The September issue of Ultrasound in Obstetrics & Gynecology includes a Physician Alert in which the STRIDER Consortium address the recent suspension of the Dutch sildenafil trial, a Review of microRNA expression patterns in cardiac remodeling and pre-eclampsia, an Original Article on longitudinal growth assessment for prediction of adverse perinatal outcome in suspected small-for-gestational-age fetuses, and a Case Series assessing fetal blood-gas values during fetoscopic myelomeningocele repair performed under carbon dioxide insufflation.

Please see below a selection of articles from the September issue of the Journal chosen specially by the UOG team. To view all UOG content, become an ISUOG member today or login and upgrade.

Clinicians should stop prescribing sildenafil for fetal growth restriction (FGR): comment from the STRIDER Consortium

The Sildenafil TheRapy In Dismal prognosis Early-onset intrauterine growth Restriction (STRIDER) Consortium provides comment in a Physician Alert in this issue of the Journal addressing the recent significant global media interest following the suspension of the Dutch STRIDER trial. The group of investigators found previously in a randomized placebo-controlled trial that sildenafil may be effective in the treatment of FGR. The Dutch trial, a subsequent Phase-II/early Phase-III trial, was halted due to possible harm and likely lack of benefit of sildenafil therapy. In this Physician Alert, the authors note that any possible harm has not yet been proven, and that the results of this trial are inconsistent with those of the completed STRIDER trials, which did not find any beneficial effect of sildenafil therapy in FGR, but found no evidence of an association with persistent pulmonary hypertension of the newborn or neonatal death. Regardless, the authors acknowledge that the findings of the Dutch trial are of great concern and advise that, until clarity on the effects of sildenafil treatment in FGR emerges, sildenafil should not be prescribed for FGR outside the setting of high-quality randomized clinical trials.  

Cardiac remodeling and pre-eclampsia: an overview of microRNA expression patterns

Pre-eclampsia (PE) is strongly associated with heart failure later in life. During PE, the left ventricle undergoes concentric remodeling which often persists after delivery. This aberrant remodeling can induce a molecular signature that can be evaluated in terms of microRNAs (miRNAs) and which may help to explain the associated increased risk of heart failure. In a Review by Mohseni et al., available evidence on miRNA expression in relation to cardiac remodeling, as well as that in relation to PE, was collated to provide a list of miRNAs expressed in both. Nine miRNAs were identified in both concentric remodeling and PE-complicated pregnancy, five of which were upregulated in both, two of which were downregulated in both, and the remaining two were upregulated in PE but downregulated in cardiac remodeling. The authors propose that this innovative approach may be a step towards finding relevant biomarkers for complicated pregnancy and elucidating their relationship with remote cardiovascular disease.

Longitudinal growth assessment for prediction of adverse perinatal outcome in fetuses suspected to be small-for-gestational age

Slow growth has been proposed as a contributory criterion to define late FGR. However, its value in the prediction of adverse perinatal outcome over other standard criteria of late FGR has been evaluated scarcely. In this issue of the Journal, a study by Caradeux et al. aimed to establish whether the use of longitudinal growth assessment by means of estimated fetal weight z-velocity is of additional value in predicting adverse perinatal outcome among fetuses suspected to be late small-for-gestational age. It was found that longitudinal assessment of fetal growth did not add value to Doppler criteria (cerebroplacental ratio and uterine artery Doppler) in predicting adverse outcome (download the accompanying Journal Club slides).

Fetal blood-gas values during fetoscopic myelomeningocele repair performed under carbon dioxide insufflation

In the development of fetoscopic surgical treatments, the concern for severe fetal acidemia due to CO2 insufflation is considered a serious drawback, although these concerns are based solely on animal experiments. In a Case Series, Baschat et al. present perioperative blood-gas values obtained during three consecutive fetoscopic myelomeningocele repairs. It was found that, while the observed drop in fetal pH and increase in CO2 were similar in magnitude to those observed in sheep experiments, base excess was maintained in the normal range and blood-gas pH values were well above the levels considered harmful for neurodevelopment. It is also noted that pH decrease was less in the patient who received humidified CO2 insufflation. The authors conclude that CO2 insufflation during fetoscopic myelomeningocele repair does not cause acidemia in human fetuses. 

Addressing this study is Correspondence in which Moise Jr and Spike express concerns regarding aspects of the procedures performed and conclusions drawn by Baschat et al., particularly in relation to the rationale for performing cordocentesis twice in each patient given the associated safety concerns. Baschat and Miller provide a Reply addressing these concerns, presenting justification for fetal blood sampling and arguing that maternal and fetal risks of open fetal myelomeningocele repair far exceed those of fetal blood sampling as performed in their study.

Coming up in the next issue of UOG… 

  • Two articles reporting fetoscopic techniques for repair of neural tube defects. Preview the Accepted Articles of Lapa et al. and Giné et al.
  • A Systematic Review by Conde‐Agudelo et al. on the predictive accuracy of the cerebroplacental ratio for adverse perinatal and neurodevelopmental outcomes in suspected fetal growth restriction. Preview the Accepted Article.
  • A Systematic Review by Melchor et al. on the prediction of preterm delivery in symptomatic women using placental alpha‐microglobulin‐1, fetal fibronectin and phosphorylated insulin‐like growth factor‐binding protein‐1 tests. Preview the Accepted Article.

Coming soon… An ISUOG Guideline on the role of ultrasound in screening for and follow-up of pre-eclampsia.