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• W4362699831 abstract "Steller et al1Steller J.G. Driver C. Gumina D. et al.Doppler velocimetry discordance between paired umbilical artery vessels and clinical implications in fetal growth restriction.Am J Obstet Gynecol. 2022; 227: 285.e1-285.e7Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar reports that in a cohort of babies with intrauterine growth restriction (IUGR) the mean difference in the umbilical artery (UA) pulsatility index (PI) between each UA was 11.7%, and in 16.7% there was discordance in categorization between 1 normal and 1 abnormal Doppler recording. Overall, over 1 in 2 fetuses with an abnormal UA PI showed discordant results between the 2 umbilical arteries, and in these cases the outcome was intermediate with respect to IUGR fetuses showing both normal or both abnormal UA PI. We congratulate Steller et al1Steller J.G. Driver C. Gumina D. et al.Doppler velocimetry discordance between paired umbilical artery vessels and clinical implications in fetal growth restriction.Am J Obstet Gynecol. 2022; 227: 285.e1-285.e7Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar and would like to comment on some of the findings of the research. UA Doppler plays a key role in the diagnosis, management and also in the prediction of adverse perinatal outcome in fetuses with IUGR,2Lees C.C. Romero R. Stampalija T. et al.Clinical Opinion: the diagnosis and management of suspected fetal growth restriction: an evidence-based approach.Am J Obstet Gynecol. 2022; 226: 366-378Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar and its assessment is endorsed by the International Guidelines.3Society for Maternal-Fetal Medicine (SMFM). Electronic address: [email protected], Martins JG, Biggio JR, Abuhamad A. Society for Maternal-Fetal Medicine Consult Series #52: diagnosis and management of fetal growth restriction: (Replaces Clinical Guideline Number 3, April 2012). Am J Obstet Gynecol 2020;223:B2–17.Google Scholar, 4Lees C.C. Stampalija T. Baschat A. et al.ISUOG Practice Guidelines: diagnosis and management of small-for-gestational-age fetus and fetal growth restriction.Ultrasound Obstet Gynecol. 2020; 56: 298-312Crossref PubMed Scopus (256) Google Scholar, 5Melamed N. Baschat A. Yinon Y. et al.FIGO (international Federation of Gynecology and Obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction.Int J Gynaecol Obstet. 2021; 152: 3-57Crossref PubMed Scopus (110) Google Scholar Discordant UA Doppler findings may impact on the decision as to how often to monitor and when to deliver a IUGR fetus.2Lees C.C. Romero R. Stampalija T. et al.Clinical Opinion: the diagnosis and management of suspected fetal growth restriction: an evidence-based approach.Am J Obstet Gynecol. 2022; 226: 366-378Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 3Society for Maternal-Fetal Medicine (SMFM). Electronic address: [email protected], Martins JG, Biggio JR, Abuhamad A. Society for Maternal-Fetal Medicine Consult Series #52: diagnosis and management of fetal growth restriction: (Replaces Clinical Guideline Number 3, April 2012). Am J Obstet Gynecol 2020;223:B2–17.Google Scholar, 4Lees C.C. Stampalija T. Baschat A. et al.ISUOG Practice Guidelines: diagnosis and management of small-for-gestational-age fetus and fetal growth restriction.Ultrasound Obstet Gynecol. 2020; 56: 298-312Crossref PubMed Scopus (256) Google Scholar, 5Melamed N. Baschat A. Yinon Y. et al.FIGO (international Federation of Gynecology and Obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction.Int J Gynaecol Obstet. 2021; 152: 3-57Crossref PubMed Scopus (110) Google Scholar Reproducibility of the UA PI has been investigated, and studies show suboptimal agreement.6Segev M. Weissmann-Brenner A. Weissbach T. Kassif E. Weisz B. Intra-observer variability of Doppler measurements in umbilical artery (UA) and middle cerebral artery (MCA) in uncomplicated term pregnancies.J Matern Fetal Neonatal Med. 2022; 35: 5653-5658Crossref PubMed Scopus (0) Google Scholar,7Bhide A. Badade A. Khatal K. The effect of sampling site on the variability of umbilical artery PI.Eur J Obstet Gynecol Reprod Biol. 2019; 235: 102-105Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Although in practice, it is difficult to ascertain which UA is sampled, from a pathophysiological point of view, the results reported by Steller et al1Steller J.G. Driver C. Gumina D. et al.Doppler velocimetry discordance between paired umbilical artery vessels and clinical implications in fetal growth restriction.Am J Obstet Gynecol. 2022; 227: 285.e1-285.e7Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar can be explained either because the diameter of paired umbilical arteries may vary in the same fetus or that difference in PI is occurring through biological natural variation of impedance in the same artery. Another hypothesis is that focal areas of placental infarction/thrombosis or other types of focal placental pathology, may be accounted as the determinants of such phenomenon given that the 2 umbilical arteries are tributary of different areas of the placenta. In such context, information on the pathology reports of the placenta would add knowledge in the cases with discordant findings. Another subject of debate is represented by the fact that different cutoff thresholds and reference charts for defining normal and abnormal UA PI have been proposed,8Drukker L. Staines-Urias E. Papageorghiou A.T. The INTERGROWTH-21st Doppler centile charts: complementing tools for monitoring of growth and development from pregnancy to childhood.Am J Obstet Gynecol. 2021; 224: 249-250Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,9Acharya G. Wilsgaard T. Berntsen G.K. Maltau J.M. Kiserud T. Reference ranges for serial measurements of umbilical artery Doppler indices in the second half of pregnancy.Am J Obstet Gynecol. 2005; 192: 937-944Abstract Full Text Full Text PDF PubMed Scopus (304) Google Scholar and it is uncertain whether different Doppler charts would have performed differently compared with those used in the study by Steller et al.1Steller J.G. Driver C. Gumina D. et al.Doppler velocimetry discordance between paired umbilical artery vessels and clinical implications in fetal growth restriction.Am J Obstet Gynecol. 2022; 227: 285.e1-285.e7Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar,9Acharya G. Wilsgaard T. Berntsen G.K. Maltau J.M. Kiserud T. Reference ranges for serial measurements of umbilical artery Doppler indices in the second half of pregnancy.Am J Obstet Gynecol. 2005; 192: 937-944Abstract Full Text Full Text PDF PubMed Scopus (304) Google Scholar Finally, changes in the fetal biophysical status may play a role in determining inconsistent UA Doppler recordings during 1 single examination.4Lees C.C. Stampalija T. Baschat A. et al.ISUOG Practice Guidelines: diagnosis and management of small-for-gestational-age fetus and fetal growth restriction.Ultrasound Obstet Gynecol. 2020; 56: 298-312Crossref PubMed Scopus (256) Google Scholar Hence there is an urgent need to improve our understanding on the clinical significance of discordant Doppler recordings in the context of IUGR fetuses. The finding of severe Doppler abnormalities such as intermittently absent end-diastolic flow in 1 of the 2 umbilical arteries is not uncommon, and may impact on timing and mode of delivery at gestational age, remote from term. Discordant UA Doppler findings may also impact on the diagnosis of IUGR in those settings where the definition of IUGR includes not only biometry3Society for Maternal-Fetal Medicine (SMFM). Electronic address: [email protected], Martins JG, Biggio JR, Abuhamad A. Society for Maternal-Fetal Medicine Consult Series #52: diagnosis and management of fetal growth restriction: (Replaces Clinical Guideline Number 3, April 2012). Am J Obstet Gynecol 2020;223:B2–17.Google Scholar but also Doppler indicators of the placental function4Lees C.C. Stampalija T. Baschat A. et al.ISUOG Practice Guidelines: diagnosis and management of small-for-gestational-age fetus and fetal growth restriction.Ultrasound Obstet Gynecol. 2020; 56: 298-312Crossref PubMed Scopus (256) Google Scholar,5Melamed N. Baschat A. Yinon Y. et al.FIGO (international Federation of Gynecology and Obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction.Int J Gynaecol Obstet. 2021; 152: 3-57Crossref PubMed Scopus (110) Google Scholar and be taken into account in terms of frequency of monitoring of IUGR. However, common practice is to repeat measurements and only where consistently abnormal in both umbilical arteries consider to expedite delivery. It is also uncertain whether repeat measurement discordance is less common as the UA Doppler becomes progressively more abnormal. Based on this, caution should be advocated before reporting Doppler findings as discordant, and strict monitoring could represent the optimal management in cases where at least 1 UA shows reassuring Doppler recordings before term gestation. Addressing pitfalls in the study of discrepant umbilical artery DopplersAmerican Journal of Obstetrics & GynecologyVol. 229Issue 2PreviewWe thank Drs Dall’Asta et al for their interest and comments on our study. We agree with their assessment that discordant umbilical artery (UA) Doppler findings can potentially impact fetal growth restriction (FGR) surveillance and management. The challenge of reproducibility of the UA pulsatility index (PI), as described in their letter, will likely remain a challenge if only 1 of the paired UAs is sampled given the inability to know if the same vessel is repeatedly sampled. In practice, we find sampling both arteries to be quite straightforward if a long segment of the cord is visualized with color Doppler, which allows the 2 arteries to be seen running side by side as noted in Figure 1 of our manuscript. Full-Text PDF" @default.
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• W4362699831 title "Umbilical artery Doppler velocimetry in fetal growth restriction: evidence and unanswered questions" @default.
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