http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2015; 28(1): 12–15 ! 2015 Informa UK Ltd. DOI: 10.3109/14767058.2014.899574
ORIGINAL ARTICLE
Prognostic value of obstetric Doppler ultrasound in fetuses with fetal growth restriction: an observational study in a tertiary care hospital J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by York University Libraries on 03/05/15 For personal use only.
Zaheena Shamsul Isalm, Dhanwanti Dileep, and Shama Munim Section of Fetal and Maternal Medicine and Neonatal Health, Aga Khan University Hospital, Karachi, Pakistan
Abstract
Keywords
Objective: To determine the prognostic value of umbilical artery Doppler (UAD) with fetal growth restriction (FGR) and their perinatal outcomes. Methods: This was a retrospective cohort study of fetuses with growth 5th centile from 2001 to 2012. Pregnancy outcomes were compared according to UAD findings for 253 cases. Doppler findings were categorized as; Normal End Diastolic Flow (NEDF), Reduced End Diastolic Flow (REDF) and Absent/Reverse End Diastolic Flow (AREDF). Mean and proportion were calculated and odds of perinatal complications were compared by using logistic regression for REDF and AREDF with NEDF at 5% level of significance. Results: The perinatal morality rate was 3.2%. Neonates with abnormal Doppler were at increased risk of cesarean delivery, low birth weights and low Apgar scores. Among the perinatal morbidity, neonatal intensive care unit (NICU) admission was 4.2 and 15.3 times in neonates with REDF and AREDF and similarly the perinatal mortality of AREDF was 12.5 times higher as compared to NEDF. Other morbidities were also much higher in abnormal Doppler groups. Conclusion: There is a prognostic value of UAD in predicting the outcomes for FGR fetuses and therefore recommend its use in the conservative management of such pregnancies to reduce perinatal mortality and morbidity.
Absent or reverse end diastolic flow, Doppler velocimetry, fetal growth restriction, perinatal outcome, umbilical artery
Introduction Fetal growth is one of the best indicators of fetal well-being and affects approximately 10% of pregnancies [1]. Fetuses that are growth restricted are more prone to serious complications such as severe fetal distress, cerebral damage, longterm neurological sequaele and fetal death [2–4]. In the absence of congenital or chromosomal abnormalities, small fetal size is either due to constitutional smallness or pathological growth restriction [5]. Most commonly used cut off to define growth restriction is 510th centile [1]. However, studies have suggested that adverse perinatal outcomes are generally not anticipated unless birth weights are below the fifth or even the third percentiles [6]. As fetal growth restricted pregnancies are caused by defective placentation. This may result in abnormalities of blood flow in umbilical vessels ranging from reduced to absent/reverse UA end-diastolic flow [7]. Therefore, evaluation of placental function by umbilical artery Doppler
Address for correspondence: Shama Munim, Section Head and Associate Professor, Section of Fetal & Maternal Medicine and Neonatal Health, The Aga Khan University Hospital, Karachi, Pakistan. Tel: +92-2134864645, +92-213-4864606. Fax: +92-213-493-4294. E-mail: shama. [email protected]
History Received 31 August 2013 Accepted 26 February 2014 Published online 9 April 2014
(UAD) is a clinical standard to distinguish between small for gestational age and fetal growth restriction (FGR) [8]. The umbilical artery pulsatility index (PI) and systolic to diastolic (S/D) ratio remain the most widely used assessments of fetal well-being [9]. Changes in the umbilical artery velocimetry diastolic flow can be considered as an early Doppler change [5,10]. Hence, surveillance with Doppler ultrasound is an important tool that allows time for the safe prolongation of pregnancy and also helps in deciding the time and mode of delivery [11]. The purpose of our study was to compare the UAD with adverse perinatal outcome in fetuses with growth 5th centile.
Material and methods This was a retrospective cohort study, conducted at Aga Khan University Hospital, Karachi, Pakistan from January 2001 to December 2012. This study included all women with gestational age of 28 completed weeks referred to fetal medicine department with diagnosis of FGR. Pregnant women with fetuses having antenatal diagnosis of chromosomal abnormality, structural defects, multiple pregnancies or those with later catch up growth were excluded from the study. A prior approval was obtained by the hospital ethical review committee.
Prognostic value of obstetric Doppler ultrasound
DOI: 10.3109/14767058.2014.899574
13
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by York University Libraries on 03/05/15 For personal use only.
Table 1. Maternal characteristics.
N (%) Maternal age GA at which IUGR identified Gestational age at delivery BMI* Under weight (518.5) Normal (18.5–24.9) Overweight (25–29.9) Obese (30) Parity Primiparous Multiparous Mode of delivery SVD C-section
Normal EDF, N (%) Mean ± SD
Reduced EDF, N (%) Mean ± SD
Absent EDF, N (%) Mean ± SD
189 (74.7) 27.62 ± 4.65 32.71 ± 2.91 36.94 ± 1.93 22.85 ± 4.15 29 (15.3) 112 (59.3) 35 (18.5) 13 (6.9)
40 (15.8) 27.60 ± 4.73 31.40 ± 3.11 35.05 ± 2.20 23.39 ± 4.38 7 (17.5) 17 (42.5) 13 (32.5) 3 (7.5)
24 (9.5) 29.29 ± 4.69 30.21 ± 2.64 33.13 ± 2.63 25.77 ± 4.35 0 11 (45.8) 10 (41.7) 3 (12.5)
101 (53.4) 88 (46.6)
23 (57.5) 17 (42.5)
12 (50) 12 (50)
70 (37.0) 119 (63.0)
4 (10.0) 36 (90.0)
3 (12.5) 21 (87.5)
*IOM 2009.
All women included in this study, were subjected to UAD measurement in addition to growth parameters. The umbilical artery PI was measured by ultrasound with color Doppler equipment utilizing frequencies of 5.0 MHz and filters at 50–100 Hz. In this study subjects were divided into three groups depending on their Doppler findings. Group 01: Includes women with normal end diastolic flow (NEDF) (n ¼ 189), Group 02: PI shows reduced end diastolic flow (REDF) (n ¼ 40) and group 03: Absent/reverse end diastolic flow (AREDF) (n ¼ 24). A total of 382 cases were diagnosed with FGR. Of which 98 cases were excluded due to multiple pregnancies and congenital anomalies. Another 31 women, showed catch up growth (45th centile) on further scans were also excluded from the study. Therefore, 253 cases of singleton pregnancies with FGR were served as our study subjects. Finally, umbilical artery investigation before delivery was used for analysis. Demographic details of mother were collected from the hospital medical records and labor room management system database. Details of the newborn were obtained from hospital medical records, labor room medical record system and neonatal intensive care unit records. The following outcomes were examined and considered: mean gestational week at delivery, new born birth weight, Apgar score, neonatal intensive care unit (NICU) admission, neonatal death (NND) and intrauterine death (IUD). Perinatal mortality included the number of deaths in utero and late NNDs (28 d). Neonatal morbidity was also analyzed for respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), sepsis, neonatal hyperbilirubinemia, meconium aspiration syndrome, and intubation/mechanical ventilation. Data were entered and analyzed by IBM SPSS version 19.0 (Armonk, NY) software. Mean and standard deviation was calculated for continuous variables. Birth outcomes of all three groups were compared. For categorical variables frequencies and proportions were calculated. Groups 02 and 03 were compared to group 01 by binary logistic regression by calculating odds ratio. A p value less than 0.05 was considered to be significant.
Results The study population comprises of 253 women identified with FGR in 12-year-period at a tertiary referral center in Karachi. There were 189 cases in group 1(74.7%), which served as a control group; there were 40 cases (15.8%) cases in group 2; while group three comprised of 24 cases (9.5%). The mean maternal age in the study population was 27.78 ± 4.68 years. Details of maternal characteristics are shown in Table 1. The onset of FGR was earlier in REDF and AREDF groups as compared to NEDF group (31.40 ± 3.11 and 30.21 ± 2.64 versus 32.71 ± 2.91) therefore, delivery was preferred earlier in these groups. So, the mean gestational age at delivery was lower in the abnormal Doppler groups and as expected they were at greater risk for operative delivery. It was observed that absent/reverse end diastolic flow was seen more in overweight and obese women (Table 1). The mean of estimated fetal weight (EFW) percentile were lowest in abnormal umbilical artery group as compared to NEDF group. Therefore, the mean birth weight was lower in the group with absent and reverse UAD. Table 2 summarizes the birth weight categories and Apgar scores in the different sub groups. Table 3 describes the morbidities arising in the neonatal period in the different sub groups. The odds ratio of NICU admission was 4.2 with reduced end diastolic flow and was 15.3 with absent/reverse end diastolic group. Similarly, odds of all perinatal complications were substantially higher in groups with abnormal Doppler ultrasound. There was a single case of intrauterine fetal demise and seven NNDs in the study cohort. Two infants died at 428 d of life, i.e. at 32 and 56 d of life, respectively. The perinatal mortality was 3.2%. There were three cases of NNDs in the group with normal Doppler. Causes include inborn error of metabolism, extreme prematurity and one case of sudden infant death syndrome (SIDS).
Discussion This study highlights the importance of UAD (UAD) in surveillance of pregnancies complicated with FGR. The UAD
14
Z. S. Isalm et al.
J Matern Fetal Neonatal Med, 2015; 28(1): 12–15
Table 2. Fetal/neonatal characteristics.
Variables
Normal EDF, N (%) Mean ± SD
Reduced EDF, N (%) Mean ± SD
Absent EDF, N (%) Mean ± SD
2173.1 ± 408.79 40 (21.2) 139 (73.5) 8 (4.2) 2 (1.1) 7.68 ± 0.83 8.88 ± 0.41 2.24 ± 1.41
1809.3 ± 468.8 4 (10.0) 28 (70.0) 6 (15.0) 2 (5.0) 7.15 ± 1.44 8.53 ± 1.24 1.64 ± 1.31
1403.3 ± 543.3 2 (8.3) 6 (25.0) 12 (50.0) 4 (16.7) 7.04 ± 1.49 8.48 ± 0.73 0.92 ± 1.04
Birth weight (gms) Normal (2500) LBW (1500–2499) VLBW (1000–1499) ELBW (51000) Apgar at 1 min Apgar at 5 min Percentile
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by York University Libraries on 03/05/15 For personal use only.
Table 3. Perinatal complications. Reduced EDF Variable NICU admission RDS Sepsis NEC Hyperbilirubinemia Intubation/Mechanical ventilation Perinatal death
N (%) 18 7 3 1 17 4 1
(45.0) (17.5) (7.5) (2.6) (42.5) (10.0) (2.5)
Absent EDF
OR 95%(CI) 4.2 5.5 15.2 1.6 2.1 4.1 1.6
p value
(2.01–8.67) (1.82–16.76) (1.54–150.59) (0.16–15.69) (1.04–4.28) (1.05–15.97) (0.16–15.69)
0.000 0.023 0.020 0.691 0.028 0.043 0.691
N (%) 18 5 5 3 12 3 4
(75.0) (20.8) (20.8) (12.5) (50.0) (12.5) (16.7)
OR 95%(CI) 15.3 6.8 49.5 8.9 2.9 5.3 12.4
(5.62–41.60) (1.98–23.67) (5.49–445.73) (1.68–46.71) (1.21–6.83) (1.17–23.58) (2.60–59.38)
p value 0.000 0.002 0.001 0.010 0.016 0.030 0.002
Reference category for both groups was group 01, i.e. normal end diastolic flow.
remains the gold standard in the diagnosis of growth retardation as it correlates directly with perinatal morbidity and mortality. Total perinatal mortality in our cohort was 32 per 1000. This was twice than that in the group with normal UAD velocimetry alone, i.e. 16 per 1000. In our study the mean birth weight and gestational age at delivery decreased as the Doppler progressively got worse. This finding is consistent with that of another studies published from this region [12–14]. About three fourth of the babies with absent or reverse end diastolic flow were admitted to NICU compared to 45% in reduced EDF and 16% in normal EDF. Roy et al. [12] reported similar results. In another study the NICU admissions were as high as 94% in the abnormal Doppler group [15]. As expected other perinatal complications like RDS, sepsis and NEC were directly proportional to the deterioration in the UAD velocimetry, Soregaroli et al. [16] and Jang et al. [17] also reported the same results. Unlike others [12] we did not find a difference in incidence of meconium aspiration in the three groups. The odds of perinatal death were 12.4 in the group with absent or reversed Doppler compared to 1.6 in the group with reduced end diastolic flow. Karsdorp et al. [18] has also reported similar results. The results of the current study highlight the prognostic value of UAD in pregnancies complicated with FGR. In our set up a vast majority of sonologists perform biometry as a standard protocol and Doppler ultrasound only when requested. But the finding of our study emphasizes the importance of the use of UAD along with biometry in the management and surveillance of pregnancies complicated by growth restriction.
Declaration of interest The authors report no declaration of interest.
References 1. Unterscheider J, Daly S, Geary MP, et al. Optimizing the definition of intrauterine growth restriction: the multicenter prospective PORTO Study. Am J Obstet Gynecol 2013;208:290.e1–6. 2. Chauhan SP, Gupta LM, Hendrix NW, Berghella V. Intrauterine growth restriction: comparison of American College of Obstetricians and Gynecologists practice bulletin with other national guidelines. Am J Obstet Gynecol 2009;200:409. e1. 3. Jacobsson B, Ahlin K, Francis A, et al. Cerebral palsy and restricted growth status at birth: population-based case-control study. BJOG: Int J Obstet Gynaecol 2008;115:1250–5. 4. M Kady S, Gardosi J. Perinatal mortality and fetal growth restriction. Best Pract Res Clin Obstetr Gynaecol 2004;18:397–410. 5. Royal College of Obstetrics and Gynaecology Green-Top Guidelines. The Investigation and management of the small-forgestational- age fetus; 2002. Available from: http://www.rcog.org. uk/guidelines [last accessed 26 Dec 2012]. 6. Marsa´l K, Persson PH, Larsen T, et al. Intrauterine growth curves based on ultrasonically estimated foetal weights. Acta Paediatrica 1996;85:843–8. 7. Maulik D. Hemodynamic interpretation of the arterial Doppler waveform. Ultrasound Obstetr Gynecol 1993;3:219–27. 8. Platz E, Newman R. Diagnosis of IUGR: traditional biometry. Semin Perinatol 2008;32:140–7. 9. Berkley E, Chauhan SP, Abuhamad A. Doppler assessment of the fetus with intrauterine growth restriction. Am J Obstetr Gynecol 2012;206:300–8. 10. Marconi AM, Ronzoni S, Vailati S, et al. Neonatal morbidity and mortality in intrauterine growth restricted (IUGR) pregnancies is predicated upon prenatal diagnosis of clinical severity. Reprod Sci 2009;16:373–9. 11. Thornton JG, Hornbuckle J, Vail A, et al. Infant wellbeing at 2 years of age in the Growth Restriction Intervention Trial (GRIT): multicentred randomised controlled trial. Lancet 2004;364:513–20. 12. Roy A, Mukherjee S, Bhattacharyya SK, et al. Perinatal outcome in pregnancies with intra-uterine growth restriction by using umbilical
DOI: 10.3109/14767058.2014.899574
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by York University Libraries on 03/05/15 For personal use only.
and middle cerebral artery colour Doppler. J Ind Med Assoc 2010; 110:154–7, 163. 13. Anshul D, Neelu S, Suneeta G. Significance of umbilical artery Doppler velocimetry in the perinatal outcome of the growth restricted fetuses. J Obstetr Gynecol India 2010;60: 38–43. 14. Malhotra N, Chanana C, Kumar S, et al. Comparison of perinatal outcome of growth-restricted fetuses with normal and abnormal umbilical artery Doppler waveforms. Ind J Med Sci 2006;60: 311–17. 15. Trudinger BJ, Cook CM, Giles WB, et al. Fetal umbilical artery velocity waveforms and subsequent neonatal outcome.
Prognostic value of obstetric Doppler ultrasound
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BJOG: An International Journal of Obstetrics & Gynaecology 1991:98:378–84. 16. Soregaroli M, Bonera R, Danti L, et al. Prognostic role of umbilical artery Doppler velocimetry in growth-restricted fetuses. J Matern Fetal Neonatal Med 2002;11:199–203. 17. Jang DG, Jo YS, Lee SJ, et al. Perinatal outcomes and maternal clinical characteristics in IUGR with absent or reversed enddiastolic flow velocity in the umbilical artery. Arch Gynecol Obstetr 2011;284:73–8. 18. Karsdorp VHM, Van Vugt JMG, Van Geijn HP, et al. Clinical significance of absent or reversed end diastolic velocity waveforms in umbilical artery. Lancet 1994;344:1664–8.
ORIGINAL ARTICLE
Prognostic value of obstetric Doppler ultrasound in fetuses with fetal growth restriction: an observational study in a tertiary care hospital J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by York University Libraries on 03/05/15 For personal use only.
Zaheena Shamsul Isalm, Dhanwanti Dileep, and Shama Munim Section of Fetal and Maternal Medicine and Neonatal Health, Aga Khan University Hospital, Karachi, Pakistan
Abstract
Keywords
Objective: To determine the prognostic value of umbilical artery Doppler (UAD) with fetal growth restriction (FGR) and their perinatal outcomes. Methods: This was a retrospective cohort study of fetuses with growth 5th centile from 2001 to 2012. Pregnancy outcomes were compared according to UAD findings for 253 cases. Doppler findings were categorized as; Normal End Diastolic Flow (NEDF), Reduced End Diastolic Flow (REDF) and Absent/Reverse End Diastolic Flow (AREDF). Mean and proportion were calculated and odds of perinatal complications were compared by using logistic regression for REDF and AREDF with NEDF at 5% level of significance. Results: The perinatal morality rate was 3.2%. Neonates with abnormal Doppler were at increased risk of cesarean delivery, low birth weights and low Apgar scores. Among the perinatal morbidity, neonatal intensive care unit (NICU) admission was 4.2 and 15.3 times in neonates with REDF and AREDF and similarly the perinatal mortality of AREDF was 12.5 times higher as compared to NEDF. Other morbidities were also much higher in abnormal Doppler groups. Conclusion: There is a prognostic value of UAD in predicting the outcomes for FGR fetuses and therefore recommend its use in the conservative management of such pregnancies to reduce perinatal mortality and morbidity.
Absent or reverse end diastolic flow, Doppler velocimetry, fetal growth restriction, perinatal outcome, umbilical artery
Introduction Fetal growth is one of the best indicators of fetal well-being and affects approximately 10% of pregnancies [1]. Fetuses that are growth restricted are more prone to serious complications such as severe fetal distress, cerebral damage, longterm neurological sequaele and fetal death [2–4]. In the absence of congenital or chromosomal abnormalities, small fetal size is either due to constitutional smallness or pathological growth restriction [5]. Most commonly used cut off to define growth restriction is 510th centile [1]. However, studies have suggested that adverse perinatal outcomes are generally not anticipated unless birth weights are below the fifth or even the third percentiles [6]. As fetal growth restricted pregnancies are caused by defective placentation. This may result in abnormalities of blood flow in umbilical vessels ranging from reduced to absent/reverse UA end-diastolic flow [7]. Therefore, evaluation of placental function by umbilical artery Doppler
Address for correspondence: Shama Munim, Section Head and Associate Professor, Section of Fetal & Maternal Medicine and Neonatal Health, The Aga Khan University Hospital, Karachi, Pakistan. Tel: +92-2134864645, +92-213-4864606. Fax: +92-213-493-4294. E-mail: shama. [email protected]
History Received 31 August 2013 Accepted 26 February 2014 Published online 9 April 2014
(UAD) is a clinical standard to distinguish between small for gestational age and fetal growth restriction (FGR) [8]. The umbilical artery pulsatility index (PI) and systolic to diastolic (S/D) ratio remain the most widely used assessments of fetal well-being [9]. Changes in the umbilical artery velocimetry diastolic flow can be considered as an early Doppler change [5,10]. Hence, surveillance with Doppler ultrasound is an important tool that allows time for the safe prolongation of pregnancy and also helps in deciding the time and mode of delivery [11]. The purpose of our study was to compare the UAD with adverse perinatal outcome in fetuses with growth 5th centile.
Material and methods This was a retrospective cohort study, conducted at Aga Khan University Hospital, Karachi, Pakistan from January 2001 to December 2012. This study included all women with gestational age of 28 completed weeks referred to fetal medicine department with diagnosis of FGR. Pregnant women with fetuses having antenatal diagnosis of chromosomal abnormality, structural defects, multiple pregnancies or those with later catch up growth were excluded from the study. A prior approval was obtained by the hospital ethical review committee.
Prognostic value of obstetric Doppler ultrasound
DOI: 10.3109/14767058.2014.899574
13
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by York University Libraries on 03/05/15 For personal use only.
Table 1. Maternal characteristics.
N (%) Maternal age GA at which IUGR identified Gestational age at delivery BMI* Under weight (518.5) Normal (18.5–24.9) Overweight (25–29.9) Obese (30) Parity Primiparous Multiparous Mode of delivery SVD C-section
Normal EDF, N (%) Mean ± SD
Reduced EDF, N (%) Mean ± SD
Absent EDF, N (%) Mean ± SD
189 (74.7) 27.62 ± 4.65 32.71 ± 2.91 36.94 ± 1.93 22.85 ± 4.15 29 (15.3) 112 (59.3) 35 (18.5) 13 (6.9)
40 (15.8) 27.60 ± 4.73 31.40 ± 3.11 35.05 ± 2.20 23.39 ± 4.38 7 (17.5) 17 (42.5) 13 (32.5) 3 (7.5)
24 (9.5) 29.29 ± 4.69 30.21 ± 2.64 33.13 ± 2.63 25.77 ± 4.35 0 11 (45.8) 10 (41.7) 3 (12.5)
101 (53.4) 88 (46.6)
23 (57.5) 17 (42.5)
12 (50) 12 (50)
70 (37.0) 119 (63.0)
4 (10.0) 36 (90.0)
3 (12.5) 21 (87.5)
*IOM 2009.
All women included in this study, were subjected to UAD measurement in addition to growth parameters. The umbilical artery PI was measured by ultrasound with color Doppler equipment utilizing frequencies of 5.0 MHz and filters at 50–100 Hz. In this study subjects were divided into three groups depending on their Doppler findings. Group 01: Includes women with normal end diastolic flow (NEDF) (n ¼ 189), Group 02: PI shows reduced end diastolic flow (REDF) (n ¼ 40) and group 03: Absent/reverse end diastolic flow (AREDF) (n ¼ 24). A total of 382 cases were diagnosed with FGR. Of which 98 cases were excluded due to multiple pregnancies and congenital anomalies. Another 31 women, showed catch up growth (45th centile) on further scans were also excluded from the study. Therefore, 253 cases of singleton pregnancies with FGR were served as our study subjects. Finally, umbilical artery investigation before delivery was used for analysis. Demographic details of mother were collected from the hospital medical records and labor room management system database. Details of the newborn were obtained from hospital medical records, labor room medical record system and neonatal intensive care unit records. The following outcomes were examined and considered: mean gestational week at delivery, new born birth weight, Apgar score, neonatal intensive care unit (NICU) admission, neonatal death (NND) and intrauterine death (IUD). Perinatal mortality included the number of deaths in utero and late NNDs (28 d). Neonatal morbidity was also analyzed for respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), sepsis, neonatal hyperbilirubinemia, meconium aspiration syndrome, and intubation/mechanical ventilation. Data were entered and analyzed by IBM SPSS version 19.0 (Armonk, NY) software. Mean and standard deviation was calculated for continuous variables. Birth outcomes of all three groups were compared. For categorical variables frequencies and proportions were calculated. Groups 02 and 03 were compared to group 01 by binary logistic regression by calculating odds ratio. A p value less than 0.05 was considered to be significant.
Results The study population comprises of 253 women identified with FGR in 12-year-period at a tertiary referral center in Karachi. There were 189 cases in group 1(74.7%), which served as a control group; there were 40 cases (15.8%) cases in group 2; while group three comprised of 24 cases (9.5%). The mean maternal age in the study population was 27.78 ± 4.68 years. Details of maternal characteristics are shown in Table 1. The onset of FGR was earlier in REDF and AREDF groups as compared to NEDF group (31.40 ± 3.11 and 30.21 ± 2.64 versus 32.71 ± 2.91) therefore, delivery was preferred earlier in these groups. So, the mean gestational age at delivery was lower in the abnormal Doppler groups and as expected they were at greater risk for operative delivery. It was observed that absent/reverse end diastolic flow was seen more in overweight and obese women (Table 1). The mean of estimated fetal weight (EFW) percentile were lowest in abnormal umbilical artery group as compared to NEDF group. Therefore, the mean birth weight was lower in the group with absent and reverse UAD. Table 2 summarizes the birth weight categories and Apgar scores in the different sub groups. Table 3 describes the morbidities arising in the neonatal period in the different sub groups. The odds ratio of NICU admission was 4.2 with reduced end diastolic flow and was 15.3 with absent/reverse end diastolic group. Similarly, odds of all perinatal complications were substantially higher in groups with abnormal Doppler ultrasound. There was a single case of intrauterine fetal demise and seven NNDs in the study cohort. Two infants died at 428 d of life, i.e. at 32 and 56 d of life, respectively. The perinatal mortality was 3.2%. There were three cases of NNDs in the group with normal Doppler. Causes include inborn error of metabolism, extreme prematurity and one case of sudden infant death syndrome (SIDS).
Discussion This study highlights the importance of UAD (UAD) in surveillance of pregnancies complicated with FGR. The UAD
14
Z. S. Isalm et al.
J Matern Fetal Neonatal Med, 2015; 28(1): 12–15
Table 2. Fetal/neonatal characteristics.
Variables
Normal EDF, N (%) Mean ± SD
Reduced EDF, N (%) Mean ± SD
Absent EDF, N (%) Mean ± SD
2173.1 ± 408.79 40 (21.2) 139 (73.5) 8 (4.2) 2 (1.1) 7.68 ± 0.83 8.88 ± 0.41 2.24 ± 1.41
1809.3 ± 468.8 4 (10.0) 28 (70.0) 6 (15.0) 2 (5.0) 7.15 ± 1.44 8.53 ± 1.24 1.64 ± 1.31
1403.3 ± 543.3 2 (8.3) 6 (25.0) 12 (50.0) 4 (16.7) 7.04 ± 1.49 8.48 ± 0.73 0.92 ± 1.04
Birth weight (gms) Normal (2500) LBW (1500–2499) VLBW (1000–1499) ELBW (51000) Apgar at 1 min Apgar at 5 min Percentile
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by York University Libraries on 03/05/15 For personal use only.
Table 3. Perinatal complications. Reduced EDF Variable NICU admission RDS Sepsis NEC Hyperbilirubinemia Intubation/Mechanical ventilation Perinatal death
N (%) 18 7 3 1 17 4 1
(45.0) (17.5) (7.5) (2.6) (42.5) (10.0) (2.5)
Absent EDF
OR 95%(CI) 4.2 5.5 15.2 1.6 2.1 4.1 1.6
p value
(2.01–8.67) (1.82–16.76) (1.54–150.59) (0.16–15.69) (1.04–4.28) (1.05–15.97) (0.16–15.69)
0.000 0.023 0.020 0.691 0.028 0.043 0.691
N (%) 18 5 5 3 12 3 4
(75.0) (20.8) (20.8) (12.5) (50.0) (12.5) (16.7)
OR 95%(CI) 15.3 6.8 49.5 8.9 2.9 5.3 12.4
(5.62–41.60) (1.98–23.67) (5.49–445.73) (1.68–46.71) (1.21–6.83) (1.17–23.58) (2.60–59.38)
p value 0.000 0.002 0.001 0.010 0.016 0.030 0.002
Reference category for both groups was group 01, i.e. normal end diastolic flow.
remains the gold standard in the diagnosis of growth retardation as it correlates directly with perinatal morbidity and mortality. Total perinatal mortality in our cohort was 32 per 1000. This was twice than that in the group with normal UAD velocimetry alone, i.e. 16 per 1000. In our study the mean birth weight and gestational age at delivery decreased as the Doppler progressively got worse. This finding is consistent with that of another studies published from this region [12–14]. About three fourth of the babies with absent or reverse end diastolic flow were admitted to NICU compared to 45% in reduced EDF and 16% in normal EDF. Roy et al. [12] reported similar results. In another study the NICU admissions were as high as 94% in the abnormal Doppler group [15]. As expected other perinatal complications like RDS, sepsis and NEC were directly proportional to the deterioration in the UAD velocimetry, Soregaroli et al. [16] and Jang et al. [17] also reported the same results. Unlike others [12] we did not find a difference in incidence of meconium aspiration in the three groups. The odds of perinatal death were 12.4 in the group with absent or reversed Doppler compared to 1.6 in the group with reduced end diastolic flow. Karsdorp et al. [18] has also reported similar results. The results of the current study highlight the prognostic value of UAD in pregnancies complicated with FGR. In our set up a vast majority of sonologists perform biometry as a standard protocol and Doppler ultrasound only when requested. But the finding of our study emphasizes the importance of the use of UAD along with biometry in the management and surveillance of pregnancies complicated by growth restriction.
Declaration of interest The authors report no declaration of interest.
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