Amniotic-Umbilical-to-Cerebral Ratio – A Novel Ratio Combining Doppler Parameters and Amniotic Fluid Volume to Predict Adverse Perinatal Outcome in SGA Fetuses At Term

Abstract

Purpose Introduction of a novel ratio – the amniotic-umbilical-to-cerebral ratio (AUCR) – to predict adverse perinatal outcome in SGA fetuses at term and comparison of its predictive accuracy with established parameters.

Materials and Methods This retrospective cohort study included 165 singleton pregnancies with SGA fetuses (birth weight < 10^th percentile) at term. Cases with planned vaginal delivery and documented pulsatility indices (PI) of the umbilical artery (UA), middle cerebral artery (MCA), and single deepest pocket (SDP) were included. CPR was calculated as the ratio between MCA PI and UA PI, UCR as the ratio between UA PI and MCA PI. AUCR was defined as follows: SDP/(UA PI/MCA PI). Adverse perinatal outcomes were defined as operative intervention (OI), OI due to fetal distress, admission to the neonatal intensive care unit (NICU), and composite adverse perinatal outcome (CAPO). Associations between Doppler parameters and these outcomes were estimated using regression analyses.

Results OI was statistically significantly associated with UCR, SDP, and AUCR, whereas no association was observed for UA PI, MCA PI, and CPR. Fetuses requiring OI due to fetal distress revealed a significantly higher UA PI and UCR as well as a lower MCA PI, CPR, and AUCR. With regard to NICU admission and CAPO, a significantly higher UA PI and lower CPR were found. Furthermore, a significant association was shown for SDP, UCR, and AUCR. AUCR achieved the best area under the curve for all outcome parameters.

Conclusion AUCR leads to an improvement in the prediction of unfavorable outcome in SGA fetuses at term. Furthermore, results of our study show that UCR might be superior to CPR.

Zusammenfassung

Ziel Beschreibung einer neuen Ratio – der Amniotic-Umbilical-to-Cerebral-Ratio (AUCR) – zur Prädiktion eines ungünstigen Geburtsoutcomes bei SGA-Föten am Geburtstermin und Vergleich mit etablierten Parametern.

Material und Methoden Retrospektive Kohortenstudie mit 165 SGA-Föten (Geburtsgewicht < 10. Perzentile) am Geburtstermin. Fälle mit geplanter Spontangeburt und dokumentierten Pulsatilitätsindizes (PI) der A. umbilicalis (UA), A. cerebri media (MCA) und tiefstem Fruchtwasserdepot (single deepest pocket, SDP) wurden eingeschlossen. Die CPR wurde als Quotient aus MCA und UAPI berechnet, die UCR umgekehrt. Die AUCR wurde wie folgt definiert: AUCR = SDP/(UA PI/MCA PI). Die Assoziationen zwischen Dopplerparametern, operativer Intervention (OI), OI bei pathologischem CTG, Verlegung auf die neonatologische Intensivstation (NICU) und kombiniertem adversem Outcome (CAPO) wurden mittels Regressionsanalyse ausgewertet.

Ergebnisse Eine OI war signifikant mit der UCR, dem SDP und der AUCR assoziiert, wohingegen kein Zusammenhang für UA PI, MCA PI und CPR gefunden wurde. Föten mit OI bei pathologischem CTG hatten signifikant höhere UA PI, niedrigere MCA PI und niedrigere CPR. Weiterhin war die UCR signifikant höher und die AUCR signifikant niedriger. Signifikant höhere UA PI und niedrigere CPR zeigten sich bei NICU und CAPO. Weiterhin bestand ein signifikanter Zusammenhang auch für SDP, UCR und AUCR. Die beste Area under the curve wurde bei allen Outcome-Parametern durch die AUCR erreicht.

Schlussfolgerungen Die AUCR verbessert die Prädiktion eines ungünstigen Outcomes bei SGA-Föten am Termin. Außerdem zeigt unsere Studie, dass die UCR der CPR überlegen zu sein scheint.

Key words

SDP - amniotic fluid - CPR - UCR - AUCR

Publikationsverlauf

Eingereicht: 08. Januar 2020

Angenommen: 09. Juni 2020

Artikel online veröffentlicht:
28. Juli 2020

• References

• 1 Baier F, Weinhold L, Stumpfe FM. et al Longitudinal Course of Short-Term Variation and Doppler Parameters in Early Onset Growth Restricted Fetuses. Ultraschall in Med 2019;
• 2 Sirico A, Diemert A, Glosemeyer P. et al Third Trimester Umbilical Artery Doppler in Low-Risk Pregnancies and its Correlation to Estimated Fetal Weight and Birthweight. Ultraschall in Med 2019;
• 3 Gordijn S, Beune I, Thilaganathan B. et al Consensus definition of fetal growth restriction: a Delphi procedure. Ultrasound Obstet Gynecol 2016; 48: 333-339
• 4 Vasak B, Koenen S, Koster M. et al Human fetal growth is constrained below optimal for perinatal survival. Ultrasound Obstet Gynecol 2015; 45: 162-167
• 5 Prior T, Mullins E, Bennett P. et al Prediction of intrapartum fetal compromise using the cerebroumbilical ratio: a prospective observational study. Am J Obstet Gynecol 2013; 208: 124. e121–126
• 6 Stumpfe FM, Faschingbauer F, Kehl S. et al Correlation of short-term variation and Doppler parameters with adverse perinatal outcome in small-for-gestational age fetuses at term. Arch Gynecol Obstet 2019; 300: 575-581
• 7 Buca D, Rizzo G, Gustapane S. et al Diagnostic Accuracy of Doppler Ultrasound in Predicting Perinatal Outcome in Appropriate for Gestational Age Fetuses: A Prospective Study. Ultraschall in Med 2020;
• 8 Khalil AA, Morales-Rosello J, Elsaddig M. et al The association between fetal Doppler and admission to neonatal unit at term. Am J Obstet Gynecol 2015; 213: 57. e51–57
• 9 Graupner O, Koch J, Enzensberger C. et al Cerebroplacental and Uterine Doppler Indices in Pregnancies Complicated by Congenital Heart Disease of the Fetus. Ultraschall in Med 2019;
• 10 Khalil A, Morales-Rosello J, Khan N. et al Is cerebroplacental ratio a marker of impaired fetal growth velocity and adverse pregnancy outcome?. Am J Obstet Gynecol 2017; 216: 606 e601-606 e610
• 11 Stumpfe FM, Kehl S, Pretscher J. et al Correlation of short-term variation and Doppler parameters with adverse perinatal outcome in low-risk fetuses at term. Arch Gynecol Obstet 2019; 299: 411-420
• 12 Hecher K, Spernol R, Stettner H. et al Potential for diagnosing imminent risk to appropriate- and small-for-gestational-age fetuses by Doppler sonographic examination of umbilical and cerebral arterial blood flow. Ultrasound Obstet Gynecol 1992; 2: 266-271
• 13 Stampalija T, Arabin B, Wolf H. et al Is middle cerebral artery Doppler related to neonatal and 2-year infant outcome in early fetal growth restriction?. Am J Obstet Gynecol 2017;
• 14 Beall MH, van den Wijngaard JP, van Gemert MJ. et al Regulation of amniotic fluid volume. Placenta 2007; 28: 824-832
• 15 Veille JC, Penry M, Mueller-Heubach E. Fetal renal pulsed Doppler waveform in prolonged pregnancies. Am J Obstet Gynecol 1993; 169: 882-884
• 16 Kehl S, Schelkle A, Thomas A. et al Single deepest vertical pocket or amniotic fluid index as evaluation test for predicting adverse pregnancy outcome (SAFE trial): a multicenter, open‐label, randomized controlled trial. Ultrasound Obstet Gynecol 2016; 47: 674-679
• 17 Nabhan AF, Abdelmoula YAJCDoSR. Amniotic fluid index versus single deepest vertical pocket as a screening test for preventing adverse pregnancy outcome. Cochrane Database Syst Rev 2008;
• 18 Miremberg H, Grinstein E, Herman HG. et al The association between isolated oligohydramnios at term and placental pathology in correlation with pregnancy outcomes. Placenta 2020; 90: 37-41
• 19 Bahlmann F, Reinhard I, Krummenauer F. et al Blood flow velocity waveforms of the fetal middle cerebral artery in a normal population: reference values from 18 weeks to 42 weeks of gestation. J Perinat Med 2002; 30: 490-501
• 20 Baschat AA, Gembruch U. The cerebroplacental Doppler ratio revisited. Ultrasound Obstet Gynecol 2003; 21: 124-127
• 21 Kehl S, Schelkle A, Thomas A. et al Single deepest vertical pocket or amniotic fluid index as evaluation test for predicting adverse pregnancy outcome (SAFE trial): a multicenter, open-label, randomized controlled trial. Ultrasound Obstet Gynecol 2016; 47: 674-679
• 22 Villar J, Cheikh Ismail L, Victora CG. et al International standards for newborn weight, length, and head circumference by gestational age and sex: the Newborn Cross-Sectional Study of the INTERGROWTH-21^st Project. Lancet 2014; 384: 857-868
• 23 Kehl S, Weiss C, Dammer U. et al Induction of Labour in Growth Restricted and Small for Gestational Age Foetuses – A Historical Cohort Study. Geburtshilfe Frauenheilkd 2019; 79: 402-408
• 24 Bligh LN, Alsolai AA, Greer RM. et al Cerebroplacental ratio thresholds measured within 2 weeks before birth and risk of Cesarean section for intrapartum fetal compromise and adverse neonatal outcome. Ultrasound Obstet Gynecol 2018; 52: 340-346
• 25 Nicolaides KH, Peters MT, Vyas S. et al Relation of rate of urine production to oxygen tension in small-for-gestational-age fetuses. Am J Obstet Gynecol 1990; 162: 387-391
• 26 Fiolna M, Kostiv V, Anthoulakis C. et al Prediction of adverse perinatal outcome by cerebroplacental ratio in women undergoing induction of labor. Ultrasound Obstet Gynecol 2019; 53: 473-480
• 27 Cruz-Martinez R, Figueras F, Hernandez-Andrade E. et al Fetal brain Doppler to predict cesarean delivery for nonreassuring fetal status in term small-for-gestational-age fetuses. Obstet Gynecol 2011; 117: 618-626
• 28 Gramellini D, Folli MC, Raboni S. et al Cerebral-umbilical Doppler ratio as a predictor of adverse perinatal outcome. Obstet Gynecol 1992; 79: 416-420
• 29 Chauhan SP, Sanderson M, Hendrix NW. et al Perinatal outcome and amniotic fluid index in the antepartum and intrapartum periods: A meta-analysis. Am J Obstet Gynecol 1999; 181: 1473-1478
• 30 Locatelli A, Vergani P, Toso L. et al Perinatal outcome associated with oligohydramnios in uncomplicated term pregnancies. Arch Gynecol Obstet 2004; 269: 130-133