Cerebroplacental Ratio in Fetal Well Being Assessment in SGA and AGA Fetus
Cerebroplacental Ratio in Fetal Well Being Assessment in SGA and AGA Fetus
Cerebroplacental Ratio in Fetal Well Being Assessment in SGA and AGA Fetus
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OBSTETRICS
Appropriate-for-gestational-age
fetuses: the role of CPR in the
detection of fetuses at risk for
adverse outcome
Prior et al19 prospectively evaluated 400
AGA fetuses at term and reported an
abnormal CPR in 11%. Of those who
underwent cesarean delivery for fetal
distress, 36.4% had an abnormal CPR
compared with 10.1% (P < .001) that
had a normal CPR (Table 2).19 An
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Obstetrics
TABLE 1
Year
Study type
Doppler indices
Computation of ratio
Abnormal criteria
1988
Cross-sectional
S-D/S
MCA/UA
Ratio <1
1994
Cross-sectional
RI
MCA/UA
Ratio <1
1992
Cross-sectional
PI
MCA/UA
Ratio <1.08
Bahado-Singh et al8
1999
Cross-sectional
PI
MCA/UA MoM
2003
Cross-sectional
PI
MCA/UA
10
2005
Cross-sectional
PI
MCA/UA
Ratio <1.08
2007
Longitudinal
PI
MCA/UA
<2.5th centile
2014
Cross-sectional
PI
MCA/UA
Gramellini et al
Odibo et al
Ebbing et al
11
Morales et al12
MCA, middle cerebral artery; MoM, multiple of the median; PI, pulsatility index; RI, resistance index; S/D, systolic/diastolic ratio; UA, umbilical artery.
DeVore. Cerebroplacental ratio in fetal well-being in SGA and AGA fetuses. Am J Obstet Gynecol 2015.
intrapartum and neonatal complications. Because the majority of these fetuses have a normal Doppler resistance
(PI, RI, or S/D ratio) of the UA, the
physician may falsely conclude that there
is no increased risk for adverse outcome,
even though an abnormal CPR may be
present but not measured. Therefore,
it is imperative that Doppler assessment
of the MCA occurs and the CPR
computed in late-onset SGA fetuses
to identify those at risk for perinatal
complications.
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independently associated with the risk
for emergency operative delivery in both
the SGA and AGA birthweight groups.
Fetuses with an abnormal CPR had a
higher rate of NICU admissions (14.3%)
compared with those with a normal
CPR (9.7%; P < .004) (Table 2).18 In
this group, however, birthweight centile
was not independently associated with
NICU admissions.
When the newborns were divided
into groups based on whether SGA was
present or absent and the CPR was
normal or abnormal, those with an
abnormal CPR had a higher cesarean
delivery rate (11% vs 8.7%; P .043)
and higher instrumental delivery rate
(11.2% vs 7.8%; P .003).
These data underscore that an abnormal CPR was a better predictor than
low birthweight for identifying those
fetuses requiring emergent operative
delivery for fetal distress in labor and
NICU admission associated with neonatal complications. Therefore, when a
fetus with late-onset SGA is identied,
the examiner should strongly consider
computing the CPR to stratify risk for
intrapartum fetal distress and adverse
neonatal outcome prior to the onset of
labor.
Obstetrics
Expert Reviews
FIGURE 1
Recordings from a fetus whose mother was a late registrant for prenatal
care
These recordings are from a fetus whose mother was a late registrant for prenatal care. There was
a 14 day difference between the menstrual age and the mean ultrasound gestational age. The
abnormal cerebroplacental ratio suggested that fetal growth restriction was the correct diagnosis. How
to acquire the images and make the measurements is illustrated in the Video available at ajog.org.
DeVore. Cerebroplacental ratio in fetal well-being in SGA and AGA fetuses. Am J Obstet Gynecol 2015.
Expert Reviews
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Obstetrics
FIGURE 2
=
This is an example of a fetus with A, a high but
normal PI of the umbilical artery, B, low but
normal PI of the middle cerebral artery, and C,
an abnormal cerebroplacental ratio below the
fifth centile (red ). Each graph illustrates the raw
data for the mean (dots ) and 95th and fifth
centiles (solid lines ). The dotted line is the mean
of the regression line. The reference ranges are
from a study by Baschat and Gembruch.9
CPR, abnormal cerebroplacental ratio.
DeVore. Cerebroplacental ratio in fetal well-being in SGA
and AGA fetuses. Am J Obstet Gynecol 2015.
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Obstetrics
Expert Reviews
FIGURE 3
<
This is an example of a fetus with A, a normal PI
of the umbilical artery, B, abnormal low PI of the
middle cerebral artery, and C, an abnormal CPR
below the fifth centile (red ). Each graph illustrates the raw data for the mean (dots ) and 95th
and fifth centiles (solid lines ). The dotted line is
the mean of the regression line. The reference
ranges are from a study by Baschat and
Gembruch.9
CPR, cerebroplacental ratio; SGA, small for gestational age; PI,
pulsatility index.
DeVore. Cerebroplacental ratio in fetal well-being in SGA
and AGA fetuses. Am J Obstet Gynecol 2015.
Expert Reviews
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Obstetrics
FIGURE 4
Fetus with an elevated PI of the UA, low PI of the MCA, and an abnormal
CPR
=
This is an example of a fetus with A, an elevated
PI of the umbilical artery, B, low PI of the middle
cerebral artery, and C, an abnormal CPR below
the fifth centile (red ). Each graph illustrates the
raw data for the mean (dots ) and 95th and fifth
centiles (solid lines ). The dotted line is the mean
of the regression line. The reference ranges are
from a study by Baschat and Gembruch.9
CPR, cerebroplacental ratio; MCA, middle cerebral artery; PI,
pulsatility index; SGA, small for gestational age; UA, umbilical
artery.
DeVore. Cerebroplacental ratio in fetal well-being in SGA
and AGA fetuses. Am J Obstet Gynecol 2015.
Comparison of findings at birth and adverse neonatal outcomes in term fetuses with normal vs CPRs
Cruz-Martinez et al
(2011)26
Prior et al
(2013)19
Figueras et al
(2014)27
Morales-Rosello et al
(2015)20
Khalil et al
(2015)17
Khalil et al (Part I)
(2015)18
Type of study
Prospective
Prospective
Prospective
Retrospective
Retrospective
Retrospective
Purpose of study
Evaluate CPR
obtained before labor
to detect fetuses at
risk for emergency
cesarean delivery for
fetal distress
Develop an integrated
model to predict
adverse outcome in
fetuses with lateonset SGA
>37
37e42
34e40
37e41.9
340 to 356
>37
Control (n 210),
suspected SGA (n 210)
Low-risk patients
(n 400)
No control SGA
(n 509)
All patients
(n 2485) SGA
(n 640, 25.8%)
Examined within 72 h
of delivery
Not stated
Up to 2 wks
Up to 6 wks
2 wks
PI <10th centile
(<1.24)
PI (<10th centile)9
PI MoM <0.6765
PI MoM <0.6765
PI MoM <0.6765
Yes (MCA)
No (CPR combined
with UtA PI >95th
centile and EFW less
than third centile)
Yes (birthweight)
Yes (EFW,
birthweight
centile)
405 vs 403
(P < .004)
Mean birthweight, g
Not significant
2280 vs 2466
(P < .001)
48 vs 55 (P .04)
86% vs 31%
(P < .001)
36.4% vs 10.1%
(P < .001)
79.1% vs 10.7%
(P < .001)
(continued)
11
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DeVore. Cerebroplacental ratio in fetal well-being in SGA and AGA fetuses. Am J Obstet Gynecol 2015.
Obstetrics
Variable
ajog.org
TABLE 2
Neonatal complications
DeVore. Cerebroplacental ratio in fetal well-being in SGA and AGA fetuses. Am J Obstet Gynecol 2015.
AGA, appropriate for gestational age; CPR, abnormal cerebroplacental ratio; EFW, ultrasound estimated fetal weight; MCA, middle cerebral artery; MoM, multiple of the median; NICU, newborn intensive care unit; PI, pulsatility index; SGA, late-onset small for
gestational age; UA, umbilical artery; UV, umbilical vein.
Abnormal cord pH
Not significant
Not significant
11.25% vs 5.6% (P
.03)
14.3% vs 9.7%
(P .004)
All patients 12.6%
vs 6.1% (P <
.001) SGA 22.5%
vs 8.4% (P <
.001) AGA 9.8%
vs 5.5% Not
significant
UA 7.17 vs 7.25
(P < .001)
Not significant
UA and UV
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Obstetrics
22.7% vs 9%
(P .02)
Morales-Rosello et al
(2015)20
Figueras et al
(2014)27
Prior et al
(2013)19
Cruz-Martinez et al
(2011)26
Variable
Comparison of findings at birth and adverse neonatal outcomes in term fetuses with normal vs CPRs (continued)
TABLE 2
Khalil et al
(2015)17
Khalil et al (Part I)
(2015)18
Expert Reviews
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TABLE 3
Studies evaluating the CPR as a diagnostic tool in fetuses with predominantly early-onset fetal growth restriction (SGA)
Variable
Gramellini et al (1992)5
Arias et al (1994)6
Bahado-Singh et al
(1999)8
Makhseed et al
(2000)28
Ebrashy et al (2005)29
Flood et al (2014)30
Type of study
Retrospective
Prospective
Prospective
Prospective
Prospective
Retrospective
Evaluate CPR to
predict adverse
outcome in SGA
Evaluate CPR to
predict adverse
outcome in SGA
30e41
24e38
<34
29e42
Control (n 45),
SGA (n 45)
>28
29e36
Not stated
<2
<3
3.8e8.6
Not stated
32e42
PI (<1.08)
RI (<1.0)
MoM (<0.5)
RI (<1.05)
RI (<1.0)
Yes (UA)
Equal (UA)
31.6 vs 35.7
(P < .0001)
1138 vs 2098
(P < .0001)
1835 vs 2351
(P < .0001)
45.4% vs 7.6%
(P < .001)
94.4% vs 57.5%
(P < .001)
86.3% vs 51.2%
(P .01)
41.7% vs 13.8%
(P < .01)
65.7% vs 42.9%
(P < .05)
Not significant
Not significant
Abnormal cord pH
26 d vs 14.5 d
(P .03)
77.8% vs 41.4%
(P < .001)
74.3% vs 31.4%
(P < .001)
Neonatal complications
Obstetrics
DeVore. Cerebroplacental ratio in fetal well-being in SGA and AGA fetuses. Am J Obstet Gynecol 2015.
(continued)
13
Expert Reviews
Mean birthweight, g
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Obstetrics
TABLE 4
Measurement
standard
Sensitivity
Specificity
Odds ratio
<1
Pulsatility index
66%
85%
11.7
<1
Resistance index
66%
84%
11.8
Centile
80%
60%
6.2
Centile
85%
41%
4.1
DeVore. Cerebroplacental ratio in fetal well-being in SGA and AGA fetuses. Am J Obstet Gynecol 2015.
DeVore. Cerebroplacental ratio in fetal well-being in SGA and AGA fetuses. Am J Obstet Gynecol 2015.
2% vs 0% (P < .0001)
Perinatal death
AEDV, absent end-diastolic flow; BP, biophysical profile; CPR, abnormal cerebroplacental ratio; EFW, ultrasound estimate of fetal weight; MCA, middle cerebral artery; MoM, multiple of the median; PI, pulsatility index; RI, resistance index; SGA, small for gestational
age; UA, umbilical artery; UtA, uterine artery.
Not significant
Necrotizing enterocolitis
1.7% vs 1.1%
(P < .01)
Brochopulmonary dysplasia
Flood et al (2014)30
Ebrashy et al (2005)29
Makhseed et al
(2000)28
Bahado-Singh et al
(1999)8
Arias et al (1994)6
Gramellini et al (1992)5
Variable
Studies evaluating the CPR as a diagnostic tool in fetuses with predominantly early-onset fetal growth restriction (SGA) (continued)
TABLE 3
Expert Reviews
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18. Khalil AA, Morales-Rosello J, Morlando M,
et al. Is fetal cerebroplacental ratio an independent predictor of intrapartum fetal compromise
and neonatal unit admission? Am J Obstet
Gynecol 2015;213:54.e1-10.
19. Prior T, Mullins E, Bennett P, Kumar S.
Prediction of intrapartum fetal compromise
using the cerebroumbilical ratio: a prospective
observational study. Am J Obstet Gynecol
2013;208:124.e1-6.
20. Morales-Rosello J, Khalil A, Morlando M,
Bhide A, Papageorghiou A, Thilaganathan B.
Poor neonatal acid-base status in term fetuses
with low cerebroplacental ratio. Ultrasound
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21. Oros D, Figueras F, Cruz-Martinez R, et al.
Middle versus anterior cerebral artery Doppler for
the prediction of perinatal outcome and neonatal
neurobehavior in term small-for-gestational-age
fetuses with normal umbilical artery Doppler.
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journal of the International Society of Ultrasound
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22. Savchev S, Figueras F, Sanz-Cortes M, et al.
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2013;209:539.e1-7.
25. Ferrazzi E, Bozzo M, Rigano S, et al.
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