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First-Trimester Uterine Artery Doppler for the Prediction of SGA at Birth: The Great Obstetrical Syndromes Study

  • Olivier Drouin
    Affiliations
    Department of Gynecology, Obstetrics and Reproduction, Faculty of Medicine, Université Laval, Québec City, QC

    Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, AB
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  • Amélie Boutin
    Affiliations
    Reproduction, Mother and Child Health Unit, CHU de Québec - Université Laval Research Centre, Université Laval, Québec City, QC
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  • Kim Paquette
    Affiliations
    Reproduction, Mother and Child Health Unit, CHU de Québec - Université Laval Research Centre, Université Laval, Québec City, QC
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  • Cédric Gasse
    Affiliations
    Reproduction, Mother and Child Health Unit, CHU de Québec - Université Laval Research Centre, Université Laval, Québec City, QC
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  • Paul Guerby
    Affiliations
    Department of Obstetrics and Gynecology, Hôpital Paule de Viguier (CHU Toulouse), Toulouse, France
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  • Suzanne Demers
    Affiliations
    Department of Gynecology, Obstetrics and Reproduction, Faculty of Medicine, Université Laval, Québec City, QC

    Reproduction, Mother and Child Health Unit, CHU de Québec - Université Laval Research Centre, Université Laval, Québec City, QC
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  • Emmanuel Bujold
    Correspondence
    Corresponding Author: Dr. Emmanuel Bujold, Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Centre de recherche du CHU de Québec-Université Laval, Québec City, QC.
    Affiliations
    Department of Gynecology, Obstetrics and Reproduction, Faculty of Medicine, Université Laval, Québec City, QC

    Reproduction, Mother and Child Health Unit, CHU de Québec - Université Laval Research Centre, Université Laval, Québec City, QC
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Published:October 10, 2018DOI:https://doi.org/10.1016/j.jogc.2018.02.004

      Abstract

      Objective

      To estimate the role of first-trimester uterine artery pulsatility index (UtA-PI) for the prediction of small-for-gestational age (SGA).

      Methods

      We conducted a prospective cohort study of nulliparous women with singleton pregnancy (Great Obstetrical Syndromes study). UtA-PI was performed at 11 + 0 to 13 + 6 weeks and was reported in multiple of median (MoM). SGA was defined as birth weight below the 10th percentile and stratified as term or preterm SGA. Receiver operating characteristic curves analyses with their area under the curve (AUC) were used to estimate the predictive values of UtA-PI, alone and UtA-PI combined with maternal characteristics. We computed the detection rate and false-positive rate (FPR) of the SOGC SGA screening guidelines in our population.

      Results

      Of 4610 participants, SGA was identified in 486 pregnancies (10.3%), including 15 (0.3%) associated with preterm delivery. Compared with unaffected pregnancies, the mean log UtA-PI was significantly higher in term SGA and preterm SGA. The difference between preterm SGA and unaffected pregnancies remains significant after exclusion of SGA without preeclampsia. First-trimester UtA-PI was more predictive of preterm (AUC: 0.89) than term (AUC: 0.60) SGA (P < 0.01). Combined with maternal characteristics, UtA-PI could have predicted 64% of preterm and 20% of term SGA (10% FPR). The SOGC guidelines criteria for early screening of SGA had a detection rate of 21% for a FPR of 21%.

      Conclusions

      First-trimester UtA-PI can be used to predict SGA, but mainly preterm SGA. The current SOGC guidelines criteria for SGA screening are not efficient in nulliparous women.

      Résumé

      Objectif

      Évaluer le rôle de l'indice de pulsatilité des artères utérines (IPAU) au premier trimestre pour prédire les bébés petits pour l'âge gestationnel (PAG).

      Méthodologie

      Nous avons mené une étude de cohorte prospective auprès de femmes nullipares enceintes d'un seul fœtus (étude sur les grands syndromes obstétricaux). L'IPAU a été mesuré entre 11+0 et 13+6 semaines de grossesse et a été exprimé en multiples de la médiane (MoM). La notion de PAG était définie comme étant un poids à la naissance sous le 10e centile, et les cas ont été stratifiés selon que les bébés étaient nés à terme ou prématurément. L'analyse des courbes caractéristiques de la performance d'un test, notamment la surface sous la courbe (SSC), a servi à estimer les valeurs prédictives de l'IPAU, seul et combiné aux caractéristiques maternelles. Nous avons calculé dans notre population les taux de détection et de faux positifs associés aux recommandations de la SOGC pour le dépistage des bébés PAG.

      Résultats

      Parmi les 4 610 participantes, nous avons recensé 486 cas (10,3 %) de bébés PAG, dont 15 (0,3 %) étaient associés à la prématurité. La moyenne logarithmique de l'IPAU était significativement plus élevée chez les cas de bébés PAG (nés à terme et avant terme) que chez les grossesses non touchées. La différence entre les bébés PAG prématurés et les bébés des grossesses non touchées était significative après l'exclusion des cas de PAG où la prééclampsie n'était pas un facteur. L'IPAU au premier trimestre était un meilleur facteur de prédiction de bébés PAG nés avant terme (SSC : 0,89) que de bébés PAG nés à terme (SSC : 0,60) [P < 0,01]. Combiné aux caractéristiques maternelles, l'IPAU aurait permis de prédire 64 % des cas de PAG avant terme et 20 % des cas à terme (taux de faux positifs : 10 %). Les recommandations de la SOGC pour le dépistage précoce des bébés PAG avaient un taux de détection de 21 % et un taux de faux positifs de 21 %.

      Conclusions

      L'IPAU au premier trimestre peut servir à prédire les bébés PAG, mais surtout chez les bébés prématurés. Les recommandations actuelles de la SOGC ne sont pas efficaces chez les femmes nullipares.

      Key Words

      Abbreviations:

      ART (assisted reproductive technology), DR (detection rate), FPR (false-positive rate), MoM (multiple of median), UtA-PI (uterine artery pulsatility index)
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      References

        • Baer R.J.
        • Rogers E.E.
        • Partridge J.C.
        • et al.
        Population-based risks of mortality and preterm morbidity by gestational age and birth weight.
        J Perinatol. 2016; 36: 1008-1013
        • Malin G.L.
        • Morris R.K.
        • Riley R.
        • et al.
        When is birthweight at term abnormally low? A systematic review and meta-analysis of the association and predictive ability of current birthweight standards for neonatal outcomes.
        BJOG. 2014; 121: 515-526
        • Levine T.A.
        • Grunau R.E.
        • McAuliffe F.M.
        • et al.
        Early childhood neurodevelopment after intrauterine growth restriction: a systematic review.
        Pediatrics. 2015; 135: 126-141
        • Kaijser M.
        • Bonamy A.K.
        • Akre O.
        • et al.
        Perinatal risk factors for ischemic heart disease: disentangling the roles of birth weight and preterm birth.
        Circulation. 2008; 117: 405-410
        • Bujold E.
        • Roberge S.
        • Lacasse Y.
        • et al.
        Prevention of preeclampsia and intrauterine growth restriction with aspirin started in early pregnancy: a meta-analysis.
        Obstet Gynecol. 2010; 116: 402-414
        • Roberge S.
        • Nicolaides K.
        • Demers S.
        • et al.
        The role of aspirin dose on the prevention of preeclampsia and fetal growth restriction: systematic review and meta-analysis.
        Am J Obstet Gynecol. 2017; 216 (110–20e6)
        • Hargreaves K.
        • Cameron M.
        • Edwards H.
        • et al.
        Is the use of symphysis-fundal height measurement and ultrasound examination effective in detecting small or large fetuses?.
        J Obstet Gynaecol. 2011; 31: 380-383
        • Lausman A.
        • Kingdom J.
        • Maternal Fetal Medicine Committee
        Intrauterine growth restriction: screening, diagnosis, and management.
        J Obstet Gynaecol Can. 2013; 35: 741-757
        • Velauthar L.
        • Plana M.N.
        • Kalidindi M.
        • et al.
        First-trimester uterine artery Doppler and adverse pregnancy outcome: a meta-analysis involving 55 974 women.
        Ultrasound Obstet Gynecol. 2014; 43: 500-507
        • Cnossen J.S.
        • Morris R.K.
        • ter Riet G.
        • et al.
        Use of uterine artery Doppler ultrasonography to predict pre-eclampsia and intrauterine growth restriction: a systematic review and bivariable meta-analysis.
        CMAJ. 2008; 178: 701-711
        • Carbillon L.
        • Uzan M.
        • Largilliere C.
        • et al.
        Prospective evaluation of uterine artery flow velocity waveforms at 12–14 and 22–24 weeks of gestation in relation to pregnancy outcome and birth weight.
        Fetal Diagn Ther. 2004; 19: 381-384
        • Dugoff L.
        • Lynch A.M.
        • Cioffi-Ragan D.
        • et al.
        First trimester uterine artery Doppler abnormalities predict subsequent intrauterine growth restriction.
        Am J Obstet Gynecol. 2005; 193: 1208-1212
        • Gomez O.
        • Martinez J.M.
        • Figueras F.
        • et al.
        Uterine artery Doppler at 11–14 weeks of gestation to screen for hypertensive disorders and associated complications in an unselected population.
        Ultrasound Obstet Gynecol. 2005; 26: 490-494
        • Gomez O.
        • Figueras F.
        • Martinez J.M.
        • et al.
        Sequential changes in uterine artery blood flow pattern between the first and second trimesters of gestation in relation to pregnancy outcome.
        Ultrasound Obstet Gynecol. 2006; 28: 802-808
        • Akolekar R.
        • Syngelaki A.
        • Sarquis R.
        • et al.
        Prediction of early, intermediate and late pre-eclampsia from maternal factors, biophysical and biochemical markers at 11–13 weeks.
        Prenat Diagn. 2011; 31: 66-74
        • Prefumo F.
        • Sebire N.J.
        • Thilaganathan B.
        Decreased endovascular trophoblast invasion in first trimester pregnancies with high-resistance uterine artery Doppler indices.
        Hum Reprod. 2004; 19: 206-209
        • Melchiorre K.
        • Leslie K.
        • Prefumo F.
        • et al.
        First-trimester uterine artery Doppler indices in the prediction of small-for-gestational age pregnancy and intrauterine growth restriction.
        Ultrasound Obstet Gynecol. 2009; 33: 524-529
        • Martin A.M.
        • Bindra R.
        • Curcio P.
        • et al.
        Screening for pre-eclampsia and fetal growth restriction by uterine artery Doppler at 11–14 weeks of gestation.
        Ultrasound Obstet Gynecol. 2001; 18: 583-586
        • Pilalis A.
        • Souka A.P.
        • Antsaklis P.
        • et al.
        Screening for pre-eclampsia and small for gestational age fetuses at the 11–14 weeks scan by uterine artery Dopplers.
        Acta Obstet Gynecol Scand. 2007; 86: 530-534
        • Vainio M.
        • Kujansuu E.
        • Koivisto A.M.
        • et al.
        Bilateral notching of uterine arteries at 12–14 weeks of gestation for prediction of hypertensive disorders of pregnancy.
        Acta Obstet Gynecol Scand. 2005; 84: 1062-1067
        • Familiari A.
        • Bhide A.
        • Morlando M.
        • et al.
        Mid-pregnancy fetal biometry, uterine artery Doppler indices and maternal demographic characteristics: role in prediction of small-for-gestational-age birth.
        Acta Obstet Gynecol Scand. 2016; 95: 238-244
        • Parry S.
        • Sciscione A.
        • Haas D.M.
        • et al.
        Role of early second-trimester uterine artery Doppler screening to predict small-for-gestational-age babies in nulliparous women.
        Am J Obstet Gynecol. 2017; 217: e1-10
        • Bujold E.
        • Morency A.M.
        • Roberge S.
        • et al.
        Acetylsalicylic acid for the prevention of preeclampsia and intra-uterine growth restriction in women with abnormal uterine artery Doppler: a systematic review and meta-analysis.
        J Obstet Gynaecol Can. 2009; 31: 818-826
        • Gasse C.
        • Boutin A.
        • Demers S.
        • et al.
        Body mass index and the risk of hypertensive disorders of pregnancy: the Great Obstetrical Syndromes (GOS) study.
        J Matern Fetal Neonatal Med. 2017; : 1-6
        • Boutin A.
        • Gasse C.
        • Demers S.
        • et al.
        Maternal characteristics for the prediction of preeclampsia in nulliparous women: the Great Obstetrical Syndromes (GOS) Study.
        J Obstet Gynaecol Can. 2017; https://doi.org/10.1016/j.jogc.2017.07.025
        • Gasse C.
        • Boutin A.
        • Cote M.
        • et al.
        First-trimester mean arterial blood pressure and the risk of preeclampsia: the Great Obstetrical Syndromes (GOS) study.
        Pregnancy Hypertens. 2017; https://doi.org/10.1016/j.preghy.2017.11.00
        • Kramer M.S.
        • Platt R.W.
        • Wen S.W.
        • et al.
        A new and improved population-based Canadian reference for birth weight for gestational age.
        Pediatrics. 2001; 108: E35
        • Magee L.A.
        • Pels A.
        • Helewa M.
        • et al.
        Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: executive summary.
        J Obstet Gynaecol Can. 2014; 36: 416-438
        • Gardosi J.
        • Mul T.
        • Mongelli M.
        • et al.
        Analysis of birthweight and gestational age in antepartum stillbirths.
        Br J Obstet Gynaecol. 1998; 105: 524-530
        • Ananth C.V.
        • Vintzileos A.M.
        Distinguishing pathological from constitutional small for gestational age births in population-based studies.
        Early Hum Dev. 2009; 85: 653-658
        • Rolnik D.L.
        • Wright D.
        • Poon L.C.
        • et al.
        Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia.
        N Engl J Med. 2017; 377: 613-622
        • Crovetto F.
        • Triunfo S.
        • Crispi F.
        • et al.
        First-trimester screening with specific algorithms for early- and late-onset fetal growth restriction.
        Ultrasound Obstet Gynecol. 2016; 48: 340-348
        • Poon L.C.
        • Zaragoza E.
        • Akolekar R.
        • et al.
        Maternal serum placental growth factor (PlGF) in small for gestational age pregnancy at 11(+0) to 13(+6) weeks of gestation.
        Prenat Diagn. 2008; 28: 1110-1115
        • Poon L.C.
        • Syngelaki A.
        • Akolekar R.
        • et al.
        Combined screening for preeclampsia and small for gestational age at 11–13 weeks.
        Fetal Diagn Ther. 2013; 33: 16-27
        • Brosens I.
        • Pijnenborg R.
        • Vercruysse L.
        • et al.
        The “Great Obstetrical Syndromes” are associated with disorders of deep placentation.
        Am J Obstet Gynecol. 2011; 204: 193-201
        • Kim Y.M.
        • Bujold E.
        • Chaiworapongsa T.
        • et al.
        Failure of physiologic transformation of the spiral arteries in patients with preterm labor and intact membranes.
        Am J Obstet Gynecol. 2003; 189: 1063-1069
        • Roberge S.
        • Villa P.
        • Nicolaides K.
        • et al.
        Early administration of low-dose aspirin for the prevention of preterm and term preeclampsia: a systematic review and meta-analysis.
        Fetal Diagn Ther. 2012; 31: 141-146
        • Roberge S.
        • Bujold E.
        • Nicolaides K.H.
        Aspirin for the prevention of preterm and term preeclampsia: systematic review and meta-analysis.
        Am J Obstet Gynecol. 2018; 218 (e1): 287-293
        • Ogge G.
        • Chaiworapongsa T.
        • Romero R.
        • et al.
        Placental lesions associated with maternal underperfusion are more frequent in early-onset than in late-onset preeclampsia.
        J Perinat Med. 2011; 39: 641-652
        • Ridding G.
        • Hyett J.A.
        • Sahota D.
        • et al.
        Assessing quality standards in measurement of uterine artery pulsatility index at 11 to 13 + 6 weeks' gestation.
        Ultrasound Obstet Gynecol. 2015; 46: 299-305