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The PORTO Trial is a prospective study conducted at the seven largest obstetric centers in Ireland, with its goal being to evaluate the optimal management of the IUGR fetus. For the purpose of the trial, IUGR was defined as EFW <10th centile. The objective of this analysis was to evaluate Doppler changes in multiple vessels including UA, MCA, DV, AoI and MPI to establish whether there is a predictable progressive sequence and an added benefit in applying these Doppler assessments in IUGR pregnancies.
Over 1,000 unselected consecutive ultrasound-dated singleton pregnancies with EFW <10th centile were recruited between January 2010 and June 2012. Perinatal and early neonatal outcomes were documented for all participants. IUGR pregnancies were assessed by serial Doppler interrogation of UA, MCA, DV, AoI and MPI. Intervals between Doppler changes and patterns of deterioration were correlated with cases of abnormal umbilical artery Doppler (UA PI<95th centile or AEDF) and gestational age.
Of the 1,056 fetuses, 489 (46%) had an abnormal UA Doppler with 82 (8%) of them developing AEDF/ REDF; 296 (28%) had an abnormal MCA, 14 (1%) had an abnormal DV, 55 (5%) had an abnormal AoI and 113 (11%) had an abnormal MPI. Table 1 summarizes the median gestation at diagnosis and delivery for each vessel. 20% of AEDF cases progressed to REDF and prompted delivery. The mean gestation at AEDF diagnosis was 33 2/7 weeks and the mean time to delivery was 5 days (range 0-89). Figure 1 depicts the progression of Doppler abnormalities for each vessel.
1Onset of Doppler abnormalities and time to delivery interval
Doppler interrogation of the umbilical and middle cerebral arteries remain the most predictable to demonstrate progressive temporal changes in IUGR pregnancies. Evaluation of the ductus venosus and cardiac indices have been described as a useful adjunct assessment tool in the evaluation of IUGR to inform delivery decision, however our study cannot demonstrate an added benefit.