Showing papers by "Elisenda Eixarch published in 2010"

Fetal Growth Restriction Results in Remodeled and Less Efficient Hearts in Children

Abstract: Background—Fetal growth restriction (FGR) affects 5% to 10% of newborns and is associated with increased cardiovascular mortality in adulthood. The most commonly accepted hypothesis is that fetal metabolic programming leads secondarily to diseases associated with cardiovascular disease, such as obesity, diabetes mellitus, and hypertension. Our main objective was to evaluate the alternative hypothesis that FGR induces primary cardiac changes that persist into childhood. Methods and Results—Within a cohort of fetuses with growth restriction identified in fetal life and followed up into childhood, we randomly selected 80 subjects with FGR and compared them with 120 normally grown fetuses, matched for gender, birth date, and gestational age at birth. Cardiovascular assessment was performed in childhood (mean age of 5 years). Compared with control subjects, children with FGR had a different cardiac shape, with increased transversal diameters and more globular cardiac ventricles. Although left ejection fraction was similar among the study groups, stroke volume was reduced significantly, which was compensated for by an increased heart rate to maintain output in severe FGR. This was associated with subclinical longitudinal systolic dysfunction (decreased myocardial peak velocities) and diastolic changes (increased E/E ratio and E deceleration time). Children with FGR also had higher blood pressure and increased intima-media thickness. For all parameters evaluated, there was a linear increase with the severity of growth restriction. Conclusions—These findings suggest that FGR induces primary cardiac and vascular changes that could explain the increased predisposition to cardiovascular disease in adult life. If these results are confirmed, the impact of strategies with beneficial effects on cardiac remodeling should be explored in children with FGR. (Circulation. 2010;121:2427-2436.)

Selective intrauterine growth restriction in monochorionic twins: pathophysiology, diagnostic approach and management dilemmas

Abstract: summary Selective intrauterine growth restriction (sIUGR) in monochorionic twins is associated with a substantial increase in perinatal mortality and morbidity for both twins. Clinical evolution depends on the combination of the effects of placental insufficiency in the IUGR twin with inter-twin blood transfer through placental anastomoses. Classification of sIUGR into types according to the characteristics of umbilical artery diastolic flow in the IUGR twin permits the differentiation of clinical and prognostic groups. sIUGR type I has normal diastolic flow and relatively good outcome. Type II is defined by persistently absent/ reverse end-diastolic flow and is associated with a high risk of intrauterine demise of the IUGR twin and/ or very preterm delivery. Type III is defined by the presence of intermittent absent/reverse end-diastolic flow (iAREDF), and is associated with 10e20% risk of unexpected fetal demise of the smaller twin and 10e20% risk of neurological injury in the larger twin. The management strategy for sIUGR with abnormal umbilical artery Doppler (types II and III) remains a challenge, and may include elective fetal therapy or close surveillance with fetal therapy or elective delivery in the presence of severe fetal deterioration. Small clinical series reporting the use of cord occlusion or laser therapy in severe cases suggest that the outcome of the larger twin might be improved. There is probably no single optimal strategy, since decisions will ultimately be influenced by the severity of IUGR, gestational age, parents’ wishes and technical issues. 2010 Published by Elsevier Ltd.

Selective intrauterine growth restriction in monochorionic diamniotic twin pregnancies

Abstract: Selective intrauterine growth restriction (sIUGR) occurs in 10 to 15% of monochorionic (MC) twins, and it is associated with a substantial increase in perinatal mortality and morbidity. Clinical evolution is largely influenced by the existence of intertwin placental anastomoses: pregnancies with similar degrees of fetal weight discordance are associated with remarkable differences in clinical behavior and outcome. We have proposed a classification of sIUGR into three types according to umbilical artery (UA) Doppler findings (I-normal, II-absent/reverse end-diastolic flow, III-intermittent absent/reverse end-diastolic flow), which correlates with distinct clinical behavior, placental features and may assist in counseling and management. In terms of prognosis, sIUGR can roughly be divided in two groups: type I cases, with a fairly good outcome, and types II and III, with a substantial risk for a poor outcome. Management of types II and III may consist in expectant management until deterioration of the IUGR fetus is observed, with the option of cord occlusion if this occurs before viability. Alternatively, active management can be considered electively, including cord occlusion or laser coagulation. Both therapies seem to increase the chances of intact survival of the larger fetus, while they entail, or increase the chances of, intrauterine demise of the IUGR fetus.

OC07.05: Incidence and clinical implications of unintended septostomy after fetoscopic laser therapy for twin–twin transfusion syndrome

Abstract: Objectives: Fetoscopic SLP improves outcome in TTTS by promoting resolution of cardiovascular (CV) manifestations. The time course and pattern of disease regression is unknown. We sought to investigate the nature of CV disease regression after SLP by analysis of individual cardiovascular elements through application of the CHOP score for TTTS. Methods: The CHOP score is a fetal echo derived system for detailed CV characterization of TTTS. Elements of the Score include 4 domains in the recipient: 1) ventricular characteristics of dilation, hypertrophy, systolic dysfunction, 2) atrioventricular valve (AV) regurgitation, 3) diastolic properties of Doppler AV inflow (double or single peak), ductus venosus, and umbilical venous flow, 4) right ventricular outflow tract obstruction (RVOTO) as assessed by pulmonary artery measuring smaller than aorta or pulmonary stenosis/atresia; and in the donor, evaluation of umbilical artery diastolic flow. In 32 twin pairs individual elements of the Score as well as myocardial performance indices (MPI) were measured at 1 day and 1 week after SLP and compared to pre-op values using paired t-test. Results: Overall score was unchanged at 1 day (pre-op 6.6 + 4.0 vs. 6.0 + 3.8, P = NS) but significantly improved by 1 week (4.2 + 4.1, P < 0.001) after SLP. At 1 day, there was no improvement in systolic or diastolic parameters and AV regurgitation worsened, however there was slight improvement in RVOTO (P < 0.05) and recipient RV and LV MPI (P = 0.02). At 1 week, improvements in ventricular dilation (P = 0.01), hypertrophy (P = 0.01) and all of the diastolic parameters were noted, with further improvement in RVOTO (P = 0.002) and recipient RV and LV MPI (P < 0.01). Systolic performance and AV regurgitation did not improve. Conclusions: Minimal improvement is seen 1 day after SLP, however diastolic CV elements, but not systolic, improve substantially at 1 week. Acute diastolic relaxation of the recipient right ventricle after SLP may improve filling and result in an increase in pulmonary artery diameter.

Acute Coronary Artery Vasospasm Associated with Misoprostol for Termination of Pregnancy

Abstract: Prostaglandin E1 analogues, gemeprost and misoprostol, are the most widely used drugs for medical termination of pregnancy within the first two trimesters of pregnancy. Gemeprost has been r

Outcome prediction in monochorionic diamniotic twin pregnancies with moderately discordant amniotic fluid

Abstract: The aim of this study was to identify predictors of twin‐to‐twin transfusion syndrome (TTTS) and selective intrauterine growth restriction (sIUGR) in monochorionic diamniotic (MCDA) twin pregnancies with moderate amniotic fluid discordance (mAFD).

OP06.07: Cardiac function assessed by myocardial performance index fails to distinguish clear patterns between twin–twin transfusion syndrome and selective intrauterine growth restriction

Abstract: measures were survival at 28 days of age and survival at 6 months of age without major neurological complications. A logistic regression was performed to describe ROC curves for discriminating survivors. The association between reversed or absent end-diastolic velocity in the umbilical artery (EDV-UA) and fetal weight was examined. Results: Survival of donor at 28 days of age and 6 months of age without major neurological complications were 73% and 67%, respectively. Survival of recipient at 28 days of age and 6 months of age without major neurological complications were 83% and 78%, respectively. The mean EFW of donor and recipient were −1.93 SD and 0.44 SD, respectively. Area under curve (AUC) in the ROC curve for discriminating survivors was 0.630. The sum of sensitivity and specificity was maximized with EFW = −2.06 SD (sensitivity of 0.633 and specificity of 0.603). The median EFW was −2.58 SD (IQR: −3.18 to −2.26) in reversed EDV-UA cases, −2.39 SD (IQR: −2.85 to −1.76) in absent EDV-UA cases and −1.53 SD (IQR: −2.44 to −0.93) in normal EDV-UA cases. EFW alone did not show strong power to predict survival. Conclusions: EFW correlates with reversed or absent donor EDVUA. EFW itself has less effect on the outcome of TTTS following fetoscopic laser surgery.

OC03.03: Cardiac dysfunction is present in small‐for‐gestational age fetuses with normal umbilical artery Doppler

Abstract: Objectives: Tissue Doppler imaging (TDI) echocardiography is a novel imaging tool that allows quantification of a modified fetal myocardial performance index (MPI) in transversal four chamber view in fetuses with intrauterine growth restriction (IUGR). The aim of this study was to compare fetal cardiac function in pregnancies complicated by IUGR with normal controls. Methods: A prospective study was performed on fetuses with IUGR (n = 37, group 1) and normal fetuses (n = 60, group 2) between the 20th and 40th week of gestation by transversal four chamber view colour TDI raw data. Isovolemic contraction time (ICT), isovolemic relaxation time (IRT) and ejection time (ET) were measured offline with TDIQ-Software (Toshiba Medical Systems). The MPI was calculated by the formula (ICT + IRT)/ET for the left (LV) and right ventricle (RV). Results: The measurements were feasible in all cases. The MPI of group 1 was significant elevated in both ventricles (LV: group 1 0.59 ± 0.21/group 2 0.46 ± 0.13, P < 0.0001; RV: group 1 0.68 ± 0.15/group 2 0.47 ± 0.15, P < 0.0001). We identified cut off values for a suspected significant elevated MPI in IUGR fetuses (LV 0.55, specificity 70%, sensitivity 70%, ROC: area under curve 0.73/RV 0.60, specificity 83%, sensitivity 71%, ROC: area under curve 0.85). Conclusions: This is the first report of quantification of radial modified MPI by TDI in IUGR fetuses and normal controls. IUGR fetuses showed signs of fetal myocardial dysfunction. TDI is a useful new ultrasound tool for quantification and monitoring of abnormal myocardial function in high-risk pregnancies.