الفهرس 
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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
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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.
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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.
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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%,
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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).
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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).
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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.
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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.