10 research outputs found
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
Infant outcome after active management of earlyâonset fetal growth restriction with absent or reversed umbilical artery blood flow
OBJECTIVE: To describe the shortâ and longâterm outcomes of infants with earlyâonset fetal growth restriction (FGR) and umbilical artery absent or reversed endâdiastolic flow (AREDF), delivered before 30âweeks' gestation and managed proactively. METHODS: This was a retrospective cohort study of fetuses delivered for fetal indication before 30 completed weeks' gestation that had earlyâonset FGR (defined as estimated fetal weight more than 2âSD below the mean) with AREDF in the umbilical artery (FGR group), at the levelâ3 perinatal unit in Lund, Sweden, between 1998 and 2015. Perinatal outcome and neurodevelopment at â„â2âyears of age in surviving infants were compared with those of a group of infants without smallâforâgestationalâage birth weight or any known fetal Doppler changes delivered before 30âweeks in Lund during the corresponding time period (nonâFGR group). In the FGR group, the main indication for delivery was the Doppler finding of AREDF in the umbilical artery. RESULTS: There were 139 fetuses (of which 26% were a twin/triplet) in the FGR group and 946 fetuses (of which 28% were a twin/triplet) in the nonâFGR group. The FGR infants had a median birth weight of 630âg (range, 340â1165âg) and gestational age at birth of 187âdays (range, 164â209âdays), as compared with 950âg (range, 470â2194âg) and 185âdays (range, 154â209âdays), respectively, in the nonâFGR group. The rate of fetal mortality did not differ between the two groups (5.0% and 5.4% in the FGR and nonâFGR groups, respectively). All seven intrauterine deaths in the FGR group occurred before 26âweeks' gestation. In the FGR group compared with the nonâFGR group, severe intraventricular hemorrhage was less frequent and bronchopulmonary dysplasia and septicemia were more frequent (Pâ=â0.008, Pâ<â0.001 and Pâ=â0.017, respectively). In the FGR group, the survival rate at 2âyears (83% of liveborn infants) and the rate of cerebral palsy (7%) did not differ significantly from those in the nonâFGR group (82% and 8%, respectively). The rate of survival without neurodevelopmental impairment was higher in the nonâFGR group (83%) than in the FGR group (62%) (Pâ<â0.001), as well as in infants in the FGR group delivered at or after 26âweeks (72%) compared with those delivered before 26âweeks (40%) (Pâ=â0.003). Within the FGR group, outcomes were similar between twins and singletons and, in those who survived beyond 2 years, outcomes were similar between fetuses with absent and those with reversed endâdiastolic flow in the umbilical artery. CONCLUSIONS: Infants delivered very preterm after severe FGR with AREDF in the umbilical artery had a similar rate of survival as did nonâFGR infants of corresponding gestational age; however, they were at higher risk of neurodevelopmental impairment, the risk being most pronounced following birth before 26âweeks. Gestational age remains an important factor associated with the prognosis of earlyâonset FGR; nevertheless, the present results support the hypothesis, which should be tested prospectively, that fetuses with earlyâonset FGR and umbilical artery AREDF may benefit from early intervention rather than expectant management, and that umbilical artery Doppler findings could be incorporated into clinical protocols for cases very early in gestation. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology
Placental phenotypes of intrauterine growth
The placenta is essential to nutrition before birth. Recent work has shown that a range of clearly defined alterations can be found in the placentas of infants with intrauterine growth restriction (IUGR). In the mouse, a placental specific knockout of a single imprinted gene, encoding IGF-2, results in one pattern of alterations in placenta structure and function which leads to IUGR. We speculate that the alterations in the human placenta can also be grouped into patterns, or phenotypes, that are associated with specific patterns of fetal growth. Identifying the placental phenotypes of different fetal growth patterns will improve the ability of clinicians to recognize high-risk patients, of laboratory scientists to disentangle the complexities of IUGR, and of public health teams to target interventions aimed at ameliorating the long-term adverse effects of inadequate intrauterine growth