title: Doppler assessment of the aortic isthmus and perinatal outcome in preterm fetuses with severe intrauterine growth restriction.
abstract: OBJECTIVE
  To evaluate the characteristics and association with perinatal outcome of the aortic isthmus (AoI) circulation as assessed by Doppler imaging in preterm growth-restricted fetuses with placental insufficiency.
  
  
  METHODS
  This was a prospective cross-sectional study. Fifty-one fetuses with intrauterine growth restriction (IUGR) and either an umbilical artery (UA) pulsatility index (PI) > 95(th) centile or a cerebroplacental ratio < 5(th) centile were examined at 24-36 weeks' gestation. AoI impedance indices (PI and resistance index) and absolute velocities (peak systolic (PSV), end-diastolic and time-averaged maximum (TAMXV) velocities), were measured in all cases and compared with reference ranges by gestational age. Furthermore, fetuses were stratified into two groups according to the direction of the diastolic blood flow in the AoI: those with antegrade flow (n = 41) and those with retrograde flow (n = 10). Clinical surveillance was based on gestational age and Doppler assessment of the UA, middle cerebral artery and ductus venosus (DV). Adverse perinatal outcome was defined as stillbirth, neonatal death and severe morbidity (respiratory distress syndrome, bronchopulmonary dysplasia, Grade III/IV intraventricular hemorrhage, necrotizing enterocolitis and a neonatal intensive care unit stay > 14 days).
  
  
  RESULTS
  Adverse perinatal outcome was significantly associated with an increased AoI-PI (area under the curve 0.77; 95% CI, 0.63-0.92; P < 0.005). A significant correlation (P < 0.001) was found between retrograde blood flow in the AoI and adverse perinatal outcome, the overall perinatal mortality being higher in the retrograde group (70% vs. 4.8%, P < 0.001). In 4/5 (80%) fetuses the reversal of flow in the AoI preceded that in the DV by 24-48 h. AoI-PSV and AoI-TAMXV were < 5(th) centile in 40/51 (78%) and 48/51 (94%) cases, respectively, whereas AoI-PI was > 95(th) centile in 21/51 (41%) cases.
  
  
  CONCLUSIONS
  Retrograde flow in the AoI in growth-restricted fetuses correlates strongly with adverse perinatal outcome. Absolute velocities in the AoI are decreased in growth-restricted fetuses. The data suggest a potential role for Doppler imaging of the AoI in the clinical surveillance of fetuses with severe IUGR, which should be confirmed in larger prospective studies.
authors.affiliation: Department of Maternal-Fetal Medicine, ICGON, Hospital Clínic, University of Barcelona and Centre for Biomedical Research on Rare Diseases (CIBERER), Barcelona, Spain. maria331973@hotmail.com
authors.forename: M
authors.initials: M
authors.lastname: Del Río
authors.forename: J M
authors.initials: JM
authors.lastname: Martínez
authors.forename: F
authors.initials: F
authors.lastname: Figueras
authors.forename: M
authors.initials: M
authors.lastname: Bennasar
authors.forename: A
authors.initials: A
authors.lastname: Olivella
authors.forename: M
authors.initials: M
authors.lastname: Palacio
authors.forename: O
authors.initials: O
authors.lastname: Coll
authors.forename: B
authors.initials: B
authors.lastname: Puerto
authors.forename: E
authors.initials: E
authors.lastname: Gratacós
mesh_terms: D001013:Aorta, Thoracic / Q000000981:diagnostic imaging* / Q000196:embryology / Q000503:physiopathology; D001783:Blood Flow Velocity / Q000502:physiology; D004812:Epidemiologic Methods; D005260:Female; D005312:Fetal Blood / Q000000981:diagnostic imaging; D005317:Fetal Growth Retardation / Q000000981:diagnostic imaging* / Q000401:mortality / Q000503:physiopathology; D005333:Fetus / Q000098:blood supply*; D005865:Gestational Age; D006801:Humans; D010920:Placenta / Q000098:blood supply / Q000000981:diagnostic imaging; D010927:Placental Insufficiency / Q000000981:diagnostic imaging* / Q000401:mortality / Q000503:physiopathology; D011247:Pregnancy; D047928:Premature Birth / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology*; D018608:Ultrasonography, Doppler / Q000379:methods