Antepartum Fetal Surveillance

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CDC is not responsible for the content of pages found at these sites. Clin Infect Dis ;44 7: Int Dent J ;44 4 Suppl 1: However, it you want to do it multi-stage, stratified, I am not able to assist you. Non-Hispanic white adults had the lowest percentage 8. Relevant documents were identified using PubMed US National Library of Medicine, through publications, written in English, which describe the peri-partum outcomes of IUGR according to Doppler assessment of umbilical arterial, middle cerebral artery, and ductus venosus. Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change.

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The most recent definitions for fiber generally address at least one of four characteristics: With the advances of food science, isolation, modification, and synthesis of many fibers are possible, which have resulted in some jurisdictions distinguishing between naturally occurring fibers from plant source and isolated or synthesized fibers. Others have chosen not to adopt this division by either considering all nondigestible carbohydrates as fiber or only those carbohydrates that are intrinsic and intact in plants.

Table 1 lists examples of such definitions based on this division. As seen in the previous section, fibers are often classified by their source plant, animal, isolated, synthetic, etc. Chemical classification can divide carbohydrates based on their chain length, or DP: However, some carbohydrates do not fit into this categorization.

For instance, inulin may have from 2 to fructose units and thus can be both oligo- and polysaccharide [ 35 ]. Fibers are most commonly characterized based on their solubility. Distinction between soluble and insoluble dietary fibers is based on the solubility characteristics of dietary fiber in hot aqueous buffer solutions [ 38 ].

Solubility of dietary fiber structure cannot be simply described as the solubility in water. Solubility of dietary fibers is rather defined as dissolved or liquefied in a buffer and enzyme solution modeled after, but not necessarily identical to, the aqueous enzyme solutions or slurries present in the human system [ 39 ].

Solubility can be used as a means to broadly characterize the physiological effects of fibers. In general, insoluble fibers increase fecal bulk and the excretion of bile acids and decrease intestinal transit time i. Soluble fibers increase total transit time by delaying gastric emptying and also slow glucose absorption [ 40 ]. Although this characterization of fiber is used to generalize the effects of each fiber type, only soluble viscous fibers delay gastric emptying time and slow glucose absorption while nonviscous soluble fibers primarily act as a substrate for microbial fermentation in the colon [ 33 ].

The rate at which a carbohydrate is digested is determined by a number of factors, including the rate at which carbohydrate leaves the stomach and becomes available for absorption as well as diffusion of released sugars occurs from food bolus [ 41 ]. Thus, the rate at which carbohydrates leave the food matrix and the ability for amylase to act on the carbohydrate is an important determinant of glucose absorption rate and resulting blood glucose levels.

Based on digestion, carbohydrates can be categorized as rapidly or slowly digested or even resistant. Resistant carbohydrates include plant cell wall polysaccharides, gums, fructans, resistant maltodextrins, and resistant starches. These carbohydrates that resist digestion make their way to the large intestine, where they may be fermented by the gut microflora [ 33 ] or have prebiotic effects [ 34 ]. However, not all fiber is fermented. Short-chained fatty acids produced from fermentation are mainly sourced from resistant starches [ 42 , 43 ].

Prebiotic fibers alter the balance of the gut microflora towards what is considered to be a healthier one [ 34 ] and includes fructans and resistant starches [ 45 ]. For food labelling purposes, it is important that analytical methods complement the fiber definition in a given jurisdiction. Fibers are typically measured by enzymatic-gravimetric methods, although there are also gravimetric, nonenzymatic-gravimetric, and enzymatic chemical methods.

Fibers recovered with enzymatic-gravimetric methods include cellulose, hemicelluloses, pectins, some other nonstarch polysaccharides, lignin and some resistant starch. Soluble and insoluble fibers can also be measured separately by this method [ 46 ].

However, these methods do not capture inulin and polydextrose and partially measure resistant starch. To remedy this, separate procedures have been proposed to quantify these other compounds. Resistant starch, oligofructan, inulin, fructo-oligosaccharides, and polydextrose can also be measured independently by several methods [ 29 ].

However, these methods incompletely measure all fibers included in the Codex definition, and the use of some or all of these methods could result in underestimation of some fibers as well as overestimation of others due to double counting.

It is also particularly important for food labelling that fiber analysis be completed on foods as they would be eaten in order to provide more accurate fiber values that account for the effects of processing and cooking procedures [ 49 ].

The AOAC method Dietary fibers have been strongly implicated in the prevention and treatment of various characteristics of the metabolic syndrome. The beneficial effect of fiber-rich foods and isolated fibers, both insoluble and soluble, on obesity, cardiovascular diseases, and type 2 diabetes has been shown in randomized studies [ 6 , 11 ]. Diets rich in fiber improve glycemic control in type 2 diabetes [ 54 ], reduce low-density lipoprotein LDL cholesterol in hypercholesterolemia [ 55 — 57 ], and contribute positively to long-term weight management [ 58 ].

In epidemiological studies, positive associations were noted between increased cereal consumption, a source of both insoluble and soluble fibers, and reduced risk of metabolic syndrome, cardiovascular diseases, and markers of systemic inflammation [ 59 — 61 ]. Diets rich in whole-grain foods have also been negatively associated with metabolic syndrome [ 6 , 8 , 11 ].

In comparison to insoluble fibers, soluble fibers are more potent in attenuating the presence of components of the metabolic syndrome in both animals and humans. Serum leptin levels were normalized and insulin sensitivity index was improved. The diet supplemented with the soluble fermentable fiber Plantago Ovata husks also resulted in the greatest improvement in hyperinsulinemia and hyperleptinemia, and lowered the production and accumulation of lipids in the liver.

This effect was associated with activation of the AMP-activated protein kinase AMPK system [ 63 ], known to increase fatty acid oxidation and decrease fatty acid synthesis [ 64 ]. Moreover, a high fiber meal, in which refined-wheat flour was replaced with whole-wheat flour High adiponectin levels are associated with improved glycemic control and insulin sensitivity, a more favorable lipid profile and reduced inflammation in diabetic females [ 68 ].

Glucans from barley, oats, or wheat are found in cell walls of the endosperm, while being concentrated in the aleurone layer of barley, oats, wheat, sorghum, and other cereals.

They are major structural components of the cell walls of yeast, fungi, and some bacteria [ 75 ]. These glucans are important for plant-microbe interactions, and act as signalling molecules during plant infection [ 76 ]. However, no sharp distinction exists between the insoluble and soluble fractions and the ratio is highly dependent on the extraction conditions of the soluble fiber [ 82 ]. This conformation allows for stronger interactions and associations between chains than between the chains and water molecules.

Solubility increases as the degree of polymerization is lowered. One study completed in mice found that effects of chronic consumption of chitin-glucan from a fungal source improved metabolic abnormalities induced by a high fat diet [ 99 ].

In this particular study, chitin-glucan decreased high fat diet-induced body weight gain, fat mass development, fasting hyperglycemia, glucose intolerance, hepatic triglyceride accumulation, and hypercholesterolemia, irrespective of caloric intake. These benefits include lowering postprandial glucose and insulin responses, decreasing cholesterol levels, and potentiating the feelings of satiety. Insulin resistance, whether or not accompanied with hyperglycemia, and type 2 diabetes are well-established components of metabolic syndrome [ ].

Beta glucan also contributes to glycemic control. Several factors were found to influence such an interaction, including dose, food form, and molecular weight. In subjects with noninsulin-dependent diabetes mellitus, consumption of three breakfasts with 4, 6, and 8.

Consumption of oat bran providing 7. The consumption of oat bran flour containing 9. This is perhaps because wheat pasta itself has a low glycemic response. One of the mechanisms includes the ability of soluble fibers to form viscous solutions. Delayed gastric emptying occurs with increased digesta viscosity [ — ], slowing subsequent digestion and absorption [ ]. High digesta viscosity decreases enzyme diffusion [ ] and stimulates the formation of the unstirred water layer [ ], decreasing glucose transport to enterocytes [ 31 ].

Reducing the viscosity of guar gum following acid hydrolysis resulted in concurrent loss of its clinical efficacy [ 31 ]. A relationship was noted between guar gum viscosity and its glycemic response.

Similarly, the addition of 13 C-labelled glucose to a meal containing 8. Individuals with metabolic syndrome often present with atherogenic dyslipidemia, characterized by elevated concentrations of triacylglycerols and low levels of HDL cholesterol in blood [ 3 ]. This lipid profile presents an individual with a high risk for cardiovascular disease. Soluble fibers have the most reported beneficial effects on cholesterol metabolism.

In a meta-analysis, soluble fibers pectin, psyllium, oat bran, and guar gum were all proven to be equally effective in reducing plasma total and LDL cholesterol levels [ 55 ]. Conversely, soluble fibers from barley, oats, psyllium, and pectin had no effect on HDL cholesterol levels [ 55 , ]. Variable effects of soluble fibers on triglyceridemia have been noted.

In two meta-analyses, soluble fibers, including barley, oats, psyllium, and pectin, had no significant impacts on triglyceride concentrations [ ]. Other studies have described hypotriglyceridemic effects of soluble fibers in various populations. The soluble fiber in Plantago Ovata husk reduced triglyceridemia in human secondary cardiovascular disease risk trials, when consumed at Discrepancies in findings could be attributed to the variability in fiber structure, the degree of solubility and viscosity, different administered doses, the duration of administration, and baseline triglyceride levels of the subjects.

However, other studies found no hypocholesterolemic effect of incorporating oats into bread [ , — ]. The activation of these enzymes depends on the processing technique used in bread making. Altering bile acid excretion and the composition of bile acid pool is one of the mechanisms. Beta glucans can decrease the reabsorption of bile acids and increase their transport towards the large intestine [ ], promoting their increased microbial conversion to metabolites and their higher excretion, subsequently inducing increased hepatic synthesis of bile acids from circulating cholesterol [ ].

In addition, some soluble fibers decrease the absorption of dietary cholesterol by altering the composition of the bile acid pool. In fact, oat bran increased the portion of total bile acid pool that was deoxycholic acid [ ], a microbial byproduct of bile acid which decreases the absorption of exogenous cholesterol in humans [ ]. Fermentation changes the concentration of bile acids in the intestinal tract of rats [ ] as well as the production of short-chain fatty acids, which influence lipid metabolism.

For example, propionate is thought to suppress cholesterol synthesis, though results are still inconclusive [ — ] and acetate may contribute to the lowering of cholesterol circulating levels [ ]. It should be well noted that differences between soluble fibers in the relative production of acetate, propionate, butyrate, and total short-chain fatty acids do exist.

However, such differences may not be that important to generate varied degrees of hypocholesterolemic impacts among soluble fibers. Two mechanisms include a possible delay in the absorption of triglycerides in the small intestine [ ], as well as a reduced rate of glucose absorption [ ].

Glucose-induced hypertriglyceridemia, via the process of de novo lipogenesis, is well established in the literature [ ]. Furthermore, direct inhibition of lipogenesis by soluble fibers is also suggested as an explanatory mechanism. The hypotriglyceridemic effect of oligofructose was reported to result from the inhibition of hepatic lipogenesis via the modulation of fatty acid synthase activity [ , ].

Hypertension is another core component of the metabolic syndrome, and is an established risk factor for heart diseases, stroke, and renal diseases [ ]. In one meta-analysis, increased dietary fiber consumption provided a safe and acceptable means to reduce blood pressure in patients with hypertension [ ]. In another randomized parallel-group study on hypertensive and hyperinsulinemic men and women, the oat cereal group standardized to 5.

Various mechanisms underlying the antihypertensive effects of soluble dietary fibers have been hypothesized. Insulin resistance is a major underlying mechanism contributing to the development of hypertension [ ] and soluble fibers may affect blood pressure by modulating insulin metabolism [ ]. Reductions in plasma cholesterol, observed following the ingestion of soluble fibers, are also associated with improvements in endothelium-mediated vasodilation [ , ].

Preliminary findings in animals support a direct relationship between changes in circulating cholesterol levels and blood pressure [ ]. Finally, soluble fiber-induced weight loss, which will be discussed in the coming section, has also been suggested as a potential mechanism.

Increased body weight is a strong risk factor for hypertension [ ]. In conclusion, additional studies are still needed in order to fully elucidate the mechanisms underlying the protective effects of soluble fibers against hypertension. Central obesity is a well-established component of the metabolic syndrome [ 3 ]. One potential countermeasure to the current obesity epidemic is to identify and recommend foods that spontaneously reduce energy intake by inducing satiation and increasing satiety.

Dietary fiber has documented effects on satiety, food intake, and body weight although the outcomes have not been consistent [ ]. A number of randomized controlled trials have shown weight reduction with diets rich in dietary fiber or dietary fiber supplements [ — ], while others have not [ ]. More specifically, the soluble dietary fiber glucomannan, which has a strong water-holding capacity, resulted in a significantly greater reduction of weight, when consumed at a dose of 1.

Despite the clear association between soluble fibers and weight loss, their effects on subjective measures of satiety are not conclusive. For example, the addition of 2. The soluble resistant dextrins promoted, in a dose-dependent manner, increased satiety when added to desserts and to carbohydrate-based meals [ — ]. Moreover, a nutrition bar containing guar gum 5. Subjects described to be significantly less hungry before lunch after consuming barley—but not wheat—and rice-containing foods [ ].

Barley-based foods enhanced as well satiety when compared to a high-glycemic index food or a food with no dietary fiber [ — ]. Similarly, a preload of 5. This was also associated with a significant reduction of energy intake at the subsequent lunch [ ].

In contrast, a meal replacement bar containing 1. Dose is one of the major determinants. Solid foods are known to increase satiety and decrease hunger more effectively than liquid ones [ ]. Moreover, another concern to be addressed in future studies is the type of control to use. No dietary fiber that may function as a control for satiety studies has been actually identified. It should be noted that the body weight was not the primary concern of these studies as they focused on changes in blood sugar or blood lipids.

The satiating properties of soluble dietary fibers have been explained by various mechanisms, all of which are related to several stages in the process of appetite regulation such as taste, gastric emptying, absorption, and fermentation [ ].

Firstly, the viscosity of soluble fibers plays an important role in their ability to induce satiety [ , , ]. A higher viscosity meal delays gastric emptying [ , , ] and slows the digestion and absorption of nutrients, more precisely glucose, due to reduced enzymatic activity and mucosal absorption [ 31 , ], leading to early satiety sensations. The overall gastric emptying rate of healthy volunteers, as assessed by the paracetamol absorption test, was slower after the high viscosity oat bran-enriched beverage as compared to the low viscosity drink [ ].

Secondly, the lower palatability of fiber-rich meals may affect food intake in a negative manner [ — ]. A strong inverse relationship is described between palatability and satiation [ ]. A significant inverse relationship is reported between satiety and glucose and insulin responses to carbohydrate-rich breakfast cereals [ , ] and to beverages with different glycemic effects [ ]. However, other studies did not report any association of glucose and insulin postprandial levels with satiety [ , ].

They suggested that the release of putative satiety peptides is a more crucial component of mechanisms initiating and maintaining satiety. Such statement leads to the fourth suggested mechanism that delineates the role of short-chain fatty acids in appetite control. Short-chain fatty acids regulate the release of various gut hormones, which play an important role in satiety signaling. The role of short-chain fatty acids in appetite regulation and the potential underlying mechanisms will be elucidated in the following sections.

The fermentability of soluble fibers by colonic microbiota is greater than that of insoluble fibers. Pectin, resistant starches, gums, and polyfructans such as inulin are the most highly fermented substrates. On the other hand, acetate passes more freely into the peripheral circulation [ ]. Several functions are attributed to short-chain fatty acids, being recently proposed as key energy homeostasis signaling molecules [ ].

Accumulating evidence has attributed the satiating effects of fermentable carbohydrates to short-chain fatty acids, their major fermentation products [ ]. Short-chain fatty acids regulate appetite through several mechanisms. First, short-chain fatty acids have a role in slowing gastrointestinal motility, thus controlling digestion and nutrient absorption and eliciting an anorexigenic effect.

The majority of the studies linking short-chain fatty acids to gastrointestinal motility stems from ruminant animal studies [ ], where the production of short-chain fatty acids is greater than that in humans due to differences in gut physiology [ ].

However, there are some studies on nonruminants showing that short-chain fatty acids may regulate the overall transit time of the digesta through the large intestine [ , ]. Such responses were hypothesized to occur via three possible pathways: In addition, short-chain fatty acids were suggested to regulate gastrointestinal motility by affecting the release of the gastrointestinal 5-hydroxytryptamine 5-HT via the activation of the free fatty acid receptor 2 FFA2 , the major receptor for short-chain fatty acids.

The activation of various 5-HT receptor subtypes stimulates vagal nodose neurons and consequently prolongs colonic transit time [ , ].

Short-chain fatty acids also regulate appetite by modulating the release of various appetite-related hormones throughout the gastrointestinal tract [ ]. Peptide YY Peptide YY is a amino acid peptide, first isolated from porcine upper small intestine [ ]. PYY is secreted throughout the entire length of the gastrointestinal tract, with the highest concentrations found in the colon and rectum [ ].

Circulating PYY levels are the lowest in the fasting state and increase following the consumption of a meal, peaking at hours and remaining elevated for several hours. Peripheral PYY administration decreased food intake and body weight gain in rats [ ]. Similarly, it decreased appetite and food intake both in lean and obese humans [ , ]. An increased PYY response was consistently described following the consumption of various soluble dietary fibers. Postprandial PYY clearly increased after the consumption of psyllium-enriched test meals in healthy volunteers [ ].

Based on the lack of evidence on the clinical utility of uterine artery blood flow measurements, the Cochrane reviewers concluded: Fetal vessels other than the umbilical artery can also be studied, especially using pulsed wave Doppler with or without color flow imaging; as yet, there is no evidence from controlled studies that these studies are of clinical value. Guidelines from the ACOG have concluded that uterine artery Doppler is not an effective method for identifying women at risk for eclampsia.

The ACOG guidelines on eclampsia and preeclampsia state that "Doppler velocimetry of the uterine arteries was reported not to be a useful test for screening pregnant women at low risk for preeclampsia.

The review concluded that, "[u]ntil such time as these are available, routine uterine artery Doppler screening of women considered at low risk is not recommended. The review found that uterine artery Doppler screening of high-risk women e.

Normal Doppler studies could potentially lead to a reduction in such testing and interventions. Use of umbilical artery Doppler should be individualized, and a plan of management based on the results should be put in place. Because standards for the study technique, gestational age, and criteria for an abnormal test are lacking, uterine artery Doppler studies should not be considered to be a required medical practice in low or high risk populations. Several tests provided moderate or convincing prediction of early PE, but screening for late PE was poor.

Performance of screening was consistently lower in populations with risk factors for PE in the maternal history. The different performance of tests in screening for early versus late PE, and of low- versus high-risk populations, supports the concept that PE is a heterogeneous disease. In a systematic review, Kuc et al examined the literature on the predictive potential of first-trimester serum markers and of UAD velocity waveform assessment uterine artery [Ut-A] Doppler.

In the selected literature, a combination of these markers was analyzed, and where relevant, the value of maternal characteristics was added.

Therefore, a combination of multiple markers yields high detection rates and is promising to identify patients at high-risk of developing PE. In a prospective cohort study, Bezircioglu et al examined the diagnostic value of blood flow measurements in endometrial, myometrial and uterine vasculature by trans-vaginal Doppler ultrasonography in the differentiation of the neoplastic endometrial pathologies in women with post-menopausal bleeding.

A total of women who presented with post-menopausal bleeding were enrolled in this study. Endometrial thickness, pulsatility and resistance indices PI and RI of the uterine, myometrial and endometrial vasculature, endometrial histopathology were measured by trans-vaginal Doppler sonography.

Dilatation and curettage were performed for all women. Sonographic and histopathological results were evaluated. Endometrial malignancy was diagnosed in 24 of the patients Endometrial thickness was found to be higher in the patients with malign histopathology compared with the patients of benign histopathology.

In multi-variate regression model, only uterine artery PI was identified as independent determinant of malignant endometrium. The authors concluded that blood flow of uterine artery and also myometrial and endometrial vasculature displayed lower impedance in patients with malignant endometrium, but these lower indices are not already adequate for using as diagnostic tests. Relevant documents were identified using PubMed US National Library of Medicine, through publications, written in English, which describe the peri-partum outcomes of IUGR according to Doppler assessment of umbilical arterial, middle cerebral artery, and ductus venosus.

Additionally, the Cochrane Library, organizational guidelines, and studies identified through review of the above were utilized to identify relevant articles. Consistent with US Preventive Task Force suggestions, references were evaluated for quality based on the highest level of evidence, and recommendations were graded. Summary of randomized and quasi-randomized studies indicated that, among high-risk pregnancies with suspected IUGR, the use of umbilical arterial Doppler assessment significantly decreases the likelihood of labor induction, cesarean delivery, and perinatal deaths 1.

Antepartum surveillance with Doppler of the umbilical artery should be started when the fetus is viable and IUGR is suspected. Although Doppler studies of the ductus venous, middle cerebral artery, and other vessels have some prognostic value for IUGR fetuses, currently there is a lack of randomized trials showing benefit. Thus, Doppler studies of vessels other than the umbilical artery, as part of assessment of fetal well-being in pregnancies complicated by IUGR, should be reserved for research protocols.

These researchers conducted a prospective cohort study of patients presenting for 1 st trimester aneuploidy screening between 11 and 14 weeks' gestation.

Outcomes of interest included PE, early PE defined as requiring delivery at less than 34 weeks' gestation , and gestational hypertension. The sensitivity, specificity, and area under the receiver operating characteristic curves were used to compare the screening efficiency of the models using nonparametric U statistics. Among patients with complete outcome data, there were 54 cases of PE 9. Combining these 1 st trimester parameters did not improve the predictive efficiency of the models.

Combinations of these parameters do not further improve their screening efficiency. Although meta-analyses show that uterine artery Doppler analysis can predict women at increased risk of preeclampsia, we and most experts do not recommend these studies for screening purposes. Close clinical monitoring for preeclampsia is already a major component of prenatal care; improved identification of women at increased or decreased risk of a disease that cannot be prevented and has no treatment other than delivery is unlikely to improve maternal or fetal outcome.

Furthermore, the false positive rate of this test is quite high, leading to excessive patient anxiety and health care costs. Seravalli et al noted that 1 st trimester screening for subsequent delivery of a SGA infant typically focuses on maternal risk factors and Ut-A Doppler.

They performed a prospective screening study of singletons at 11 to 14 weeks. These parameters were tested for their ability to predict subsequent delivery of a SGA infant. Among 2, enrolled women, 8. Predictive sensitivity was low; receiver operating characteristic curve analysis yields areas under the curve of 0.

Moreover, they stated that despite the statistical association with Ut-A Doppler 1 st trimester SGA prediction is poor and not improved by the incorporation of fetal Doppler. In a Cochrane review, Alfirevic et al examined the effects of routine fetal and umbilical Doppler ultrasound on obstetric practice and pregnancy outcome in unselected and low-risk pregnancies.

These investigators searched the Cochrane Pregnancy and Childbirth Group Trials Register February 28, and reference lists of retrieved studies. Randomized and quasi-randomized controlled trials of Doppler ultrasound for the investigation of umbilical and fetal vessels waveforms in unselected pregnancies compared with no Doppler ultrasound were selected for analysis. Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction.

In addition to standard meta-analysis, the 2 primary outcomes and 5 of the secondary outcomes were assessed using GRADE software and methodology. These researchers included 5 trials that recruited 14, women, with data analyzed for 14, women.

All trials had adequate allocation concealment, but none had adequate blinding of participants, staff or outcome assessors. Overall and apart from lack of blinding, the risk of bias for the included trials was considered to be low. Overall, routine fetal and umbilical Doppler ultrasound examination in low-risk or unselected populations did not result in increased antenatal, obstetric and neonatal interventions.

There were no group differences noted for the review's primary outcomes of perinatal death and neonatal morbidity. Results for perinatal death were as follows: Only 1 included trial assessed serious neonatal morbidity and found no evidence of group differences RR 0. For the comparison of a single Doppler assessment versus no Doppler, evidence for group differences in perinatal death was detected RR 0. However, these results were based on a single trial, and the authors would recommend caution when interpreting this finding.

There was no evidence of group differences for the outcomes of caesarean section, neonatal intensive care admissions or pre-term birth less than 37 weeks. Evidence for admission to neonatal intensive care unit was assessed as of moderate quality, and evidence for the outcomes of caesarean section and pre-term birth less than 37 weeks was graded as of high quality.

There was no available evidence to assess the effect on substantive long-term outcomes such as childhood neurodevelopment and no data to assess maternal outcomes, particularly maternal satisfaction. The authors concluded that existing evidence does not provide conclusive evidence that the use of routine UAD ultrasound, or combination of umbilical and UAD ultrasound in low-risk or unselected populations benefits either mother or baby. They stated that future studies should be designed to address small changes in peri-natal outcome, and should focus on potentially preventable deaths.

Allen et al evaluated the predictive accuracy for stillbirth of 2nd trimester UAD. Included studies were those that assessed the association of abnormal UAD parameters and stillbirth. Two independent reviewers selected studies, extracted data and assessed quality.

Overall summary of test accuracy was provided by the diagnostic odds ratio OR. Literature searches returned relevant citations with 32 considered in full; 13 studies met search criteria, 85, women, stillbirths and were included in the review.

The positive likelihood ratio was 3. The authors concluded that abnormal UAD indices are associated with a 3- to 4-fold increase in the risk of stillbirth. However, the heterogeneity was particularly high in the high-risk group rendering it impossible to draw firm conclusions.

Levine and colleagues stated that maternal prenatal stress is associated with pre-term birth, IUGR, and developmental delay. However, the impact of prenatal stress on hemodynamics during pregnancy remains unclear. These researchers carried out a systematic review to evaluate the quality of the evidence available to-date regarding the relationship between prenatal stress and maternal-fetal hemodynamics.

Studies were eligible for inclusion if prenatal stress was assessed with standardized measures, hemodynamics was measured with Doppler ultrasound, and methods were adequately described. A specifically designed data extraction form was used.

The methodological quality of included studies was assessed using well-accepted quality appraisal guidelines. Of 2, studies reviewed, 12 met the criteria for inclusion; 6 reported that prenatal stress significantly affected maternal or fetal hemodynamics; 6 found no significant association between maternal stress and circulation.

The authors concluded that there is limited evidence that prenatal stress is associated with changes in circulation. They stated that more carefully designed studies with larger sample sizes, repeated assessments across gestation, tighter control for confounding factors, and measures of pregnancy-specific stress are needed to clarify this relationship.

YKL, a kDA macrophage-derived glycoprotein, is a member of the "mammalian chitinase-like proteins". It is expressed and secreted by several types of solid tumors; however, the exact function of YKL in cancer is unclear. YKL exhibits growth factor activity for cells involved in tissue re-modeling processes; it may have a role in cancer cell proliferation, survival, and invasiveness, angiogenesis, and re-modeling of the extracellular matrix.

Retrospective studies of patients with 8 different types of primary or advanced solid tumors suggested that serum concentration of YKL may be a new biomarker in cancer patients. YKL is neither organ- nor tumor-specific. Moreover, the pattern of its expression in certain tissues e.

The authors concluded that this study may be the first to demonstrate maternal and fetal macrophage activation in pre-eclampsia. In a prospective, cohort study, Gybel-Brask et al examined if serum YKL is increased in women developing pre-eclampsia or small-for-gestational age fetuses. These researchers also assessed the association between uterine artery pulsatility index, notching and serum YKL levels.

All women had ultrasound and blood sample collection at the nuchal translucency scan, a week malformation scan and week and week fetal growth examinations. Uterine artery Doppler was assessed and outcome was registered from medical records. Main outcome measures were pre-eclampsia, hypertension, and small-for-gestational age.

Serum YKL increased from 12 to 20 weeks and decreased from 20 to 25 and 25 to 32 weeks of gestation. No association was found between pre-eclampsia and serum YKL Small-for-gestational-age at birth was significantly associated with a 5. The authors concluded that serum YKL was not associated with pre-eclampsia.

Increasing serum YKL was related to maternal age, BMI and small-for-gestational age and may reflect an exaggerated inflammatory response. Kucur et al examined if alterations in the serum levels of apelin and YKL differ between early and late onset pre-eclampsia and whether there is a correlation between apelin and YKL in women who subsequently develop early and late pre-eclampsia.

A total number of 80 pregnant women, 40 with normal pregnancy and 40 with pre-eclampsia, were included in the present study. Both the normal pregnant and pre-eclamptic subjects were subdivided into 2 groups. Serum YKL and apelin concentrations were measured. Mean maternal serum YKL levels were lower in women who subsequently developed early Mean maternal serum apelin levels were both higher in women who subsequently developed early 8.

The authors concluded that circulating levels of apelin were significantly increased in early-onset pre-eclampsia, indicating the role of apelin in the discrimination of the early-onset of pre-eclampsia. On the other hand, maternal serum YKL levels were not elevated significantly, indicating that adipose-derived apelin was primarily involved in the vascular pathogenesis of early-onset pre-eclampsia than macrophage-derived YKL In a prospective, clinical study, Musilova and Hodík evaluated the clinical utility of Doppler velocimetry as a comprehensive test for the prediction of discordant twins.

Biometrical measurements and Doppler velocimetry of umbilical artery UA and middle cerebral artery MCA were performed in twins in 3rd trimester. Studied parameters were evaluated using ROC analysis. The mean gestational age at delivery was The more accurate one of Doppler parameters was MCA, with sensitivity and specificity values of The authors concluded that it is possible to predict the discordant twins birth using MCA Doppler velocimetry, but the EFW assessment remains the most accurate method.

The authors noted that umbilical artery Doppler velocimetry did not appeared as effective. Absent or reversed end-diastolic flow in the umbilical artery is associated with an increased risk of perinatal mortality.

It does not mention the use of umbilical artery Doppler velocimetry for multiple gestations pregnancies. These recommendations are based upon current evidence and should be used to guide patient management with individualization of care as dictated by the specific clinical circumstance algorithm 1.

Doppler velocimetry is recommended as a primary surveillance tool for monitoring these pregnancies. Clinical Policy Bulletin Notes. Links to various non-Aetna sites are provided for your convenience only.

The following medical necessity guidelines apply: Accepted guidelines state that fetal testing should not begin until interventions can be undertaken. For most pregnancies at increased risk of stillbirth due to utero-placental insufficiency, testing is considered appropriate beginning at 32 to 34 weeks of gestation. Testing is considered medically necessary beginning at 26 weeks gestation for pregnancies with multiple or particularly worrisome high-risk conditions.

Examples of such high-risk conditions include bleeding, chronic or pregnancy-induced hypertension, collagen vascular disease including anti-phospholipid syndrome , fetal growth restriction, gestational diabetes, impaired renal function, maternal heart disease New York Heart Association Class III or IV , oligohydramnios, significant isoimmunization, steroid-dependent or poorly controlled asthma not an all-inclusive list.

If the clinical condition that has prompted testing persists, repeat testing either weekly or twice-weekly, depending on the test used and the presence of certain high-risk conditions is considered medically necessary until delivery. Repeat testing is also considered medically necessary for any significant deterioration in the maternal medical status or any acute diminution in fetal activity, regardless of the amount of time that has elapsed since the last test.

Subsequent management should then be predicated on the results of the CST or BPP, the gestational age, the degree of oligohydramnios if assessed , and the maternal condition. Recent, normal antepartum fetal test results should not preclude the determination that intrapartum fetal monitoring is medically necessary. If used in this setting, accepted guidelines indicate that decisions regarding timing of delivery should be made using a combination of information from the Doppler ultrasonography and other tests of fetal well being, along with careful monitoring of maternal status.

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Uterine and umbilical artery velocimetry in pre-eclampsia. Acta Obstet Gynecol Scand.

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