Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Drs Gevaerd Martins, Kawakita, Gould, Sinkovskaya, and Abuhamad).
Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Drs Gevaerd Martins, Kawakita, Gould, Sinkovskaya, and Abuhamad).
Am J Obstet Gynecol MFM. 2024 Mar;6(3):101283. doi: 10.1016/j.ajogmf.2024.101283. Epub 2024 Jan 12.
Incorporation of umbilical artery Doppler in the surveillance of fetal growth restriction has been shown to reduce the risk of perinatal deaths. Systole/Diastole ratio, Pulsatility Index and Resistance Index are obtained upon Doppler interrogation of the umbilical artery however it is unknown which index predicts more advanced stages of placental deterioration.
This study aimed to examine risk factors for the development of absent or reversed end-diastolic velocity and the time intervals of deterioration from normal umbilical artery end-diastolic velocity (indicated by systole/diastole ratio, pulsatility index, or resistance index) to decreased and absent or reversed end-diastolic velocity in fetuses with early-onset severe fetal growth restriction.
This was a retrospective cohort study performed from 2005 to 2020. All singleton pregnancies with severe (estimated fetal weight or abdominal circumference below the third percentile) and early-onset (diagnosed between 20 0/7 and 31 6/7 weeks of gestation) fetal growth restriction were included. Patients with fetal genetic or structural anomalies, suspected congenital infections, absent or reversed end-diastolic velocity at diagnosis, poor pregnancy dating, and absence of follow-up ultrasounds were excluded. Estimated fetal weight, abdominal circumference, and Doppler indices were reviewed longitudinally from diagnosis to delivery. To examine risk factors for absent or reversed end-diastolic velocity, we performed backward stepwise logistic regression and calculated odds ratios with 95% confidence intervals. Kaplan-Meier curves were compared using log-rank tests.
A total of 985 patients met the inclusion criteria, and 79 (8%) progressed to absent or reversed end-diastolic velocity. Factors associated with development of absent or reversed end-diastolic velocity included gestational age at diagnosis (adjusted odds ratio, 4.88 [95% confidence interval, 2.55-9.37] at 20 0/7 to 23 6/7 weeks; adjusted odds ratio, 1.56 [95% confidence interval, 0.86-2.82] at 24 0/7 to 27 6/7 weeks compared with 28 0/7 to 31 6/7 weeks) and presence of chronic hypertension (adjusted odds ratio, 2.37 [95% confidence interval, 1.33-4.23]). Rates of progression from diagnosis of fetal growth restriction with normal umbilical artery Doppler to absent or reversed end-diastolic velocity were significant after 4 weeks from diagnosis (5.84% [95% confidence interval, 4.50-7.57]). Regarding the Doppler indices, the progression from normal values to abnormal indices was similar at 1 and 2 weeks. However, the rate of progression from normal to abnormal systole/diastole ratio compared with the rates of progression from normal to abnormal pulsatility index or resistance index was higher at 4 and 6 weeks. Deterioration from abnormal indices to absent or reversed end-diastolic velocity was shorter with abnormal resistance index and pulsatility index when compared with the systole/diastole ratio at 2, 4, and 6 weeks after diagnosis and at 6 weeks, respectively.
Earlier gestational age at diagnosis and chronic hypertension are considered as risk factors for Doppler deterioration and development of absent or reversed end-diastolic velocity in the umbilical artery. With normal Doppler indices, significant deterioration and progression to absent or reversed end-diastolic velocity is unlikely until 4 weeks after diagnosis. Abnormal systole/diastole ratio seems to appear first. However, abnormal pulsatility index or resistance index was associated with absent or reversed end-diastolic velocity.
在胎儿生长受限的监测中纳入脐动脉多普勒已被证明可以降低围产期死亡的风险。通过对脐动脉进行多普勒检查，可以获得收缩期/舒张期比值、搏动指数和阻力指数。然而，目前尚不清楚哪种指数可以预测胎盘恶化的更晚期阶段。
本研究旨在探讨早发型严重胎儿生长受限胎儿脐动脉舒张末期血流消失或反流的发生风险因素，以及从正常脐动脉舒张末期血流（由收缩期/舒张期比值、搏动指数或阻力指数表示）到舒张末期血流减少和消失或反流的时间间隔。
这是一项回顾性队列研究，于 2005 年至 2020 年进行。所有严重（估计胎儿体重或腹围低于第 3 百分位）和早发型（诊断于 20 0/7 至 31 6/7 孕周之间）胎儿生长受限的单胎妊娠均被纳入研究。排除存在胎儿遗传或结构异常、疑似先天性感染、诊断时脐动脉舒张末期血流消失或反流、妊娠孕周不准确以及缺乏随访超声的患者。从诊断到分娩，纵向回顾估计胎儿体重、腹围和多普勒指数。为了研究脐动脉舒张末期血流消失或反流的发生风险因素，我们进行了逐步向后的逻辑回归分析，并计算了 95%置信区间的优势比。使用对数秩检验比较 Kaplan-Meier 曲线。
共有 985 名患者符合纳入标准，其中 79 名（8%）进展为脐动脉舒张末期血流消失或反流。与 28 0/7 至 31 6/7 孕周相比，脐动脉舒张末期血流消失或反流的发生风险因素包括诊断时的孕龄（校正优势比，20 0/7 至 23 6/7 孕周时为 4.88 [95%置信区间，2.55-9.37]；24 0/7 至 27 6/7 孕周时为 1.56 [95%置信区间，0.86-2.82]）和存在慢性高血压（校正优势比，2.37 [95%置信区间，1.33-4.23]）。从胎儿生长受限伴正常脐动脉多普勒诊断到脐动脉舒张末期血流消失或反流的进展速度在诊断后 4 周显著加快（5.84% [95%置信区间，4.50-7.57]）。关于多普勒指数，从正常值到异常值的进展在 1 周和 2 周时相似。然而，与从正常到异常搏动指数或阻力指数的进展率相比，从正常到异常收缩期/舒张期比值的进展率在 4 周和 6 周时更高。与收缩期/舒张期比值相比，在诊断后 2、4 和 6 周以及 6 周时，异常阻力指数和搏动指数与脐动脉舒张末期血流消失或反流的进展速度更快。
诊断时的孕龄较早和慢性高血压被认为是脐动脉多普勒恶化和舒张末期血流消失或反流发生的风险因素。在多普勒指数正常的情况下，直到诊断后 4 周，才有可能出现明显的恶化和进展为脐动脉舒张末期血流消失或反流。收缩期/舒张期比值似乎首先出现异常。然而，异常的搏动指数或阻力指数与脐动脉舒张末期血流消失或反流有关。
