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Early functional and morphological brain disturbances in late-onset intrauterine growth restriction
Mirta Starčević1, Maja Predojević2, Dražan Butorac3
1Division of Neonatology, Department of Pediatrics, Clinical Hospital Center "Sestre milosrdnice", Medical School, University of Zagreb, Vinogradska cesta 29, 10000 Zagreb, Croatia.
Insights
Brain disturbances in late-onset intrauterine growth restriction (IUGR) occur before compensatory blood flow changes. The cerebroumbilical (C/U) ratio effectively predicts adverse neurological outcomes in IUGR fetuses.
Area of Science:
- Perinatal Medicine
- Fetal Neurology
- Medical Imaging and Diagnostics
Background:
- Late-onset intrauterine growth restriction (IUGR) poses risks to fetal neurological development.
- Compensatory cardiovascular mechanisms, like blood flow redistribution, are typically monitored in IUGR.
- The timing of brain disturbances relative to these compensatory mechanisms is not fully understood.
Purpose of the Study:
- To investigate if brain disturbances in late-onset IUGR precede detectable blood flow redistribution.
- To assess the predictive value of Doppler indices and umbilical cord blood gases for early neurological issues in IUGR.
- To correlate Doppler findings with functional and morphological neurological outcomes.
Main Methods:
- A cohort study of 60 term pregnancies with late-onset IUGR (after 34 weeks).
- Weekly monitoring of umbilical artery resistance index (URI), middle cerebral artery resistance index (CRI), and the cerebroumbilical (C/U) ratio.
- Analysis of umbilical cord blood gases (pO2, pCO2, pH) and neurological assessments (cranial ultrasound, Amiel-Tison Neurological Assessment at Term).
Main Results:
- Abnormal neurological findings were prevalent: 53.37% had abnormal cranial ultrasounds and 70.00% had non-optimal Amiel-Tison scores.
- Doppler indices demonstrated higher predictive validity for early brain disturbances than blood gas analysis.
- The C/U ratio showed the highest predictive value, with a threshold of 1.13 (ROC analysis) for adverse neurological outcomes.
Conclusions:
- Functional and/or structural brain disturbances in late-onset IUGR can manifest before fetal cardiovascular compensation is evident.
- Cerebroumbilical (C/U) ratio exceeding 1 indicates adverse neurological outcomes, even before Doppler signs of blood flow redistribution.
- Early detection of neurological disturbances in IUGR is possible through monitoring Doppler indices, particularly the C/U ratio.
Aims:
To determine whether the brain disturbances develop in late-onset intrauterine growth restriction (IUGR) before blood flow redistribution towards the fetal brain (detected by Doppler measurements in the middle cerebral artery and umbilical artery). Further, to evaluate predictive values of Doppler arterial indices and umbilical cord blood gases and pH for early functional and/or morphological brain disturbances in late-onset IUGR.
Study Design:
This cohort study included 60 singleton term pregnancies with placental insufficiency caused late-onset IUGR (IUGR occurring after 34 gestational weeks). Umbilical artery resistance index (URI), middle cerebral artery resistance index (CRI), and cerebroumbilical (C/U) ratio (CRI/URI) were monitored once weekly. Umbilical blood cord samples (arterial and venous) were collected for the analysis of pO2, pCO2 and pH. Morphological neurological outcome was evaluated by cranial ultrasound (cUS), whereas functional neurological outcome by Amiel-Tison Neurological Assessment at Term (ATNAT).
Results:
50 fetuses had C/U ratio>1, and 10 had C/U ratio≤1; among these 10 fetuses, 9 had abnormal neonatal cUS findings and all 10 had non-optimal ATNAT. However, the total number of abnormal neurological findings was much higher. 32 neonates had abnormal cUS (53.37%), and 42 (70.00%) had non-optimal ATNAT. Furthermore, Doppler indices had higher predictive validity for early brain disturbances than umbilical cord blood gases and pH. C/U ratio had the highest predictive validity with threshold for adverse neurological outcome at value 1.13 (ROC analysis), i.e., 1.18 (party machine learning algorithm).
Conclusion:
Adverse neurological outcome at average values of C/U ratios>1 confirmed that early functional and/or structural brain disturbances in late-onset IUGR develop even before activation of fetal cardiovascular compensatory mechanisms, i.e., before Doppler signs of blood flow redistribution between the fetal brain and the placenta.
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