Severe early onset pre-eclampsia: prognostic value of ultrasound and Doppler assessment

Abstract

Objective: Assess the prognostic value of ultrasound and Doppler parameters in severe preterm pre-eclampsia.Study design: Prospective cohort study in Cape Town, South Africa, involving 113 women with severe pre-eclampsia between 24 and 34 weeks of gestation and managed expectantly when suitable. Serial ultrasound and multivessel Doppler assessments were performed 2 to 3 times weekly. Observations included fetal weight estimation, growth pattern, amniotic fluid volume, appearance of the heart and bowel, pulsatility index of the uterine, umbilical and middle cerebral arteries and ductus venosus. Perinatal outcome (death or neurological compromise, n ¼ 12) and major morbidity (n ¼ 62) were related to findings at recruitment and on the last assessment preceding delivery.Results: In univariate analysis, fetal growth asymmetry and waveform analysis of all three fetal vessels significantly correlated with both end points. The initial fetal weight estimation with a cutoff weight of 1080 g had the highest sensitivity (83.3%) and negative predictive value (97.5%) for poor outcome (P<0.001) while the final ductus venosus pulsatility index had the highest specificity (92%) and positive predictive value (33%). The combination of a raised placentocerebral ratio and ductus venosus pulsatility index close to delivery had the highest (57.1%) positive predictive value. Logistic regression showed the best overall predictive model for poor outcome to be a combination of initial fetal weight estimation and final ductus venosus pulsatility index (overall accuracy 94.6%, RR 20.20 (7.36, 55.41)). The initial fetal weight estimation with a cutoff weight of 1283 g provided the best correct prediction of major morbidity (83.2% overall accuracy, sensitivity 79.0%, specificity 88.2%, positive and negative predictive values of 89.1 and 77.6% respectively). This was better than using the gestational age at recruitment or delivery, birth weight or any of the Doppler results. The prediction of morbidity was not improved by the addition of any other variable in logistic regression analysis. Conclusion:For the short-term outcome measures assessed in this study, the estimated fetal weight at the time of diagnosis is the most important prognostic factor in severe pre-eclampsia with some additional value of ductus venosus assessment.

Prognostic Role of Uterine Artery Doppler in Patients with Preeclampsia

“…Also, regional brain perfusion studies in IUGR fetuses showed that brain hypoxia is present long before 11 significant changes in MCA are observed [23] . In keeping with this, Geerts and Odendaal [24] found that in severe PE, umbilical and cerebral Doppler parameters were not associated with adverse outcome, once adjusted for fetal size. On the contrary, our multivariate analysis that included SGA as a covariate confirmed the significant and independent value of UtA Doppler in predicting adverse outcome.…”

Impaired A2A adenosine receptor/nitric oxide/VEGF signaling pathway in fetal endothelium during late- and early-onset preeclampsia

“…Preeclampsia is characterized by placental insufficiency, mainly during early onset [8], which has been associated with low placental angiogenesis [3,4,6,28]. We have studied the cell proliferation/migration of HUVECs as the initial steps linked with angiogenesis.…”

“…Both a reduction in placental blood flow and impaired placental structure have been associated with neonatal complications following preeclampsia, such as growth retardation [4][5][6][7]. Specifically, Doppler studies reveal that impaired feto-placental blood flow is mainly evident in women with early-onset preeclampsia (EOPE) [8] rather than late-onset preeclampsia (LOPE) [9]. Moreover, EOPE exhibits placental histological changes related with reduced perfusion [10][11][12][13] as well as the anomalous structure of the peripheral villi and vasculature compared to respective controls identified by stereological analysis following EOPE, but not LOPE [13].…”

Reduced Cystathionine γ-Lyase and Increased miR-21 Expression Are Associated with Increased Vascular Resistance in Growth-Restricted Pregnancies

“…Umbilical artery Doppler velocimetry provides an indirect measure of downstream vascular resistance in the fetoplacental vasculature 2 . Pregnancies complicated by severe early-onset forms of preeclampsia (PE) 3 and/or intrauterine growth restriction (IUGR) 4 typically exhibit increased resistance in the umbilical circulation, with absent or even reversed end-diastolic flow velocity. These highly abnormal Doppler flow patterns are associated with a poor perinatal prognosis, 5 in part because they identify a subset of pregnancies with chronic fetal hypoxia, metabolic acidosis, and reduced circulating glucose and amino acid levels 6–8 …”