BackgroundAttrition amongst obstetrics trainees is high worldwide and attributed to sources of stress and burnout. The role of formal education and simulation as a means to prepare trainees for stressful periods such as transition into senior roles is underexplored.ObjectiveThis study set out to explore whether the creation of a dedicated educational intervention might positively influence burnout and self-estimated preparedness for practice among obstetric trainees transitioning into more senior roles.Study designA six-week preparatory training programme for year 2 trainees was created specifically for this study. The intervention used the flipped classroom design incorporating online learning that prepared participants for six simulation-based workshops. Participants were randomised by training cluster into an intervention group (n = 4) who participated in the educational intervention and a control group (n = 7) who received standard online and workplace training. The effects on trainee well-being was assessed using the Maslach burnout inventory (MBI) and a self-report questionnaire estimating preparedness for practice. Technical and non-technical skills were assessed using standardised OSAT and NOTSS assessment tools. The primary outcomes were MBI and preparedness for practice scores. Secondary outcomes included OSAT and NOTSS scores. Group comparisons were made using by t-test or Pearson Chi2 analysis where appropriate.ResultsThe study indicated a positive, non-significant trend in pre-post burnout scores in the intervention group. The following improving trends were noted in all subscales: emotional exhaustion 21.5 ± 2.6 (pre-intervention 23 ± 6.2); depersonalisation 9.8 ± 4.0 (pre-intervention 12.3 ± 2.8); personal accomplishment 35.5 ± 6.51 (pre-intervention 33 ± 5.5). The educational intervention engendered an increase in self estimated preparedness for practice amongst the intervention group (p = 0.006). From a training perspective, increased preparedness was noted for the following practical skills: forceps delivery (p = 0.0001), rotational forceps delivery (p = 0.02), delivery of twins vaginally (p = 0.0007) and performing a pudendal block (p = 0.001).ConclusionThis is one of the first studies to investigate whether the provision of a targeted training module can improve burnout scores and preparedness for practice amongst obstetrics trainees at an important time of transition. The positive but largely non-significant findings of this study should be examined in larger longitudinal and adequately powered studies.

Introduction: Prenatal counselling for cerebral ventriculomegaly is challenging due to varied factors and prognoses. There is limited data about the natural history of affected pregnancies managed expectantly. We sought to review the prenatal course, obstetric and paediatric outcomes in cases of moderate to severe cerebral ventriculomegaly in an Irish tertiary maternity unit. Materials and methods: Retrospective review of patients attending the Fetal Assessment Unit from 2006-2014 with lateral cerebral ventricular measurements >12 mm on ultrasound. Results: During the nine-year period, 93 cases were identified with pregnancy outcome data available for 80 cases and 54 continuing in our institution. Vaginal delivery was achieved in 28.9% of women with 71.1% undergoing caesarean. There were 9 cases of intrauterine demise and an additional six neonatal deaths and three paediatric deaths. An isolated neural tube defect was present in 12 babies. Of the remaining 33 babies a diagnosis was confirmed in 60.6% of which, 45% were achieved antenatally. Conclusions: A diagnosis was obtained in 70% of live births. The presence of ventriculomegaly had a significant impact on the mode of delivery and maternal morbidity. The survival rate was 66.6% with high rate of neurodevelopmental delay recognized in survivors particularly in cases without a clear diagnosis.

Background Pre-eclampsia (PET) affects 2-3% of all pregnancies, rising to 5-7% in nulliparous women. This study aimed to investigate the prevalence of PET over a 13-year period. Methods A retrospective review was performed over a 13-year period (2004-2016) via interrogation of the annual clinical reports of The Rotunda Hospital, Dublin. Results There was a fall in the overall incidence of PET (nulliparous and multiparous), from a peak of 3.8% in 2007 to 1.5% in 2015. Comparing the first and second halves of the study time-period this decrease was statistically significant (p < .0001). In nulliparous women, the thirteen-year mean was 4.4% for the study period, with a similar observed reduction from a peak of 5.3% in 2005 to a trough of 2.4% in 2015. Discussion In our institution, we have shown a decrease in preeclampsia rates over a 13-year period. While the reason for this trend remains unclear, a similar trend has been observed in another tertiary unit and additional research is required to explain the etiology behind these observations.

The aim of the PORTO- NeuroDevelopmental Assessment Study (PANDA) was to determine if children born after fetal growth restriction (FGR) pregnancies are at additional risk of early childhood development delays compared to children born small for gestational age (SGA). The objective of this secondary analysis was to describe the role of the cerebroplacental ratio (CPR) in the prediction of adverse early childhood neurodevelopmental outcome. Participants were prospectively recruited from the Perinatal Ireland multicenter observational PORTO study cohort. FGR was defined as birth weight <10th with abnormal antenatal Doppler indices. SGA was similarly defined in the absence of abnormal Doppler indices. CPR was calculated using the pulsatility indices of the middle cerebral and divided by umbilical artery (UA) with an abnormal value <1. Children (n=375) were assessed at three years using the Ages and Stages Questionnaire and the Bayley Scales of Infant and Toddler Development, III. SGA pregnancies with normal Doppler indices were compared with: 1) FGR cases with abnormal UA Doppler and normal CPR; or 2) FGR cases with both abnormal UA & CPR. Statistical analysis was performed using SAS version 9.2 via two-sample t-test with Bonferroni adjustment and p-value of 0.00625 significant. Assessments were performed on 198 SGA children; 136 FGR children with abnormal UA Doppler and normal CPR and 41 FGR children with both abnormal UA Doppler and CPR. At three years of age, while there were no differences in head circumference, children who also had an abnormal CPR had persistently shorter stature (p=0.005) and lower weight (p=0.18). Children from FGR affected pregnancies demonstrated poorer neurodevelopmental outcome than their SGA counterparts. FGR pregnancies with an abnormal CPR had significantly poorer neurological outcome at three years of age across all measured variables (Tables 1 & 2). We have demonstrated that growth restricted pregnancies with a CPR <1, have significantly increased risk of delayed neurodevelopment at three years of age when compared to pregnancies with abnormal UA Doppler alone. This study further substantiates the benefit of routine assessment of CPR in FGR pregnancies and for counseling parents regarding the long-term outcome of affected infants.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

BACKGROUND:Fetal growth restriction accounts for a significant proportion of perinatal morbidity and death. The cerebroplacental ratio is gaining much interest as a useful tool in differentiating the "at-risk" fetus in both fetal growth restriction and appropriate-for-gestational-age pregnancies. The Prospective Observational Trial to Optimize Pediatric Health in Fetal Growth Restriction group has demonstrated previously that the presence of this "brain-sparing" effect is associated significantly with adverse perinatal outcomes in the fetal growth restriction cohort. However, data about neurodevelopment in children from pregnancies that are complicated by fetal growth restriction are sparse and conflicting.OBJECTIVE:The aim of the Prospective Observational Trial to Optimize Pediatric Health in Fetal Growth Restriction NeuroDevelopmental Assessment Study was to determine whether children born after fetal growth-restricted pregnancies are at additional risk of adverse early childhood developmental outcomes compared with children born small for gestational age. The objective of this secondary analysis was to describe the role of cerebroplacental ratio in the prediction of adverse early childhood neurodevelopmental outcome.STUDY DESIGN:Participants were recruited prospectively from the Perinatal Ireland multicenter observational Prospective Observational Trial to Optimize Pediatric Health in Fetal Growth Restriction study cohort. Fetal growth restriction was defined as birthweight <10th percentile with abnormal antenatal umbilical artery Doppler indices. Small for gestational age was defined similarly in the absence of abnormal Doppler indices. Cerebroplacental ratio was calculated with the pulsatility indices of the middle cerebral artery and divided by umbilical artery with an abnormal value <1. Children (n=375) were assessed at 3 years with the use of the Ages and Stages Questionnaire and the Bayley Scales of Infant and Toddler Development, 3rd edition. Small-for-gestational-age pregnancies with normal Doppler indices were compared with (1) fetal growth-restricted cases with abnormal umbilical artery Doppler and normal cerebroplacental ratio or (2) fetal growth restriction cases with both abnormal umbilical artery and cerebroplacental ratio. Statistical analysis was performed with statistical software via 2-sample t-test with Bonferroni adjustment, and a probability value of .00625 was considered significant.RESULTS:Assessments were performed on 198 small-for-gestational-age children, 136 fetal growth-restricted children with abnormal umbilical artery Doppler images and normal cerebroplacental ratio, and 41 fetal growth-restricted children with both abnormal umbilical artery Doppler and cerebroplacental ratio. At 3 years of age, although there were no differences in head circumference, children who also had an abnormal cerebroplacental ratio had persistently shorter stature (P=.005) and lower weight (P=.18). Children from fetal growth restriction-affected pregnancies demonstrated poorer neurodevelopmental outcome than their small-for-gestational-age counterparts. Fetal growth-restricted pregnancies with an abnormal cerebroplacental ratio had significantly poorer neurologic outcome at 3 years of age across all measured variables.CONCLUSION:We have demonstrated that growth-restricted pregnancies with a cerebroplacental ratio <1 have a significantly increased risk of delayed neurodevelopment at 3 years of age when compared with pregnancies with abnormal umbilical artery Doppler evidence alone. This study further substantiates the benefit of routine assessment of cerebroplacental ratio in fetal growth-restricted pregnancies and for counseling parents regarding the long-term outcome of affected infants.

Objective:; Early-onset preeclampsia is a rare pregnancy-specific disorder associated with significantly increased maternal and fetal morbidity and mortality. Whilst it is known that even normotensive pregnancies are associated with changes in clot formation and dissolution, the nature of how these changes differ in those with early onset preeclampsia has not been well established. We sought to evaluate parameters of fibrin formation and fibrinolysis in individuals with early onset preeclampsia in comparison to both pregnant and non-pregnant controls. Furthermore, such parameters were correlated with markers of disease severity in this patient cohort, including the presence of multiorgan involvement, the rate of disease progression and the extent of the anti-angiogenic state in this condition. Study design:; Patients with early onset preeclampsia (N = 20) and both pregnant (N = 16) and non-pregnant (N = 16) controls were recruited from the cohort at a large urban maternity hospital which saw over 15,000 deliveries during the study period. Platelet poor plasma was prepared from collected whole blood and analysed for parameters of fibrin formation and fibrinolysis (lagtime to and rate of fibrin formation; PAI-1; PAI-2; D-dimer; plasmin-antiplasmin; tPA) in addition to markers of angiogenesis (sFLT-1; Endoglin) using commercially available specific immunoassays. Results:; The maximum rate of fibrin formation as well as PAI-1, PAI-2 and D-dimer levels were all significantly increased in those with early onset preeclampsia and pregnant controls when compared to non-pregnant controls without significant differences between the 2 former groups. Plasmin-antiplasmin levels were significantly reduced in a similar manner. tPA levels were significantly elevated in EOP compared to both pregnant and non-pregnant controls. EOP was associated with significantly increased anti-angiogenic factors (sFLT-1; Endoglin) when compared to both pregnant and non-pregnant controls. Conclusion:; Markers of fibrin formation and fibrinolysis are significantly alerted in early onset preeclampsia; furthermore, certain markers correlate with disease severity in this patient cohort. (C) 2019 Elsevier B.V. All rights reserved.

To assess the ability of non-invasive cardiac output monitoring (NICOM®), a novel method of non-invasive maternal hemodynamic assessment using bioreactance, in combination with first trimester biomarkers to predict the evolution of gestational hypertension (GH), pre-eclampsia (PE) and normotensive fetal growth restriction (FGR). Low risk nulliparous women were enrolled in a single center prospective observational study. NICOM® assessments were performed at 14 weeks' gestation and data obtained on cardiac output (CO), indexed CO (adjusted for maternal body surface area; COI), total peripheral resistance (TPR), indexed TPR (adjusted for maternal body surface area; TPRi), stroke volume (SV), indexed SV (adjusted for maternal body surface area; SVi) and heart rate (HR). Maternal serum samples were obtained in the first trimester and the following markers were analysed: placental growth factor (PLGF; Cobas Roche); soluble fms-like tyrosine-1 (s-flt-1; Elecsys®) Apelin 13 (Nori® ELISA) and mean platelet volume (MPV). Corrleation between cardiac variables and biomarkers was assessed using Spearman coefficient. Discriminant analysis was employed to model GH, PE and FGR with NICOM® and biomarker measurements as predictors. Logistic regression was performed on variables of interest via SAS version 9.0. The haemodynamic profile of pregnancies complicated by uteroplacental disease- GH (n=13), PE (n=5) and FGR (n=18) were compared to 61 healthy unaffected pregnant controls.Apelin 13 demonstrated a negative correlation with TPRi (r=-0.29, p=0.004), and a positive correlation with COi (r=0.29, p=0.005). In the prediction of PE s-flt-1 and MPV had a combined prediction model AUC 0.88 (p=0.01). Whereas in the prediction of FGR s-flt-1, SV and TPRI had a combined prediction model AUC 0.76 (p=0.007). Apelin 13 is an inodilator produced by the normal placenta in pregnancy. This study shows the hemodynamic effects of Apelin 13 are present as early as 14 weeks' gestation. Down regulation of placental Apelin 13 has been linked with PE and lower serum Apelin with FGR, from 20 weeks' gestation onwards. However, this association was not present at 14 weeks' gestation. In addition to its known use in PE, first trimester s-flt-1 may have an role in the prediction of FGR which is strengthened by the addition of hemodynamic variables.

Abstract Objective: To characterise Mean platelet volume (MPV) in patients with early onset preeclampsia (EOPE) and unaffected controls from time of first antenatal visit until the postpartum. Materials and methods: Retrospective secondary analysis of an observational study in an Irish tertiary referral centre with 9000 deliveries annually. The MPV of 27 women with EOPE was compared to 19 unaffected controls. The inclusion criteria for the disease state was the development of EOPE defined by the National Institute for Health and Care Excellence (NICE) guideline, as new onset hypertension presenting after 20 weeks and prior to 34 weeks with significant proteinuria. Between October 2013 and July 2015 we recruited 27 women with EOPE and 19 pregnant controls. Statistical analysis was performed using paired T-test of Mann-Whitney test where appropriate and a P-value <0.05 was deemed significant. Results: At time of diagnosis and late in the third trimester MPV was significantly increased to 9.0 (±0.3) fL in cases of EOPE in comparison to 8.5 (±0.6) fL in normotensive controls (P<0.05). There was no significant difference during the first trimester or postpartum when comparing the MPV in EOPE to controls. Conclusion: Despite an increased MPV at time of diagnosis of EOPE this study did not demonstrate a potential use for increased MPV as a first trimester screening tool.

Our objective was to prospectively validate a Point-of-Care (POC) hemoglobin device (Hemocue 201 DM system) as an alternative to a laboratory based complete blood count (CBC) in the setting of hemoglobin evaluation during cordocentesis and intrauterine fetal transfusion. This prospective study was performed in a tertiary level maternity hospital. Fifteen consecutive cases of fetal anemia attending the hospital for cordocentesis and intrauterine fetal transfusion over an 18 month period were included. At the time of cordocentesis all participants had at least two episodes of dual fetal blood sampling with both a POC Test and a laboratory-based CBC. Statistical analysis was performed via Pearson's test. Fifteen cordocentesis procedures were performed during the 18 month period yielding a total of 35 paired samples. There was strong correlation between the POC hemoglobin and a CBC hemoglobin with r=0.976 (95% CI 0.952-0.988) and a p value <0.0001. This study demonstrated a linear fit between both methods of hemoglobin quantification enabling the prediction of the anticipated CBC hemoglobin from CBC hemoglobin via the equation Hemocue Hemoglobin = 2.902 + 0.9617 Laboratory Hemoglobin. Overall there is good agreement between the POC fetal hemoglobin and the CBC fetal hemoglobin. This suggests that the Hemocue 201 DM system is a viable and reproducible alternative form of measurement of fetal hemoglobin, with the important advantage of providing expedited results at the bedside. This ultimately may reduce fetal morbidity associated with cordocentesis and intrauterine transfusion, minimizing the time required to complete the procedure.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Our aim was to assess if the aberrant changes measured by non-invasive cardiac output monitoring (NICOM) in women with pregnancies complicated by Gestational Hypertension (GH), Preeclampsia (PE), or Fetal growth restriction (FGR) persist postpartum. Low risk nulliparous women were enrolled in a single center prospective study assessing the ability of NICOM to predict the evolution of GH, PE and FGR, as part of the HANDLE study. NICOM was performed at >6 weeks postpartum. Hemodynamic variables assessed included cardiac output (CO), indexed cardiac output (CO), total peripheral resistance (TPR), indexed total peripheral resistance (TPRI), heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), stroke volume (SV) and indexed stroke volume (SVI). Comparison was made to 30 matched non-pregnant controls. Statistical analysis was performed by independent t-test using SPSS Version 23. Of 318 recruits, 291 (79.5%) of women attended the postpartum review. Four pregnancies were affected by PE, 17 by GH, 18 by FGR and 252 uncomplicated pregnancies. In comparison to non-pregnant values, uncomplicated pregnancies postnatally exhibited an increase in TPRI (p=0.04) and a decrease in COI (p<0.001), SV (p=0.003) and SVI (p<0.001) while HR, CO, TPR and BP were unchanged. FGR pregnancies exhibited a similar trend but did not achieve significance. Pregnancies complicated by hypertensive disease in the postpartum period maintained a lower SVI (p=0.04) but higher SBP (p=0.03), DBP (p=0.01), HR (p<0.05) and TPRI (p=0.009) when compared to non-pregnant values (Table 1). Pregnancy is associated with hemodynamic changes, which persist in the postpartum period. Women with pregnancies complicated by GH/PE were characterised by persistently higher intravascular resistance, coupled with persistently elevated blood pressures. This altered postnatal adaption may explain why women with a pregnancy complicated by PE have a life-long increased risk of cardiovascular disease.

Background: Assessment of myocardial performance in neonates using advanced techniques such as deformation imaging and rotational mechanics has gained considerable interest. The applicability of these techniques for elucidating abnormal myocardial performance in various clinical scenarios is becoming established. We hypothesise that term infants born to mothers with gestational hypertension (GH) may experience impaired performance of the left and right ventricles during the early neonatal period. Objectives: We aimed to assess left and right ventricular (LV and RV) function using echocardiography in infants born to mothers with GH and compare them to a control group. Methods: Term infants (>36+6 weeks) born to mothers with GH underwent assessment to measure biventricular function using ejection fraction (EF), deformation imaging, left-ventricle rotational mechanics (apical rotation, basal rotation, twist, twist rate, and untwist rate), and right ventricle-specific functional parameters (tricuspid annular plane systolic excursion and fractional area change) in the first 48 h after birth. A control group comprising infants born to healthy mothers was used for comparison. Results: Fifteen infants with maternal GH and 30 age-matched controls were enrolled. The GH infants exhibited no differences in birthweight or LV or RV length, but they had lower EF (54 vs. 61%; p < 0.01), LV global longitudinal strain (-20 vs. -25%; p < 0.01), and LV twist (11 vs. 16°; p = 0.04). There were no differences in any of the RV functional parameters. Conclusion: Infants born to mothers with GH exhibited lower LV function than healthy controls, while RV function appeared to be preserved. This relationship warrants further exploration in a larger cohort.

Screening for fetal aneuploidy using non-invasive prenatal testing (NIPT) methods is increasingly utilised for assessment of pregnancies both with and without risk factors for aneuploidy. Our objective was to determine the effect of NIPT availability on the rates of, and indications for, invasive procedures for fetal genetic testing. A retrospective analysis was performed of prenatal aneuploidy screening and testing over two one-year time periods; Jan to Dec 2012 (Pre-NIPT) and Jan-Dec 2016 (Post- NIPT). The total number of patients undergoing chorionic villus sampling (CVS) or amniocentesis was determined for each time period and grouped by the following indications: advanced maternal age (AMA), maternal anxiety (MA), high risk combined first trimester screening or NIPT, abnormal ultrasound finding (US), personal or family history of genetic anomaly (FH) and other indications combined. Differences were compared using chi-square test. Combined first trimester screening (FTS) was the primary method of aneuploidy screening in 2012. By 2016 only 21.7% opted for this method of screening. Post-NIPT, the number of invasive procedures has decreased significantly; 157 amniocentesis and 128 CVS in 2012 to 96 amniocentesis and 63 CVS in 2016 (p<0.001). There was a significant change in the distribution of indications for combined diagnostic testing (p<0.001) across the two time periods, with reductions in the reasons of maternal age (20% to 1%), maternal history (13% to 7%) and other indications (13% to 4%). Conversely, there was increase for ultrasound indications (36% to 73%) (Figure1). CVS indicated by high risk aneuploidy screening increased (18% to 22%), coupled with a significant decrease in amniocentesis for this indication (11% to 4%). The number of invasive diagnostic tests has decreased significantly with the advent of NIPT. The majority of invasive tests are now performed for abnormal ultrasound findings, with fewer low risk pregnancies being exposed to the risks of these procedures.

Background. Non-invasive cardiac output monitoring (NICOM) using bioreactance (BRT) in pregnancy is gaining interest but lacks validation. We compared simultaneous cardiac output (CO) measurements obtained using the NICOM ® (BRT-CO) and echocardiography (echo-CO), and assessed the relationship between maternal characteristics and myocardial performance. Methods. Paired stroke volume (SV) and CO readings were obtained using NICOM ® and echocardiography, in a group of healthy nulliparous women throughout a 15 min period. Agreement between NICOM ® and echocardiography was assessed using Bland-Altman analysis and the intraclass correlation coefficient (ICC). Left ventricular (LV) function was assessed using systolic strain and tissue Doppler velocities (S', E', and A' waves). Results. Thirty-five women with a median [interquartile range] age, weight, and gestation of 29 [26-34] yr, 71 [64-79] kg, and 28 [21-29] weeks, respectively, were enrolled. There was good agreement between NICOM ® -measured and echocardiographically measured SV [mean bias 6 ml (limits of agreement -18 to 29); ICC 0.8 (95% confidence interval 0.6-0.9), P <0.001] and CO [mean bias 0.2 litres (limits of agreement -1.3-1.7); ICC 0.8 (95% confidence interval 0.7-0.9), P <0.001; mean percentage error ±26%; coefficient of error (precision)=3.4%]. The mean ( sd ) LV S' was 9.7 (2.3) cm s -1 . The mean ( sd ) LV strain was -18.6 (2.6)%. There was a negative relationship between BMI and LV diastolic function measured using the E':A' ratio ( r  = -0.51, P <0.01). Conclusions. Stroke volume and CO measurements obtained using NICOM ® were comparable to those obtained using echocardiography, with acceptable limits of agreement. Increased maternal BMI negatively impacts LV diastolic function measured using tissue Doppler imaging.

Objectives: We aimed to firstly identify the different haemodynamic profiles amongst nulliparous women who develop either gestational hypertension (GH), pre-eclampsia (PE), normotensive fetal growth restriction (FGR) versus unaffected pregnancies using non-invasive cardiac output monitoring (NICOM (R)). Our second primary objective was to assess the ability of NICOM (R) derived variables to predict the evolution of PE, GH and FGR.Study design: Low risk nulliparous women were enrolled in a single center prospective observational study. NICOM (R) assessments were performed at 14, 20 and 28 weeks' gestation and data was obtained on cardiac output (CO), total peripheral resistance (TPR), indexed TPR (adjusted for maternal body surface area; TPRi), stroke volume (SV), indexed SV (adjusted for maternal body surface area; SVi) and heart rate (HR). Logistic regression was used to model GH, PE and FGR with NICOM (R) measurements as predictors. Linear, non-linear and interaction terms were assessed using the Akaike Information Criterion.Results: The haemodynamic profile of pregnancies complicated by uteroplacental disease- GH (n = 18), PE (n = 6) and FGR (n = 24) were compared to 318 healthy unaffected pregnant controls. Women with evolving PE have a different haemodynamic profile to those developing either GH or FGR. The best independent predictors for the evolution of uteroplacental disease at 14 weeks' gestation were CO in the prediction of FGR (AUC = 0.61; p 0.002), TPR in the prediction of GH (AUC = 0.63; p < 0.02) and SVi in the prediction of PE (AUC = 0.62; p < 0.05). The performance of haemodynamic variables was enhanced when combined in a multivariate logistic model. We demonstrated that TPR, CO and SV when combined with BP were significant predictors of pregnancies complicated by FGR (AUC = 0.64, p = 0.004; AUC = 0.65, p = 0.004; and AUC = 0.65, p = 0.007 respectively). Whereas in pregnancies complicated by PE, HR and SVi in combination with BP were also statistically significant predictors (AUC = 0.75, p = 0.017 and AUC = 0.77, p = 0.007 respectively).Conclusions: NICOM (R) derived maternal haemodynamic profile at 14 weeks' gestation has the novel potential to identify pregnancies which will ultimately develop uteroplacental disease. (C) 2017 Elsevier B.V. All rights reserved.