Integrated fetal testing is the most accurate predictor of perinatal outcome in intrauterine growth restriction (IUGR)

Abstract

OUTCOME IN INTRAUTERINE GROWTH RESTRICTION (IUGR) AHMET BASCHAT, MICHELLE KUSH, ANITA MANOGURA, DOLORES MOYANO, SIFA TURAN, UTE GERMER, CHRISTOPH BERG, AMARNATH BHIDE, DICK OEPKES, BASKARAN THILAGANATHAN, HENRY GALAN, SARAH BOWER, KYPROS NICOLAIDES, ULRICH GEMBRUCH, CHRISTOPHER HARMAN, University of Maryland, Obstetrics, Gynecology and Reproductive Sciences, Baltimore, Maryland, King’s College Hospital, London, United Kingdom, Medical University Lubeck, Obstetrics & Gynecology, Lubeck, Germany, Friedrich Wilhelm University, Obstetrics & Prenatal Medicine, Bonn, Germany, St. George’s Hospital Medical School, Fetal Medicine Unit, London, United Kingdom, Leiden University, Leiden, Ontario, Netherlands, University of Colorado Health Sciences Center, Obstetrics and Gynecology, Denver, Colorado, Medical University Lubeck, Obstetrics & Gynecology, Bonn, Germany OBJECTIVE: Biophysical profile scoring (BPS) and arterial and venous multivessel Doppler each test fetal behavioral and cardiovascular responses to compromised placental function. We aimed to study if integration of two testing modaIities improves prediction of critical perinatal outcomes in IUGR fetuses. STUDY DESIGN: Fetuses with IUGR (Abdominal Circumference !5%ile, elevated umbilical artery (UA) Doppler) were studied in a multicenter collaboration. UA end-diastolic velocity (EDV), middle cerebral artery brain sparing, abnormal ductus venosus Doppler (DV-RAV) and BPS were compared for their ability to predict stillbirth (SB), neonatal death (NND), birth acidemia, low 5 minute Apgar, and major neonatal morbidity (intraventricular hemorrhage OGrade 2, bronchopulmonary dysplasia, necrotizing enterocolitis). Integration of the two testing modalities was modelled to provide the best outcome prediction. RESULTS: In 534 IUGR fetuses, there were 38 stillborn, 32 neonatal deaths (PNM 13.1%). Low Apgar and birth acidemia occured in 7.3% and 9.6% respectively. In survivors, 67 (14.8%) had major morbidity. Prediction of PNM by single abnormal parameter ranged from Odds Ratios of 2.1 for brain sparing and fetal tone, to 14.6 for DV-RAV. However, DV-RAV was present in only 22 of deaths. No single parameter correctly predicted more than 2/3 of PNM. This pattern was repeated for all individual outcomes. The analysis was repeated for combined test domains. Combining DV index, UA-EDV, amniotic fluid volume, fetal movement, and fetal breathing (in declining order of statistical contribution), produced highest predictive accuracy for both normal and abnormal outcomes. Eighteen of twenty possible test domains (nine normal and nine abnormal parameters) provided enhanced outcome specifictity. CONCLUSION: Optimal prediction of critical perinatal outcome in IUGR requires combined evaluation of fetal cardiovacular and behavioral responses. For the clinincian, the combination of umbilical and venous Doppler with the four ultrasound parameters of BPS, can provide this optimal assessment.