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Calculation of gestational age in late second and third trimesters by ex vivo magnetic resonance spectroscopy of amniotic fluid
Abstract
The purpose of this study was to develop a reliable model for the calculation of gestational age (GA) in second and third trimesters with the use of amniotic fluid (AF) metabolite profiles that were determined by magnetic resonance spectroscopy.
High-resolution (11.7 T) ex vivo magnetic resonance spectroscopy was performed on 95 AF samples (mean, 31.7 weeks; range, 15.6-39.9 weeks). GA was determined by last menstrual period or first-trimester ultrasound scanning. Concentrations of 21 AF metabolites were measured with automated techniques. Metabolite concentrations, inverses, natural logs, and squares were entered as predictive variables in a stepwise linear regression model.
The following formula was derived: GA = 64.922 - (14.456 x alanine) + (4.965 x natural log [creatinine]) - (0.931 x glucose) - (5.202 x valine). This model fit the data with an R(2) value of 0.926. Average error among all samples was +/-1.75 weeks (SD, +/-1.43 weeks), for the second trimester was +/-2.21 weeks (SD, +/-1.78 weeks), and for the third trimester was +/-1.59 weeks (SD, +/-1.26 weeks).
Statistical modeling accurately predicted GA with amniotic fluid metabolite profiles that were obtained by magnetic resonance spectroscopy, which may represent a significant improvement over conventional ultrasound dating in the third trimester. Future studies should compare these techniques directly.
... Metabolomics is commonly used to measure the entire metabolomic profile in biological fluids, cells, tissues or organs and to elucidate the association between metabolic pathways and perturbations that arise as a result of disease or organ malformation [10][11][12][13]. ...
... Metabolomics of human AF has been recently used to detect different fetal pathologies in pregnancy such as chromosomal disorders [18][19][20], renal dysfunction [10,21], metabolic disease [10], neural tube anomalies [10,[22][23][24] and defects of intrauterine growth [25][26][27][28]. Recent advances in metabolomics [10][11][12][13]29] also introduce AF evaluation as a new approach to fetal pulmonary development studies. ...
... The profile of these metabolites increases constantly during gestational age. These molecules are detectable in AF in different concentrations, according to the gestational period [11,12]. Changes in the gestational choline profile have already been correlated with the fetal lung maturity [30]. ...
Background: Tracheal occlusion (TO) stimulates lung growth in fetuses affected with congenital diaphragmatic hernia (CDH) although the processes involved in lung maturation still remain unknown. The objective of this study was to evaluate the metabolomic profile of amniotic fluid (AF) following TO in fetal lamb model in order to obtain an indirect view of mechanisms involved in pulmonary reversal hypoplasia and biochemical maturity in response to fetal TO. Methods: Liquid Chromatography Mass Spectrometry was performed on lamb AF samples at: age I (70 days’gestation); age II (102 days’ gestation); age III (136 days’ gestation). CDH was induced at age I and TO at age II. Results: Betaine, choline, creatinine were found significantly increased during gestation in the control group. The CDH group showed choline (p =0.007) and creatinine (p =0.004) decreases during pregnancy. In the TO group choline and creatinine profiles were restored. Conclusions: Alveolar tissue and fetal global growth ameliorated after TO. Metabolomics provided useful information on biochemical details during lung maturation. Metabolomic profiling would help to identify the best time to perform TO, in order to increase survival of CDH affected patients.
... Metabolomics is commonly used to measure the entire metabolomic profile in biological fluids, cells, tissues or organs and to elucidate the association between metabolic pathways and perturbations that arise as a result of disease or organ malformation [10][11][12][13]. ...
... Metabolomics of human AF has been recently used to detect different fetal pathologies in pregnancy such as chromosomal disorders [18][19][20], renal dysfunction [10,21], metabolic disease [10], neural tube anomalies [10,[22][23][24] and defects of intrauterine growth [25][26][27][28]. Recent advances in metabolomics [10][11][12][13]29] also introduce AF evaluation as a new approach to fetal pulmonary development studies. ...
... The profile of these metabolites increases constantly during gestational age. These molecules are detectable in AF in different concentrations, according to the gestational period [11,12]. Changes in the gestational choline profile have already been correlated with the fetal lung maturity [30]. ...
Tracheal occlusion (TO) stimulates lung growth in fetuses affected with congenital diaphragmatic hernia (CDH) although the processes involved in lung maturation still remain unknown. The objective of this study was to evaluate the metabolomic profile of amniotic fluid (AF) following TO in fetal lamb model in order to obtain an indirect view of mechanisms involved in pulmonary reversal hypoplasia and biochemical maturity in response to fetal TO.
Liquid Chromatography Mass Spectrometry was performed on lamb AF samples at: age I (70 days' gestation); age II (102 days' gestation); age III (136 days' gestation). CDH was induced at age I and TO at age II.
Betaine, choline, creatinine were found significantly increased during gestation in the control group. The CDH group showed choline (p =0.007) and creatinine (p =0.004) decreases during pregnancy. In the TO group choline and creatinine profiles were restored.
Alveolar tissue and fetal global growth ameliorated after TO. Metabolomics provided useful information on biochemical details during lung maturation. Metabolomic profiling would help to identify the best time to perform TO, in order to increase survival of CDH affected patients.
... HRMAS MRS metabolic profiles of AF were generated for second and third gestation trimesters. 191,192 Using a targeted approach and measuring metabolite concentration through the electronic reference to access in vivo concentrations (ERETIC) method, 10,193 194 HRMAS MRS results were further corroborated by proteoglycan (PG) assay, where amino acids derived from collagen (hydroxyproline, Gly) were found to be increased in annular disc tissue, indicating breakdown of the extracellular matrix component collagen. As occurs with matrix breakdown, a smaller N-acetyl peak enables the peaks of collagen-derived amino acids to be visualized since they occur at the same resonance. ...
... HRMAS MRS resultspresented increases in creatinine and decreases in Glc, Cit, pyruvate, Cr, Ala, Glu, Lys, and Val with advancing GA (p < 0.001). A linear GA prediction model (R 2 = 0.926)191,192 that incorporated Ala, Cr, Glc, and Val was proposed. Interestingly, a better estimate was obtained for third trimester pregnancies, possibly due to the larger sample size (71 versus 24 samples) or superior performance of the model in late gestation. ...
High-resolution magic angle spinning (HRMAS) MRS is a powerful method for gaining insight into the physiological and pathological processes of cellular metabolism. Given its ability to obtain high-resolution spectra of non-liquid biological samples, while preserving tissue architecture for subsequent histopathological analysis, the technique has become invaluable for biochemical and biomedical studies. Using HRMAS MRS, alterations in measured metabolites, metabolic ratios, and metabolomic profiles present the possibility to improve identification and prognostication of various diseases and decipher the metabolomic impact of drug therapies. In this review, we evaluate HRMAS MRS results on human tissue specimens from malignancies and non-localized diseases reported in the literature since the inception of the technique in 1996. We present the diverse applications of the technique in understanding pathological processes of different anatomical origins, correlations with in vivo imaging, effectiveness of therapies, and progress in the HRMAS methodology.
... Metabolomics is a feasible and promising approach that applies advanced separation and detection methods to investigate the global metabolite change and obtain the related biochemical pathways to elucidate specific sites of perturbations (Nicholson and Lindon, 2008). In recent years, the analysis of biological fluids or tissues has been used successfully in identification of typical compounds of various physiologic or pathologic conditions by providing the underlying metabolic changes during the pregnancy period, and a steady inflow of research development has been reported in this context by using maternal blood and urine, amniotic fluid, and umbilical cord blood to characterized the relevant prenatal diseases such as preeclampsia (Austdal et al., 2014;Luque et al., 2014;Redman and Sargent, 2005), fetal malformations (Diaz et al., 2011), gestational diabetes mellitus (Bo et al., 2015;Hernandez et al., 2014), poor pregnancy outcome (Halscott et al., 2014;Hourrier et al., 2010), preterm delivery (Alexandre- Gouabau et al., 2013) and small for the gestational age (Cohn et al., 2010). Moreover, protein and nitrogen metabolism were found to play extremely important roles in pregnancy and the development of the fetus (Altobelli et al., 2013). ...
... Meanwhile, the dynamic metabolic adaptations of maternal urine from healthy pregnancies has been evaluated by NMR-based metabolomics techniques, in which the levels of 21 metabolites including choline, creatinine, 4-deoxyerythronic acid, 4-deoxythreonic acid, furoylglycine, guanidoacetate, 3hydroxybutyrate, and lactate were found to change significantly throughout pregnancy (Diaz et al., 2013). In addition, some targeted studies of amniotic fluid have shown that the levels of alanine, glutamine, valine, creatinine, glucose, and succinic acid reflect gestational age (Athanasiadis et al., 2011;Cohn et al., 2010;Ottolenghi et al., 2010). The advances in these previous studies consistently demonstrated the potential of metabolomics to reveal prenatal disorders and corresponding individual responses, thus setting the reference for the detection of deviant trajectories in biofluids in the context of the metabolic follow-up of pregnancy. ...
In this study, NMR-based metabolomics in combination with multivariate pattern recognition technologies were employed to evaluate the physiological variations in the Wistar rats' plasma that are induced by pregnancy on the gestational days (GDs) 11, 14, 17 and 20. Untargeted metabolomics analysis revealed some possible mechanism of physiological effects for healthy pregnancies and showed a metabolic trajectory during pregnancy process. The levels of 24 metabolites were found to change significantly throughout pregnancy in maternal plasma. These metabolite changes involved in varied kinds of metabolic pathways including synthesis of biological substances, microbial metabolism in diverse environments, protein digestion and absorption, carbohydrate metabolism, digestion and absorption, mineral absorption, and ATP (Adenosine Triphosphate)-binding cassette transporters (ABC transporters). The substantial cores of all the metabolic pathways are promoting fetal growth and development and regulating maternal physiological state. This work showed relevant metabolic pathways perturbation in the maternal plasma due to normal pregnancy and provided the physical basis of time-dependent metabolic trajectory against which disease-related maternal physiological responses may be better understood in future studies.
... p = 0.406; d = 0.228; Table 1). This gestational age was selected because the first 15-20 weeks are the most vulnerable for neurodevelopment [25], and the relatively narrow range minimizes putative metabolic profile differences that occur across the gestational period [26,27]. In support of this last premise, no correlation was observed between the fetal biomarker alpha-fetoprotein (AFP) and gestational age [28], as expected for the short timeframe (13-21 weeks) of sample collection, thereby allowing for a direct case-control comparison independent of the exact gestational week. ...
Fifty-five to two hundred CGG repeats (called a premutation, or PM) in the 5′-UTR of the FMR1 gene are generally unstable, often expanding to a full mutation (>200) in one generation through maternal inheritance, leading to fragile X syndrome, a condition associated with autism and other intellectual disabilities. To uncover the early mechanisms of pathogenesis, we performed metabolomics and proteomics on amniotic fluids from PM carriers, pregnant with male fetuses, who had undergone amniocentesis for fragile X prenatal diagnosis. The prenatal metabolic footprint identified mitochondrial deficits, which were further validated by using internal and external cohorts. Deficits in the anaplerosis of the Krebs cycle were noted at the level of serine biosynthesis, which was confirmed by rescuing the mitochondrial dysfunction in the carriers’ umbilical cord fibroblasts using alpha-ketoglutarate precursors. Maternal administration of serine and its precursors has the potential to decrease the risk of developing energy shortages associated with mitochondrial dysfunction and linked comorbidities.
... With advances in metabolomics, amniotic fluid (AF) evaluation has been introduced as a new approach in fetal pulmonary development studies [18][19][20][21][22][23][24]. AF volume and composition are the result of complex and dynamic mechanisms; however, these are not well defined. ...
Objective:
To compare endotracheal fluid (EF) and amniotic fluid (AF) phospholipidic profile changes following tracheal occlusion (TO) in the congenital diaphragmatic hernia (CDH) fetal lamb model, in order to support the efficacy of TO on lung maturity.
Methods:
A diaphragmatic defect was induced at 70 days' gestation, TO was carried out at day 102 and cesarean section at 136 days' gestation. EF and AF samples, collected at delivery, were evaluated using mass spectrometry (the analysis focused on palmitoyloleoyl-phosphatidylcholine [POPC, PC(18:1/16:0)], dipalmitoyl-phosphatidylcholine [DPPC, PC(16:0/16:0)] and sphingomyelins [SMs]).
Results:
The effects of CDH and TO were different on AF and EF. POPC levels were higher than DPPC levels in AF of healthy lambs. Following induction of the diaphragmatic malformation, an evident decrease in POPC was noted, while a substantial return to normal POPC levels and an increased DPPC peak were prompted by the TO. After CDH induction, a decrease in N-palmitoyl-D-sphingomyelin [SM(d18:1/16:0)] was revealed (P<0.01) and an increased peak in SMs in AF was prompted by the TO (P=0.05). While the most represented phosphatidylcholine (PC) species in EF of healthy lambs was DPPC, CDH induced a decrease in the DPPC peak and treatment with TO induced its partial recovery. SMs were detectable only in healthy EF samples.
Conclusion:
The phospholipid recovery profile following TO suggests the potential role of this therapy in restoring processes involved in surfactant-mediated lung maturation, even though other interactions involved in AF turnover should be considered. Moreover, these metabolites could be used as biomarkers of fetal pulmonary development.
... Current understanding of the relationship between metabolite composition of amniotic fluid and maternal plasma during normal pregnancy is still not complete. Few studies have monitored healthy pregnancy using either amniotic fluid or plasma but these biofluids have not been studied in combination by metabolomics [16][17][18][19]. Other reports have mainly focused on selected stages or disorders of pregnancy [20][21][22], such as fetal malformations [23], gestational diabetes mellitus [24], macrosomia [25], preeclampsia [26,27], preterm delivery [13,14], spina bifida [28] and very-low birth weight [29], and did not clearly show the changes that occur between trimesters. ...
Metabolic profiles of amniotic fluid and maternal blood are sources of valuable information about fetus development and can be potentially useful in diagnosis of pregnancy disorders. In this study, we applied 1H NMR-based metabolic profiling to track metabolic changes occurring in amniotic fluid (AF) and plasma (PL) of healthy mothers over the course of pregnancy. AF and PL samples were collected in the 2nd (T2) and 3rd (T3) trimester, prolonged pregnancy (PP) until time of delivery (TD). A multivariate data analysis of both biofluids reviled a metabolic switch-like transition between 2nd and 3rd trimester, which was followed by metabolic stabilization throughout the rest of pregnancy probably reflecting the stabilization of fetal maturation and development. The differences were further tested using univariate statistics at alpha = 0.001. In plasma the progression from T2 to T3 was related to increasing levels of glycerol, choline and ketone bodies (3-hydroxybutyrate and acetoacetate) while pyruvate concentration was significantly decreased. In amniotic fluid, T2 to T3 transition was associated with decreasing levels of glucose, carnitine, amino acids (valine, leucine, isoleucine, alanine, methionine, tyrosine, and phenylalanine) and increasing levels of creatinine, succinate, pyruvate, choline, N, N-dimethylglycine and urocanate. Lactate to pyruvate ratio was decreased in AF and conversely increased in PL. The results of our study, show that metabolomics profiling can be used to better understand physiological changes of the complex interdependencies of the mother, the placenta and the fetus during pregnancy. In the future, these results might be a useful reference point for analysis of complicated pregnancies.
... 19 A metabolomic study on secondand third-trimester amniotic fluid samples identified metabolites associated with increasing gestational age. 20 Neither of these studies attempted to provide any detailed biological interpretation of the differentially expressed proteins in the third compared with the second trimester. Gene expression atlas mapping and the DAVID tissue expression analysis of genes upregulated at term showed a dominance of lung, upper gastrointestinal tract, and renal transcripts. ...
To identify the tissue expression patterns and biological pathways enriched in term amniotic fluid cell-free fetal RNA by comparing functional genomic analyses of term and second-trimester amniotic fluid supernatants.
This was a prospective whole genome microarray study comparing eight amniotic fluid samples collected from women at term who underwent prelabor cesarean delivery and eight second-trimester amniotic fluid samples from routine amniocenteses. A functional annotation tool was used to compare tissue expression patterns in term and second-trimester samples. Pathways analysis software identified physiologic systems, molecular and cellular functions, and upstream regulators that were significantly overrepresented in term amniotic fluid.
There were 2,871 significantly differentially regulated genes. In term amniotic fluid, tissue expression analysis showed enrichment of salivary gland, tracheal, and renal transcripts as compared with brain and embryonic neural cells in the second trimester. Functional analysis of genes upregulated at term revealed pathways that were highly specific for postnatal adaptation such as immune function, digestion, respiration, carbohydrate metabolism, and adipogenesis. Inflammation and prostaglandin synthesis, two key processes involved in normal labor, were also activated in term amniotic fluid.
Transcriptomic analysis of amniotic fluid cell-free fetal RNA detects fetal maturation processes activated in term pregnancy. These findings further develop the concept of amniotic fluid supernatant as a real-time gene expression "summary fluid" and support its potential for future studies of fetal development.
: II.
... This paper describes the use of metabonomics, mainly based on nuclear magnetic resonance (NMR) spectroscopy, as a holistic analytical strategy in the quest for new and earlier biomarkers of both fetal and maternal health. In this context, previous reports of NMR of amniotic fluid (AF) have addressed, at a preliminary level, fetal maturity [2, 3], gestational age [4, 5], and several disorders, for example, PE, fetal malformations (FM), GDM, PTD, and premature rupture of membranes (PROM) [2,678. Metabolite profiling of urine and blood has been, however, less developed, in spite of the great potential of these biofluids for less-invasive diagnosis methods. ...
This paper describes a metabonomics study of 2nd trimester biofluids (amniotic fluid, maternal urine, and blood plasma), in an attempt to correlate biofluid metabolic changes with suspected/diagnosed fetal malformations (FM) and chromosomal disorders as well as with later occurring gestational diabetes mellitus (GDM), preterm delivery (PTD), and premature rupture of membranes (PROM). The global biochemical picture given by the threesome of biofluids should enable the definition of potential disease signatures and unveil potential metabolite markers for clinical use in predictive prenatal diagnostics. Results show that relatively strong metabolic disturbances accompany FM, reflected in all three biofluids and thus suggesting the involvement of both fetal and maternal metabolisms. Regarding GDM, amniotic fluid and maternal urine seem potential good media to detect early metabolic changes, and PTD subjects show small metabolite changes in the same biofluids, undergoing work being focused on plasma composition. Chromosomal disorders show an interestingly marked effect on maternal urine, whereas no statistically relevant early changes have been observed for PROM subjects. Interestingly, in the case of FM and chromosomal disorders, maternal biofluids show some sensitivity to disorder type, for example, for central nervous system malformations and trisomy 21, respectively. These results show the usefulness of biofluid metabonomics to probe overall metabolic disturbances in relation to prenatal disorders.
Metabolomics, the global characterisation of the small molecule complement involved in metabolism, has evolved into a powerful suite of approaches for understanding the global physiological and pathological processes occurring in biological organisms. The diversity of metabolites, the wide range of metabolic pathways and their divergent biological contexts require a range of methodological strategies and techniques. Methodologies for Metabolomics provides a comprehensive description of the newest methodological approaches in metabolomic research. The most important technologies used to identify and quantify metabolites, including nuclear magnetic resonance and mass spectrometry, are highlighted. The integration of these techniques with classical biological methods is also addressed. Furthermore, the book presents statistical and chemometric methods for evaluation of the resultant data. The broad spectrum of topics includes a vast variety of organisms, samples and diseases, ranging from in vivo metabolomics in humans and animals to in vitro analysis of tissue samples, cultured cells and biofluids.
Metabolomics, the global characterisation of the small molecule complement involved in metabolism, has evolved into a powerful suite of approaches for understanding the global physiological and pathological processes occurring in biological organisms. The diversity of metabolites, the wide range of metabolic pathways and their divergent biological contexts require a range of methodological strategies and techniques. Methodologies for Metabolomics provides a comprehensive description of the newest methodological approaches in metabolomic research. The most important technologies used to identify and quantify metabolites, including nuclear magnetic resonance and mass spectrometry, are highlighted. The integration of these techniques with classical biological methods is also addressed. Furthermore, the book presents statistical and chemometric methods for evaluation of the resultant data. The broad spectrum of topics includes a vast variety of organisms, samples and diseases, ranging from in vivo metabolomics in humans and animals to in vitro analysis of tissue samples, cultured cells and biofluids.
Metabolomics, the global characterisation of the small molecule complement involved in metabolism, has evolved into a powerful suite of approaches for understanding the global physiological and pathological processes occurring in biological organisms. The diversity of metabolites, the wide range of metabolic pathways and their divergent biological contexts require a range of methodological strategies and techniques. Methodologies for Metabolomics provides a comprehensive description of the newest methodological approaches in metabolomic research. The most important technologies used to identify and quantify metabolites, including nuclear magnetic resonance and mass spectrometry, are highlighted. The integration of these techniques with classical biological methods is also addressed. Furthermore, the book presents statistical and chemometric methods for evaluation of the resultant data. The broad spectrum of topics includes a vast variety of organisms, samples and diseases, ranging from in vivo metabolomics in humans and animals to in vitro analysis of tissue samples, cultured cells and biofluids.
This paper presents the first NMR metabolomics study of maternal plasma during pregnancy, including correlation between plasma and urine metabolites. The expected decrease in circulating amino acids early in pregnancy was confirmed with six amino acids being identified as required by the fetus in larger extents. Newly observed changes in citrate, lactate and dimethyl sulfone suggested early adjustments in energy and gut microflora metabolisms. Alterations in creatine levels were also noted, in addition to creatinine variations reflecting alterations in glomerular filtration rate. Regarding plasma macromolecules, HDL and LDL+VLDL levels were confirmed to increase throughout pregnancy, although at different rates and accompanied by increases in fatty acid chain length and degree of unsaturation. Correlation studies suggested a) an inverse relationship between lipoproteins (HDL and LDL+VLDL) and albumin, with a possible direct correlation to excreted (unassigned) pregnancy markers resonating at δ 0.55 and δ 0.63; b) a direct link between LDL+VLDL and N-acetyl-glycoproteins, together with excreted marker at δ 0.55 and c) correlation of plasma albumin with particular circulating and excreted metabolites. These results have unveiled specific lipoprotein/protein metabolic aspects of pregnancy with impact on the excreted metabolome and, therefore, provide an interesting lead for the further understanding of pregnancy metabolism.
Abstract Objective: To study the evolution profile of amniotic fluid (AF) glucose, uric acid, phosphate, potassium, and sodium, in the second trimester of pregnancy, and explore the possible relations between the concentration of these components and maternal, as well as neonatal characteristics. Methods: AF of 52 pregnant women was analyzed using an automatic multichannel analyzer. Maternal age, pre-pregnancy Body Mass Index (BMI), inter-pregnancy intervals, and smoking status were derived from questionnaires. Information on pregnancy and delivery was collected from medical records. Results: Uric acid increased (r = 0.423, p < 0.01), while phosphate and glucose concentrations decreased during the period of 16-26th week of pregnancy (r = -0.590, p < 0.001 and r = -0.314, p < 0.05, respectively). Maternal pre-pregnancy BMI was significantly correlated with AF uric acid concentration (r = 0.460, p < 0.01) and marginally with AF glucose (r = 0.274, p = 0.052) and sodium (r = 0.254, p = 0.070) levels. Multiple linear regression indicated that mid-trimester AF uric acid and phosphate levels were significantly related to birth weight centiles (R(2)( )= 0.345, p < 0.05). Conclusions: Our results suggest that: (a) AF phosphate levels reflect gestational age to a satisfactory extent, (b) maternal pre-pregnancy BMI is significantly correlated with AF uric acid concentration, and (c) in appropriate for gestational age infants, AF phosphate and uric acid levels may serve as potential biomarkers of birth weight centiles. Further studies on AF composition may help to unravel the biochemical pathways underlying fetal development and could offer insight on the potential impact of maternal nutritional management on fetal growth regulation.
This paper describes a metabonomics study of 2nd trimester biofluids (amniotic fluid, maternal urine and blood plasma), in an attempt to correlate biofluid metabolic changes with suspected/diagnosed fetal malformations (FM) and chromosomal disorders, as well as with later occurring gestational diabetes mellitus (GDM), preterm delivery (PTD) and premature rupture of membranes (PROM). The global biochemical picture given by the threesome of biofluids should enable the definition of potential disease signatures and unveil potential metabolite markers for clinical use in predictive prenatal diagnostics. Results show that relatively strong metabolic disturbances accompany FM, reflected in all three biofluids and thus suggesting the involvement of both fetal and maternal metabolisms. Regarding GDM, amniotic fluid and maternal urine seem potential good media to detect early metabolic changes and PTD subjects show small metabolite changes in the same biofluids, undergoing work being focused on plasma composition. Chromosomal disorders show an interestingly marked effect on maternal urine whereas no statistically relevant early changes have been observed for PROM subjects. Interestingly, in the case of FM and chromosomal disorders, maternal biofluids show some sensitivity to disorder type e.g. for central nervous system malformations and trisomy 21, respectively. These results show the usefulness of biofluid metabonomics to probe overall metabolic disturbances in relation to prenatal disorders.
In this work, untargeted NMR metabonomics was employed to evaluate the effects of pregnancy on the metabolite composition of maternal urine, thus establishing a control excretory trajectory for healthy pregnancies. Urine was collected for independent groups of healthy non-pregnant and pregnant women (in 1(st), 2(nd), 3(rd) trimesters) and multivariate analysis performed on the corresponding NMR spectra. Models were validated through Monte Carlo Cross Validation and permutation tests and metabolite correlations measured through Statistical Total Correlation Spectroscopy. The levels of 21 metabolites were found to change significantly throughout pregnancy, with variations observed for the first time to our knowledge for choline, creatinine, 4-deoxyerythronic acid, 4-deoxythreonic acid, furoylglycine, guanidoacetate, 3-hydroxybutyrate and lactate. Results confirmed increased aminoaciduria across pregnancy and suggested a) a particular involvement of isoleucine and threonine in lipid oxidation/ketone body synthesis, b) a relation of excreted choline, taurine and guanidoacetate to methionine metabolism and urea cycle regulation and c) a possible relationship of furoylglycine and creatinine to pregnancy, based on a tandem study of non-fasting confounding effects. Results demonstrate the usefulness of untargeted metabonomics in finding biomarker metabolic signatures for healthy pregnancies, against which disease-related deviations may be confronted in future studies, as a base for improved diagnostics and prediction.
Accurate gestational assessment is essential for adequate growth assessment, appropriate aneuploidy screening and correct management of term. Based on expert opinion and beside ART pregnancies, it is recommended to use crown-rump length (CRL) to determine date of conception whenever there is an appropriate measurement taken at 11-14 weeks. This allows accurate dating at approximately 5 days in 95% of cases.
Copyright © 2011. Published by Elsevier Masson SAS.
This work describes an exploratory NMR metabonomic study of second trimester maternal urine and plasma, in an attempt to characterize the metabolic changes underlying prenatal disorders and identify possible early biomarkers. Fetal malformations have the strongest metabolic impact in both biofluids, suggesting effects due to hypoxia (leading to hypoxanthine increased excretion) and a need for enhanced gluconeogenesis, with higher ketone bodies (acetone and 3-hydroxybutyric acid) production and TCA cycle demand (suggested by glucogenic amino acids and cis-aconitate overproduction). Choline and nucleotide metabolisms also seem affected and a distinct plasma lipids profile is observed for mothers with fetuses affected by central nervous system malformations. Urine from women who subsequently develop gestational diabetes mellitus exhibits higher 3-hydroxyisovalerate and 2-hydroxyisobutyrate levels, probably due to altered biotin status and amino acid and/or gut metabolisms (the latter possibly related to higher BMI values). Other urinary changes suggest choline and nucleotide metabolic alterations, whereas lower plasma betaine and TMAO levels are found. Chromosomal disorders and pre-preterm delivery groups show urinary changes in choline and, in the latter case, in 2-hydroxyisobutyrate. These results show that NMR metabonomics of maternal biofluids enables the noninvasive detection of metabolic changes associated to prenatal disorders, thus unveiling potential disorder biomarkers.
To establish and compare normative metabolite concentrations in 2nd and 3rd trimester human amniotic fluid samples in an effort to reveal metabolic biomarkers of fetal health and development.
Twenty-one metabolite concentrations were compared between 2nd (15-27 weeks gestation, N = 23) and 3rd (29-39 weeks gestation, N = 27) trimester amniotic fluid samples using (1)H high resolution magic angle spinning (HR-MAS) spectroscopy. Data were acquired using the electronic reference to access in vivo concentrations method and quantified using a modified semi-parametric quantum estimation algorithm modified for high-resolution ex vivo data.
Sixteen of 21 metabolite concentrations differed significantly between 2nd and 3rd trimester groups. Betaine (0.00846+/-0.00206 mmol/kg vs. 0.0133+/-0.0058 mmol/kg, P < 0.002) and creatinine (0.0124+/-0.0058 mmol/kg vs. 0.247+/-0.011 mmol/kg, P < 0.001) concentrations increased significantly, while glucose (5.96+/-1.66 mmol/kg vs. 2.41+/-1.69 mmol/kg, P < 0.001), citrate (0.740+/-0.217 mmol/kg vs. 0.399+/-0.137 mmol/kg, P < 0.001), pyruvate (0.0659+/-0.0103 mmol/kg vs. 0.0299+/-0.286 mmol/kg, P < 0.001), and numerous amino acid (e.g. alanine, glutamate, isoleucine, leucine, lysine, and valine) concentrations decreased significantly with advancing gestation. A stepwise multiple linear regression model applied to 50 samples showed that gestational age can be accurately predicted using combinations of alanine, glucose and creatinine concentrations.
These results provide key normative data for 2nd and 3rd trimester amniotic fluid metabolite concentrations and provide the foundation for future development of magnetic resonance spectroscopy (MRS) biomarkers to evaluate fetal health and development.
Resonances for the ketone bodies 3-D-hydroxybutyrate, acetone and acetoacetate are readily detected in serum, plasma and urine samples from fasting and diabetic subjects by 1H n.m.r. spectroscopy at 400 MHz. Besides the simultaneous observation of metabolites, the major advantage of n.m.r. is that little or no pretreatment of samples is required. N.m.r. determinations of 3-D-hydroxybutyrate, acetoacetate, lactate, valine and alanine were compared with determinations made with conventional assays at six 2-hourly intervals after insulin withdrawal from a diabetic subject. The n.m.r. results closely paralleled those of other assays although, by n.m.r., acetoacetate levels continued to rise rather than reaching a plateau 4h after insulin withdrawal. The 3-D-hydroxybutyrate/acetoacetate ratio in urine during withdrawal gradually increased to the value observed in plasma (3.0 +/- 0.2) as determined by n.m.r. The acetoacetate/acetone ratio in urine (17 +/- 6) was much higher than in plasma (2.5 +/- 0.7). Depletion of a mobile pool of fatty acids in plasma during fasting, as seen by n.m.r., paralleled that seen during insulin withdrawal. These fatty acids were thought to be largely in chylomicrons, acylglycerols and lipoproteins, and were grossly elevated in plasma samples from a non-insulin-dependent diabetic and in cases of known hyperlipidaemia.
In a non-selected population comprising 15,241 women, an evaluation was performed of the ultrasonic measurement of the biparietal diameter compared with a reliable last menstrual period as the basis for estimation of the day of delivery. In women with a reliable menstrual history and spontaneous onset of labor, the ultrasound estimate was the significantly better predictor of the day of delivery in 52% of cases, and the last menstrual period estimate was the better predictor in 46% of cases. The percentages of women who delivered within 7 days of the predicted day were 61 and 56% for the ultrasound and the last menstrual period estimations, respectively. There was a significantly narrower distribution of births according to the ultrasound estimate (p < 0.001). The proportion of estimated postterm births was 4% using the ultrasound method and 10% using the last menstrual period method (p < 0.001). Even when the difference between the methods in predicting the day of delivery was less than 7 days, the ultrasound method was better than the last menstrual period method. It is concluded that ultrasonic measurement of the biparietal diameter between 15 and 22 weeks of pregnancy is the best method for the estimation of the day of delivery and should be used as a routine procedure.
Background
Existing fetal growth references all suffer from 1 or more major methodologic problems, including errors in reported gestational age, biologically implausible birth weight for gestational age, insufficient sample sizes at low gestational age, single-hospital or other non-population–based samples, and inadequate statistical modeling techniques.
Methods
We used the newly developed Canadian national linked file of singleton births and infant deaths for births between 1994 and 1996, for which gestational age is largely based on early ultrasound estimates. Assuming a normal distribution for birth weight at each gestational age, we used the expectation-maximization algorithm to exclude infants with gestational ages that were more consistent with 40-week births than with the observed gestational age. Distributions of birth weight at the corrected gestational ages were then statistically smoothed.
Results
The resulting male and female curves provide smooth and biologically plausible means, standard deviations, and percentile cutoffs for defining small- and large-for-gestational-age births. Large-for-gestational age cutoffs (90th percentile) at low gestational ages are considerably lower than those of existing references, whereas small-for-gestational-age cutoffs (10th percentile) postterm are higher. For example, compared with the current World Health Organization reference from California (Williams et al, 1982) and a recently proposed US national reference (Alexander et al, 1996), the 90th percentiles for singleton males at 30 weeks are 1837 versus 2159 and 2710 g. The corresponding 10th percentiles at 42 weeks are 3233 versus 3086 and 2998 g.
Conclusions
This new sex-specific, population-based reference should improve clinical assessment of growth in individual newborns, population-based surveillance of geographic and temporal trends in birth weight for gestational age, and evaluation of clinical or public health interventions to enhance fetal growth. fetal growth, birth weight, gestational age, preterm birth, postterm birth.
The preterm delivery rate in North Carolina is consistently higher than the national average. However, recent reports suggest that singleton preterm delivery rates for non-Hispanic Whites are increasing while those for non-Hispanic African Americans are decreasing. To study this pattern further, the authors examined data on singleton non-Hispanic White and non-Hispanic African-American births in 1989 and 1999 by using North Carolina vital statistics data. They found that the frequency of preterm delivery rose 1.1% (8.5% to 9.6%) among non-Hispanic Whites but declined 1.4% (17.9% to 16.5%) among non-Hispanic African Americans over the same time period. For both subgroups, a bimodal distribution of birth weights was apparent among preterm births at 28-31 weeks of gestation. The second peak with its cluster of normal-weight infants was more prominent among non-Hispanic African Americans in 1989 than in 1999. To reduce the potential for bias due to misclassification of infant gestational age, frequencies of preterm delivery of infants who weighed less than 2,500 g were calculated. Unlike the original analysis, this calculation showed that preterm delivery increased for both subgroups. A number of non-Hispanic African-American births classified as preterm were apparently term births mistakenly assigned short gestational ages. Such misclassification was more frequent in 1989 than in 1999, inflating 1989 preterm delivery rates.
1D and 2D 800 MHz high-resolution nuclear magnetic resonance spectroscopy of human amniotic fluid (HAF) enabled the identification of approximately 50 metabolites. In addition, liquid chromatography-NMR and diffusion ordered spectroscopy (DOSY) allowed signal overlap to be reduced and the characterization of higher molecular weight (Mw) components, respectively. Indeed, the DOSY spectrum of a Mw >10 kDa HAF fraction enabled three protein families, differing in average Mw, to be detected and may therefore be of potential value in the study of disorder-related variations in HAF protein profiles. The effects of freeze-drying, storage at -20 or -70 degrees C, and freeze-thawing cycles on HAF compositional stability were investigated, as well as stability at room temperature (to account for overnight data acquisition runs). These data are the basis for establishing statistically validated correlations between HAF NMR data and any physiological disorders of the fetus/mother. Freeze-drying caused signal loss for urea, ethanol, and compounds resonating at 2.22 and 1.17 ppm. Storage at -70 degrees C or lower is recommended since only minor compositional changes were observed, affecting mainly acetate and pyruvate. Freeze-thaw cycles did not cause significant compositional changes, and room-temperature stability studies indicated a 4-5 h maximum period of handling/acquisition time to ensure HAF stability.
An investigation was carried out to decide whether the time of quickening would provide useful information to estimate the duration of pregnancy. In 291 primigravidas and 165 multiparas, movements were first felt at 19 weeks, 5 days, and 18 weeks, 3 days, respectively. This can be used to check on the duration estimated by dates alone. In 42 patients, pregnancy was prolonged for more than 42 weeks according to the dates. In 26 of these, the calculation of duration of pregnancy according to the time of movements was less than 42 weeks. In these patients labor was not induced and no fetal loss resulted. The recording of the time when the fetal movements are first perceived increases the accuracy of the estimate of duration of pregnancy and prevents needless induction of labor for “postmaturity.”
Ten amniotic fluid samples obtained from third trimester pregnant women suffering from insulin dependant diabetes mellitus were analysed by 1H-NMR and compared to ten samples from a group of normal volunteers. A subset of the metabolites identified; valine, lactate, alanine, acetate, citrate and glucose were quantitated using standard addition methods. Apart from valine and citrate, a general diminution in the concentration of each of these species was found, especially glucose, in the diabetic group. The abnormally low glucose levels in the diabetic group are suggestive of infection in the patient group. However, the depressed lactate levels in the diabetic group suggest that in these cases the fetus was not subjected to stress.
We have investigated the ability of high-resolution proton NMR spectroscopy to provide a biochemical constituent screening of human amniotic fluid (AF). Proton NMR spectra were obtained at 300 MHz on AF from patients undergoing amniocentesis in the mid-trimester. Only AF from normal pregnancies (normal fetal karyotype, normal a-fetoprotein levels, normal birth outcome) was used in this study. The AF supernatant was lyophilized and resuspended in deuterated water containing 0.1 mm phosphate buffer and 6.02 mm disodium maleate. Identification of low molecular weight compounds was confirmed by two-dimensional NMR spectra (primarily correlated spectroscopy, or COSY) and standard addition techniques. A broad profile of compounds were ‘NMR visible’ in a single proton spectrum, including creatinine, glucose, organic acids (acetate, citrate, and lactate) and several amino acids (alanine, histidine, leucine, phenylalanine, tyrosine and valine). The proton spectrum was unaffected by prior freezing/thawing of AF samples. We were able to quantify compounds by comparison with an added concentration standard (maleate) at concentrations as low as 30 μm. Good agreement with literature values based on other analytical techniques was obtained.
Low digestive enzyme activities in human amniotic fluid can be observed in normal and disease-affected pregnancies: cystic fibrosis, trisomy 21, intestinal atresia. Amniotic fluids were analyzed by proton nuclear magnetic resonance (NMR) spectroscopy in order to specify prenatally the etiology of low digestive enzyme activities observed at 17–18 weeks of amenorrhea. A total of 114 amniotic fluid samples were collected at 17–18 weeks of amenorrhea. Karyotyping and assays of digestive enzyme activities were performed in all cases. Samples were divided into six groups according to enzyme activities and pathology. Proton spectra were retrospectively recorded. Many compounds, such as amino acids and carboxylic acids, were detected by NMR. The same resonance intensities (normalized to creatinine) were observed in the six groups. Nevertheless, an unidentified resonance at 1.05 ppm was detected in seven out of 13 cases of cystic fibrosis affected fetuses. The NMR spectra demonstrated the stability of the amniotic fluid composition at 17–18 weeks of amenorrhea, even when the fetus was affected by a disease such as trisomy 21 or intestinal atresia. The resonance associated with most cases of cystic fibrosis should be further investigated.
An NMR-metabonomic study of malformed fetuses was carried out through human amniotic fluid (HAF) analysis. Over 70 compounds were detected in control HAF by NMR. Possible confounding variables (fetus gender and gestational and maternal ages) were shown not to induce detectable compositional trends in the control group considered. Malformed fetuses showed variations in glucose, some amino acids and organic acids and proteins. In tandem with enzymatic assays, these NMR results suggest that changes in gycolysis and gluconeogenesis as well as kidney underdevelopment occur in the malformed fetuses studied here.
The Electronic REference To access In vivo Concentrations (ERETIC) method was applied to (1)H HR-MAS spectroscopy. The accuracy, precision, and stability of ERETIC as a quantitative reference were evaluated in solution and human prostate tissue samples. For comparison, the reliability of 3-(trimethylsilyl)propionic-2,2,3,3-d(4) acid (TSP) as a quantitation reference was also evaluated. The ERETIC and TSP peak areas were found to be stable in solution over the short-term and long-term, with long-term relative standard deviations (RSDs) of 4.10% and 2.60%, respectively. Quantification of TSP in solution using the ERETIC peak as a reference and a calibrated, rotor-dependent conversion factor yielded results with a precision < or =2.9% and an accuracy error < or =4.2% when compared with the expected values. The ERETIC peak area reproducibility was superior to TSP's reproducibility, corrected for mass, in both prostate surgical and biopsy samples (4.53% vs. 21.2% and 3.34% vs. 31.8%, respectively). Furthermore, the tissue TSP peaks exhibited only 27.5% of the expected area, which would cause an overestimation of metabolite concentrations if used as a reference. The improved quantification accuracy and precision provided by ERETIC may enable the detection of smaller metabolic differences that may exist between individual tissue samples and disease states.
At present a large number of different charts are used for prediction of gestational age from sonar biparietal diameter (BPD). In this report the reasons for these observed differences are presented. Additionally, the usefulness of all these charts is questioned because a) the mean differences in 7059 BPDs derived by the B-scan from four large fetal population studies are not significantly different from zero and b) BPDs obtained by B scan are statistically comparable to gray-scale or real-time BPDs if medium gain is used. Thus, it is our suggestion that a chart showing the composite mean BPD values of all four studies be used universally for prediction of fetal age. Finally, the guidelines of using sonar BPD as an index of gestational age are presented and the role of the obstetrician in interpreting BPD data is emphasized.
In a study to evaluate the reproducibility and accuracy of the sonar technique of measurement of the in vivo fetal crown-rump length (Robinson, 1973), a series of in vivo and in vitro experiments was performed in which the random and systematic errors inherent in the technique were assessed. The potential sources of random error were those of operator judgement, movement of the fetus and mother, machine sensitivity settings and measurement from the photograph; while the sources of systematic error were those of oscilloscope scale factor, and velocity calibration inaccuracies, and the effect of beam width. The overall effect of the random errors, that is, the reproducibility of the technique, was assessed in an in vivo blind trial in which three independent measurements were made of the fetus. In a series of 30 experiments the average standard deviation of the three readings was found to be 1.2 mm. Evaluation of the systematic errors by in vivo experimentation, on the other hand, showed that the basic sonar measurements were in error by an overestimate of 1 mm for the beam width effect and 3.7 per cent for the scale factor and velocity calibration errors. A weighted non-linear regression analysis of 334 measurements was performed in order to obtain a "curve of best fit" for the period covering 6 to 14 weeks of menstrual age. The values obtained were corrected for the systematic errors and compared with widely quoted anatomical figures. In the second part of this investigation the original data was further analyzed to determine on a statistical basis the accuracy of the technique as a method of estimating maturity. It was shown that such an estimate could be made to within 4.7 days with a 95 per cent probability on the basic of a single measurement, and to within 2.7 days if three independent measurements were made.
To investigate the current epidemiology of menstrual patterns among women of fertile age.
Cross-sectional postal questionnaire study.
County of Copenhagen, Denmark.
3743 women, aged 15-44, selected at random from a Danish county, who were asked to provide information on menstrual pattern during the preceding year, 1981. The response rate was 78%. Information from non-responders was obtained via telephone interviews.
In women with regular menstrual cycles, the 5th-95th centile range of usual cycle length decreased from 23-35 days in the 15-19 years age group to 23-30 days in the 40-44 years age group. Only 0.5% of regular menstruating women had a usual cycle length of less than 21 days and 0.9% had a usual cycle length of greater than 35 days. At least one cycle length of less than 21 days was experienced by 18.6%, whereas 29.5% had at least one cycle of greater than 35 days. Menstrual cycle variation of greater than 14 days was present in 29.3% of all women. Cycle length variation of greater than 14 days was 2.7 times more frequent in women from lower social groups (controlled by age).
The study confirmed the normally used definitions of polymenorrhoea (cycle length less than 21 days) and oligomenorrhoea (cycle length between 36 and 90 days), as these very short or long menstrual cycle lengths were very seldom recorded for a longer period. However, the high frequency in a normal population of large menstrual cycle length variation challenges the view that an intra-individual variation of greater than 5 days should be regarded as a sign of disease in the woman.
The purpose of this study was to determine whether amniotic fluid glucose concentrations is of value in the rapid diagnosis of intraamniotic infection. Amniocenteses were performed in 168 patients with preterm labor and intact membranes. Amniotic fluid was cultured for aerobic and anaerobic bacteria, as well as Mycoplasma species. The prevalence of positive amniotic fluid cultures was 13.6% (23/168). Patients with positive amniotic fluid cultures for microorganisms had significantly lower median amniotic fluid glucose concentrations than patients with negative amniotic fluid cultures (median 11 mg/dl, range 2 to 30 mg/dl vs median 28 mg/dl, range 3 to 74, respectively; p less than 0.001). Amniotic fluid glucose concentrations below 14 mg/dl had a sensitivity of 86.9% (20/23), a specificity of 91.7% (133/145), a positive predictive value of 62.5% (20/32), and a negative predictive value of 97.8% (133/136) in the detection of a positive amniotic fluid culture. Amniotic fluid glucose determination is a rapid, sensitive, inexpensive, and simple test for the detection of intraamniotic infection in women with preterm labor and intact membranes.
Human amniotic fluid (HAF) is a dynamic system whose characteristics depend on continuous interchanges between fetal and maternal circulations. HAF reflects not only the environment of the fetus but may also provide information about fetal development or pathology. The concentration of HAF constituents varies with gestational age and pathological states. The number of the compounds currently implicated in fetal developmental pathology are relatively few. Currently used assay methods are not adequate to totally explain or predict the complex biochemistry of the fetus. The purpose of this work was to investigate HAF with NMR spectroscopy. In the present study HAF was obtained from 47 women undergoing routine amniocentesis. Cells were separated for karyological analysis and the supernatant was acid-extracted, lyophilized and re-suspended in D20 resulting in a concentration increase over native fluid. 1H NMR spectra were obtained at 360 MHz and 60 MHz. Eighteen compounds including several amino acids, were identified using parallel reference and standard addition protocols. NMR spectroscopy detected compounds of known clinical importance including glucose, leucine, isoleucine, lactate and creatinine. In conclusion, we have demonstrated that a number of physiologically relevant compounds are readily observable in HAF using 1H NMR spectroscopy. This technique can currently provide valuable information regarding HAF composition and has the potential of being used in vivo in the future.
An investigation was carried out to decide whether the time of quickening would provide useful information to estimate the duration of pregnancy. In 291 primigravidas and 165 multiparas, movements were first felt at 19 weeks, 5 days, and 18 weeks, 3 days, respectively. This can be used to check on the duration estimated by dates alone. In 42 patients, pregnancy was prolonged for more than 42 weeks according to the dates. In 26 of these, the calculation of duration of pregnancy according to the time of movements was less than 42 weeks. In these patients labor was not induced and no fetal loss resulted. The recording of the time when the fetal movements are first perceived increases the accuracy of the estimate of duration of pregnancy and prevents needless induction of labor for "postmaturity.".
Urea and creatinine concentrations in the amniotic fluid and maternal blood were studied in normal and toxaemic mothers. There was a good correlation between liquor creatinine and duration of pregnancy, but a significant relationship between liquor urea and gestational age was not established. In pre-eclampsia, levels of urea and creatinine in the amniotic fluid were significantly greater than normal values, at corresponding periods of gestation. These changes in the amniotic fluid were not accompanied by a similar increase in the maternal serum, and are consistent with the concept of a renal origin for this fluid. It is postulated that this trend in pre-eclampsia reflects the inability of the placenta to fulfil its transfer function.
Regression models for predicting menstrual age based on real-time sonographic measurements of four fetal parameters (biparietal diameter, head circumference, abdominal circumference, and femur length), used alone and in combination, were developed in a cross-sectional study of 361 fetuses between 14 and 42 menstrual weeks. The head circumference and femur length were the strongest individual predictors of age. A number of combinations of fetal parameters, including the combination of head circumference and femur length, provided age estimates that were significantly better (p = 0.05) than those using any single parameter alone. It was also demonstrated that simply averaging individual age estimates in a given case could provide results that were not significantly different from those obtained by using the same parameters in a complex regression equation. The advantages and potential pitfalls of this system of fetal dating are discussed.
Computerized birth files compiled by the State of North Carolina for the years 1975-1977 were analyzed for omissions and inaccuracies. A wide range in the per cent missing values was found for different data items, from essentially none missing (birthweight, sex, race) to about 20 per cent missing (gestational age, paternal social data). Recorded birthweight showed the expected skewing from a normal distribution. The only demonstrable inaccuracy was in the form of digit preference, probably causing errors of +/- 1 oz (28.3 g). Reported gestational ages were more suspect, falling outside the range of biologically plausible gestation length in 2.8 per cent of cases. An additional 1.5 per cent of gestational ages were found to be misdated by four to 20 weeks based on the observed bimodal weight distributions among births of the same reported gestational age. Hospitals of various sizes and administrative affiliations submitted records with missing or inaccurate gestational age data with roughly equal frequency. These records were found to come from a socio-demographically high-risk subpopulation. The implications of elimination of incomplete or erroneous birth record data in perinatal epidemiologic research are discussed.
To describe birth-weight-for-gestational-age patterns by race, sex, and parity in the United States population, and to discuss the measurements of gestational age by different methods, the pitfalls of each method, and the potential effects of the errors on birth-weight-for-gestational-age curves.
We used the computerized certificates of live births from the entire population in 1989, consisting of more than four million infants born to residents of the United States. Gestational age was based on the date of the last menstrual period (LMP) modified by the clinical estimate in those situations in which normal distribution of birth weight does not apply. Birth weights for the tenth, 25th, 50th, 75th, and 90th percentiles were calculated by each gestational age and by race, sex, and parity.
Eight sets of smoothed birth-weight-for-gestational-age curves were created for black-white, male-female, and primipara-multipara comparisons in sequence. Compared with previous major curves, our curves were closer to those in which the gestational age was derived from the LMP. There were marked differences observed between our curves and those in which the gestational age was based on ultrasound estimation.
In the measurement of gestational age, the LMP may produce misclassification of gestational age, thereby elevating birth weight percentiles in preterm births and lowering birth weight percentiles in postterm births. However, ultrasound estimation is likely to create a differential misclassification of gestational age, which exerts the opposite effect of lowering birth weight percentiles early in gestation and increasing the percentiles late in gestation.
Ten amniotic fluid samples (36-38 weeks gestation) are analysed by NMR spectroscopy. Of the species identified in the spectra, valine (mean 198 microM: SEM 57 microM), lactate (9.73 mM; 2.05 mM), alanine (689 microM: 115 microM), acetate (6.87 mM: 1.54 mM), citrate (363 microM: 59 microM), glucose (4.54 mM: 1.28 mM) indoxyl-sulphate (n = 4,270 microM), histidine (n = 6, 125 microM: 31 microM) and formate (n = 4, 92 microM) are quantified using standard addition. The factors governing the detection limits and lowest quantifiable amounts are discussed as are the extension of the work into in vivo magnetic resonance spectroscopy (MRS) in the clinic.
Proton NMR spectroscopy at 600 MHz was performed on 70 specimens of human amniotic fluid, representing pregnancies at different stages of maturation and with different fetomaternal complications. Spectra with good signal-to-noise characteristics were obtained in 3.5 min of acquisition time, directly on untreated fluid, with presaturation to suppress the intense water resonance. Metabolites that generally gave rise to well-resolved resonances included lactate, glucose, creatinine, choline derivatives, citrate, acetate, alanine, glycine, glutamate, succinate, and others. For three of these metabolites--creatinine, glucose, and lactate--the peak intensities correlated well with results of conventional chemical analysis. The NMR spectra of third-trimester specimens were readily distinguishable from those of second-trimester specimens, and several peak intensities correlated with fetal maturation during the third trimester. Significant correlations with maternal preeclampsia and fetal open spina bifida were also observed.
750 MHz 1H NMR spectroscopy has been used to characterise in detail the abnormal low molecular weight metabolites of urine from two patients with inborn errors of metabolism. One case of the rare condition 2-hydroxyglutaric aciduria has been examined. There is at present no rapid routine method to detect this genetic defect, although NMR spectroscopy of urine is shown to provide a distinctive pattern of resonances. Assignment of a number of prominent urinary metabolites not normally seen in control urine could be made on the basis of their known NMR spectral parameters including the diagnostic marker 2-hydroxyglutaric acid, which served to confirm the condition. In addition, 750 MHz 1H NMR spectroscopy has been used to characterise further the abnormal metabolic profile of urine from a patient with maple syrup urine disease. This abnormality arises from a defect in branched chain keto-acid decarboxylase activity and results in a build up in the urine of high levels of branched chain oxo- and hydroxy-acids resulting from altered metabolism of the branched chain amino acids, valine, leucine and isoleucine. A number of previously undetected abnormal metabolites have been identified through the use of one-dimensional and two-dimensional J-resolved and COSY 750 MHz 1H NMR spectroscopy, including ethanol, 2-hydroxy-isovalerate, 2,3-dihydroxy-valerate, 2-oxo-3-methyl-n-valerate and 2-oxo-isocaproate. NMR spectroscopy of urine, particularly when combined with automatic data reduction and computer pattern recognition using a combination of biochemical markers, promises to provide an efficient alternative to other techniques for the diagnosis of inborn errors of metabolism.
Longitudinal studies of multiple parameters in the first trimester for assessment of embryonic growth are lacking. This study's aim was to register changes in growth over time, by taking several measurements of embryos on successive occasions and evaluating these changes by longitudinal analysis.
This prospective longitudinal study describes the normal embryonic growth in vivo. Inclusion criteria were non-smoking women with single uneventful pregnancies, regular menstrual periods (28-30 days) and no hormone therapy in the 3 months prior to the pregnancy. Exclusion criteria were pregnancy complications such as diabetes, pre-eclampsia, delivery of preterm or growth-restricted infants. Of 36 recruited pregnant women, 29 met these criteria. Each pregnancy was examined five times between 7 and 12 weeks of gestation. This resulted in a two-level data set, where level 1 consisted of the observations and level 2 consisted of the individuals. The longitudinal data were analyzed with a software package specially created for multilevel analysis.
The growth of the biparietal diameter (BPD), occipitofrontal diameter (OFD), mean abdominal diameter (MAD), chorionic cavity diameter and amniotic cavity diameter was constant; the growth of the crown-rump length (CRL) and the yolk sac diameter was not constant. Variation in the data sets was mainly caused by variation between the embryos/fetuses.
The measured parameters except for the yolk sac showed a high degree of uniformity with virtually the same growth velocities. The yolk sac demonstrated uniform growth until week 10 only. Differences between the gestational age based on the last menstrual period and the true gestational age, and/or differences in the early growth of the embryos before the start of the study at 7 weeks, may have contributed to the variation between the individuals.
Proton magnetic resonance spectroscopy is a noninvasive technique that detects molecules within a specified region in vivo. Lecithin, the major component of surfactant, has a characteristic magnetic resonance signal, but to our knowledge, it has never been reported in fetal lung or amniotic fluid (AF). The objective of this study was to characterize the lecithin signal in utero, which could lead to a noninvasive fetal lung maturity test.
Human fetal lung and AF pockets can be identified and studied with magnetic resonance spectroscopy with the use of a 1.5-tesla Vision whole-body magnetic resonance scanner (Siemens Medical Systems; Erlangen, Germany). Spectroscopy data are collected with a single-voxel-point-resolved spectroscopy sequence. After identification of fetal anatomy with the use of scout magnetic resonance images, magnetic resonance spectroscopy of human fetal lung and AF identifies a lecithin peak.
Three healthy gravidas near term were studied and lecithin peaks were identified in all.
Lecithin can be identified in vivo with the use of volume-selected proton magnetic resonance spectroscopy. Patient comfort and extremely short scan times suggest that refined magnetic resonance spectroscopy might be a safe, quick, and comfortable test of fetal lung maturity.
The purpose of this study was to evaluate the accuracy of algorithms for the assignment of gestational age with the use of the last menstrual period and early ultrasound information.
Gestational age estimates that are based on last menstrual period, ultrasound scanning, or their combination were compared among women who attended prenatal care clinics in central North Carolina (n = 3655) by an evaluation of digit preference in the last menstrual period dates and a comparison of mean gestational age, preterm and postterm categories with the use of kappa statistics, difference between actual and expected delivery date, and birth weight among subgroups with discrepant assignments.
Last menstrual period reports show digit preference, assign gestation 2.8 days longer on average than ultrasound scanning, yield substantially more postterm births (12.1% vs 3.4%), and predict delivery among term births less accurately. Misclassification of births as postterm was more common in younger women, those of nonoptimal prepregnancy body weight, cigarette smokers, and women who reported last menstrual period using preferred dates of the month.
Last menstrual period estimates of the duration of gestation are subject to both random error and a systematic tendency to overstate the duration of gestation, most likely because of delayed ovulation.
To provide a statistically sound criterion for identifying implausibly large birthweights for gestational age.
Review of ISTAT 1990-1994 national newborn records.
Italy
Forty-two thousand and twenty-nine single first and second liveborn preterm babies.
Two-component Gaussian mixture models are used to describe the birthweight distributions stratified by gestational age. Implausibly large babies are identified through model-based probabilistic clustering.
Gestational age misclassification and weight-for-gestational age centile curves
Gestational age appears under-estimated by about six weeks in 12.3% of the cases. Large babies are equally present in males and females, but are more frequent in second-borns than in first-borns, even when parity-specific models are fitted.
The approach allows for a quantification of the gestational age under-estimate error and for data correction through model-based clustering. Correct birthweight distributions and growth curves are also provided.
To quantify proton containing metabolites by in vitro 1H NMR spectroscopy of amniotic fluids from fetuses with spina bifida and controls.
Fourteen amniotic fluids from spina bifida fetuses and 18 controls were obtained. Concentrations of carbohydrates, organic acids and amino acids were determined. Multiple linear regression analysis was used to evaluate the data.
At 15 and 39 weeks amenorrhea, the estimated median amniotic fluid concentrations of succinic acid and glutamine were significantly higher in the spina bifida group compared to controls, 37 and 64%, respectively. Whereas creatine and creatinine were significantly lower, 27 and 36%, respectively. Amenorrhea influenced the concentrations of most compounds with the exception of lactic acid.
1H NMR spectroscopy shows significantly higher succinic acid and glutamine concentrations in amniotic fluids derived from spina bifida fetuses compared with controls. A derangement in amino acid metabolism is suggested.
This study was designed to test the null hypothesis that first trimester ultrasound crown-rump length measurement for gestational age determination will result in no difference in the rate of induction of labor for postterm pregnancy, compared with second trimester biometry alone.
Two hundred eighteen women were randomly assigned to receive either first trimester ultrasound screening or second trimester ultrasound screening to establish the expected date of confinement. Sample size was calculated by using a 2-tailed alpha=.05 and power (1-beta)=80%. Data were analyzed with chi(2) and Fisher exact tests.
Of 104 women randomly assigned to the first trimester screening group, 41.3% had their gestational age adjusted on the basis of the crown-rump length measurement. Of 92 women randomly assigned to the second trimester screening group, 10.9% were corrected as a result of biometry (P <.001, relative risk=0.26, 95% CI=0.15-0.46). Five women in the first trimester screening group and 12 women in the second trimester screening group had labor induced for postterm pregnancy (P=0.04, relative risk=0.37, 95% CI=0.14-0.96).
The application of a program of first trimester ultrasound screening to a low-risk obstetric population results in a significant reduction in the rate of labor induction for postterm pregnancy.
A novel and fast time-domain quantitation algorithm--quantitation based on semi-parametric quantum estimation (QUEST)--invoking optimal prior knowledge is proposed and tested. This nonlinear least-squares algorithm fits a time-domain model function, made up from a basis set of quantum-mechanically simulated whole-metabolite signals, to low-SNR in vivo data. A basis set of in vitro measured signals can be used too. The simulated basis set was created with the software package NMR-SCOPE which can invoke various experimental protocols. Quantitation of 1H short echo-time signals is often hampered by a background signal originating mainly from macromolecules and lipids. Here, we propose and compare three novel semi-parametric approaches to handle such signals in terms of bias-variance trade-off. The performances of our methods are evaluated through extensive Monte-Carlo studies. Uncertainty caused by the background is accounted for in the Cramér-Rao lower bounds calculation. Valuable insight about quantitation precision is obtained from the correlation matrices. Quantitation with QUEST of 1H in vitro data, 1H in vivo short echo-time and 31P human brain signals at 1.5 T, as well as 1H spectroscopic imaging data of human brain at 1.5 T, is demonstrated.
To assess the association between maternal and fetal characteristics and discrepancy between last normal menstrual period and early (<20 weeks) ultrasound-based gestational age and the association between discrepancies and pregnancy outcomes.
Hospital-based cohort study.
Montreal, Canada.
A total of 46,514 women with both menstrual- and early ultrasound-based gestational age estimates.
Positive (last normal menstrual period > early ultrasound, i.e. menstrual-based gestational age is higher than early ultrasound-based gestational age, so that the expected date of delivery is earlier with the menstrual-based gestational age) discrepancies > or =+7 days, mean birthweight, low birthweight, stillbirth and in-hospital neonatal death.
Multiparous mothers and those with diabetes, small stature or high pre-pregnancy body mass index were more likely to have positive discrepancies. The proportion of women with discrepancies > or =+7 days was significantly higher among chromosomally malformed and female fetuses. The mean birthweight declined with increasingly positive differences. The risk of low birthweight was significantly higher for positive differences. Associations with fetal growth measures were more plausible with early ultrasound estimates.
Although most discrepancies between last normal menstrual period- and early ultrasound-based gestational age are attributable to errors in menstrual dating, our results suggest that some positive differences reflect early growth restriction.
Amniocentesis is an invasive procedure with inherent risks. Magnetic resonance (MR) spectroscopy is a safe noninvasive way of measuring levels of choline-containing compounds (including surfactant) and other metabolites. The purpose of this study was to test the feasibility of assessing fetal lung maturity in vivo and ex vivo using MR spectroscopy to determine differences in amniotic fluid choline concentrations between the second and third trimesters.
Magnetic resonance spectroscopy was performed on ex vivo samples of amniotic fluid from second- and third-trimester fetuses. In vivo MR spectroscopy was performed on amniotic fluid and fetal lungs in third-trimester fetuses. Spectral acquisition and analysis were performed by an attending radiologist in conjunction with an MR spectroscopist.
Choline-containing compounds were observed from 3.20 to 3.25 ppm. Comparison of spectra from second- and third-trimester amniocentesis revealed a trend toward increased choline at later gestational ages. Spectra from amniotic fluid and lungs of a third-trimester fetus showed that choline can be detected in the in vivo setting.
Magnetic resonance spectroscopy is a safe noninvasive procedure that enables measurement of choline-containing compounds in fetal lung and amniotic fluid. Magnetic resonance spectroscopy shows a trend toward an increased quantity of choline in third- vs second-trimester amniocentesis.
The objective of the study was to examine the effect of first-trimester obstetric ultrasound (OBUS) on the measurement of the effect of complications ascribed to postterm pregnancies.
We conducted a retrospective cohort study of all term, singleton pregnancies delivered at our institution who had an OBUS at a gestation of 24 weeks or less. Those women who underwent an OBUS at a gestation of 12 weeks or less (OBUS12) were compared with those who had an OBUS at 13-24 weeks of gestation (OBUS13-24). The primary outcome measures were the rates of postterm pregnancies greater than 41 or 42 weeks' gestation. Secondary outcomes were the differences between the postterm and term gestations in maternal and neonatal outcomes.
In the OBUS12 group, the rate of postterm pregnancy 42 weeks or longer was lower (2.7%) as compared with the OBUS13-24 group (3.7%, P = .022). With regard to reaching 41 weeks of gestation, the OBUS12 group was again lower (18.2%) as compared with the OBUS13-24 group (22.1%, P < .001). There were also fewer postterm inductions at 42 weeks or longer in the OBUS12 group (1.8%) as compared with the OBUS13-24 group (2.6%, P = .017). When comparing perinatal outcomes between those women who reached 41 weeks of gestation and those prior to 41 weeks of gestation, the OBUS12 group demonstrated greater differences between these 2 groups.
Our findings suggest that earlier obstetric ultrasound, which leads to better pregnancy dating, reduces the rate of estimated postterm pregnancies. This may, in turn, reduce unnecessary intervention and lead to better identification of postterm pregnancies at greater risk of complications.
Comparison of pregnancy dating by last menstrual period, ultrasound scanning, and their combination
- Savitz