Is middle cerebral artery Doppler related to neonatal and 2-year infant outcome in early fetal growth restriction?

on behalf of the, TRUFFLE investigators, TRUFFLE investigators

Research output: Contribution to journalArticle

Abstract

Background Reduced fetal middle cerebral artery Doppler impedance is associated with hypoxemia in fetal growth restriction. It remains unclear as to whether this finding could be useful in timing delivery, especially in the third trimester. In this regard there is a paucity of evidence from prospective studies. Objectives The aim of this study was to determine whether there is an association between middle cerebral artery Doppler impedance and its ratio with the umbilical artery in relation to neonatal and 2 year infant outcome in early fetal growth restriction (26+0–31+6 weeks of gestation). Additionally we sought to explore which ratio is more informative for clinical use. Study Design This is a secondary analysis from the Trial of Randomized Umbilical and Fetal Flow in Europe, a prospective, multicenter, randomized management study on different antenatal monitoring strategies (ductus venosus Doppler changes and computerized cardiotocography short-term variation) in fetal growth restriction diagnosed between 26+0 and 31+6 weeks. We analyzed women with middle cerebral artery Doppler measurement at study entry and within 1 week before delivery and with complete postnatal follow-up (374 of 503). The primary outcome was survival without neurodevelopmental impairment at 2 years corrected for prematurity. Neonatal outcome was defined as survival until first discharge home without severe neonatal morbidity. Z-scores were calculated for middle cerebral artery pulsatility index and both umbilicocerebral and cerebroplacental ratios. Odds ratios of Doppler parameter Z-scores for neonatal and 2 year infant outcome were calculated by multivariable logistic regression analysis adjusted for gestational age and birthweight p50 ratio. Results Higher middle cerebral artery pulsatility index at inclusion but not within 1 week before delivery was associated with neonatal survival without severe morbidity (odds ratio, 1.24; 95% confidence interval, 1.02–1.52). Middle cerebral artery pulsatility index Z-score and umbilicocerebral ratio Z-score at inclusion were associated with 2 year survival with normal neurodevelopmental outcome (odds ratio, 1.33; 95% confidence interval, 1.03–1.72, and odds ratio, 0.88; 95% confidence interval, 0.78–0.99, respectively) as were gestation at delivery and birthweight p50 ratio (odds ratio, 1.41; 95% confidence interval, 1.20–1.66, and odds ratio, 1.86; 95% confidence interval, 1.33–2.60, respectively). When comparing cerebroplacental ratio against umbilicocerebral ratio, the incremental range of the cerebroplacental ratio tended toward zero, whereas the umbilicocerebral ratio tended toward infinity as the values became more abnormal. Conclusion In a monitoring protocol based on ductus venosus and cardiotocography in early fetal growth restriction (26+0–31+6 weeks of gestation), the impact of middle cerebral artery Doppler and its ratios on outcome is modest and less marked than birthweight and delivery gestation. It is unlikely that middle cerebral artery Doppler and its ratios are informative in optimizing the timing of delivery in fetal growth restriction before 32 weeks of gestation. The umbilicocerebral ratio allows for a better differentiation in the abnormal range than the cerebroplacental ratio.

Original languageEnglish
Pages (from-to)521.e1-521.e13
JournalAmerican Journal of Obstetrics and Gynecology
Volume216
Issue number5
DOIs
Publication statusPublished - May 1 2017

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Middle Cerebral Artery
Fetal Development
Odds Ratio
Confidence Intervals
Pregnancy
Cardiotocography
Survival
Electric Impedance
Morbidity
Umbilicus
Umbilical Arteries
Cerebral Arteries
Third Pregnancy Trimester
Gestational Age
Prospective Studies

Keywords

  • cerebroplacental ratio
  • Doppler velocimetry
  • intrauterine growth restriction
  • middle cerebral artery
  • neonatal
  • umbilicocerebral ratio

ASJC Scopus subject areas

  • Obstetrics and Gynaecology

Cite this

Is middle cerebral artery Doppler related to neonatal and 2-year infant outcome in early fetal growth restriction? / on behalf of the; TRUFFLE investigators; TRUFFLE investigators.

In: American Journal of Obstetrics and Gynecology, Vol. 216, No. 5, 01.05.2017, p. 521.e1-521.e13.

Research output: Contribution to journalArticle

on behalf of the ; TRUFFLE investigators ; TRUFFLE investigators. / Is middle cerebral artery Doppler related to neonatal and 2-year infant outcome in early fetal growth restriction?. In: American Journal of Obstetrics and Gynecology. 2017 ; Vol. 216, No. 5. pp. 521.e1-521.e13.
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title = "Is middle cerebral artery Doppler related to neonatal and 2-year infant outcome in early fetal growth restriction?",
abstract = "Background Reduced fetal middle cerebral artery Doppler impedance is associated with hypoxemia in fetal growth restriction. It remains unclear as to whether this finding could be useful in timing delivery, especially in the third trimester. In this regard there is a paucity of evidence from prospective studies. Objectives The aim of this study was to determine whether there is an association between middle cerebral artery Doppler impedance and its ratio with the umbilical artery in relation to neonatal and 2 year infant outcome in early fetal growth restriction (26+0–31+6 weeks of gestation). Additionally we sought to explore which ratio is more informative for clinical use. Study Design This is a secondary analysis from the Trial of Randomized Umbilical and Fetal Flow in Europe, a prospective, multicenter, randomized management study on different antenatal monitoring strategies (ductus venosus Doppler changes and computerized cardiotocography short-term variation) in fetal growth restriction diagnosed between 26+0 and 31+6 weeks. We analyzed women with middle cerebral artery Doppler measurement at study entry and within 1 week before delivery and with complete postnatal follow-up (374 of 503). The primary outcome was survival without neurodevelopmental impairment at 2 years corrected for prematurity. Neonatal outcome was defined as survival until first discharge home without severe neonatal morbidity. Z-scores were calculated for middle cerebral artery pulsatility index and both umbilicocerebral and cerebroplacental ratios. Odds ratios of Doppler parameter Z-scores for neonatal and 2 year infant outcome were calculated by multivariable logistic regression analysis adjusted for gestational age and birthweight p50 ratio. Results Higher middle cerebral artery pulsatility index at inclusion but not within 1 week before delivery was associated with neonatal survival without severe morbidity (odds ratio, 1.24; 95{\%} confidence interval, 1.02–1.52). Middle cerebral artery pulsatility index Z-score and umbilicocerebral ratio Z-score at inclusion were associated with 2 year survival with normal neurodevelopmental outcome (odds ratio, 1.33; 95{\%} confidence interval, 1.03–1.72, and odds ratio, 0.88; 95{\%} confidence interval, 0.78–0.99, respectively) as were gestation at delivery and birthweight p50 ratio (odds ratio, 1.41; 95{\%} confidence interval, 1.20–1.66, and odds ratio, 1.86; 95{\%} confidence interval, 1.33–2.60, respectively). When comparing cerebroplacental ratio against umbilicocerebral ratio, the incremental range of the cerebroplacental ratio tended toward zero, whereas the umbilicocerebral ratio tended toward infinity as the values became more abnormal. Conclusion In a monitoring protocol based on ductus venosus and cardiotocography in early fetal growth restriction (26+0–31+6 weeks of gestation), the impact of middle cerebral artery Doppler and its ratios on outcome is modest and less marked than birthweight and delivery gestation. It is unlikely that middle cerebral artery Doppler and its ratios are informative in optimizing the timing of delivery in fetal growth restriction before 32 weeks of gestation. The umbilicocerebral ratio allows for a better differentiation in the abnormal range than the cerebroplacental ratio.",
keywords = "cerebroplacental ratio, Doppler velocimetry, intrauterine growth restriction, middle cerebral artery, neonatal, umbilicocerebral ratio",
author = "{on behalf of the} and {TRUFFLE investigators} and {TRUFFLE investigators} and Tamara Stampalija and Birgit Arabin and Hans Wolf and Bilardo, {Caterina M.} and Christoph Lees and C. Brezinka and Derks, {J. B.} and A. Diemert and Duvekot, {J. J.} and E. Ferrazzi and T. Frusca and W. Ganzevoort and K. Hecher and J. Kingdom and N. Marlow and K. Marsal and P. Martinelli and E. Ostermayer and Papageorghiou, {A. T.} and D. Schlembach and Schneider, {K. T.M.} and B. Thilaganathan and J. Thornton and T. Todros and A. Valcamonico and H. Valensise and {van Wassenaer-Leemhuis}, A. and Visser, {G. H.A.} and A. Aktas and S. Borgione and R. Chaoui and Cornette, {J. M.J.} and T. Diehl and {van Eyck}, J. and N. Fratelli and {van Haastert}, {I. C.} and S. Lobmaier and E. Lopriore and H. Missfelder-Lobos and G. Mansi and P. Martelli and G. Maso and U. Maurer-Fellbaum and {Mensing van Charante}, N. and {Mulder-de Tollenaer}, S. and R. Napolitano and M. Oberto and D. Oepkes and G. Ogge and A. Skabar",
year = "2017",
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language = "English",
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TY - JOUR

T1 - Is middle cerebral artery Doppler related to neonatal and 2-year infant outcome in early fetal growth restriction?

AU - on behalf of the

AU - TRUFFLE investigators

AU - TRUFFLE investigators

AU - Stampalija, Tamara

AU - Arabin, Birgit

AU - Wolf, Hans

AU - Bilardo, Caterina M.

AU - Lees, Christoph

AU - Brezinka, C.

AU - Derks, J. B.

AU - Diemert, A.

AU - Duvekot, J. J.

AU - Ferrazzi, E.

AU - Frusca, T.

AU - Ganzevoort, W.

AU - Hecher, K.

AU - Kingdom, J.

AU - Marlow, N.

AU - Marsal, K.

AU - Martinelli, P.

AU - Ostermayer, E.

AU - Papageorghiou, A. T.

AU - Schlembach, D.

AU - Schneider, K. T.M.

AU - Thilaganathan, B.

AU - Thornton, J.

AU - Todros, T.

AU - Valcamonico, A.

AU - Valensise, H.

AU - van Wassenaer-Leemhuis, A.

AU - Visser, G. H.A.

AU - Aktas, A.

AU - Borgione, S.

AU - Chaoui, R.

AU - Cornette, J. M.J.

AU - Diehl, T.

AU - van Eyck, J.

AU - Fratelli, N.

AU - van Haastert, I. C.

AU - Lobmaier, S.

AU - Lopriore, E.

AU - Missfelder-Lobos, H.

AU - Mansi, G.

AU - Martelli, P.

AU - Maso, G.

AU - Maurer-Fellbaum, U.

AU - Mensing van Charante, N.

AU - Mulder-de Tollenaer, S.

AU - Napolitano, R.

AU - Oberto, M.

AU - Oepkes, D.

AU - Ogge, G.

AU - Skabar, A.

PY - 2017/5/1

Y1 - 2017/5/1

N2 - Background Reduced fetal middle cerebral artery Doppler impedance is associated with hypoxemia in fetal growth restriction. It remains unclear as to whether this finding could be useful in timing delivery, especially in the third trimester. In this regard there is a paucity of evidence from prospective studies. Objectives The aim of this study was to determine whether there is an association between middle cerebral artery Doppler impedance and its ratio with the umbilical artery in relation to neonatal and 2 year infant outcome in early fetal growth restriction (26+0–31+6 weeks of gestation). Additionally we sought to explore which ratio is more informative for clinical use. Study Design This is a secondary analysis from the Trial of Randomized Umbilical and Fetal Flow in Europe, a prospective, multicenter, randomized management study on different antenatal monitoring strategies (ductus venosus Doppler changes and computerized cardiotocography short-term variation) in fetal growth restriction diagnosed between 26+0 and 31+6 weeks. We analyzed women with middle cerebral artery Doppler measurement at study entry and within 1 week before delivery and with complete postnatal follow-up (374 of 503). The primary outcome was survival without neurodevelopmental impairment at 2 years corrected for prematurity. Neonatal outcome was defined as survival until first discharge home without severe neonatal morbidity. Z-scores were calculated for middle cerebral artery pulsatility index and both umbilicocerebral and cerebroplacental ratios. Odds ratios of Doppler parameter Z-scores for neonatal and 2 year infant outcome were calculated by multivariable logistic regression analysis adjusted for gestational age and birthweight p50 ratio. Results Higher middle cerebral artery pulsatility index at inclusion but not within 1 week before delivery was associated with neonatal survival without severe morbidity (odds ratio, 1.24; 95% confidence interval, 1.02–1.52). Middle cerebral artery pulsatility index Z-score and umbilicocerebral ratio Z-score at inclusion were associated with 2 year survival with normal neurodevelopmental outcome (odds ratio, 1.33; 95% confidence interval, 1.03–1.72, and odds ratio, 0.88; 95% confidence interval, 0.78–0.99, respectively) as were gestation at delivery and birthweight p50 ratio (odds ratio, 1.41; 95% confidence interval, 1.20–1.66, and odds ratio, 1.86; 95% confidence interval, 1.33–2.60, respectively). When comparing cerebroplacental ratio against umbilicocerebral ratio, the incremental range of the cerebroplacental ratio tended toward zero, whereas the umbilicocerebral ratio tended toward infinity as the values became more abnormal. Conclusion In a monitoring protocol based on ductus venosus and cardiotocography in early fetal growth restriction (26+0–31+6 weeks of gestation), the impact of middle cerebral artery Doppler and its ratios on outcome is modest and less marked than birthweight and delivery gestation. It is unlikely that middle cerebral artery Doppler and its ratios are informative in optimizing the timing of delivery in fetal growth restriction before 32 weeks of gestation. The umbilicocerebral ratio allows for a better differentiation in the abnormal range than the cerebroplacental ratio.

AB - Background Reduced fetal middle cerebral artery Doppler impedance is associated with hypoxemia in fetal growth restriction. It remains unclear as to whether this finding could be useful in timing delivery, especially in the third trimester. In this regard there is a paucity of evidence from prospective studies. Objectives The aim of this study was to determine whether there is an association between middle cerebral artery Doppler impedance and its ratio with the umbilical artery in relation to neonatal and 2 year infant outcome in early fetal growth restriction (26+0–31+6 weeks of gestation). Additionally we sought to explore which ratio is more informative for clinical use. Study Design This is a secondary analysis from the Trial of Randomized Umbilical and Fetal Flow in Europe, a prospective, multicenter, randomized management study on different antenatal monitoring strategies (ductus venosus Doppler changes and computerized cardiotocography short-term variation) in fetal growth restriction diagnosed between 26+0 and 31+6 weeks. We analyzed women with middle cerebral artery Doppler measurement at study entry and within 1 week before delivery and with complete postnatal follow-up (374 of 503). The primary outcome was survival without neurodevelopmental impairment at 2 years corrected for prematurity. Neonatal outcome was defined as survival until first discharge home without severe neonatal morbidity. Z-scores were calculated for middle cerebral artery pulsatility index and both umbilicocerebral and cerebroplacental ratios. Odds ratios of Doppler parameter Z-scores for neonatal and 2 year infant outcome were calculated by multivariable logistic regression analysis adjusted for gestational age and birthweight p50 ratio. Results Higher middle cerebral artery pulsatility index at inclusion but not within 1 week before delivery was associated with neonatal survival without severe morbidity (odds ratio, 1.24; 95% confidence interval, 1.02–1.52). Middle cerebral artery pulsatility index Z-score and umbilicocerebral ratio Z-score at inclusion were associated with 2 year survival with normal neurodevelopmental outcome (odds ratio, 1.33; 95% confidence interval, 1.03–1.72, and odds ratio, 0.88; 95% confidence interval, 0.78–0.99, respectively) as were gestation at delivery and birthweight p50 ratio (odds ratio, 1.41; 95% confidence interval, 1.20–1.66, and odds ratio, 1.86; 95% confidence interval, 1.33–2.60, respectively). When comparing cerebroplacental ratio against umbilicocerebral ratio, the incremental range of the cerebroplacental ratio tended toward zero, whereas the umbilicocerebral ratio tended toward infinity as the values became more abnormal. Conclusion In a monitoring protocol based on ductus venosus and cardiotocography in early fetal growth restriction (26+0–31+6 weeks of gestation), the impact of middle cerebral artery Doppler and its ratios on outcome is modest and less marked than birthweight and delivery gestation. It is unlikely that middle cerebral artery Doppler and its ratios are informative in optimizing the timing of delivery in fetal growth restriction before 32 weeks of gestation. The umbilicocerebral ratio allows for a better differentiation in the abnormal range than the cerebroplacental ratio.

KW - cerebroplacental ratio

KW - Doppler velocimetry

KW - intrauterine growth restriction

KW - middle cerebral artery

KW - neonatal

KW - umbilicocerebral ratio

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U2 - 10.1016/j.ajog.2017.01.001

DO - 10.1016/j.ajog.2017.01.001

M3 - Article

C2 - 28087423

AN - SCOPUS:85015681176

VL - 216

SP - 521.e1-521.e13

JO - American Journal of Obstetrics and Gynecology

JF - American Journal of Obstetrics and Gynecology

SN - 0002-9378

IS - 5

ER -