E Gratacós

IDIBAPS August Pi i Sunyer Biomedical Research Institute, Barcino, Catalonia, Spain

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Publications (526)1640.17 Total impact

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    ABSTRACT: Objectives: We used magnetic resonance spectroscopy (MRS) to evaluate brain metabolic differences in small fetuses near term as compared to appropriate for gestational age (AGA) fetuses. Study Design: 71 term small fetuses (estimated fetal weight <10th centile for gestational age with normal umbilical artery Doppler sonography) were subclassified as late intrauterine growth restriction (IUGR) (n = 50) or small for gestational age (SGA) (n = 21), and compared with 65 AGA fetuses. IUGR was defined by either abnormal middle cerebral artery, abnormal uterine artery Doppler sonography or estimated fetal weight <3rd centile. All participants underwent brain magnetic resonance imaging at 37 weeks of gestation, and single-voxel magnetic resonance spectra were obtained from the frontal lobe on a 3-tesla scanner. N-acetylaspartate (NAA)/choline (Cho), NAA/creatine (Cr) and Cho/Cr ratios were calculated and compared between cases and controls. The association of the metabolic ratios with the study groups was tested. Results: After MRS processing and applying quality control criteria, 31 spectra from late-onset IUGR, 11 from SGA and 30 from AGA fetuses were selected for further analysis. Both SGA and late-onset IUGR fetuses showed significantly reduced NAA/Cho levels when compared to AGA fetuses. This decrease followed a linear trend across the three clinical groups that were considered. Conclusions: Both SGA and late-onset IUGR fetuses showed differences in MRS brain metabolic ratios. The findings suggest that despite near-normal perinatal outcomes, SGA fetuses are not constitutionally small and may represent a form of growth disorder that needs to be clarified. © 2014 S. Karger AG, Basel.
    Fetal Diagnosis and Therapy 08/2014; · 1.90 Impact Factor
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    ABSTRACT: Objective To examine whether a first-trimester strategy of secondary prevention for preeclampsia increases anxiety in pregnant women.Methods The anxiety levels of a cohort of women screened for preeclampsia at first trimester were measured by the Spielberg State Anxiety Inventory [STAI-S] and compared between women screened as low and high risk. In a subgroup of women the anxiety levels were additionally measured at second and third trimester. A General Linear Model (GLM) model for repeated measurements was performed to adjust for potential confounders (age, nulliparity and socio-economic level).ResultsA total of 255 women (135 low-risk and 120 high-risk) were evaluated. No differences were found in the mean STAI-S scores between low and high risk women: 35 (SD 9.9) and 34.6 (SD 10.1) (p = 0.77). The proportion of women with high anxiety was not significantly different between groups (28/134[20.7%]vs.24/120 [20%]; p = 0.88). No differences were found in the subgroups (51 low-risk and 50 high-risk) in which the anxiety levels were also measured at second and third trimester: 35.8 (SD 8.8)vs.35.2 (SD9.7) [p = 0.74] and 37.2 (SD 9.4)vs.35.3 (SD 8.6) [p = 0.3]. These differences remained non-significant after adjustment for potential confounders.ConclusionA strategy of first-trimester screening for preeclampsia does not increase maternal anxiety. This article is protected by copyright. All rights reserved.
    Prenatal Diagnosis 08/2014; · 2.68 Impact Factor
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    ABSTRACT: Intrauterine growth restriction (IUGR) is associated with prenatal changes in cardiac shape and function that persist in childhood and may be associated to an increased cardiovascular mortality in adulthood. Ultrasound and MRI provide information at organ level, but their resolution is too low. Microscopy provides detail at cellular and subcellular level, but an integrated evaluation at organ level is extremely challenging. We hypothesize that X-ray phase-contrast synchrotron radiation-based micro-CT could provide information regarding detailed cardiac anatomy to better understand the cardiac remodeling in IUGR.
    Cardiovascular research. 07/2014; 103(suppl 1):S34-S35.
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    ABSTRACT: While cardiomyocytes have a limited ability to shorten, the heart efficiently pumps a large volume-fraction thanks to a complex cell organisation in a 3D fibre structure. Such information is essential to understand diseases. CT/MRI provide structural information, however, their resolution is too low to study cellular mechanics in detail. Microscopy provides sufficient detail, but 3D imaging of whole hearts often results in distortions of detailed geometry and fibres. Therefore we developed a novel approach to study heart in great detail, but on the whole organ scale.
    Cardiovascular research. 07/2014; 103(suppl 1):S142.
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    ABSTRACT: -Fetal growth restriction (FGR) is associated with global adverse cardiac remodeling in utero and increased cardiovascular mortality in adulthood. Prenatal myocardial deformation has not been evaluated in FGR so far. We aimed to comprehensively evaluate prenatal cardiac remodeling in FGR including myocardial deformation imaging.
    Circulation Cardiovascular Imaging 06/2014; · 5.80 Impact Factor
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    ABSTRACT: To develop and evaluate the performance of a novel method to predict neonatal respiratory morbidity based on quantitative analysis of fetal lung by ultrasound.
    Ultrasound in Obstetrics and Gynecology 06/2014; · 3.56 Impact Factor
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    ABSTRACT: Previous studies showed that soluble LHCGR/hCG-sLHCGR concentrations in serum or plasma combined with PAPP-A and free betahCG significantly increased the sensitivity of Down's syndrome screen at early pregnancy without altering the false positive rate. The goal of the present study was to further examine the role of sLHCGR forms as combinatorial markers and to investigate whether sLHCGR could serve as an independent biomarker for Down's syndrome in first trimester pregnancy screens.
    BMC Pregnancy and Childbirth 06/2014; 14(1):197. · 2.52 Impact Factor
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    ABSTRACT: Characterization of brain changes produced by intrauterine growth restriction (IUGR) is among the main challenges of modern fetal medicine and pediatrics. This condition affects 5-10% of all pregnancies and is associated with a wide range of neurodevelopmental disorders. Better understanding of the brain reorganization produced by IUGR opens a window of opportunity to find potential imaging biomarkers in order to identify the infants with a high risk of having neurodevelopmental problems and apply therapies to improve their outcomes. Structural brain networks obtained from diffusion magnetic resonance imaging (MRI) is a promising tool to study brain reorganization and to be used as a biomarker of neurodevelopmental alterations. In the present study this technique is applied to a rabbit animal model of IUGR, which presents some advantages including a controlled environment and the possibility to obtain high quality MRI with long acquisition times. Using a Q-Ball diffusion model, and a previously published rabbit brain MRI atlas, structural brain networks of 15 IUGR and 14 control rabbits at 70days of age (equivalent to pre-adolescence human age) were obtained. The analysis of graph theory features showed a decreased network infrastructure (degree and binary global efficiency) associated with IUGR condition and a set of generalized fractional anisotropy (GFA) weighted measures associated with abnormal neurobehavior. Interestingly, when assessing the brain network organization independently of network infrastructure by means of normalized networks, IUGR showed increased global and local efficiencies. We hypothesize that this effect could reflect a compensatory response to reduced infrastructure in IUGR. These results present new evidence on the long-term persistence of the brain reorganization produced by IUGR that could underlie behavioral and developmental alterations previously described. The described changes in network organization have the potential to be used as biomarkers to monitor brain changes produced by experimental therapies in IUGR animal model.
    NeuroImage 06/2014; · 6.25 Impact Factor
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    ABSTRACT: Intrauterine growth restriction (IUGR) due to placental insufficiency is associated with blood flow redistribution in order to maintain delivery of oxygenated blood to the brain. Given that, in the fetus the aortic isthmus (AoI) is a key arterial connection between the cerebral and placental circulations, quantifying AoI blood flow has been proposed to assess this brain sparing effect in clinical practice. While numerous clinical studies have studied this parameter, fundamental understanding of its determinant factors and its quantitative relation with other aspects of haemodynamic remodeling has been limited. Computational models of the cardiovascular circulation have been proposed for exactly this purpose since they allow both for studying the contributions from isolated parameters as well as estimating properties that cannot be directly assessed from clinical measurements. Therefore, a computational model of the fetal circulation was developed, including the key elements related to fetal blood redistribution and using measured cardiac outflow profiles to allow personalization. The model was first calibrated using patient-specific Doppler data from a healthy fetus. Next, in order to understand the contributions of the main parameters determining blood redistribution, AoI and middle cerebral artery (MCA) flow changes were studied by variation of cerebral and peripheral-placental resistances. Finally, to study how this affects an individual fetus, the model was fitted to three IUGR cases with different degrees of severity. In conclusion, the proposed computational model provides a good approximation to assess blood flow changes in the fetal circulation. The results support that while MCA flow is mainly determined by a fall in brain resistance, the AoI is influenced by a balance between increased peripheral-placental and decreased cerebral resistances. Personalizing the model allows for quantifying the balance between cerebral and peripheral-placental remodeling, thus providing potentially novel information to aid clinical follow up.
    PLoS Computational Biology 06/2014; 10(6):e1003667. · 4.87 Impact Factor
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    ABSTRACT: Aim: To establish normal ranges of maternal placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1) and sFlt-1/PlGF ratio at 32-41 weeks' gestation and to evaluate the influence of maternal characteristics, and of fetoplacental Doppler. Material and Methods: Serum levels of PlGF, sFlt-1 and sFlt-1/PlGF ratio were measured in 300 noncomplicated pregnancies (30 at each gestational week between 32 and 41). Quantile regression analysis was used to derive gestational age (GA)-adjusted normal ranges, and to account for characteristics that might influence serum levels. The relationship with Doppler indices was tested, including umbilical artery pulsatility index and middle cerebral artery pulsatility index. Results: PlGF decreased with GA from 32 weeks, while sFlt-1 and sFlt-1/PlGF ratio increased steadily. None of the factors evaluated showed any significant influence on the levels of angiogenic factors. PlGF multiple of the median significantly correlated with mean uterine artery Doppler (R -0.17; p = 0.029). Conclusions: In normal pregnancies during the third trimester, serum PlGF decreases, sFlt-1 increases and sFlt-1/PlGF ratio increases with GA. Angiogenic factor levels needed no adjustment for factors such as smoking, body mass index, blood pressure or parity. © 2014 S. Karger AG, Basel.
    Fetal Diagnosis and Therapy 05/2014; · 1.90 Impact Factor
  • Stefan Savchev, Francesc Figueras, Eduard Gratacos
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    ABSTRACT: Objective: To provide a snapshot of the current trends in managing intrauterine growth restriction (IUGR) and to assess the agreement on the gestational age and the way of delivery in different clinical scenarios. Methods: A PubMed search was performed to identify all original articles on IUGR in the last 6 years. The most active 20 authors were selected as experts and were invited to respond to a survey on their preferred gestational age for elective delivery in several IUGR cases depending on Doppler measurements (including umbilical artery (UA), middle cerebral artery, cerebroplacental ratio, uterine artery and ductus venosus), biophysical profile and cardiotocography. Results: 15 of the 20 selected experts agreed to participate in the survey, of which 3 failed to meet the deadline to complete the survey. Management of IUGR was relatively uniform for abnormal UA, uterine artery or cerebroplacental ratio. Although average gestational age at delivery reflected a clear progression with accepted markers of severity, discrepancies of up to 4 weeks were found for abnormal middle cerebral artery Doppler and absent end-diastolic velocity in the UA, and of up to 8 weeks for reverse end-diastolic velocity in the UA and abnormalities in the ductus venosus Doppler. Conclusions: Management of IUGR is still far from being uniform among centers, with most controversy surrounding the management of early-onset IUGR. There is a need of prospective studies to address this issue. © 2014 S. Karger AG, Basel.
    Fetal Diagnosis and Therapy 05/2014; · 1.90 Impact Factor
  • Francesc Figueras, Eduard Gratacós
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    ABSTRACT: FGR is among the obstetrical entities with the greatest variation in clinical practice. The first clinically relevant step in the management of fetal growth restriction (FGR) is the distinction of "true" FGR, associated with signs of abnormal feto-placental function and poorer perinatal outcome, from small-for-gestational age (SGA) fetuses, which do not present abnormal Doppler and have near normal perinatal outcome. Such distinction should not be only relied on umbilical artery Doppler, since this parameter identifies only severe, early-onset, forms of placental insufficiency. Instead, FGR should be diagnosed in the presence of any of the factors associated with a poorer perinatal outcome, including Doppler cerebroplacental ratio, uterine artery Doppler, a growth centile below the 3rd centile. Upon diagnosis, differentiating into early-onset and late-onset FGR is useful to distinguish two clear phenotypes, with differences in severity, association with preeclampsia, and sequence of fetal deterioration. Finally, management of FGR aims at an optimal balance between minimizing fetal injury or death versus the risks of iatrogenic preterm delivery. We propose a protocol that integrates current evidence to classify stages of fetal deterioration, and establishes follow-up intervals and optimal delivery timings, which may facilitate decision-making and minimize variability in the clinical management. This article is protected by copyright. All rights reserved.
    Prenatal Diagnosis 05/2014; · 2.68 Impact Factor
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    ABSTRACT: Automatic quantification of cardiac muscle properties in tissue sections might provide important information related to different types of diseases. Second harmonic generation (SHG) imaging provides a stain-free microscopy approach to image cardiac fibers that, combined with our methodology of the automated measurement of the ultrastructure of muscle fibers, computes a reliable set of quantitative image features (sarcomere length, A-band length, thick-thin interaction length, and fiber orientation). We evaluated the performance of our methodology in computer-generated muscle fibers modeling some artifacts that are present during the image acquisition. Then, we also evaluated it by comparing it to manual measurements in SHG images from cardiac tissue of fetal and adult rabbits. The results showed a good performance of our methodology at high signal-to-noise ratio of 20 dB. We conclude that our automated measurements enable reliable characterization of cardiac fiber tissues to systematically study cardiac tissue in a wide range of conditions.
    Journal of Biomedical Optics 05/2014; 19(5):56010. · 2.88 Impact Factor
  • Rogelio Cruz-Martínez, Eduard Gratacos
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    ABSTRACT: At present, the fetus is already considered a "patient" and as such, can develop diseases with fatal outcome in which the only therapeutic option can be fetal surgery. Currently, fetal surgery is limited almost exclusively to endoscopic surgery. Different techniques have gained clinical acceptance for improving the prognosis of various lethal fetal pathologies. Laser therapy for twin to twin transfusion syndrome and cord occlusion in monochorionic twins with selective intrauterine growth restriction are the procedures of choice for the management of monochorionic twins complications, and are associated with survival rates of up to 80-90% for at least one fetus. In fetuses with isolated congenital diaphragmatic hernia and severe pulmonary hypoplasia, fetal endoscopic tracheal occlusion has shown to improve the survival probabilities from 5% to 55% and from 1% to 33% in left and right congenital diaphragmatic hernia, respectively, and a decrease in the rate of pulmonary hypertension and neonatal morbidity. In selected cases with low urinary tract obstruction (megacystis) and without renal failure; fetal cystoscopy is a diagnostic method that excludes the possibility of urethral stenosis or atresia and may be used to ablate posterior urethral valves by laser, restoring urethral patency and potentially preserving respiratory and bladder function. In fetuses with pulmonary masses, either primary or due to airway obstruction, there is high risk of fetal death due to cardiac compression and contralateral pulmonary hypoplasia. In such cases fetal bronchoscopy can provide a successful therapeutic option to release airway obstruction.
    Ginecología y obstetricia de México 05/2014; 82(5):325-36.
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    ABSTRACT: Objective To investigate whether signs of placental underperfusion (PUP), defined as any maternal and/or fetal vascular pathology, confer a higher risk of neonatal morbidity in late-onset small for gestational age (SGA) fetuses with normal umbilical artery Doppler.MethodsA cohort of 126 SGA singleton fetuses with normal umbilical artery Doppler delivered after 34 weeks was created. For each case, the placenta was histologically evaluated for signs of PUP using a hierarchical and standardized classification system. Neonatal morbidity was assessed by calculation of the morbidity assessment index for newborns (MAIN) score, a validated outcome scale. The independent association between PUP and neonatal morbidity was evaluated using multivariable median regression.ResultsIn a total of 84 placentas (66.7%), there were 97 placental histological findings that qualified as signs of PUP. These cases had a significantly higher incidence of emergent delivery for non-reassuring fetal status (44.1% vs. 21.4%; p=0.013) and neonatal metabolic acidosis at birth (33.3% vs. 14.3%; p=0.023). The median MAIN score significantly differed between groups (89 vs. 0; p=0.025). This difference remained significant after adjustment for potential confounders. The proportion of cases with mild to severe morbidity scores was also significantly higher in the PUP group (31% vs. 14.3%; p=0.043).Conclusion In late-onset SGA with normal umbilical artery Doppler, signs of PUP confer higher neonatal morbidity. These findings allow phenotypic profiling of fetal growth restriction among the general population of late-onset SGA.
    Ultrasound in Obstetrics and Gynecology 05/2014; · 3.56 Impact Factor
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    ABSTRACT: Objective: To explore the predictive role of angiogenic factors for the prediction of early and late preeclampsia (PE) in the first trimester. Methods: A nested case-control study, within a cohort of 5,759 pregnancies, including 28 cases of early, 84 of late PE (cut-off 34 weeks) and 84 controls. Maternal characteristics, mean blood pressure (MAP), uterine artery (UtA) Doppler (11-13 weeks), vascular endothelial growth factor, placental growth factor (PlGF), soluble Fms-like tyrosine kinase-1 (sFlt-1) and soluble endoglin (8-11 weeks) were measured/recorded. All parameters were normalized by logarithmic transformation; logistic regression analysis was used to predict PE. Results: For early PE, significant contributions were chronic hypertension, previous PE, MAP, UtA Doppler, PlGF and sFlt-1. A model including these predictors achieved detection rates (DR) of 77.8 and 88.9% for 5 and 10% false-positive rates (FPR), respectively (AUC 0.958; 95% CI 0.920-0.996). For late PE, significant contributions were provided by body mass index, previous PE, UtA Doppler, PlGF and sFlt-1. The model including these factors achieved DR of 51.2 and 69% at 5 and 10% FPR, respectively (AUC 0.888; 95% CI 0.840-0.936). Conclusions: Among angiogenic factors, not only PlGF but also sFlt-1 substantially improve the prediction for early and late PE. The data need confirmation in larger studies. © 2014 S. Karger AG, Basel.
    Fetal Diagnosis and Therapy 04/2014; · 1.90 Impact Factor
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    ABSTRACT: This study was designed to explore the association between angiogenic factors levels at diagnosis of small-for-gestational age (SGA) and placental underperfusion (PUP). In a cohort of SGA singleton pregnancies, each delivered at >34 weeks, uterine (UtA), umbilical (UA), and middle cerebral (MCA) arteries were evaluated by Doppler upon diagnosis of SGA status. In addition, maternal circulating concentrations of placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) were assayed by ELISA, and each placenta was evaluated for histologic signs of PUP using a hierarchical and standardized classification system. Logistic regression was applied to analyze independent relationships (at diagnosis) between angiogenic factors and Doppler parameters. A total of 122 suspected SGA pregnancies were studied, 70 (57.4%) of which ultimately met PUP criteria. In this group, 85 placental findings qualified as PUP. Both mean UtA pulsatility index z-values (1.26 vs. 0.84; p = 0.038) and PlGF multiples of normal median (0.21 vs. 0.55; p = 0.002) differed significantly in pregnancies with and without PUP, respectively. By logistic regression, PlGF alone was independently predictive of PUP (OR = 0.11 [95% CI 0.025-0.57]; p = 0.008). Histologic placental abnormalities in term SGA neonates reflect latent insufficiency in uteroplacental blood supply. The heightened risk of adverse perinatal outcomes in this context underscores a need for new Doppler or biochemical prenatal markers of placental disease. Angiogenic factors may be pivotal identifying SGA neonates. Diminished circulating levels of placental growth factor, determined upon discovery of SGA status, are associated with histologic evidence of PUP.
    Placenta 04/2014; · 3.12 Impact Factor
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    ABSTRACT: Objective To evaluate corpus callosum (CC) development by Magnetic Resonance Imaging (MRI) in late-onset intrauterine growth restricted (IUGR) fetuses compared to appropriatefor gestational age (AGA) and its association with neurobehavioral outcome.Method117 late-onset IUGR and 73 control fetuses were imaged using a 3 T MRI scanner at term, obtaining T2 half-Fourier acquisition single-shot turbo spin-echo (HASTE) anatomical slices. CC length, thickness, total area and the areas after a subdivision in 7 portions were assessed. Neonatal Behavioral Assessment Scale (NBAS) test was performed on IUGR newborns at 42 ± 1 weeks.ResultsIUGR fetuses showed significantly smaller CC (Total CC Area IUGR: 1.3996 ± 0.26 vs. AGA: 1.664 ± 0.31; p < 0.01) and smaller subdivision areas as compared with controls. The differences were slightly more pronounced in fetuses with very low birth weight and abnormal brain or uterine Doppler. CC measurements were significantly associated with neurobehavioral outcome in IUGR cases.ConclusionsCC development was significantly altered in late-onset IUGR fetuses and correlated with worse neurobehavioral performance. CC could be further explored as a potential imaging biomarker to predict abnormal neurodevelopment in pregnancies at risk. This article is protected by copyright. All rights reserved.
    Prenatal Diagnosis 04/2014; · 2.68 Impact Factor
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    ABSTRACT: Objective To describe the distribution of placental growth factor (PlGF) plasma levels in pregnancies complicated by preeclampsia (PE) according to the gestational age at clinical onset and to assess PlGF's predictive role for maternal complications.MethodsA total of 84 women whose pregnancies were complicated by PE before 37 gestational weeks were enrolled. According to gestational age at onset, three groups were defined: group I, < 28 weeks; group II, 28-31+6 weeks; and group III, 32-36+6 weeks. PlGF plasma levels were measured at diagnosis and their association with maternal complications was investigated. Plasma PlGF levels below 12 pg/mL were designated as very low.ResultsPlGF levels were very low in 7 (87.5%) of 8 women diagnosed before 28 gestational weeks, 29 (78.4%) of 37 patients diagnosed between 28 and 32 gestational weeks, and 16 (41%) of 39 cases diagnosed after 32 gestational weeks. The sensitivity of very low PlGF values for predicting maternal complications was 76.9%, but the false positive rate was 65.5%. Positive and negative predictive values were 34.5% and 76.9%, respectively.Conclusion The predictive role of a low PlGF level in predicting maternal complications in very early PE is limited because of both its low specificity and low positive predictive value. This article is protected by copyright. All rights reserved.
    Prenatal Diagnosis 04/2014; · 2.68 Impact Factor
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    ABSTRACT: Objective To elucidate the association between Doppler parameters and histological signs of placental underperfusion (PUP) in late-onset small-for-gestational age (SGA) babies. Methods The umbilical and middle cerebral arteries, uterine arteries (UtA), and umbilical vein blood flow (UVBF) were evaluated within 7 days of delivery in a cohort of 95 SGA singleton fetuses delivered after 34 weeks’ gestation and confirmed as birth weight <10th percentile by local standards. For each case, the placenta was histologically evaluated for signs of PUP using a hierarchical and standardized classification system. The independent association of the Doppler parameters to PUP was evaluated using logistic regression and decision tree analysis. ResultsIn 51 cases (53.7%), 61 placental histological findings were qualified as signs of PUP. These cases had a significantly higher incidence of cesarean section (CS) for non-reassuring fetal status (49% vs. 11.4%; p<0.001) and neonatal metabolic acidosis at birth (21.6% vs. 0%; p=0.001). Significant and independent contributions to PUP lesions were provided by the mean UtA pulsatility index (PI; p=0.018, OR 2 [95%CI: 1.1–3.7]) and UVBF normalized to estimated fetal weight (p=0.027, OR 0.97 [95%CI: 0.95–0.99]). The combination of both parameters revealed three groups with differing risk for PUP: normalized UVBF >82 mL/min/kg (risk 31.2%), normalized UVBF ≤82 mL/min/kg and mean UtA-PI ≤95th percentile (risk 65.5%), and normalized UVBF ≤82 mL/min/kg and UtA-PI >95th percentile (risk 94.4%). Conclusion In late-onset SGA pregnancies, uterine Doppler and umbilical vein flow are surrogates for PUP. These findings facilitate phenotypic profiling of fetal growth restriction cases among the general population of late-onset SGA.
    Ultrasound in Obstetrics and Gynecology 03/2014; · 3.56 Impact Factor

Publication Stats

4k Citations
1,640.17 Total Impact Points

Institutions

  • 2008–2014
    • IDIBAPS August Pi i Sunyer Biomedical Research Institute
      Barcino, Catalonia, Spain
    • Instituto de Salud Carlos III
      Madrid, Madrid, Spain
    • King's College London
      Londinium, England, United Kingdom
    • University of the Andes (Chile)
      • Faculty of Medicine
      CiudadSantiago, Santiago, Chile
  • 1994–2014
    • Hospital Clínic de Barcelona
      • Servicio de Medicina Materno Fetal
      Barcino, Catalonia, Spain
  • 1993–2014
    • University of Barcelona
      • • Departament de Psiquiatria i Psicobiologia Clínica
      • • Departament d'Obstetrícia i Ginecologia, Pediatria, Radiologia i Anatomia
      Barcino, Catalonia, Spain
  • 2008–2013
    • Hospital Sant Joan de Déu
      • Servicio de Cirugía cardiaca pediátrica
      Barcino, Catalonia, Spain
  • 2000–2013
    • Universitair Ziekenhuis Leuven
      • Department of Gynaecology and obstetrics
      Louvain, Flanders, Belgium
  • 1999–2013
    • University of Leuven
      • • Faculty of Medicine
      • • Department of Reproduction, Development and Regeneration
      Louvain, Flanders, Belgium
  • 2009–2012
    • Centro de Investigación Biomédica en Red de Enfermedades Raras
      Valenza, Valencia, Spain
    • Society for Maternal-Fetal Medicine
      Santa Maria, California, United States
    • Institut Marqués, Spain, Barcelona
      Barcino, Catalonia, Spain
  • 2011
    • IDIBELL Bellvitge Biomedical Research Institute
      Barcino, Catalonia, Spain
  • 2010
    • Universidad de Jaén
      • Department of Experimental Biology
      Jaén, Andalusia, Spain
  • 2001–2009
    • University Hospital Vall d'Hebron
      • Department of Obstetrics
      Barcino, Catalonia, Spain
  • 1999–2007
    • Autonomous University of Barcelona
      • Departamento de Pediatría, Obstetricia, Ginecología y Medicina Preventiva
      Cerdanyola del Vallès, Catalonia, Spain
  • 1994–2007
    • Southern Medical Clinic
      San Fernando, City of San Fernando, Trinidad and Tobago
  • 2006
    • University of Hamburg
      • Department of Obstetrics and Fetal Medicine
      Hamburg, Hamburg, Germany
    • Hospital Universitario 12 de Octubre
      • Department of Obstetrics and Gynecology
      Madrid, Madrid, Spain
  • 2005
    • Tufts University
      • Department of Obstetrics and Gynecology
      Boston, GA, United States