Prognostic accuracy of cerebroplacental ratio and middle cerebral artery Doppler for adverse perinatal outcome: systematic review and meta‐analysis

Abstract

ObjectiveDoppler 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.MethodsPubMed, 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.ResultsThe 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).ConclusionCalculating 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.

Predictive accuracy of cerebroplacental ratio for adverse perinatal and neurodevelopmental outcomes in suspected fetal growth restriction: systematic review and meta‐analysis

“…We identified three systematic reviews on the predictive accuracy of CPR for adverse perinatal outcome. Nassr et al .…”

“…These reviews did not report pooled estimates of predictive accuracy. Finally, Vollgraff Heidweiller‐Schreurs et al . assessed the accuracy of CPR to predict adverse perinatal outcome in singleton pregnancies of all risk profiles.…”

“…We identified three systematic reviews on the predictive accuracy of CPR for adverse perinatal outcome [70][71][72] . Nassr et al 70 included seven studies, and reported that abnormal CPR in pregnancies at high risk for FGR or with a diagnosis of FGR increased the risk for adverse perinatal outcome.…”

Using cerebroplacental ratio in non‐SGA fetuses to predict adverse perinatal outcome: caution is required

“…The main outcomes associated with low CPR in late pregnancy that have been investigated so far include mode of birth, serious composite neonatal outcome, perinatal death, low Apgar score at 5 min, low birth weight, NICU admission and emergency delivery for intrapartum fetal compromise. However, depending on the population screened, outcomes assessed, gestation at which the CPR is measured and specific threshold used, its test performance figures (e.g.…”

Screening for small for gestational age using third-trimester ultrasound markers: protocol for a systematic review and meta-analysis of screening test accuracy

“…Over the last decade, many ultrasound tools (middle cerebral artery [MCA] Doppler, uterine arteries [UtA] Doppler, umbilical artery [UA] Doppler, cerebroplacental ratio [CPR], ductus venosus [DV] Doppler, etc.) and markers (e.g., vascularization indices) have been developed to detect growth restrictions and to predict short- and long-term complications related to FGR [17–20]. However, there is a clinical equipoise regarding the use of third-trimester fetal ultrasound as a screening tool for FGR.…”