maddalena morlando

-Prenatal diagnosis of Coarctation of the Aorta (CoA) is still challenging and affected by high rates of false positive diagnoses. The aim of this study was to ascertain the strength of association and to quantify the diagnostic accuracy of different ultrasound signs in predicting CoA prenatally. -Medline, Embase, CINAHL and Cochrane databases were searched. Random-effect and HSROC model meta-analyses were used to analyse the data. -794 articles were identified and 12 (922 fetuses at risk for CoA) were included. Mean mitral valve diameter z-score was lower (p<0.001) and the mean tricuspid valve diameter z-score was higher in fetuses with CoA compared to those without CoA (p=0.01). Mean Aortic valve diameter z-score was lower in fetuses with CoA compared to normal fetuses (p= <0.001), but the ascending aorta diameter, expressed as z-score or mm, was similar between groups (p= 0.07 and 0.47, respectively). Mean aortic isthmus diameter z-scores measured either in sagittal (p= 0.02) or in three-vessel trachea view (p<0.001) were lower in fetuses with CoA. Conversely, the mean pulmonary artery diameter z-score, the right/left ventricular and pulmonary artery/ascending aorta diameter ratios were higher (p<0.001, p=0.02 and p=0.02, respectively) in fetuses with CoA compared to controls, while aortic isthmus/arterial duct diameter ratio was lower in fetuses with CoA compared to those without CoA (p<0.001). The presence of coarctation shelf and aortic arch hypoplasia were more common in fetuses with CoA compared to controls (OR: 26.0, 95% CI 4.42-153, p<0.001 and OR: 38.2, 95% CI 3.01-486, p=0.005), while persistent left superior vena cava (p= 0.85), ventricular septal defect (p= 0.12) and bicuspid aortic valve (p= 0.14) did not carry an increased risk for this anomaly. Multi-parametric diagnostic models integrating different ultrasound signs for the detection of CoA were associated with an increased detection rate. -The detection rate of CoA may improve when a multiple criteria-prediction model is adopted. Further large multicenter studies sharing the same imaging protocols are needed in order to develop objective models for risk assessment in these fetuses.

Atrioventricular septal defect is associated with a high risk of a chromosomal abnormality, particularly trisomy 21. The aim of this study is to assess the rate of trisomy 21 in fetuses diagnosed with an atrioventricular septal defect and to examine the influence of prior screening on the rate of trisomy 21. Electronic ultrasound database was searched to identify fetuses diagnoses with an atrioventricular septal defect from 2002 to 2014. Rate of trisomy 21 and other aneuploidies was calculated among fetuses with normal situs. The prevalence of trisomy 21 and other aneuploidies was assessed in women with low and high first trimester risk for trisomy 21, using a cut-off value of 1:150 and 1:250. A total 110 fetuses with a diagnosis of atrioventricular septal defect were identified. Among the 98 fetuses with normal situs, the prevalence of trisomy 21 was 46% (95% CI: 36-56%). Using a 1:150 threshold, the rate of trisomy 21 within the low-risk group was 41% (95% CI: 27-57%) while in the high-risk group it was 70% (95% CI: 52-83%), significantly higher than in the low risk group (p=0.028). Similar results were obtained when the 1:250 threshold was applied (66% versus 41%, p=0.055). The rate of trisomy 21 among fetuses identified with an atrioventricular septal defect in the second trimester is high even in those that undergo first trimester combined screening. Some fetuses with a high-risk screening result show a normal karyotype. Therefore, an offer of an invasive procedure to check fetal karyotyping is indicated. Knowledge of these rates may be helpful for parents in the decision making process.

To evaluate the relative value of mid trimester fetal growth, uterine artery Doppler indices and maternal demographics in prediction of stillbirth. Retrospective cohort study; 23 894 singleton pregnancies routinely scanned between 19 and 24 weeks' gestation. Maternal characteristics included age, body mass index, ethnicity and medical history. Fetal biometry indices, birthweight and uterine artery pulsatility index values were converted to percentiles and multivariable logistic regression analysis was performed. The predictive accuracy was assessed using receiver operating characteristic curves analysis. The main outcome was prediction of preterm and term stillbirths. Non-Caucasian ethnicity, femur length centile and uterine artery pulsatility index were significantly associated with the risk of stillbirth (all p < 0.01). The detection rate of screening by maternal factors alone was 19% for all stillbirths, and 12 and 14% for term and preterm stillbirth at a 10% false positive rate, respectively. Using femur length centile alone, the detection rates were 27 and 23%, respectively. Uterine artery pulsatility index alone was able to predict 24 and 31% of term and preterm stillbirths. Screening by combining maternal factors, femur length centile and uterine artery Doppler detected 27 and 35% of term and preterm stillbirths at a 10% false positive rate. Second trimester ultrasound assessment offers an opportunity to identify pregnancies at the highest risk of stillbirth occurring as a consequence of placental dysfunction. This information may be useful to improve pregnancy outcome by identifying women who may benefit from increased ultrasound surveillance and/or timely intervention.

To evaluate the diagnostic accuracy of intracranial translucency(IT) in the detection of spina bifida in the first trimester of pregnancy METHODS: We included study assessing the accuracy of sonographic measurements of IT in a mid-sagittal view of the fetal face in prediction of spina bifida in the first trimester of pregnancy. The primary outcome was the accuracy of IT in prediction of spina bifida. Summary estimates of sensitivity, specificity, positive and negative likelihood ratios (LR + andLR-) and diagnostic odds ratio (DOR) for the overall predictive accuracy of IT were computed. 9studies(21,070fetuses)were included in the analysis. IT was successfully assessed in the majority of fetuses 97.8% (95%CI 97.6-98.0). The diagnostic performance of IT in detecting spina bifida was as follows: sensitivity:53.5% (95%CI42.4-64.3); specificity:99.7% (95%CI99.6-99.8); LR+:62.1 (95%CI12.2-317); LR-:0.55 (95%CI0.45-0.68); DOR: 223 (95%CI25-2039). IT had low diagnostic accuracy in predictio...

To evaluate whether changes in the cerebroplacental Doppler and birth weight (BW) suggestive of chronic fetal hypoxemia, precede the development of late-onset placental abruption (PA) after 32 weeks. In a multicenter retrospective study, the Doppler examinations of the fetal umbilical artery (UA) and middle cerebral artery (MCA) recorded after 32 weeks were collected in pregnancies subsequently developing PA. The BW centiles were calculated and the MCA pulsatility indices (PI), and UA PI were converted into multiples of the median (MoM). Afterwards, a comparison was made with a group of fetuses, which did not develop PA. Logistic regression was used to adjust for potential confounders and evaluate the feasibility of the prediction model. Pregnancies complicated by late-onset PA (n = 31) presented lower MCA PI (p = 0.015) and were smaller (p < 0.001) than those who did not (n = 1294). Logistic regression analysis indicated that cerebral vasodilation was more important than umbilical flow in the explanation of PA (MCA PI OR = 0.106, p = 0.014 and UA PI OR 1.901, p = 0.32). In addition, the influence of BW exerted was residual (BW centile OR = 0.989, p = 0.15). Fetuses developing late-onset PA demonstrate significant cerebral vasodilation with scarce placental dysfunction, suggesting the existence of some kind of chronic hypoxemia that follows the late-onset pattern.

We aimed to establish whether macrosomic fetuses in pregnancies complicated by gestational diabetes (GDM) show different Pulsatility Index (PI) values in umbilical artery (UA) than in non-macrosomic fetuses. We considered 106 pregnant women with GDM. Doppler recordings of UA-PI were performed at 34-41 weeks and related to neonatal birthweight. Pregnancies were divided in two groups according to birthweight, macrosomic group (>4000 g) and controls (<4000 g), and according to birthweight centile, >90th centile and <90th centile. Differences in UA-PI and maternal and fetal characteristics between groups were tested. Mean UA-PI was significantly lower in newborns with birthweight >4000 g than in controls (PI = 0.69; 95% CI 0.64-0.74 versus PI = 0.87; 95% CI 0.84-0.90, p < 000.1). Mean UA-PI was significantly lower in newborns with birthweight centile >90th centile than in controls (PI = 0.79; 95% CI 0.74-0.84 versus PI = 0.87; 95% CI 0.83-0.90; t = 2.653; p = 0.01)....

To assess the predictive accuracy for stillbirth of second trimester uterine artery Doppler. We searched MEDLINE, EMBASE and Cochrane databases from inception until March 2015 without language restrictions. Included studies were those that assessed the association of abnormal uterine artery Doppler parameters and stillbirth. Two independent reviewers selected studies, extracted data and assessed quality. Results for studies that were performed in the 2(nd) trimester were pooled and summary estimates of sensitivity, specificity, likelihood ratios and their 95% confidence intervals were obtained. Overall summary of test accuracy was provided by the diagnostic odds ratio. Literature searches returned 338 relevant citations with 32 considered in full. Thirteen studies met our search criteria, (85, 846 women, 508 stillbirths) and were included in the review. Bivariate pooled estimate for sensitivity was 65% (95% CI 38 - 85%) and for specificity it was 82% (95% CI 72- 88%). The positive l...

Objectives: A third-trimester fetal weight discordance of 25% has been proposed as an independent predictor of fetal loss in twin pregnancies. As fetal weight gain at this stage of pregnancy increases exponentially, it is not entirely certain whether a single cut-off for inter-twin weight discordance is appropriate. The aim of this study was to investigate whether a single weight discordance cut-off can be used or whether different cut-offs should be adopted according to the gestational age at assessment. Methods: This was a retrospective study of all twin pregnancies of known chorionicity from a large regional cohort over a 10-year period. Receiver operating characteristic curve and logistic regression analyses were used to explore the relation between estimated fetal weight (EFW) discordance detected within 4 weeks from the occurrence of the outcome and single fetal loss at different gestational age windows. Results: 957 twin pregnancies (173 monochorionic and 784 dichorionic) wer...

To determine whether small- and appropriate-for-gestational-age (SGA and AGA) term fetuses with a low cerebroplacental ratio (CPR) have worse neonatal acid-base status than those with normal CPR. This was a retrospective study of 2927 term fetuses divided into groups according to birth-weight centile and CPR multiple of the median. The acid-base status at birth as determined by arterial and venous umbilical cord blood pH was compared between weight-centile groups with and without low CPR. CPR was better correlated with umbilical cord blood pH (arterial pH, r(2)  = 0.008, P < 0.0001 and venous pH, r(2)  = 0.01, P < 0.0001) than was birth weight (arterial pH, r(2)  = 0.001, P =0.180 and venous pH, r(2)  = 0.005, P < 0.001). AGA fetuses with low CPR were more acidemic than were those with normal CPR (P = 0.0359 and 0.0006, respectively, for arterial and venous pH). The findings of this study demonstrate that low CPR in AGA fetuses is an equally important marker of low neonatal pH secondary to placental underperfusion as is being SGA. Although the relative importance of low CPR and birth weight in identifying pregnancies at risk of placental hypoxemia and adverse fetal and neonatal outcome remains to be determined, this finding may be of particular value in the prediction and prevention of stillbirth and long-term neurodevelopmental disability. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

Abstract Objectives: Blood flow to the fetal brain is supplied by two vascular systems: the vertebral artery (VA) and the internal carotid artery with its anatomical continuation, the middle cerebral artery (ICA/MCA). In this work, our aim was to establish consistent reference values for the comparative study of both arterial systems. The study group consisted of 2323 Doppler examinations of the VA, MCA and UA performed on 2323 single pregnancies between 19 and 41 weeks. These values were afterwards used to calculate the pulsatility index (PI), peak systolic velocity (PSV) and cerebro-placental ratio (CPR) percentiles. The VA and MCA PI reached maximum values at the end of the second trimester and decreased afterwards due to an increase in the diastolic flow. Conversely, the VA and MCA PSV increased progressively until the end of pregnancy. Regarding the VA and MCA CPR values, they were higher in the middle of the third trimester and decreased afterwards. In both arterial systems, Doppler reference values have been calculated for the PI, PSV and CPR, being available for future comparative studies.

Placenta accreta is a rare and potentially life-threatening complication of pregnancy characterized by abnormal adherence of the placenta to the uterine wall. A previously scarred uterus or an abnormal site of placentation in the lower segment is a major risk factor. The aim of this study was to investigate the change in the incidence of placenta accreta and associated risk factors along four decades, from the 1970s to 2000s, in a tertiary south Italian center. We analyzed all cases of placenta accreta in a sample triennium for each decade. The incidence increased from 0.12% during the 1970s, to 0.31% during the 2000s. During the same period, cesarean section rates increased from 17 to 64%. Prior cesarean section was the only risk factor showing a significant concomitant rise. Our results reinforce cesarean section as the most significant predisposing condition for placenta accreta.