Early‐onset fetal growth restriction: A systematic review on mortality and morbidity

Anouk Pels,Irene M Beune,Jacqueline Limpens,Wessel Ganzevoort,Aleid G Van Wassenaer‐Leemhuis

doi:10.1111/aogs.13702

Abstract

IntroductionSevere early‐onset fetal growth restriction is an obstetric condition with significant risks of perinatal mortality, major and minor neonatal morbidity, and long‐term health sequelae. The prognosis of a fetus is influenced by the extent of prematurity and fetal weight. Clinical care is individually adjusted. In literature, survival rates vary and studies often only include live‐born neonates with missing rates of antenatal death. This systematic review aims to summarize the literature on mortality and morbidity.Material and methodsA broad literature search was conducted in OVID MEDLINE from 2000 to 26 April 2019 to identify studies on fetal growth restriction and perinatal death. Studies were excluded when all included children were born before 2000 because (neonatal) health care has considerably improved since this period. Studies were included that described fetal growth restriction diagnosed before 32 weeks of gestation and antenatal mortality and neonatal mortality and/or morbidity as outcome. Quality of evidence was rated with the GRADE instrument.ResultsOf the 2604 publications identified, 25 studies, reporting 2895 pregnancies, were included in the systematic review. Overall risk of bias in most studies was judged as low. The quality of evidence was generally rated as very low to moderate, except for 3 large well‐designed randomized controlled trials. When combining all data on mortality, in 355 of 2895 pregnancies (12%) the fetus died antenatally, 192 died in the neonatal period (8% of live‐born neonates) and 2347 (81% of all pregnancies) children survived. Of the neonatal morbidities recorded, respiratory distress syndrome (34% of the live‐born neonates), retinopathy of prematurity (13%) and sepsis (30%) were most common. Of 476 children that underwent neurodevelopmental assessment, 58 (12% of surviving children, 9% of all pregnancies) suffered from cognitive impairment and/or cerebral palsy.ConclusionsWhen combining the data of 25 included studies, survival in fetal growth restriction pregnancies, diagnosed before 32 weeks of gestation, was 81%. Neurodevelopmental impairment was assessed in a minority of surviving children. Individual prognostic counseling on the basis of these results is hampered by differences in patient and pregnancy characteristics within the included patient groups.

Highlights

Severe early‐onset fetal growth restriction is an obstetric condition with significant risks of perinatal mortality, major and minor neonatal morbidity, and long‐term health sequelae
fetal growth restriction (FGR) is defined as onset before 32 weeks of gestation, a fetal abdominal circumference or estimated fetal weight (EFW) below the 3rd centile or absent end‐ diastolic flow in the umbilical artery, or abdominal circumference or EFW below the 10th centile combined with a pulsatility index of the uterine artery above the 95th centile and/or pulsatility index of the umbilical artery above the 95th centile.[2]
In this systematic review based on 25 studies comprising 2895 pregnancies complicated by severe early‐onset FGR, we found that the overall rates of antenatal and neonatal death were 12.3% and 6.6%, respectively

Summary

Introduction

Severe early‐onset fetal growth restriction is an obstetric condition with significant risks of perinatal mortality, major and minor neonatal morbidity, and long‐term health sequelae. FGR is defined as onset before 32 weeks of gestation, a fetal abdominal circumference or estimated fetal weight (EFW) below the 3rd centile or absent end‐ diastolic flow in the umbilical artery, or abdominal circumference or EFW below the 10th centile combined with a pulsatility index of the uterine artery above the 95th centile and/or pulsatility index of the umbilical artery above the 95th centile.[2] This patient group needs high amounts of care and has a high likelihood of iatrogenic premature delivery, both for fetal and for secondary maternal indications, such as the development of the maternal syndrome of preeclampsia.[3]. As these FGR children are usually born very preterm, the condition carries significant risks of neonatal mortality, major and minor morbidity, and long‐term health sequelae.[4,5].

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