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Abstract Summary and Conclusions Antiphospholipid antibodies (aPL) are a group of heterogeneous autoantibodies with well- established association with a variety of medical and obstetrical disorders e.g. recurrent first and second trimester abortion, IUFD, IUGR, placental abruption, early onset preeclampsia and infertility. The prevalence of lupus anticoagulant (LAC) ill high- risk pregnancies in Egyptian women is 8.3%, and the prevalence of anticardiolipin antibodies (ApCLA) is 39.6%. Only about 15% of small- for- gestational age (SGA) fetuses are small as a result of inadequate placental function and the majority are small normal fetuses (Chin- Chu and Evans, 1984). By contrast, on theoretical grounds, 70% of fetuses who do not acheive their full genetic growth potential because of placental disease would be expected to have a birth weight considered appropriate for gestational age when compared to reference range (Chard, 1984). If appropriate- for- gestational age (AGA) fetuses with decreased placental function suffer from chronic hypoxia in the same way as SGA fetuses (Soothill et aI., 1987), this might explain why apparently well grown fetuses die in utero, develop fetal distress in labor; or are asphyxiated at birth. Thus it would be essential to detect fetal hypoxia or acidosis to prevent unnecessary intervention or indicate appropriate intervention. Several noninvasive tests are used to detect hypoxic fetuses in highrisk population, and irrespective of fetal growth. In high- risk pregnancy -250_ Summary and Conclusions monitored by CTG or BPP, fetal death is rare (Baskett et al., 1987 and Manning et aI., 1990), but these tests have disadvantages. They offer only short term prediction, have to be repeated frequently, and because its ability to select truly at risk pregnancies is poor, large numbers may be monitored unnecessarily. Doppler recording offers a different and complementary type of test. It may give long. term warning of potential fetal compromise due to uteroplacental cause, and is thus of potential value as a discriminator. It improves the logical basis of obstetric management, segregating those pregnancies truly at risk (where delivery or intensive fetal monitoring is required) from those pregnancies not at high risk (where clinical care alone is adequate). The objectives of the present work were to assess the effects of aPL (LAC and / or ACLA) on pregnancy complications and outcome, and fetal outcome, beside the role of umbilical and uterine arteries. Doppler velocimetry in the follow- up of such cases, effects on obstetric practice and its correlation with fetal outcome. Other tests of fetal monitoring are used viz ultrasound imaging and fetal biophysical profile. This work was carried out during the period from August 1993 to August 1995. Six hundred and thirty eight pregnant women, among those attending the antenatal clinics of As- Salam General Hospital and Al- Matareiya Teaching General Hospital, Cairo, were selected with past history of abortion (s), SGA neonate (s), intrauterine fetal death (s), thrombotic event(s), PE/E, or preterm delivery. They were evaluated for pregnancy complications and losses, and screened for LAC by APTT. _251_ Summary and Conclusions Fifty three cases were negative for an identifiable cause and positive for LAC (APTT > 48 seconds, after correction with normal plasma). They comprised the study group. Forty- two pregnant women with no past history of adverse obstetric outcome or medical disorder related to aPL were screened and proved to be negative for LAC, and comprised the control group. The study group showed 21 positive cases for ACLA (13 cases were positive for Ig G, and 8 cases for Ig M) and 3 cases were positive for Ig G and Ig M. APTT was significantly prolonged in study cases (P < 0.0001) (Table 3). All cases were subjected for full clinical history, examination, and investigations. Transabdominal ultrasound scanning was done at booking and routinely as indicated. Fetal biophysical profile scoring (Manning, 1990) was done at 28 weeks and onwards as indicated (4 examinations for control and study cases). Abnormal BPP score was < 8 or 8 with oligohydramnios. Doppler velocimetry studies for umbilical and uterine arteries (SID, RI and PI) were done on 3 visits for study cases (VI at 6- 28 w, V2 at 29- 33 w, and V3 at 34- 36 week’s gestation) and on 2 visits for control cases (VI at 6- 28 w, and V2 at 29- 33 week’s gestation). The mean number of examinations was 3.6 for control cases and 4 for study cases. _252_ Summary and C””clusions Monthly platelet counts were done for study cases. Nineteen study cases and 12 control cases were excluded because they developed conditions that cause adverse obstetric effects similar to aPL (e.g. congenital fetal abnormalities, multifetal pregnancy, prolonged pregnancy, polyhydranmios, chorioamnionitis, single umbilical artery, placenta previa or renal disease). Eight control cases were delivered outside the hospital with no recorded data. Hospitalization was indicated for obstetric complications, medical disorders, induction oflabor or delivery. The end points were pregnancy complications, pregnancy outcome, obstetric intervention, and fetal outcome. The results were statistically analyzed using the 2 sample ”tOOtest and X2 test. In study cases, 35.3% showed abnormal umbilical and / or uterine arteries DFVW s compared to 9.1% control cases who showed abnormal uterine arteries DFVW s only (Table II). Pregnancy complications (Table 16) were frequent in study cases with abnormal DFVWs compared to those with normal DFVWs (41.7% Vs 0% second trimester aborition, 58.3% Vs 4.5% pretenn labor, 8.3% Vs 0% preeclampsia, 100% Vs 4.5% thrombocytopenia, 8.3 Vs 4.5% placental abruption, 41.7% Vs 0% IUFD, and 75% Vs 9.1% IUGR), except first trimester abortion and DVT (0% Vs 18.18% and 0% Vs 4.5%, -253_ Summary and Conclusions respectively). Fetal loss (first & second trimester abortion, and IUFDs) was higher (Table 16) in cases with abnormal compared to cases with normal DFVWs (83.3% (10/12) Vs 18.2% (4/22). Induced labor and elective C.S (Table 14) were higher in cases with abnormal DFVWs (25% (3/12) Vs 0% & 25% (3/12) Vs 0%, respectively). Poor fetal outcome (Table 19) was evident in study cases with abnormal DFVWs compared to those with normal DFVWs (100% Vs 12.5% birth weight < 10 th percentile, 33.3% Vs 0% SB, 33.3% Vs 0% early NND, 66.6% Vs 37.5% Apgar score < 7 at 1 min, 55.6% Vs 6.26% Apgar score < 7 at 5 min, and 66.6 % Vs 12.5% neonatal ICU admission). Control cases with abnormal uterine arteries DFVWs showed no pregnancy complications, or abnormal pregnancy or fetal outcome (Table 14 &15). Abnormal DFVWs in study cases allowed prediction of pregnancy complications (Table 17) with sensitivities ranging between 0% and 92.3 % for first- trimester abortion, DVT, placental abruption, IUGR, PL and thrombocytopenia, and sensitivties of 100% for second- trimester abortion, IUFD, and preeclampsia. Fetal outcome (Table 20) was predictable with sensitivities ranging between 50% and 100% for birth weight <10 th percentile, perinatal death, Apgar score < 7 at 1 & 5 min, and neonatal ICU admission. Ultrasonic abnormal fetal biometry and abnormal placental texture (Table 4) were statistically more frequent in study cases campared to control cases (P < 0.0001 and P < 0.0001, respectively). _254_ Summary and Conclusions In control cases (Table 5), umbilical arteries DFVW indices (SID, RI, and PI) significantly decreased with advancing gestation between VI and V2 denoting lower resistance state of the placental arteriolar bed (P < 0.0001, P < 0.0001, and P < 0.0001, respectively). In study cases (Table 6), umbilical arteries DFVW indices (SID, RI and PI) were significantly lower on V2 (29- 33 w) and V3 (34- 36 w) compared to VI (6- 28 w) (P < 0.005), but no statistical change between V2 and V3 (P > 0.05) due to higher placental resistance with advancing gestation. Umbilical arteries DFVW indices (Table 7) were significantly higher in study cases compared to control cases (P < 0.0001), denoting higher placental resistance in study cases leading to reduction of blood flow to the placental arterioles. In control cases (Table 8), uterine arteries DFVW indices (SID, RI and PI) decreased with advancing gestation, denoting low- resistance vessels due to normal pregnancy changes in the uteroplacental circulation. In study cases (Table 9), uterine DFVW indices decreased at V2 (29-33 w)and V3 (34-36 w) compared to VI (6-28 w), denoting normal pregnancy changes in the uteroplacental circulation (P < 0.05). Uterine arteries DFVW indices (Table 10) showed no significant difference between control and study cases, denoting normal pregnancy changes in both groups. In control cases, no pregnancy complications were reported except PL which occurred in 4.5% of cases Vs 23.5% of study cases (Table 15). Summary and Conclusions In study cases, pregnancy complications were more frequent compared to control cases, and ranging between 2.9 & 38.2% (Table 15), also poor pregnancy outcomes were more frequent (Table 13) compared to control cases (76% Vs 100% spontaneous onset oflabor, 50% Vs 95.4% full term labor, 12% Vs 0% elective C.S, 12% Vs 0% induced labor, 36% Vs 27.3% emergency C.S, and 48% Vs 27.3% fetal distress i.e. Apgar score < 7 at I min). .In study cases, complications of fetal outcome (Table 18) were more frequent compared to control cases regarding mean birth weight (2.74 kg Vs 3.37 kg), IUGR (44% Vs 0%), SB (12% Vs 0%), early NND (12% Vs 4.5%), Apgar score < 7 at 5 min (24% Vs 0%), and neonatal lCU admission (32% Vs 18.2%). Normal BPP scoring was more frequent in control versus study cases (100% Vs 64%) (Table 12). Complications of fetal outcome were more common in study cases with abnormal BPP versus control cases regarding SGA (100% Vs 0%), perinatal death (50% Vs 0%), Apgar score < 7 at lmin (75 % Vs 27.3%), Apgar <7 at 5min (25% Vs 0%), and neonatallCU admission (100% Vs 18.2%) (Table 21). Complications of fetal outcome in study cases with abnormal BPP were more frequent compared to study cases with normal BPP reagarding SGA (100% Vs 33.3%), perinatal death (50% Vs 19%), Apgar score <7 at lmin (75% Vs 42.9 %), Apgar score < 7 at 5min (25% Vs 23.8%), and neonatallCU admission (100% Vs 19%) (Table 21). _256.. Summary and Conclusions Abnormal BPP allowed prediction of fetal outcome in study cases with sensitivity ranging between 16.7% & 50% (Table 22). In study cases, prediction of fetal outcome was better by abnormal DFVWs compared to abnormal BPP (Table 23) regarding sensitivity of SGA (81.8 % Vs 36.4 %), perinatal death (100% Vs 33.3%), Apgar score < 7 at lmin (50% Vs 25%), Apgar score < 7 at 5min (83.3% Vs 16.7%), and neonatal ICU admission (75% Vs 50%). Conclusions: * The prevalence of LAC in high- risk pregnancies in Egyptian woman is reported as 8.3%, and of ACLA as 39.6%. Antiphospholipid antibodies (aPL) are associated with pregnancy complications as first and second trimester abortions, PL, placental abruption, preeclampsia, IUGR, IUFD, DVT, and thrombocytopenia. In aPL- positive pregnant women, fetal outcome is poor and its complications are more frequent compared to aPL- negative women. * Abnormal DFVWs are detected as early as the 20th week of gestation, and they are more common in aPL- positive pregnancies compared to control cases. Abnormal umbilical arteries DFVWs are more frequent than uterine arteries in high- risk pregnancy due to aPL. * DFVWs, in contrast to other fetal monitoring techniques viz., CTG & BPP, which reflect current fetal well- being, give a long term warning of petential fetal compromise due to placental circulatory reserve. _257_ Sa:iCiiGI7 tIIUI e-daimu * DFVWs improve the logical basis of obstetric management, segregating those pregnancies truly at risk (where delivery or intensive fetal monitoring is required) from those pregnancies not at high risk (where careful clinical care alone is adequate). * Doppler monitoring mcreases fetal monitoring in high- risk pregnancy using CTG and BPP . * Contribution to perinatal outcome would be affected by availability of other biophysical tests of fetal well- being and the competence with which they are used in management. * Validity of a test is not related to the predictive power of the test but by the additional information which improves obstetric management and decision making. |