ADEPT - Abnormal Doppler Enteral Prescription Trial

<p>Abstract</p> <p>Background</p> <p>Pregnancies complicated by abnormal umbilical artery Doppler blood flow patterns often result in the baby being born both preterm and growth-restricted. These babies are at high risk of milk intolerance and necrotising enterocolitis, as well as post-natal growth failure, and there is no clinical consensus about how best to feed them. Policies of both early milk feeding and late milk feeding are widely used. This randomised controlled trial aims to determine whether a policy of early initiation of milk feeds is beneficial compared with late initiation. Optimising neonatal feeding for this group of babies may have long-term health implications and if either of these policies is shown to be beneficial it can be immediately adopted into clinical practice.</p> <p>Methods and Design</p> <p>Babies with gestational age below 35 weeks, and with birth weight below 10th centile for gestational age, will be randomly allocated to an "early" or "late" enteral feeding regimen, commencing milk feeds on day 2 and day 6 after birth, respectively. Feeds will be gradually increased over 9-13 days (depending on gestational age) using a schedule derived from those used in hospitals in the Eastern and South Western Regions of England, based on surveys of feeding practice. Primary outcome measures are time to establish full enteral feeding and necrotising enterocolitis; secondary outcomes include sepsis and growth. The target sample size is 400 babies. This sample size is large enough to detect a clinically meaningful difference of 3 days in time to establish full enteral feeds between the two feeding policies, with 90% power and a 5% 2-sided significance level. Initial recruitment period was 24 months, subsequently extended to 38 months.</p> <p>Discussion</p> <p>There is limited evidence from randomised controlled trials on which to base decisions regarding feeding policy in high risk preterm infants. This multicentre trial will help to guide clinical practice and may also provide pointers for future research.</p> <p>Trial registration</p> <p>Current Controlled Trials ISRCTN: 87351483</p

Antenatal detection of arterio-arterial anastomoses by Doppler placental assessment in monochorionic twin pregnancies.

OBJECTIVES: To evaluate the reproducibility of Doppler antenatal detection of arterio-arterial anastomoses (AAA) in monochorionic (MC) twin pregnancies. METHODS: Between October 2002 and February 2004, 21 MC diamniotic twin pregnancies and one dichorionic triamniotic triplet seen at the Twin Clinic at the University of Brescia were recruited. After routine ultrasonographic assessment, AAA were searched using Color or Power and spectral Doppler. The presence of AAA was confirmed postnatally by placental injection studies. RESULTS: Data of 19 patients were available for the analysis. AAA were detected in 12 cases (63%) antenatally and in 16 (84.2%) at injection study. Sensitivity and specificity of Doppler for detecting AAA were 75 and 100%, respectively. Detection rates increased at advanced gestations and with anterior/fundal placentae. The incidence of twin-twin transfusion syndrome was higher in the group with no AAA detected in vivo compared to the group with AAA found with Doppler (28.5 vs. 16.6%), but the difference was not statistically significant (p = 0.5). CONCLUSION: This study confirmed the feasibility of AAA Doppler detection in vivo in MC pregnancies

P12.13: Reproducibility and clinical relevance of antenatal detection of arterio-arterial anastomoses by Doppler placental assessment in monochorionic twin pregnancies

Objectives: To evaluate the reproducibility of Doppler antenatal detection of arterio-arterial anastomoses (AAA) in monochorionic twin pregnancies in a centre other than where this method was first systematically applied and to correlate the prenatal identification of AAA with the clinical outcome of these pregnancies. Methods: 21 monochorionic diamniotic twin pregnancies and one dichorionic triamniotic triplet seen at the Twin Clinic at the University of Brescia were recruited prospectively (October 2002–February 2003). After routine ultrasonographic assessment, AAA were searched using Color or Power and spectral Doppler. The presence of AAA was confirmed postnatally by placental injection studies. Data on the presence of AAA obtained from injection studies were compared with Doppler findings to establish sensitivities and specificities of prenatal Doppler investigation. Clinical outcome of the two groups (with or without AAA detected in utero) were compared. Results: Data of 19 patients were available for the analysis. AAA were detected in 12 cases (63%) antenatally and in 16 (84.2%) at injection study. Sensitivity and specificity of Doppler for detecting AAA were 75% and 100% respectively. Detection rates increased at advanced gestations and with anterior/fundal placentae. The incidence of twin–twin transfusion syndrome (TTTS) was higher in the group with no AAA detected in vivo compared to the group with AAA found with Doppler (28.6% vs 16.6%), but not statistically significant (P = 0.5). All TTTS cases with an AAA found in utero, regressed spontaneously or after one amnioreduction. All cases with a birthweight discordance > 20% and no signs of TTTS, had an AAA detected with Doppler and showed intermittent absent/reverse diastolic flow in the umbilical artery of the smaller twin. Conclusion: This study confirmed the reproducibility and clinical relevance of AAA Doppler detection in vivo in monochorionic pregnancies

External cephalic version for breech presentation at term: an effective procedure to reduce the caesarean section rate

AIM: Although term breech presentation is a relatively rare condition (3-5% of all births), it continues to be an important indication for caesarean section and has contributed to its increased use. Risk of complications may be increased for both mother and foetus in such a situation. Vaginal delivery of a breech presenting foetus is complex and may involve many difficulties, so today there is a general consensus that planned caesarean section is better than planned vaginal birth for the foetus in breech presentation at term. External cephalic version is one of the most effective procedures in modern obstetrics. It involves the external manipulation of the foetus from the breech into the cephalic presentation. A successful manoeuvre can decrease costs by avoiding operative deliveries and decreasing maternal morbidity. The aim of the present study is to evaluate the effectiveness of this obstetric manoeuvre to increase the proportion of vertex presentation among foetuses that were formerly in the breech position near term, so as to reduce the caesarean section rate. The safety of the version is also showed. METHODS: From 1999 to 2002, 89 women with foetal breech presentation underwent external cephalic version at the Department of Obstetrics and Gynaecology of the Brescia University. The gestational age was 36.8+/-0.8 weeks. The following variables have been taken into consideration: breech variety, placental location, foetal back position, parity, amount of amniotic fluid and gestational age. Every attempt was performed with a prior use of an intravenous drip of Ritodrine, and foetal heart rate was monitored continuously with cardiotocogram. RESULTS: The success rate of the procedure was 42.7% (n=38). No maternal or foetal complication or side effects occurred, both during and after the manoeuvre, except a transient foetal bradycardia that resolved spontaneously. Only one spontaneous reversion of the foetus occurred before delivery. Of all the women that underwent a successful version, 84.2% (n=32) had a non complicated vaginal delivery. Five women (15.8%) had a caesarean section. There was no significant interaction between the variables assessed. CONCLUSION: The external cephalic version is a safe and effective manoeuvre reducing the risks of vaginal breech delivery and the rate of caesarean section

Doppler velocimetry of the uterine arteries in nulliparous women.

The aim of this study was to evaluate the role of uterine artery Doppler velocimetry performed at 20 and 24 weeks gestation in predicting gestational hypertension and small-for-gestational age babies in a population of nulliparous women. Four hundred and fifty-six patients without risk factors for pregnancy complications and with fetuses free from structural abnormalities at ultrasonographic examination at 20 weeks gestation were considered in the study. During the routine 20 weeks ultrasound a continuous-wave Doppler examination of the uterine arteries was performed. The patients with abnormal uterine Resistance Index (RI) repeated the Doppler evaluation at 24 weeks by means of Colour Doppler equipment. Among the 419 women who completed the study an abnormal Doppler uterine arteries velocimetry was found in 8.6% of the patients. Pregnancy complications (gestational hypertension and/or small-for-gestational age babies) were observed in 56% of the patients presenting high uteroplacental RI versus 10% of those with normal uterine artery velocimetry (P = 0.0001). In the group of patients with an abnormal RI value, the presence of a diastolic notch in one or both of the uterine arteries identified a population of pregnant women at higher risk for pregnancy complications when compared with patients without notch (78% vs. 33%, P = 0.007). The knowledge of the uteroplacental resistance can help in identifying a subgroup of patients at higher risk of hypertensive disorders and small-for-gestational age babies that could benefit from prophylaxis with low dose aspirin