Longitudinal study of computerised cardiotocography in early fetal growth restriction.

OBJECTIVES: To 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. METHODS: The 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. RESULTS: One 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 last low STV or /and recurrent decelerations with short or long term infant outcomes. CONCLUSION: The TRUFFLE study showed that a strategy of DVPI monitoring with a safety-net delivery indication of very low STV and / or recurrent decelerations could increase infant survival without neurological impairment at two years. This post-hoc analysis demonstrates that in early FGR the day by day risk of an abnormal cCTG as defined by the DVPI protocol safety-net criteria is 5%, and that prediction of this is not possible. This supports the rationale for cCTG monitoring more often than daily in these high-risk fetuses. Low STV and/or recurrent decelerations were not associated with adverse infant outcome and it appears safe to delay intervention until such abnormalities occur, as long as DVPI is in the normal range

How to monitor pregnancies complicated by fetal growth restriction and delivery below 32 weeks: a post-hoc sensitivity analysis of the TRUFFLE-study.

OBJECTIVES: In the recent TRUFFLE study it appeared that, in pregnancies complicated by fetal growth restriction (FGR) between 26 and 32 weeks, monitoring of the ductus venosus (DV) combined with computerised cardiotocography (cCTG) as a trigger for delivery, increased the chance of infant survival without neurological impairment. However, concerns in interpretation were raised as DV monitoring appeared associated with a non-significant increase in fetal death, and part of the infants were delivered after 32 weeks, after which the study protocol was no longer applied. This secondary sensitivity analysis focuses on women who delivered before 32 completed weeks, and analyses fetal death cases in detail. METHODS: We analysed the monitoring data of 317 women who delivered before 32 weeks, excluding women with absent infant outcome data or inevitable perinatal death. The association of the last monitoring data before delivery and infant outcome was assessed by multivariable analysis. RESULTS: The primary outcome (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). Nevertheless, in surviving infants 93% was free of neurological impairment in the DV groups versus 85% in the CTG-STV group (p = 0.049). All fetal deaths (n = 7) occurred in women allocated to DV monitoring, which explains this difference. Assessment of the monitoring parameters that were obtained shortly before fetal death in these 7 cases showed an abnormal CTG in only one. Multivariable regression analysis of factors at study entry demonstrated that higher gestational age, larger estimated fetal weight 50th percentile ratio and lower U/C ratio were significantly associated with the (normal) primary outcome. Allocation to the DV groups had a smaller effect, but remained in the model (p < 0.1). Assessment of the last monitoring data before delivery showed that in the CTG-STV group abnormal fetal arterial Doppler was significantly associated with adverse outcome. In contrast, in the DV groups an abnormal DV was the only fetal monitoring parameter that was associated with adverse infant outcome, while fetal arterial Doppler, STV below CTG-group cut-off or recurrent fetal heart rate decelerations were not. CONCLUSIONS: In accordance with the results of the overall TRUFFLE study of the monitoring-intervention management of very early severe FGR we found that the difference in the proportion of infants surviving without neuroimpairment (the primary endpoint) was non-significant when comparing timing of delivery with or without changes in the DV waveform. However, the uneven distribution of fetal deaths towards the DV groups was likely by chance, and among surviving children neurological outcomes were better. Before 32 weeks, delaying delivery until abnormalities in DVPI or STV and/or recurrent decelerations occur, as defined by the study protocol, is therefore probably safe and possibly benefits long-term outcome

Longitudinal reference ranges for serial measurements of myocardial performance index (MPI) by conventional and tissue Doppler in monochorionic diamniotic pregnancies at 17–26 weeks of gestation

Objectives To establish longitudinal reference ranges for fetal MPI measured by conventional Doppler (MPI) and by tissue Doppler (MPI') based on a prospective cohort of uncomplicated MCDA twin. Methods Single-centre observational study. We measured MPI and MPI' on the right and left ventricles three times between 17and 26 weeks of gestation. Second-degree fractional polynomials were used to obtain the best fitting curves in relation to gestational age (weeks) for each parameter. Multilevel modelling was used to estimate the reference percentiles. Appropriate back transformations were performed to obtain the gestational age-specific reference values. Results Eighty-three uncomplicated MCDA pregnancies were included in our study with a total of 249 observations. Fetal cardiac function was measured as MPI RV and LV, MPI' RV and LV at a mean gestational age of 18.3 (range 17.1-19.2), 22.3 (21.1-23.5) and 24.3 (22.6-26.2) weeks. The reference ranges for MPI LV, MPI RV, MPI' LV, MPI' RV at 18–24 weeks were constructed. Conclusions The present study provides additional data on fetal cardiac function in uncomplicated MCDA twin gestations, describing the evolution of novel parameters in both ventricles

Outcome of monochorionic diamniotic twin pregnancies followed at a single center

OBJECTIVE: We aim to evaluate the outcome of a cohort of monochorionic diamniotic twin pregnancies followed from the first trimester onwards at a single center. METHOD: This was a retrospective analysis of prospectively collected data from a series of 300 monochorionic diamniotic twin pregnancies referred to our twin clinic between 2001 and 2012. Pregnancies were followed from the first trimester and fortnightly after 16 weeks of gestation. Data on pregnancy and neonatal outcome were analyzed. RESULTS: There were two surviving infants in 259/300 (86.4%) pregnancies, one survivor in 22/300 (7.3%) and no survivors in 19/300 (6.3%) with an overall mortality of 60/600 (10%). Twin-twin transfusion syndrome was diagnosed in 33 cases (11%), isolated intertwin weight discordance ≥ 25% in 35 (11.6%) and major congenital structural anomalies in ten (3.3%). After 32 weeks, the prospective risk of spontaneous fetal intrauterine death was one in 248 (0.4%) per pregnancy. CONCLUSIONS: Despite specific prenatal fetal monitoring and management, monochorionic diamniotic twin pregnancies have still to be considered at high risk of mortality, although the prospective risk of intrauterine death after 32 weeks is low. Twin-twin transfusion syndrome and congenital anomalies were the main risk factors for mortalit

Fulminant ulcerative colitis in a healthy pregnant woman

This case report concerns a 25-year-old patient with 6-7 bloody stools/d, abdominal pain, tachycardia, and weight loss occurring during the third trimester of pregnancy. Severe ulcerative colitis complicated by toxic megacolon and gravidic sepsis was diagnosed by clinical evaluation, colonoscopy, and rectal biopsy that were performed safely without risk for the mother or baby. The patient underwent a cesarean section at 28+6 wk gestation. The baby was transferred to the neonatal intensive care unit of our hospital and survived without complications. Fulminant colitis was managed conservatively by combined colonoscopic decompression and medical treatment. Although current European guidelines describe toxic megacolon as an indication for emergency surgery for both pregnant and non-pregnant women, thanks to careful monitoring, endoscopic decompression, and intensive medical therapy with nutritional support, we prevented the woman from having to undergo emergency pancolectomy. Our report seems to suggest that conservative management may be a helpful tool in preventing pancolectomy if the patient's condition improves quickly. Otherwise, surgery is mandatory

Management of discordant body stalk anomaly in monochorionic twin pregnancies

A 31-year-old woman, gravida 4 para 1 was referred to our center at 11(+1) weeks of gestation: the ultrasound examination revealed a monochorionic monoamniotic twin pregnancy, and one fetus was affected by body stalk anomaly. Chorionic villus sampling revealed a 46,XX karyotype. Extensive counselling about the prognosis of the affected fetus and possible complications of the pregnancy was provided

Insights into cardiac alterations after pre-eclampsia: an echocardiographic study

OBJECTIVES: Pre-eclampsia (PE) is associated with persistent abnormalities in cardiac findings, known to be important in cardiovascular (CV) risk stratification. Two-dimensional (2D) speckle tracking echocardiography (STE) allows an objective quantification of myocardial deformation overcoming many of the limitations of tissue Doppler imaging (TDI), and provides insights into aspects of left ventricular (LV) function that were exclusively analyzed by magnetic resonance imaging. Early-onset (EO) and late.onset (LO) PE could be more than one disease leading to a different CV involvement, being myocardial and vascular impairment more frequent after pregnancies complicated by the early form of the disease than the late one. Understanding LV performance status requires examining not only the properties of the left ventricle itself, but also investigating the modulating effects of the arterial system on LV function. This aspect is globally resumed in the concept of ventricular-arterial coupling (VAC). The aim of this study was to investigate CV performance status few years after EOPE or LOPE taking into account myocardial 2D strain, LV torsional mechanics and VAC. METHODS: 30 non-pregnant women with a previous singleton pregnancy complicated by EOPE, 30 who experienced LOPE and 30 controls underwent echocardiography from 6 months to 4 years after delivery. All the study cohort was free from any CV risk factor. VAC was defined as the ratio between aortic elastance (Ea) and left ventricular end-systolic elastance (Ees). RESULTS: The EOPE group showed a subclinical impairment in left ventricular systole and a slight alteration in right ventricular function. Although VAC was normal in the whole study cohort, Ea and Ees were altered significantly more in the EOPE group than both LOPE and controls. All parameters we studied were independently associated with GA at the diagnosis of PE. CONCLUSIONS: Women with a history of EOPE showed a persistent subclinical contractile impairment involving the whole heart, if compared with LOPE and healthy controls. In previously pre-eclamptics VAC value was maintained in normal range, although its single components showed subclinical alterations which were more significant in EOPE than LOPE and controls