, the relationship between maternal late gestational energy substrate production (glucose and glycerol), maternal weight and weight gain, and estimated foetal size in the third trimester. PATIENTS: Twenty-one nulliparous pregnant women, without gestational diabetes (GDM) assessed at 28 weeks with oral glucose tolerance test, were recruited. MEASUREMENTS: Rates of hepatic glucose production (GPR) and rates of glycerol production (reflecting lipolysis) using [(13) C6 ]-glucose and [(2) H5 ]-glycerol were measured at 34-36 weeks of gestation. Respiratory quotient was assessed by indirect calorimetry and body composition by measurements of total body water (TBW; H2(18) O) and body density (BODPOD). Foetal weight was estimated from ultrasound measures of biparietal diameter, femoral length and abdominal circumference. RESULTS: At 34-36 weeks, bivariate analyses showed that GPR and lipolysis correlated with estimated foetal weight (r=.71 and .72, respectively) as well as with maternal weight, fat mass and fat-free mass, but not maternal weight gain. In multivariate analyses, rates of both glucose production (r=.42) and lipolysis (r=.47) were independently associated with foetal size explaining 63% of the variance. CONCLUSIONS: Both maternal rates of lipolysis and hepatic glucose production in late gestation are strongly related to estimated foetal weight.
Shah H, Al-Memar M, de Bakker B, et al., 2017, The first-trimester fetal central nervous system: a novel ultrasonographic perspective, AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY, Vol: 217, Pages: 220-221, ISSN: 0002-9378
Van Wassenaer-Leemhuis AG, Marlow N, Lees C, et al., 2017, The association of neonatal morbidity with long-term neurological outcome in infants who were growth restricted and preterm at birth: secondary analyses from TRUFFLE (Trial of Randomized Umbilical and Fetal Flow in Europe), BJOG: An International Journal of Obstetrics and Gynaecology, Vol: 124, Pages: 1072-1078, ISSN: 1470-0328
ObjectiveTo study the relationship between neonatal morbidity (NNM) and two‐year neurodevelopmental impairment (NDI) in surviving children after early fetal growth restriction (FGR).DesignSecondary analysis of a European randomised trial (TRUFFLE) of delivery for very preterm fetuses dependent on venous Doppler or cardiotocographic criteria.SettingTertiary perinatal centres, participants in TRUFFLE.Population402 surviving children after early FGR.MethodsProspective data were collection from the recognition of FGR until the corrected age of two years. We studied the association between NNM and NDI, retaining trial allocation in all statistical models. NNM included any of bronchopulmonary dysplasia, brain injury, sepsis or necrotising enterocolitis. NDI was a composite of Bayley cognitive score < 85, cerebral palsy or severe sensory impairment.Main outcome measureNDI in relation to NNM.ResultsNNM occurred in 104 cases (26%) and was more frequent in 17 of 39 infants with NDI (44%) than in the 87 of 363 infants with normal outcome (24%) [odds ratio 2.5 (95% CI, 1.3–4.8); P = 0.01]. In 22 of 39 NDI cases (56%) there was no preceding NNM. NNM was inversely related to gestational age, but NDI did not vary by gestational age. In multivariable analyses, cerebral ultrasound abnormalities were most strongly associated with NDI, together with trial group allocation, birthweight ratio, infant sex and Apgar score.ConclusionsWith the exception of cerebral ultrasound abnormalities, commonly used NNMs are poor markers of later NDI and should not be used as surrogate outcomes for NDI.
Foo FL, Collins A, McEniery CM, et al., 2017, Preconception and early pregnancy maternal haemodynamic changes in healthy women in relation to pregnancy viability, Human Reproduction, Vol: 32, Pages: 985-992, ISSN: 1460-2350
STUDY QUESTIONAre there differences in preconception cardiovascular function between women who have a viable pregnancy and those who have a first trimester miscarriage?SUMMARY ANSWERPreconception cardiovascular function of central haemodynamics and arterial function are similar between women who have a viable pregnancy and those who have a first trimester miscarriage.WHAT IS KNOWN ALREADYMiscarriages have been associated with increased long-term cardiovascular disease risk, and arterial and cardiovascular dysfunction has been hypothesised as the common link. It is not known if these risks are present prior to pregnancy or are a reflection of poor arterial and haemodynamic adaptation to pregnancy.STUDY DESIGN, SIZE, DURATIONThis prospective longitudinal preconception cohort study was conducted over 18 months. In total, 367 participants were recruited pre-pregnancy, from which 197 pregnancies were recorded; 39 of these pregnancies ended in first trimester miscarriage. Complete longitudinal data were available for 172 pregnancies (140 viable pregnancies, 32 first trimester miscarriages) from pre-pregnancy to 6 weeks gestation.PARTICIPANTS/MATERIALS, SETTING, METHODSThis was a single site study based at a maternity hospital in London. Healthy women were recruited prior to natural conception and followed up once they became pregnant. All underwent haemodynamic [cardiac output (CO), peripheral vascular resistance (PVR)] and arterial function [aortic augmentation index (AIx) and pulse wave velocity (PWV)] testing prior to pregnancy and at 6 weeks gestation, using non-invasive devices (gas re-breathing method, Innocor® and an occilometric device, Vicorder®). Cross-sectional measurements at pre-pregnancy and 6 weeks gestation and a longitudinal analysis of changes were compared between women who had a subsequent viable pregnancy, and those who had a subsequent first trimester miscarriage.MAIN RESULTS AND THE ROLE OF CHANCEThere were no differences between women desti
Kahrs BH, Usman S, Ghi T, et al., 2017, Sonographic prediction of outcome of vacuum deliveries: a multicenter, prospective cohort study, American Journal of Obstetrics and Gynecology, Vol: 217, ISSN: 0002-9378
BackgroundSafe management of the second stage of labor is of great importance. Unnecessary interventions should be avoided and correct timing of interventions should be focused. Ultrasound assessment of fetal position and station has a potential to improve the precision in diagnosing and managing prolonged or arrested labors. The decision to perform vacuum delivery is traditionally based on subjective assessment by digital vaginal examination and clinical expertise and there is currently no method of objectively quantifying the likelihood of successful delivery. Prolonged attempts at vacuum delivery are associated with neonatal morbidity and maternal trauma, especially so if the procedure is unsuccessful and a cesarean is performed.ObjectiveThe aim of the study was to assess if ultrasound measurements of fetal position and station can predict duration of vacuum extractions, mode of delivery, and fetal outcome in nulliparous women with prolonged second stage of labor.Study DesignWe performed a prospective cohort study in nulliparous women at term with prolonged second stage of labor in 7 European maternity units from 2013 through 2016. Fetal head position and station were determined using transabdominal and transperineal ultrasound, respectively. Our preliminary clinical experience assessing head-perineum distance prior to vacuum delivery suggested that we should set 25 mm for the power calculation, a level corresponding roughly to +2 below the ischial spines. The main outcome was duration of vacuum extraction in relation to ultrasound measured head-perineum distance with a predefined cut-off of 25 mm, and 220 women were needed to discriminate between groups using a hazard ratio of 1.5 with 80% power and alpha 5%. Secondary outcomes were delivery mode and umbilical artery cord blood samples after birth. The time interval was evaluated using survival analyses, and the outcomes of delivery were evaluated using receiver operating characteristic curves and descriptive st
Everett TR, Wilkinson IB, Lees CC, 2017, Pre-eclampsia: the Potential of GSNO Reductase Inhibitors, Current Hypertension Reports, Vol: 19, ISSN: 1522-6417
Purpose of Review: Pre-eclampsia remains a leading worldwidecause of maternal death and of perinatal morbidity.There remains no definitive treatment except delivery of thefetus.Recent Findings: Recent insights into the cardiovascular changesthat are evident prior to, during, and persist after preeclampsiahave improved understanding of the underlying pathophysiology—disruptionof normal endothelial function and decreasednitric oxide bioavailability. S-nitrosoglutathione(GSNO) is an endogenous S-nitrosothiol that acts as a NO pooland, by replenishing or preventing the breakdown of GSNO,endothelial dysfunction can be ameliorated. GSNO reductaseinhibitors are a novel class of drug that can increase NObioavailability.Summary: GSNO reductase inhibitors have demonstrated improvementof endothelial dysfunction in animal models, andin vivo human studies have shown them to be well tolerated.
Usman S, Barton H, Wilhelm-Benartzi C, et al., 2017, Acceptability of transabdominal and transperineal ultrasound compared to vaginal examinations prior to delivery, Publisher: WILEY, Pages: 8-8, ISSN: 1470-0328
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