UOG Journal Club: Relationship of isolated single umbilical artery to fetal growth, aneuploidy and perinatal mortality: systematic review with meta-analysis
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UOG Journal Club: Relationship of isolated single umbilical artery to fetal growth, aneuploidy and perinatal mortality: systematic review with meta-analysis

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UOG Journal Club: December 2013 ...

UOG Journal Club: December 2013

Relationship of isolated single umbilical artery to fetal growth, aneuploidy and perinatal mortality: systematic review with meta-analysis

B.J. Voskamp, H. Fleurke-Rozema, K.O. Rengerink, R.J.M. Snijders, C.M. Bilardo, B.W.J. Mol and E. Pajkrt

Link to free access article:
http://onlinelibrary.wiley.com/doi/10.1002/uog.12541/abstract

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  • 1. UOG Journal Club: December 2013 Relationship of isolated single umbilical artery to fetal growth, aneuploidy and perinatal mortality: systematic review with meta-analysis B.J. Voskamp, H. Fleurke-Rozema, K.O. Rengerink, R.J.M. Snijders, C.M. Bilardo, B.W.J. Mol and E. Pajkrt Volume 42, Issue 6, Date: December 2013, pages 622-628 Journal Club slides prepared by Dr Aly Youssef (UOG Editor for Trainees)
  • 2. • Single umbilical artery (SUA) is seen in 0.5% at the time of 2nd trimester scan • Approximately 33% of fetuses with an SUA have additional structural anomalies and 10% of these are affected with aneuploidy • In approximately 65% of cases, SUA appears to be an isolated finding (iSUA) • In iSUA cases, however, aneuploidy or small for gestational age (SGA) fetuses may become apparent later on in pregnancy or at birth. The reported rate with which this occurs varies. As a result there is still no consensus regarding the extent of work-up required
  • 3. Relationship of isolated single umbilical artery to fetal growth, aneuploidy and perinatal mortality: systematic review with meta-analysis Voskamp et al., UOG 2013 The aim of this systematic review and meta-analysis was to assess whether there are sufficient data available to decide upon the appropriate work-up and management of pregnancies with iSUA diagnosed at midtrimester scan
  • 4. Methods: Literature search, study selection, data collection and quality assessment • • • • • • Medline (from 1948), EMBASE (from 1980) and Cochrane (until December 2012) were searched to identify papers reporting on SUA Studies were considered eligible if they described at least 30 cases of apparent iSUA at ultrasound performed < 24 weeks of gestation SUA was considered isolated if researchers reported that there were no additional structural anomalies, SGA or polyhydramnios at time of scan Odds ratios with 95% CIs for the occurrence of SGA, perinatal mortality and for aneuploidy in iSUA versus normal fetuses were calculated The mean birth weight difference (in g) with 95% CI between SUA and normal fetuses was calculated Funnel plots were made to check for publication bias and the heterogeneity of results across the studies was tested using the I² test
  • 5. Records identified through PubMed (n = 441) Records identified through Embase (n = 239) Results Records identified through Cochrane (n = 0) Duplicates removed (n=231) Screening title / abstract (n = 449) Records excluded (n = 383) Case reports (n = 96) Cohort is disease or condition associated with SUA (n = 86) Article on etiology, embryology, Doppler, placenta (n = 21) Article not on SUA (n = 67) Review/opinion article (n = 17) Article on visualization or detection of SUA (n = 16) Article appeared before 1975 (n = 40) Only twin gestation or case report twin (n = 10) Animal study (n = 15) Other (n = 15) Full-text articles assessed for eligibility (n = 66) Studies included in quantitative (& qualitative) synthesis (n = 7) Cohort studies (n = 3) Full-text articles excluded (n = 59) Case series (n = 27) No discrimination between isolated SUA and non-isolated SUA (n = 16) No information on prenatally diagnosed SUA, cohort based on postnatal data only (n = 10) No numbers on SUA outcome of interest (n = 5) Article on aneuploidy in selected population (n = 1) Case–control studies (n = 4)
  • 6. Results: Small-for-gestational age • Four case–control studies reported SGA • No statistically significant association between iSUA and SGA at birth (OR 1.59, 95% CI, 0.97–2.60, P=0.06)
  • 7. Results: Birth weight • Three case–control studies reported birth weight • Fetuses with iSUA did not have significantly lower birth weights than normal fetuses (mean 3154g vs 3176g; 95% CI, –154.7 to 52.6; p=0.33).
  • 8. Results: Perinatal mortality • One cohort study and three case–control studies reported perinatal mortality • No statistically significant association between iSUA and perinatal mortality (OR 1.98; 95% CI, 0.94–4.17; P=0.07)
  • 9. Results: Aneuploidy • The prevalence of aneuploidy in the apparent iSUA group was reported in 3 studies: 1. Predanic et al. had no cases of aneuploidy among cases and controls, thus its results could not be weighted in the metaanalysis 2. Lubusky et al. had no cases of aneuploidy among 77 fetuses with an SUA while the aneuploidy rate in the controls was 5.3% 3. Granese et al.: The aneuploidy rate was 2.6% among 39 SUA cases and 0.14% among controls • In view of these contradictory results, these data could not be pooled and no firm conclusions could be drawn on the association between iSUA and aneuploidy
  • 10. Discussion • This meta-analysis did not show a statistically significant difference in birth weight, incidence of SGA, and perinatal mortality between iSUA and normal • Based on this systematic review no firm conclusions can be drawn on the association between iSUA and aneuploidy. • However, well designed and properly powered studies are lacking • At present, targeted growth assessment after diagnosis of iSUA should not be routine practice
  • 11. Future perspectives • Large-scale, prospective cohort studies are needed to reach definitive conclusions on the appropriate work-up in iSUA pregnancies Limitations • Study populations differed with regard to a priori risk of anomalies • Postnatal confirmation of SUA was described in only (4/7) of studies • All included studies were too small to either show or refute a difference in the occurrence of aneuploidy
  • 12. Relationship of isolated single umbilical artery to fetal growth, aneuploidy and perinatal mortality: systematic review with meta-analysis Voskamp et al., UOG 2013 Discussion points • How can the results of this meta-analysis be applied in clinical practice? • Should women with iSUA at midtrimester scan be offered fetal karyotyping? • Should women with iSUA be offered regular fetal growth scans in the third trimester? • Is there a role for induction of labor at term in women with iSUA?