Cerebroplacental ratio for prediction of adverse intrapartum and neonatal outcomes in a term uncomplicated pregnancy

Background Fetal hypoxia is one of the major causes of high perinatal morbidity and mortality rates. Doppler ultrasound tests such as cerebroplacental ratio (CPR) evaluation are commonly used to assess blood flow disturbances in placento-umbilical and feto-cerebral circulations. A low cerebroplacental ratio has been shown to be associated with an increased risk of stillbirth regardless of the gestation or fetal weight. We conducted this study to assess the fetal cerebroplacental ratio in prediction of adverse intrapartum and neonatal outcomes in a term, uncomplicated pregnancy to reduce fetal and neonatal morbidity and mortality. Results It was found that neonates with CPR ≤1.1 had significantly higher frequencies of cesarean delivery (CS) for intrapartum fetal compromise compared to those with CPR >1.1 (p=0.043). Neonates with CPR ≤1.1 had significantly lower Apgar score at 1 min and 5 min than those with CPR >1.1 (p=0.004) and (p=0.003), respectively. Neonates with CPR ≤1.1 had significantly higher rates of NICU admission than those with CPR <1.1 (p=0.004). Conclusion The cerebroplacental ratio shows the highest sensitivity in the prediction of fetal heart rate abnormalities and adverse neonatal outcome in uncomplicated pregnancies at term. The cerebroplacental ratio index is useful in clinical practice in antenatal monitoring of these women in order to select those at high risk of intra- and postpartum complications.

Cerebroplacental Ratio on Doppler as a Predictor of Fetuses at Risk of Perinatal Complications

Background: Doppler velocimetry is the best method of surveillance for fetal hypoxemia during pregnancy. Cerebroplacental ratio (CPR), has been suggested as a useful clinical simplification. It is believed that the CPR better predicts adverse perinatal outcomes than its individual components and better than conventional anthropometric models. Therefore, the aim of this study is to evaluate the significance of the cerebroplacental 10th centile threshold measured weekly from 36 weeks of gestation till delivery as a screening test for prediction of need for Cesarean section for intrapartum fetal compromise and the adverse neonatal outcome in women with normally grown fetuses and uncomplicated pregnancy. Methods: This study was carried out on 40 pregnant women uncomplicated, singleton pregnancy with appropriately grown fetuses on clinical assessment. The last Doppler indices including cerebroplacental ratio measurement obtained before labor was reported. CPR values below 1.1 were reported as abnormal. Various studies have variably defined the threshold of abnormal CPR ratio as <1.08. Results: There was significant decrease in the Mean of CPR among patients who had anemia compared to those without anemia. In addition, there was no significant association seen between low CPR and having previous history of abortion or IUGR as well as being a smoker. There was no significant difference between cases who had normal and abnormal CPR regarding gestational age at delivery. There was no difference between cases who had normal and abnormal cerebroplacental ratio regarding mode of delivery. there was significant decrease in the prevalence of low birth weight among group who had CPR≥1.08. CPR <1.08 was significantly associated with neonatal complication like NICU admission, and neonatal death. There was no statistically significant relationship between cerebroplacental ratio and neonatal complication like IUFD, and neonatal sepsis. There was no statistically significant association between the mean cerebroplacental ratio and IUFD. There was statistically significant association between the mean cerebroplacental ratio and NICU. There was no statistically significant association between the mean cerebroplacental ratio and neonatal sepsis. The mean cerebroplacental ratio of 0.93± 0.22 has a significant association with neonatal death. Conclusion: A low cerebroplacental ratio reflects redistribution of the cardiac output to the cerebral circulation and has been shown to improve accuracy in predicting adverse outcome compared with Middle cerebral artery (MCA) or Umbilical artery (UA) Doppler alone. Therefore, integrating CPR in clinical management may help to better identify fetuses at risk for adverse perinatal events, since abnormal CPR has been associated with an increased risk of perinatal complications.

Effect of Maternal and Fetal Characteristics in Feto-Placental Doppler and Impact of Using Adjusted Standards in the Definition of Fetal Growth Restriction at Term

<b><i>Introduction:</i></b> This study aimed to determine the effect and clinical impact of physiological characteristics on the 95th/5th centile of the umbilical artery (UA) Doppler and the cerebroplacental ratio (CPR), at 36+ weeks. <b><i>Methods:</i></b> From the multicenter randomized trial “Ratio37,” we selected 4,505 low-risk pregnant women between June 2016 and January 2020. We registered physiological characteristics and the pulsatility indexes (PI) of the UA and middle cerebral artery (36–39 weeks). The 95th/5th centile of the UA PI and CPR was modeled by quantile regression. To evaluate the clinical impact of adjusting Doppler, we retrospectively applied gestational age (GA) and fully adjusted standards to 682 small for gestational age (SGA)-suspected fetuses (37 weeks) from a cohort of consecutive patients obtained between January 2010 and January 2020. <b><i>Results:</i></b> Several physiological characteristics significantly influenced the 95th/5th centile of the UA and CPR PI. The fully adjusted 95th centile of the UA was higher, and the 5th centile of the CPR was lower than GA-only-adjusted standards. Of the 682 SGA fetuses, 150 (22%) were classified as late fetal growth restricted only by GA and 112 (16.4%) when we adjusted Doppler. These 38 fetuses had similar perinatal outcome than the SGA group. <b><i>Discussion:</i></b> The 95th/5th centile of the UA and CPR PI is significantly influenced by physiological characteristics. Adjusting Doppler standards could differentiate better between FGR and SGA.

Umbilical Artery and Middle Cerebral Artery and Cerebroplacental Ratio for Doppler Indices’ Reference Ranges

Aim: To investigate the reference values of Doppler indices for umbilical artery and Middle Cerebral Artery as well as Cerebro-placental Ratio and specifically, to evaluate the quality of methodology used on which these reference values are grounded, with the help of already established quality standards for research design, statistical analysis as well as methods of results reporting. Methodology: The methodological quality of the full-text versions of eligible studies was assessed independently by the same reviewers and a medical statistician (E.S.U.). Disagreements were resolved by consensus or consultation with two other reviewers (A.T.P. and E.F.). Quality criteria for evaluation methodologies of the published articles was developed which was based on the already available research publication25,36,37. The methodology evaluation criteria was segregated into two levels, one is study design and the other one is statistics used as well as its reporting methods. Total no. of criteria of quality were 24 to be evaluated. Results: Generally, methodological quality score was parallel for the research articles designed to evaluate umbilical artery range (median 42%; range 13.8–63.8%). For the studies focusing on middle cerebral artery range showed a median of 48% with a Class interval of 22.1–72.1% whereas the median score of cerebroplacental ratio was 47.1% with a Class interval of 34.6–55.5%. Conclusion: Rigorous methodology of this review study is the major strength, which is consisted of a standard and well developed methodology of scoring the quality of studies according to their methodology selection as well as the statistical analysis and the level of its interpretation. Keywords: Umbilical artery, Middle Cerebral Artery, Cerebro-placental Ratio, Doppler indices