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1
Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands.
2
Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands.
3
Department of Medical Library, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
4
Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
5
Department of Obstetrics and Gynecology, The Robinson Institute, School of Medicine, University of Adelaide, Adelaide, Australia.
6
The South Australian Health and Medical Research Institute, Adelaide, Australia.
7
Department of Obstetrics and Gynecology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
1
Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, The Netherlands.
2
Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands.
3
Department of Medical Library, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
4
Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
5
Department of Obstetrics and Gynecology, The Robinson Institute, School of Medicine, University of Adelaide, Adelaide, Australia.
6
The South Australian Health and Medical Research Institute, Adelaide, Australia.
7
Department of Obstetrics and Gynecology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
Doppler ultrasonographic assessment of the cerebroplacental ratio (CPR) and middle cerebral artery (MCA) is widely used as an adjunct to umbilical artery (UA) Doppler to identify fetuses at risk of adverse perinatal outcome. However, reported estimates of its accuracy vary considerably. The aim of this study was to review systematically the prognostic accuracies of CPR and MCA Doppler in predicting adverse perinatal outcome, and to compare these with UA Doppler, in order to identify whether CPR and MCA Doppler evaluation are of added value to UA Doppler.
PubMed, EMBASE, the Cochrane Library and ClinicalTrials.gov were searched, from inception to June 2016, for studies on the prognostic accuracy of UA Doppler compared with CPR and/or MCA Doppler in the prediction of adverse perinatal outcome in women with a singleton pregnancy of any risk profile. Risk of bias and concerns about applicability were assessed using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) tool. Meta-analysis was performed for multiple adverse perinatal outcomes. Using hierarchal summary receiver-operating characteristics meta-regression models, the prognostic accuracy of CPR vs MCA Doppler was compared indirectly, and CPR and MCA Doppler vs UA Doppler compared directly.
The search identified 4693 articles, of which 128 studies (involving 47 748 women) were included. Risk of bias or suboptimal reporting was detected in 120/128 studies (94%) and substantial heterogeneity was found, which limited subgroup analyses for fetal growth and gestational age. A large variation was observed in reported sensitivities and specificities, and in thresholds used. CPR outperformed UA Doppler in the prediction of composite adverse outcome (as defined in the included studies) (P < 0.001) and emergency delivery for fetal distress (P = 0.003), but was comparable to UA Doppler for the other outcomes. MCA Doppler performed significantly worse than did UA Doppler in the prediction of low Apgar score (P = 0.017) and emergency delivery for fetal distress (P = 0.034). CPR outperformed MCA Doppler in the prediction of composite adverse outcome (P < 0.001) and emergency delivery for fetal distress (P = 0.013).
Calculating the CPR with MCA Doppler can add value to UA Doppler assessment in the prediction of adverse perinatal outcome in women with a singleton pregnancy. However, it is unclear to which subgroup of pregnant women this applies. The effectiveness of the CPR in guiding clinical management needs to be evaluated in clinical trials. © 2017 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
La evaluación ecográfica Doppler de la relación cerebroplacentaria (RCP) y la arteria cerebral media (ACM) se usa ampliamente como complemento del Doppler de la arteria umbilical (AU) para identificar fetos con riesgo de un resultado perinatal adverso. Sin embargo, los informes de las estimaciones de su precisión varían considerablemente. El objetivo de este estudio fue la revisión sistemática de las precisiones en el pronóstico mediante Doppler RCP y ACM para predecir resultados perinatales adversos y compararlas con el Doppler AU, a fin de identificar si la evaluación con Doppler RCP y ACM tiene un valor agregado al del Doppler AU.
Se realizaron búsquedas en PubMed, EMBASE, Cochrane Library y
ClinicalTrials.gov
, desde su inicio hasta junio de 2016, respecto a estudios sobre la precisión en el pronóstico del Doppler AU en comparación con Doppler RCP y/o ACM en la predicción de resultados perinatales adversos en embarazos con feto único de cualquier perfil de riesgo. El riesgo de sesgos y preocupaciones sobre la aplicabilidad se evaluó usando la herramienta QUADAS‐2 (Evaluación de Calidad de Estudios de Precisión de Diagnósticos‐2). Se realizó un metaanálisis respecto a múltiples resultados perinatales adversos. Utilizando modelos de metaregresión jerárquica de resumen de las características operativas del receptor, se comparó indirectamente la precisión del pronóstico del Doppler RCP versus ACM, y de forma directa la del Doppler RCP y ACM versus el Doppler AU.
La búsqueda identificó 4693 artículos, de los cuales se incluyeron 128 estudios (con 47748 mujeres). Se detectó un riesgo de sesgo o información subóptima en 120 de los 128 estudios (94%) y se encontró heterogeneidad sustancial, lo que limitó los análisis de subgrupos respecto al crecimiento fetal y la edad gestacional. Se observó una gran variación en las sensibilidades y especificidades reportadas, y en los valores umbral utilizados. El Doppler RCP superó al Doppler AU en la predicción de resultados adversos compuestos (tal y como los definen los estudios incluidos) (
P
<0,001) y del parto de emergencia por sufrimiento fetal (
P
=0,003), pero fue comparable al Doppler AU para los otros resultados. Los valores del Doppler ACM fueron significativamente peores que los del Doppler AU en la predicción de la puntuación de Apgar baja (
P
=0,017) y del parto de emergencia por sufrimiento fetal (
P
=0,034). El Doppler RCP superó al Doppler ACM en la predicción de resultados adversos compuestos (
P
<0,001) y del parto de emergencia por sufrimiento fetal (
P
=0,013).
El cálculo del Doppler RCP junto con el Doppler ACM puede agregar valor a la evaluación con Doppler UA para la predicción de resultados perinatales adversos en mujeres con embarazo con feto único. Sin embargo, no está claro a qué subgrupo de mujeres embarazadas aplica esto. La efectividad de la RCP para guiar la atención clínica debe ser evaluada mediante pruebas clínicas.
检索到4693篇文献,其中纳入128项研究(47 748例孕妇)。128项研究中有120项(94%)研究存在偏倚风险或次优报告,并发现较大异质性,从而限制了对胎儿生长和孕周进行亚组分析。报道的敏感性和特异性以及采用的临界值变化很大。在预测综合不良结局(纳入研究对其定义)(
P
<0.001)以及由于胎儿窘迫急诊分娩(
P
=0.003)方面,CPR优于UA多普勒,但在其他结局方面与UA多普勒相似。在预测Apgar评分较低(
P
=0.017)以及由于胎儿窘迫急诊分娩(
P
=0.034)方面,MCA多普勒明显不如UA多普勒。在预测综合不良结局(
P
<0.001)以及由于胎儿窘迫急诊分娩(
P
=0.013)方面,CPR优于MCA多普勒。
Hierarchal summary receiver–operating characteristics curves and
P
‐values for indirect comparisons of prognostic accuracy of cerebroplacental ratio (
, black line) and middle cerebral artery Doppler (
, green line) for outcomes perinatal death, 5‐min Apgar score < 7, emergency delivery (ED) for fetal distress, admission to neonatal intensive care unit (NICU) and composite adverse perinatal outcome (as defined in included studies).
Hierarchal summary receiver–operating characteristics curves and
P
‐values for direct comparisons of prognostic accuracy of cerebroplacental ratio (
), middle cerebral artery Doppler (
) and umbilical artery Doppler (
) for outcomes perinatal death, 5‐min Apgar score < 7, emergency delivery (ED) for fetal distress, admission to neonatal intensive care unit (NICU) and composite adverse perinatal outcome (as defined in included studies). Analyses restricted to studies that compared both tests in the same patients. Lines connect pairs of points representing the two tests from each study.
