- Email: [email protected]
439: Fetal monitoring in gastroschisis - prediction of adverse outcome
www.AJOG.org
Doppler Assessment, Fetus, Neonatology, Prematurity
438 Monochorionic triplets with TTTS: a devilish trilemma Suzanne Peeters1, Frans Klumper1, Enrico Lopriore1, Annemieke Middeldorp1, Dick Oepkes1 1
Leiden University Medical Center, Leiden
OBJECTIVE: Monochorionic (MC) triplets have placental vascular
anastomoses between all three fetuses (Figure), a much more complex situation than in dichorionic (DC) triplets where anastomoses are only present between two fetuses. We aimed to compare perinatal outcome of MC triplets complicated by twin-to-twin transfusion syndrome (TTTS) with DC triplets with TTTS. STUDY DESIGN: We combined our center’s experience with data from the literature of all triplets complicated with TTTS, from 1990 till 2010. Survival and gestational age at birth were compared between MC and DC triplets, stratified by type of intervention. We excluded triplets with one or more fetal death⬍ 16 weeks’ gestation and those with one or more fetuses with congenital anomalies. RESULTS: See table. Differences in total survival and GA at birth were significant (p⬍0.05). CONCLUSIONS: MC triplet pregnancies complicated by TTTS appear to be at considerably higher risk for mortality and preterm birth as compared to DC triplets. The optimal strategy to managed MC triplets with TTTS, including the role of selective feticide and laser of anastomoses between all three fetuses remains to be established. Survival (fetuses)
Gest. Age at birth (wks)
Intervention
MC Triplets
MC Triplets
DC Triplets
Laser
14/27
28 (18-34)
31 (20-36)
DC Triplets 90/114
..........................................................................................................................................................................................
Cord coagulation 2/4 5/10 32 (17-40) 30 (25-37) .......................................................................................................................................................................................... Amniodrainage 2/9 3/9 26 (23-27) 34 (28-39) .......................................................................................................................................................................................... Expectant
10/21
5/15
27 (23-35)
26 (20-35)
..........................................................................................................................................................................................
Total 28/61 (44%) 103/148 (67%) 28 (17-40) 31 (20-39) ..........................................................................................................................................................................................
439 Fetal monitoring in gastroschisis prediction of adverse outcome Tania Kasdaglis1, Catherine Sharoky1, Kazumasa Hashimoto1, Sheveta Jain1, Kristin Atkins1, Sifa Turan1, Ozhan Turan1, Jerome Kopelman1, Chris Harman1, Ahmet Baschat1 1
University of Maryland School of Medicine, Baltimore, MD
OBJECTIVE: Fetuses with gastroschisis are at risk for growth delay and
unexpected stillbirth (SB). Accordingly fetal surveillance with biophysical profile scoring (BPS) is commonly carried out weekly. The aim of this study was to evaluate if integration of fetal Doppler parameters can aid in the prediction of adverse outcome that is not anticipated by the BPS.
Poster Session III
STUDY DESIGN: This is an IRB approved retrospective study of patients carrying a fetus with gastroschisis that received third trimester fetal surveillance. Patients were monitored with umbilical artery (UA), middle cerebral artery (MCA), ductus venosus (DV) Doppler and five component biophysical profile score (BPS Manning). Doppler parameters were related to gestational age at exam, amniotic fluid volume, and BPS. Rates of stillbirth (SB), abnormal BPS, and oligohydramnios (maximum vertical pocket ⬍ 2cm) were related to Doppler parameters and BPS at the preceeding exam. Prediction of delivery for deterioration in fetal status, cord artery pH ⬍ 7.0, 5 min Apgar ⬍ 7, and neonatal death was evaluated for the last exam before delivery. RESULTS: Thirty-seven patients with fetal gastroschisis were included in this study. Two had unanticipated SB within one week of a normal BPS and normal UA, MCA and DV Dopplers. Eight patients were delivered for fetal deterioration (2 abnormal BPS, 6 with abnormal fetal heart rate) which occurred within 1 week of normal BPS. While UA Doppler was normal in these patients, abnormal DV waveform predicted accelerated deterioration of fetal status in 4 of these 8 patients, (Chi square, p⬍0.02). Neonatal complications were not predicted by BPS or Doppler. CONCLUSIONS: Babies with gastroschisis exhibit similar trends in Doppler parameters as other fetuses, but are capable of sudden deterioration of fetal status and unexpected fetal demise. Abnormal ductus venosus Doppler can indicate premature deterioration of biophysical variables and the need for delivery.
440 Maternal under-nutrition results in increased apoptosis in near-term and term offspring kidneys Thomas R. Magee1, Sanaz A. Tafti1, Cynthia C. Nast2, Mina Desai1, Michael G. Ross1 1 LABioMed at Harbor-UCLA Med. Ctr., Torrance, CA, 2Cedars-Sinai Med. Ctr., Los Angeles, CA
OBJECTIVE: Maternal undernutrition (MUN) results in growth restricted newborns with reduced renal glomerular numbers resulting in an increased risk of adult hypertension and renal disease. A possible cause of reduced glomeruli may be increased apoptosis (programmed cell death) and we investigated whether apoptotic signaling and cell death were increased in MUN rat kidneys. STUDY DESIGN: Pregnant rat dams were fed either ad libitum diet (control) or were 50% food restricted (MUN) from embryonic day (E10) to induce growth restricted fetuses. At E20 and postnatal day 1 (P1), male offspring kidneys (n⫽5 each MUN and control) were prepared for mRNA analysis by qPCR and protein expression analysis by Western blotting and immunohistochemistry. Apoptosis was measured by the TUNEL assay. Data were considered statistically significant by t-test (pⱕ0.05). RESULTS: MUN kidney showed a trend of increased apoptosis at E20 that was markedly increased at P1. Up-regulation of pro-apoptotic genes was detected at E20 (Fas, Fas Ligand, Caspase 9) with further gene induction at P1 (Caspase 3, Bax). The anti-apoptotic factor Bcl2 was decreased in P1 kidneys. Kidney TUNEL showed significantly increased apoptotic nuclei in the P1 nephrogenic zone (MUN 2.2 ⫾ 0.3 vs C 1.6 ⫾ 0.5, p ⱕ 0.05). The majority of apoptotic nuclei colocalized to undifferentiated mesenchyme and pretubular aggregates in the nephrogenic zone. E20 TUNEL trended upward but was not significant (p⫽0.07). CONCLUSIONS: Pro-apoptotic mRNA and proteins were increased at E20 and to a greater extent at P1 suggesting differential regulation following parturition. Apoptosis is up-regulated in P1 term MUN offspring kidneys in the mesenchyme and pretubular aggregates, thus suggesting a mechanism for impairing postpartum nephron formation. Therefore, upregulated apoptosis likely is an important mechanism for the induction of nephropenia in gestational programming of the kidney.
Supplement to JANUARY 2011 American Journal of Obstetrics & Gynecology
S177
Doppler Assessment, Fetus, Neonatology, Prematurity
438 Monochorionic triplets with TTTS: a devilish trilemma Suzanne Peeters1, Frans Klumper1, Enrico Lopriore1, Annemieke Middeldorp1, Dick Oepkes1 1
Leiden University Medical Center, Leiden
OBJECTIVE: Monochorionic (MC) triplets have placental vascular
anastomoses between all three fetuses (Figure), a much more complex situation than in dichorionic (DC) triplets where anastomoses are only present between two fetuses. We aimed to compare perinatal outcome of MC triplets complicated by twin-to-twin transfusion syndrome (TTTS) with DC triplets with TTTS. STUDY DESIGN: We combined our center’s experience with data from the literature of all triplets complicated with TTTS, from 1990 till 2010. Survival and gestational age at birth were compared between MC and DC triplets, stratified by type of intervention. We excluded triplets with one or more fetal death⬍ 16 weeks’ gestation and those with one or more fetuses with congenital anomalies. RESULTS: See table. Differences in total survival and GA at birth were significant (p⬍0.05). CONCLUSIONS: MC triplet pregnancies complicated by TTTS appear to be at considerably higher risk for mortality and preterm birth as compared to DC triplets. The optimal strategy to managed MC triplets with TTTS, including the role of selective feticide and laser of anastomoses between all three fetuses remains to be established. Survival (fetuses)
Gest. Age at birth (wks)
Intervention
MC Triplets
MC Triplets
DC Triplets
Laser
14/27
28 (18-34)
31 (20-36)
DC Triplets 90/114
..........................................................................................................................................................................................
Cord coagulation 2/4 5/10 32 (17-40) 30 (25-37) .......................................................................................................................................................................................... Amniodrainage 2/9 3/9 26 (23-27) 34 (28-39) .......................................................................................................................................................................................... Expectant
10/21
5/15
27 (23-35)
26 (20-35)
..........................................................................................................................................................................................
Total 28/61 (44%) 103/148 (67%) 28 (17-40) 31 (20-39) ..........................................................................................................................................................................................
439 Fetal monitoring in gastroschisis prediction of adverse outcome Tania Kasdaglis1, Catherine Sharoky1, Kazumasa Hashimoto1, Sheveta Jain1, Kristin Atkins1, Sifa Turan1, Ozhan Turan1, Jerome Kopelman1, Chris Harman1, Ahmet Baschat1 1
University of Maryland School of Medicine, Baltimore, MD
OBJECTIVE: Fetuses with gastroschisis are at risk for growth delay and
unexpected stillbirth (SB). Accordingly fetal surveillance with biophysical profile scoring (BPS) is commonly carried out weekly. The aim of this study was to evaluate if integration of fetal Doppler parameters can aid in the prediction of adverse outcome that is not anticipated by the BPS.
Poster Session III
STUDY DESIGN: This is an IRB approved retrospective study of patients carrying a fetus with gastroschisis that received third trimester fetal surveillance. Patients were monitored with umbilical artery (UA), middle cerebral artery (MCA), ductus venosus (DV) Doppler and five component biophysical profile score (BPS Manning). Doppler parameters were related to gestational age at exam, amniotic fluid volume, and BPS. Rates of stillbirth (SB), abnormal BPS, and oligohydramnios (maximum vertical pocket ⬍ 2cm) were related to Doppler parameters and BPS at the preceeding exam. Prediction of delivery for deterioration in fetal status, cord artery pH ⬍ 7.0, 5 min Apgar ⬍ 7, and neonatal death was evaluated for the last exam before delivery. RESULTS: Thirty-seven patients with fetal gastroschisis were included in this study. Two had unanticipated SB within one week of a normal BPS and normal UA, MCA and DV Dopplers. Eight patients were delivered for fetal deterioration (2 abnormal BPS, 6 with abnormal fetal heart rate) which occurred within 1 week of normal BPS. While UA Doppler was normal in these patients, abnormal DV waveform predicted accelerated deterioration of fetal status in 4 of these 8 patients, (Chi square, p⬍0.02). Neonatal complications were not predicted by BPS or Doppler. CONCLUSIONS: Babies with gastroschisis exhibit similar trends in Doppler parameters as other fetuses, but are capable of sudden deterioration of fetal status and unexpected fetal demise. Abnormal ductus venosus Doppler can indicate premature deterioration of biophysical variables and the need for delivery.
440 Maternal under-nutrition results in increased apoptosis in near-term and term offspring kidneys Thomas R. Magee1, Sanaz A. Tafti1, Cynthia C. Nast2, Mina Desai1, Michael G. Ross1 1 LABioMed at Harbor-UCLA Med. Ctr., Torrance, CA, 2Cedars-Sinai Med. Ctr., Los Angeles, CA
OBJECTIVE: Maternal undernutrition (MUN) results in growth restricted newborns with reduced renal glomerular numbers resulting in an increased risk of adult hypertension and renal disease. A possible cause of reduced glomeruli may be increased apoptosis (programmed cell death) and we investigated whether apoptotic signaling and cell death were increased in MUN rat kidneys. STUDY DESIGN: Pregnant rat dams were fed either ad libitum diet (control) or were 50% food restricted (MUN) from embryonic day (E10) to induce growth restricted fetuses. At E20 and postnatal day 1 (P1), male offspring kidneys (n⫽5 each MUN and control) were prepared for mRNA analysis by qPCR and protein expression analysis by Western blotting and immunohistochemistry. Apoptosis was measured by the TUNEL assay. Data were considered statistically significant by t-test (pⱕ0.05). RESULTS: MUN kidney showed a trend of increased apoptosis at E20 that was markedly increased at P1. Up-regulation of pro-apoptotic genes was detected at E20 (Fas, Fas Ligand, Caspase 9) with further gene induction at P1 (Caspase 3, Bax). The anti-apoptotic factor Bcl2 was decreased in P1 kidneys. Kidney TUNEL showed significantly increased apoptotic nuclei in the P1 nephrogenic zone (MUN 2.2 ⫾ 0.3 vs C 1.6 ⫾ 0.5, p ⱕ 0.05). The majority of apoptotic nuclei colocalized to undifferentiated mesenchyme and pretubular aggregates in the nephrogenic zone. E20 TUNEL trended upward but was not significant (p⫽0.07). CONCLUSIONS: Pro-apoptotic mRNA and proteins were increased at E20 and to a greater extent at P1 suggesting differential regulation following parturition. Apoptosis is up-regulated in P1 term MUN offspring kidneys in the mesenchyme and pretubular aggregates, thus suggesting a mechanism for impairing postpartum nephron formation. Therefore, upregulated apoptosis likely is an important mechanism for the induction of nephropenia in gestational programming of the kidney.
Supplement to JANUARY 2011 American Journal of Obstetrics & Gynecology
S177