More Maternal Vascular Malperfusion and Chorioamnionitis in Placentas After Expectant Management vs. Immediate Delivery in Fetal Growth Restriction at (Near) Term: A Further Analysis of the DIGITAT Trial.

Marjon E Feenstra,Sicco A Scherjon,Albertus Timmer,Torsten Plösch,Mirthe H Schoots,Harry Van Goor,Jelmer R Prins,Sanne J Gordijn

doi:10.3389/fendo.2019.00238

Abstract

Objective: Management of late fetal growth restriction (FGR) is limited to adequate fetal monitoring and optimal timing of delivery. The Disproportionate Intrauterine Growth Intervention Trial At Term (DIGITAT) trial compared induction of labor with expectant management in pregnancies at (near) term complicated by suspected FGR. Findings of the DIGITAT trial were that expectant monitoring prolonged pregnancy for 10 days and increased birth weight with only 130 grams. This resulted in more infants born below the 2.3rd percentile compared to induction of labor, respectively, 12.5% in induction of labor and 30.6% in expectant monitoring group. The main placental lesions associated with FGR are maternal vascular malperfusion, fetal vascular malperfusion, and villitis of unknown etiology. We investigated whether placentas of pregnancies complicated with FGR in the expectant monitoring group reveal more and more severe pathology due to pregnancy prolongation.Material and methods: The DIGITAT trial was a multicenter, randomized controlled trial with suspected FGR beyond 36 + 0 weeks. We now analyzed all available cases (n = 191) for placental pathology. The macroscopic details were collected and histological slides were recorded and classified by a single perinatal pathologist, blinded for pregnancy details and outcome. The different placental lesions were scored based on the latest international criteria for placental lesions as defined in the Amsterdam Placental Workshop Group Consensus Statement.Results: The presence of maternal vascular malperfusion and chorioamnionitis were higher in the expectant management group (p < 0.05 and p < 0.01, respectively). No differences in placental weight and maturation of the placenta between the induction of labor and the expectant management group were seen. Fetal vascular malperfusion, villitis of unknown etiology and nucleated red blood cell count did not differ between the groups.Conclusion: Expectant management of late FGR is associated with increased maternal vascular malperfusion and chorioamnionitis. This may have implications for fetal and neonatal outcome, such as programming in the developing child influencing health outcomes later in life.

Highlights

Fetal growth restriction (FGR) is a condition in pregnancy in which the fetus fails to reach its growth potential
A total of 191 cases were available for review of placental pathology, respectively, 97 (321 in the original Disproportionate Intrauterine Growth Intervention Trial At Term (DIGITAT) trail) participants in the induction of labor group and 94 (329 in original DIGITAT trail) participants in the expectant monitoring group
In the DIGITAT trial pre-eclampsia was more prominent in the expectant monitoring group than in the induction of labor group, but in our cohort of this re-analysis no significant difference was seen in the presence of pre-eclampsia

Summary

Introduction

Fetal growth restriction (FGR) is a condition in pregnancy in which the fetus fails to reach its growth potential. FGR affects up to 15% of all pregnancies [1, 2] and is associated with mortality, and with long term morbidity [3,4,5]. Several types of lesions can be found in placentas of pregnancies complicated by FGR [7,8,9]. The main placental lesions found in FGR placentas are maternal vascular malperfusion, fetal vascular malperfusion, and villitis of unknown etiology [9]. Other rare findings in placentas of FGR complicated pregnancies include chronic histiocytic intervillositis and massive perivillous fibrinoid deposition [12, 13]

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Conclusion