The intersection of detecting fetal growth restriction and patient safety.

Abstract

Patient safety has become a mantra in medical care, and this is particularly so in obstetric practice. Although all can agree that we must provide the safest care for our patients, what exactly is the safest practice when managing women with suspected fetal growth resttriction (FGR)? Although not explicitly stated, this question is at the core of the study by Monier et al. (BJOG 2014;122:519–28). These investigators have shown that, on a population basis, sonographic detection of FGR is no better than a 50/50 proposition, meaning that only about 50% of FGR fetuses are detected antenatally. Moreover, 2% of the general population was diagnosed as having FGR when in fact the babies were normally grown. If a similar study was performed in the USA, with an average of about 4 million births per year, then about 80 000 women would be misdiagnosed as having FGR. Based on reports from individual centres, we have known that we do not accurately diagnose FGR. Our sonographic tools, based on standardised growth curves, are much too crude. So while this finding is not particularly novel, the Monier et al. study has several strengths, including examination of a national population-based sample with a large sample size, clear outcome measures and a reasonably standardised algorithm to attempt to diagnose FGR. Weaknesses of the study are the lack of adherence to a standardised written clinical practice guideline, variation in skill sets across the country, and missing values requiring some imputation. However, these limitations, in a way, actually strengthen the study. As a result of these features, this is a ‘real world’ study with all of the expected variations and difficulties of performing clinical outcomes research on a national basis. So how does this relate to patient safety? Because of our inability to accurately diagnose FGR, women who are at risk for stillbirth are not identified, resulting in excessive and potentially preventable stillbirths. Second, women who are identified as having an FGR fetus, when they actually have a normally grown fetus, are subjected to unnecessary antenatal testing with resultant fiscal and psychosocial costs. Further, these women are exposed to excessive obstetric interventions such as induction of labour before 39 weeks of gestation, with risks to baby (increased neonatal intensive care unit admissions and neonatal morbidity and mortality) and to mother (increased risk of operative deliveries). So while we like to believe that we are providing excellent and safe care, our inability to diagnose FGR accurately leads to inappropriate interventions, with increased risks to mother and baby. Based on this and other reports of our global inability to accurately diagnose FGR, one can conclude that we desperately need new and innovative diagnostic tools for the accurate diagnosis of FGR. Perhaps individualised growth curves may help (Danielian et al. BJOG 1992;99:452–4; Gardosi Horm Res 2006;65:15–18; Bukowski 2008;111:1065–76), but even these are only incremental improvements. We simply must do better than this in our quest to provide the best and safest obstetric care possible. Our patients deserve no less. DJD has no relevant disclosures or conflicts to declare.