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No consensus exists for the best way to monitor and when to trigger delivery in mothers of babies with fetal growth restriction. We aimed to assess whether changes in the fetal ductus venosus Doppler waveform (DV) could be used as indications for delivery instead of cardiotocography short-term variation (STV). In this prospective, European multicentre, unblinded, randomised study, we included women with singleton fetuses at 26–32 weeks of gestation who had very preterm fetal growth restriction (ie, low abdominal circumference [<10th percentile] and a high umbilical artery Doppler pulsatility index [>95th percentile]). We randomly allocated women 1:1:1, with randomly sized blocks and stratified by participating centre and gestational age (<29 weeks vs ≥29 weeks), to three timing of delivery plans, which differed according to antenatal monitoring strategies: reduced cardiotocograph fetal heart rate STV (CTG STV), early DV changes (pulsatility index >95th percentile; DV p95), or late DV changes (A wave [the deflection within the venous waveform signifying atrial contraction] at or below baseline; DV no A). The primary outcome was survival without cerebral palsy or neurosensory impairment, or a Bayley III developmental score of less than 85, at 2 years of age. We assessed outcomes in surviving infants with known outcomes at 2 years. We did an intention to treat study for all participants for whom we had data. Safety outcomes were deaths in utero and neonatal deaths and were assessed in all randomly allocated women. This study is registered with ISRCTN, number 56204499. Between Jan 1, 2005 and Oct 1, 2010, 503 of 542 eligible women were randomly allocated to monitoring groups (166 to CTG STV, 167 to DV p95, and 170 to DV no A). The median gestational age at delivery was 30·7 weeks (IQR 29·1–32·1) and mean birthweight was 1019 g (SD 322). The proportion of infants surviving without neuroimpairment did not differ between the CTG STV (111 [77%] of 144 infants with known outcome), DV p95 (119 [84%] of 142), and DV no A (133 [85%] of 157) groups (ptrend=0·09). 12 fetuses (2%) died in utero and 27 (6%) neonatal deaths occurred. Of survivors, more infants where women were randomly assigned to delivery according to late ductus changes (133 [95%] of 140, 95%, 95% CI 90–98) were free of neuroimpairment when compared with those randomly assigned to CTG (111 [85%] of 131, 95% CI 78–90; p=0.005), but this was accompanied by a non-significant increase in perinatal and infant mortality. Although the difference in the proportion of infants surviving without neuroimpairment was non-significant at the primary endpoint, timing of delivery based on the study protocol using late changes in the DV waveform might produce an improvement in developmental outcomes at 2 years of age. ZonMw, The Netherlands and Dr Hans Ludwig Geisenhofer Foundation, Germany.

Objectives This study aimed to evaluate the perinatal outcomes of isolated single umbilical artery (iSUA) and incidence of fetuses diagnosed with Single Umbilical Artery (SUA) in the second trimester. Materials and methods We retrospectively analyzed the data of 40,800 pregnant women who had undergone detailed ultrasonography between September 2011 and September 2021 in the perinatology clinic of tertiary university hospital. Those diagnosed with SUA accompanied by structural and genetic anomalies and maternal diseases among the 402 cases and multiple pregnancies were excluded from the study. The remaining 307 iSUA cases were compared with 650 randomly selected cases Double Umbilical Artery (DUA) by need for cesarean section due to fetal distress or suspicious Non-Stress Test (NST), delivery frequency before 37 and 34 weeks, birth weight, fetal gender, oligohydramnios, small for gestational age (SGA; <10% percentile birth weight)), intrauterine fetal death (IUFD), Apgar scores, and admission to a neonatal intensive care unit (NICU) for antenatal and perinatal outcomes. Results A total of 402 (0.9%) cases were diagnosed with SUA. Thirty-nine (9.7%) cases had structural anomalies, and 13 (3.2%) had genetic anomalies. While the most frequently detected chromosomal disorder was trisomy 18, central nervous system (CNS) and cardiovascular system (CVS) anomalies were the most prevalent accompanying structural anomalies. Comparing 307 cases with iSUA with 650 cases with DUA, we detected that the group with iSUA yielded significantly lower Apgar scores at 1 st and 5th minutes, lower birth weight, SGA prevalence, higher cesarean section need due to fetal distress and unreliable non-stress test, higher IUFD, and higher preterm birth. Conclusion Overall, we believe that the patients need to be recruited for a detailed ultrasonographic examination, as well as CNS and CVS examinations, following the diagnosis of SUA and that interventional diagnostic tests need to be applied to those with structural anomalies. Although genetic diagnostic tests are not required among iSUA cases, we found that cases with iSUA had higher IUFD in the second trimester, premature birth, low birth weight, and need for cesarean section.

Purpose The purpose of this study was to investigate the risk factors for umbilical artery thrombosis (UAT) and the relationship between umbilical artery thrombosis and perinatal outcomes. Methods This was a retrospective study that enrolled singleton pregnant women who were diagnosed with umbilical artery thrombosis. The control group recruited pregnant woman with three umbilical vessels or those with isolated single umbilical artery (iSUA) who were matched with umbilical artery thrombosis group. The risk factors and perinatal outcomes were compared between the groups. Results Preconception BMI (OR [95%CI]: 1.212 [1.038–1.416]), abnormal umbilical cord insertion (OR [95%CI]: 16.695 [1.333-209.177]) and thrombophilia (OR [95%CI]: 15.840 [1.112-223.699]) were statistically significant risk factors for umbilical artery thrombosis. An elongated prothrombin time (OR [95%CI]: 2.069[1.091–3.924]) was strongly associated with the occurrence of UAT. The risks of cesarean delivery, preterm birth, fetal growth restriction, neonatal asphyxia, and intraamniotic infection were higher in pregnancies with UAT than in pregnancies with three umbilical vessels or isolated single umbilical artery ( P <0.05). Additionally, the incidence of thrombophilia was higher in pregnant women with umbilical artery thrombosis than those with isolated single umbilical artery ( P  = 0.032). Abnormal umbilical cord insertion was also found to be associated with an elevated risk of iSUA (OR [95%CI]: 15.043[1.750-129.334]). Conclusions Abnormal umbilical cord insertion was the risk factor for both umbilical artery thrombosis and isolated single umbilical artery. The pregnancies with umbilical artery thrombosis had a higher risk of the adverse perinatal outcomes.

Objective To compare real-time ultrasound (RT-US) use as an adjunct tool to verify umbilical catheter placement versus standard care without ultrasound. Study design Neonates requiring umbilical venous catheter (UVC) and umbilical artery catheter (UAC) placement were randomized into the standard formula (No-US) and the RT-US groups. X-rays were used to confirm the catheter position. Result Fifty and forty-nine neonates were in the RT-US and No-US groups, respectively. RT- US showed a significantly higher rate of initial X-ray-confirmed proper catheter position than No-US ( p  < 0.001). The rates of proper positions of UVCs and UACs were significantly higher in the RT-US group than in the No-US group (both p  < 0.001). Neonates in the RT-US group required fewer catheter adjustments and subsequent X-rays than those in the No-US group. Conclusion RT-US enhances the accuracy of UVC and UAC placement, reduces catheter adjustments, and the number of X-rays required. Trial registration TCTR20190622001

Background Routine assessment in (near) term pregnancy is often inaccurate for the identification of fetuses who are mild to moderately compromised due to placental insufficiency and are at risk of adverse outcomes, especially when fetal size is seemingly within normal range for gestational age. Although biometric measurements and cardiotocography are frequently used, it is known that these techniques have low sensitivity and specificity. In clinical practice this diagnostic uncertainty results in considerable ‘over treatment’ of women with healthy fetuses whilst truly compromised fetuses remain unidentified. The CPR is the ratio of the umbilical artery pulsatility index over the middle cerebral artery pulsatility index. A low CPR reflects fetal redistribution and is thought to be indicative of placental insufficiency independent of actual fetal size, and a marker of adverse outcomes. Its utility as an indicator for delivery in women with reduced fetal movements (RFM) is unknown. The aim of this study is to assess whether expedited delivery of women with RFM identified as high risk on the basis of a low CPR improves neonatal outcomes. Secondary aims include childhood outcomes, maternal obstetric outcomes, and the predictive value of biomarkers for adverse outcomes. Methods International multicentre cluster randomised trial of women with singleton pregnancies with RFM at term, randomised to either an open or concealed arm. Only women with an estimated fetal weight ≥ 10th centile, a fetus in cephalic presentation and normal cardiotocograph are eligible and after informed consent the CPR will be measured. Expedited delivery is recommended in women with a low CPR in the open arm. Women in the concealed arm will not have their CPR results revealed and will receive routine clinical care. The intended sample size based on the primary outcome is 2160 patients. The primary outcome is a composite of: stillbirth, neonatal mortality, Apgar score < 7 at 5 min, cord pH < 7.10, emergency delivery for fetal distress, and severe neonatal morbidity. Discussion The CEPRA trial will identify whether the CPR is a good indicator for delivery in women with perceived reduced fetal movements. Trial registration Dutch trial registry (NTR), trial NL7557 . Registered 25 February 2019.