The magnitude rather than the rate of decline in fetal growth is a stronger risk factor for perinatal mortality in term infants

Abstract

Prenatal diagnosis of an infant suspected of having fetal growth restriction is important because of its strong association with perinatal mortality and morbidity. The current Delphi consensus criteria include a decline of >50th percentiles in fetal growth when diagnosing late fetal growth restriction; however, the evidence underpinning this criterion is limited. This study aimed to analyze the relationships among the magnitude of decline in fetal growth and stillbirth, perinatal mortality, and adverse neonatal outcomes. This cohort study of 15,861 pregnancies was conducted at the Mater Mother's Hospital in Brisbane, Australia. The decline in fetal growth was calculated as a drop in either estimated fetal weight or abdominal circumference percentiles between 2 ultrasound scans performed after 18 weeks of gestation. Relationships between declining fetal growth and the outcomes were, firstly, analyzed as a continuous variable and, if significant, further assessed with the rate of decline and different magnitudes of decline, compared to the referent category (change in growth of ±10 percentiles between scans). The 3 categories of growth decline were >10th to <25th percentiles, ≤25th to <50th percentiles, and ≥50th percentiles. Associations were analyzed by logistic regressions. The primary study outcomes were stillbirth and perinatal mortality (composite of stillbirth and neonatal death). The secondary outcomes were birth of a small-for-gestational-age infant (birthweight of <10th percentile for gestation), emergency cesarean delivery for nonreassuring fetal status, and composite severe neonatal morbidity. The risks of stillbirth and perinatal mortality increased significantly by 2.6% (0.4%-4.6%) and 2.8% (1.0%-4.5%), respectively, per 1 percentile decline in fetal growth. In addition, the odds of stillbirth (adjusted odds ratio, 3.68 (1.32-10.24) and perinatal mortality (4.44) (1.82-10.84)) compared to the referent group were significantly increased only when the decline was ≥50th percentiles, regardless of birthweight. Furthermore, none of the primary outcomes were significantly associated with the rate of growth decline. The risk of a small-for-gestational-age infant increased by 2.4% (2.2%-2.7%) for every percentile decline. Conversely, reduced fetal growth was not associated with emergency cesarean delivery for nonreassuring fetal status or severe neonatal morbidity. Our results supported the use of a ≥50th percentile decline in fetal growth as a criterion for identifying infants at risk of late fetal growth restriction. This cutoff also identified fetuses at high risk of perinatal mortality, regardless of birthweight and rate of growth decline. Our findings may guide obstetrical practice by alerting clinicians to the importance of incorporating the magnitude of fetal growth decline into antenatal counseling and decisions regarding the timing of birth.