Abdominal Circumference Growth Velocity Research Articles

Predictive value of fetal growth trajectory from 20 weeks of gestation onwards for severe adverse perinatal outcome in low-risk population: secondary analysis of IRIS study.

The placental dysfunction underlying fetal growth restriction (FGR) may result in severe adverse perinatal outcome (SAPO) related to fetal hypoxia. Traditionally, the diagnostic criteria for FGR have been based on fetal size, an approach that is inherently flawed because it often results in either over- or underdiagnosis. The anomaly ultrasound scan at 20 weeks' gestation may be an appropriate time at which to set a benchmark for growth potential of the individual fetus. We hypothesized that the fetal growth trajectory from that point onwards may be informative regarding third-trimester placental dysfunction. The aim of this study was to investigate the predictive value for SAPO of a slow fetal growth trajectory between 18 + 0 to 23 + 6 weeks and 32 + 0 to 36 + 6 weeks' gestation in a large, low-risk population. This was a post-hoc data analysis of the IUGR Risk Selection (IRIS) study, a Dutch nationwide cluster-randomized trial assessing the (cost-)effectiveness of routine third-trimester sonography in reducing SAPO. In the current analysis, for the first ultrasound examination we used ultrasound data from the routine anomaly scan at 18 + 0 to 23 + 6 weeks' gestation, and for the second we used data from an ultrasound examination performed between 32 + 0 and 36 + 6 weeks' gestation. Using multilevel logistic regression, we analyzed whether SAPO was predicted by a slow fetal growth trajectory, which was defined as a decline in abdominal circumference (AC) and/or estimated fetal weight (EFW) of more than 20 percentiles or more than 50 percentiles or as an AC growth velocity (ACGV) < 10th percentile (p10). In addition, we analyzed the combination of these indicators of slow fetal growth with small-for-gestational age (SGA) (AC or EFW < p10) and severe SGA (AC/EFW < 3rd percentile) at 32 + 0 to 36 + 6 weeks' gestation. Our sample included the data of 6296 low-risk singleton pregnancies, among which 82 (1.3%) newborns experienced at least one SAPO. Standalone declines in AC or EFW of > 20 or > 50 percentiles or ACGV < p10 were not associated with increased odds of SAPO. EFW < p10 between 32 + 0 and 36 + 6 weeks'gestation combined with a decline in EFW of > 20 percentiles was associated with an increased rate of SAPO. The combination of AC or EFW < p10 between 32 + 0 and 36 + 6 weeks' gestation with ACGV < p10 was also associated with increased odds of SAPO. The odds ratios of these associations were higher if the neonate was SGA at birth. In a low-risk population, a slow fetal growth trajectory as a standalone criterion does not distinguish adequately between fetuses with FGR and those that are constitutionally small. This absence of association may be a result of diagnostic inaccuracies and/or post-diagnostic (e.g. intervention and selection) biases. We conclude that new approaches to detect placental insufficiency should integrate information from diagnostic tools such as maternal serum biomarkers and Doppler ultrasound measurements. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Maternal high body mass index, but not gestational diabetes, is associated with poorer educational attainment in mid-childhood

Previous studies suggest that gestational diabetes mellitus is associated with poorer cognitive outcomes in children. However, confounding factors, especially maternal body mass index, have been poorly accounted for. This study aimed to examine the independent associations between maternal body mass index, gestational diabetes mellitus status, and educational outcomes. Antenatal data from a prospective birth cohort (Pregnancy Outcome Prediction Study, 2008-2012, Cambridge, United Kingdom) were linked to mid-childhood educational outcomes (Department for Education, United Kingdom). A total of 3249 children born at term were stratified by maternal gestational diabetes mellitus status and body mass index at booking (<25 vs ≥25 kg/m2). Regression models adjusted for relevant maternal, child, and socioeconomic factors were used to determine associations with academic outcomes at ages of 5 to 7 years. No differences in educational attainment were found between children exposed to gestational diabetes mellitus and nonexposed children. Neither maternal glucose levels measured at 11 to 14 or 24 to 28 weeks, nor acceleration of the fetal abdominal circumference growth velocity were related to educational attainment at ages of 5 to 7 years. Children of mothers with booking body mass index ≥25 kg/m2 (vs <25 kg/m2) were ∼50% more likely to not meet expected educational standards regardless of gestational diabetes mellitus status (age 5: adjusted odds ratio, 1.44; 95% confidence interval, 1.19-1.74; P<.001; age 6: adjusted odds ratio, 1.61; 95% confidence interval, 1.28-2.02; P<.001). The association between maternal body mass index and offspring educational attainment is dose-dependent and robust to stratification by gestational diabetes mellitus status and adjustment for socioeconomic factors. Mid-childhood educational attainment is not associated with maternal glucose status. This may provide important reassurance for pregnant women and clinicians. However, maternal body mass index is associated with lower childhood educational attainment and may be modifiable with intervention before or during pregnancy.

Abdominal circumference growth velocity as a predictor of adverse perinatal outcomes in small-for-gestational-age fetuses

Objective To assess the predictive value of abdominal circumference growth velocity (ACGV) between the second and third trimesters to predict adverse perinatal outcomes in a cohort of small-for-gestational-age fetuses without evidence of placental insufficiency (i.e. fetal growth restriction). Material and methods This is a single-center retrospective cohort study of all singleton pregnancies with small-for-gestational-age fetuses diagnosed and delivered at a quaternary institution. Crude and adjusted odds ratios (ORs) and corresponding confidence intervals (CIs) were calculated via logistic regression models to assess the potential association between abnormal ACGV (i.e. ≤10th centile) and adverse perinatal outcomes defined as a composite outcome (i.e. umbilical artery pH <7.1, 5-min Apgar score <7, admission to the neonatal intensive care unit, hypoglycemia, intrapartum fetal distress requiring expedited delivery, and perinatal death). Furthermore, the area under the receiver-operating characteristic curve (AUC) of three logistic regression models based on estimated fetal weight and ACGV for predicting the composite outcome is also reported. Results A total of 154 pregnancies were included for analysis. The median birthweight for the cohort was 2,437 g (interquartile range [IQR] 2280, 2635). Overall, the primary composite outcome was relatively common (29.2%). In addition, there was a significant association between abnormal ACGV and adverse perinatal outcomes (OR 3.37, 95% CI 1.60, 7.13; adjusted OR 4.30, 95% CI 1.77, 10.49). Likewise, the AUC for the ACGV was marginally higher (0.64) than the estimated fetal weight (0.54) and ACGV + estimated fetal weight (0.54). Still, no significant difference was detected between the curves (p = 0.297). Conclusions Our results suggest that an ACGV below the 10th centile is a risk factor for adverse perinatal outcomes among small-for-gestational-age fetuses.

Longitudinal characterization of determinants associated with obesogenic growth patterns in early childhood.

Longitudinal assessment of the determinants of obesogenic growth trajectories in childhood can suggest appropriate developmental windows for intervention. Latent class growth mixture modelling was used to identify body mass index (BMI) z-score trajectories from birth to age 6 years in 994 children from a prospective mother-offspring cohort (Chinese, Indian and Malay ethnicities) based in Singapore. We evaluated the early-life determinants of the trajectories as well as their associations with cardiometabolic risk markers at age 6 years. Five BMI z-score trajectory patterns were identified, three within the healthy weight range, alongside early-acceleration and late-acceleration obesogenic trajectories. The early-acceleration pattern was characterized by elevated fetal abdominal circumference growth velocity, BMI acceleration immediately after birth and crossing of the obesity threshold by age 2 years. The late-acceleration pattern had normal fetal growth and BMI acceleration after infancy, and approached the obesity threshold by age 6 years. Abdominal fat, liver fat, insulin resistance and odds of pre-hypertension/hypertension were elevated in both groups. Indian ethnicity, high pre-pregnancy BMI, high polygenic risk scores for obesity and shorter breastfeeding duration were common risk factors for both groups. Malay ethnicity and low maternal educational attainment were uniquely associated with early BMI acceleration, whereas nulliparity and obesogenic eating behaviours in early childhood were uniquely associated with late BMI acceleration. BMI acceleration starting immediately after birth or after infancy were both linked to early cardiometabolic alterations. The determinants of these trajectories may be useful for developing early risk stratification and intervention approaches to counteract metabolic adversities linked to childhood obesity.

Prediction of small-for-gestational-age neonates at 33–39 weeks’ gestation in China: logistic regression modeling of the contributions of second- and third-trimester ultrasound data and maternal factors

ObjectivesA screening model for prediction of small-for-gestational-age (SGA) neonates (SGAp) was established by logistic regression using ultrasound data and maternal factors (MF). We aimed to evaluate the ability of SGAp as well as abdominal circumference (AC) and estimated fetal weight (EFW) measurements to predict SGA neonates at 33–39 weeks’ gestation.MethodsThis retrospective study evaluated 5298 singleton pregnancies that had involved three ultrasound examinations at 21+0–27+6, 28+0–32+6, and 33+0–39+6 weeks. All ultrasound data were transformed to MoM values (multiple of the median). Multivariate logistic regression was used to analyze the correlation between SGA status and various variables (ultrasound data and MF) during pregnancy to build the SGAp model. EFW was calculated according to the Hadlock formula at 33–39 weeks of gestation. The predictive performance of SGAp, AC MoM value at 33+0–39+6 weeks (AC-M), EFW MoM value (EFW-M), EFW-M plus MF, AC value at 33+0–39+6 weeks (AC), AC growth velocity, EFW, and EFW plus MF was evaluated using ROC curves. The detection rate (DR) of SGA neonate with SGAp, AC-M, EFW-M, and EFW-M plus MF at false positive rate (FPR) of 5% and 10%, and the FPR at DR of 85%, 90%, and 95% were observed.ResultsThe AUCs of SGAp, AC-M, EFW-M, EFW-M plus MF, AC, AC growth velocity, EFW, and EFW plus MF for SGA neonates screening were 0.933 (95%CI: 0.916–0.950), 0.906 (95%CI: 0.887–0.925), 0.920 (95%CI: 0.903–0.936), 0.925 (95%CI: 0.909–0.941), 0.818 (95%CI: 0.791–0.845), 0.786 (95%CI: 0.752–0.821), 0.810 (95%CI: 0.782–0.838), and 0.834 (95%CI: 0.807–0.860), respectively. The screening efficiency of SGAp, AC-M, EFW-M, and EFW-M plus MF are significantly higher than AC, AC growth velocity, EFW, and EFW plus MF. The DR of SGAp, AC-M, EFW-M, and EFW-M plus MF for SGA neonates were 80.4%, 69.6%, 73.8% and 74.3% at 10% FPR. The AUCs of SGAp, AC-M, EFW-M, and EFW-M plus MF 0.950 (95%CI: 0.932–0.967), 0.929 (95%CI: 0.909–0.948), 0.938 (95%CI: 0.921–0.956) and 0.941 (95%CI: 0.924–0.957), respectively for screening SGA neonates delivered within 2 weeks after the assessment. The DR for these births increased to 85.8%, 75.8%, 80.0%, and 82.5%, respectively.ConclusionThe rational use of ultrasound data can significantly improve the prediction of SGA statuses.

Ultrasound predictors of adverse outcome in pregnancy complicated by pre-existing and gestational diabetes.

Ultrasound assessment of fetuses subjected to hyperglycemia is recommended but, apart from increased size, little is known about its interpretation, and the identification of which large fetuses of diabetic pregnancy are at risk is unclear. Newer markers of adverse outcomes, abdominal circumference growth velocity and cerebro-placental ratio, help to predict risk in non-diabetic pregnancy. Our study aims to assess their role in pregnancies complicated by diabetes. This is a retrospective analysis of a cohort of singleton, non-anomalous fetuses of women with pre-existing or gestational diabetes mellitus, and estimated fetal weight at the 10th centile or above. Gestational diabetes was diagnosed by selective screening of at risk groups. A universal ultrasound scan was offered at 20 and 36 weeks of gestation. Estimated fetal weight, abdominal circumference growth velocity, presence of polyhydramnios, and cerebro-placental ratio were evaluated at the 36-week scan. A composite adverse outcome was defined as the presence of one or more of perinatal death, arterial cord pH less than 7.1, admission to Neonatal Unit, 5-minute Apgar less than 7, severe hypoglycemia, or cesarean section for fetal compromise. A chi-squared test was used to test the association of estimated fetal weight at the 90th centile or above, polyhydramnios, abdominal circumference growth velocity at the 90th centile or above, and cerebro-placental ratio at the 5th centile or below with the composite outcome. Logistic regression was used to assess which ultrasound markers were independent risk factors. Odds ratios of composite adverse outcome with combinations of independent ultrasound markers were calculated. A total of 1044 pregnancies were included, comprising 87 women with pre-existing diabetes mellitus and 957 with gestational diabetes. Estimated fetal weight at the 90th centile or above, abdominal circumference growth velocity at the 90th centile or above, cerebro-placental ratio at the 5th centile or below, but not polyhydramnios, were significantly associated with adverse outcomes: odds ratios (95% confidence intervals) 1.85 (1.21-2.84), 1.54 (1.02-2.31), 1.92 (1.21-3.30), and 1.53 (0.79-2.99), respectively. Only estimated fetal weight at the 90th centile or above and cerebro-placental ratio at the 5th centile or below were independent risk factors. The greatest risk (odds ratio 6.85, 95% confidence interval 2.06-22.78) was found where both the estimated fetal weight is at the 90th centile or above and the cerebro-placental ratio is at the 5th centile or below. In diabetic pregnancies, a low cerebro-placental ratio, particularly in a macrosomic fetus, confers additional risk.

Slowing of fetal growth and elevated maternal serum sFLT1:PlGF are associated with early term spontaneous labor

BackgroundThe physiological control of human parturition at term is unknown.ObjectiveThis study aimed to test the hypothesis that slowing of fetal growth or elevated maternal serum levels of markers of placental hypoxia in late gestation will be associated with earlier term labor.Study DesignWe observed 2208 women having first births and performed serial blinded ultrasonography and immunoassay of soluble fms-like tyrosine kinase-1 and placenta growth factor. We estimated the probability of spontaneous delivery from 37 weeks of gestational age concerning (1) fetal growth between 20 and 36 weeks of gestational age and (2) the maternal serum soluble fms-like tyrosine kinase-1–to–placenta growth factor ratio measured at approximately 36 weeks of gestational age. Data were analyzed using logistic regression and Cox regression.ResultsFetal size at 36 weeks of gestational age was not independently associated with the timing of delivery at term. However, there was an inverse relationship between fetal growth between 20 weeks of gestational age and 36 weeks of gestational age and the probability of spontaneous labor at 37 to 38 weeks’ gestation (hazard ratio [95% confidence interval] for a 50 percentile increase in abdominal circumference growth velocity, 0.60 [0.47–0.78]; P=.0001). This association was weaker at 39 to 40 weeks’ gestation (0.83 [0.74–0.93]; P=.0013), and there was no association at ≥41 weeks’ gestation. Very similar associations were observed for estimated fetal weight growth velocity. There was a positive relationship between soluble fms-like tyrosine kinase-1–to–placenta growth factor ratio and the probability of spontaneous labor at 37 to 38 weeks’ gestation (hazard ratio [95% confidence interval] for a 50 percentile increase in soluble fms-like tyrosine kinase-1–to–placenta growth factor ratio, 3.05 [2.32–4.02]; P<.0001). This association was weaker at 39 to 40 weeks’ gestation (1.46 [1.30–1.63]; P<.0001), and there was no association at ≥41 weeks’ gestation. Adjustment for maternal characteristics was without material effect on any of these associations.ConclusionSlowing of fetal growth and biomarkers of placental insufficiency were associated with an increased probability of early onset of spontaneous term labor. We speculated that progressive placental insufficiency may be a physiological phenomenon that occurs with advancing gestational age near and at term and promotes the initiation of labor.

407 Accelerated fetal abdominal circumference growth velocity (ACGV): a predictor of adverse outcomes in diabetic pregnancies

Diabetes mellitus in pregnancy is associated with an increased risk of fetal macrosomia and profound perinatal morbidity and mortality. Current prediction methods for macrosomia, including third trimester estimated fetal weight (tEFW), have poor sensitivity. Other modalities like the use of abdominal circumference (AC) have been used but still fare poorly in predicting outcomes. Our objective was to investigate the predictive ability of the change in the AC over time, or AC growth velocity (ACGV), for fetal macrosomia and adverse perinatal outcomes. In this retrospective cohort study, 312 subjects with either pre-gestational diabetes (PGD) or gestational diabetes mellitus (GDM) with documented ultrasounds at 19w0d – 21w6d and 35w0d – 36w6d from 2013-2019 were analyzed. ACs at these intervals were used to calculate ACGV. ACGV ≥90th percentile was considered accelerated and was compared to tEFW ≥90th percentile. Chi square tests were used for categorical variables and area under the receiver operator curves (AUC) were calculated for ACGV and tEFW. Of the 312 patients, 39.4% had PGD and 60.6% had GDM. An accelerated ACGV (aACGV) was predictive of several clinically important adverse outcomes in diabetic pregnancies (see Table 1) and was a significantly better predictor for large for gestational age (LGA) babies in women with PGD as compared to women with GDM (AUC 0.86 vs 0.74, p=0.03). When comparing aACGV with tEFW, both performed similarly in their prediction of fetal macrosomia. tEFW was better at predicting LGA (AUC 0.84 vs 0.75, p=0.001), but aACGV was significantly better at predicting neonatal hypoglycemia (AUC 0.62 vs 0.56, p=0.04). Accelerated ACGV is an effective screening tool for predicting adverse outcomes in diabetic pregnancies and appears to fare better than tEFW for determining which neonates will require glycemic support after delivery. aACGV performed similarly to tEFW in predicting fetal macrosomia.

408 Use of decelerated abdominal circumference growth velocity (ACGV) in diabetic pregnancies

Fetal growth restriction (FGR) is associated with significant perinatal morbidity and mortality. FGR is a known complication of diabetes in pregnancy. A small fetal abdominal circumference can predict the development of FGR and other adverse outcomes. Our objective was to determine if a slowing of the AC growth velocity over time (decelerated AC growth velocity, dACGV) is associated with adverse pregnancy outcomes in patients with diabetes in pregnancy. A retrospective cohort of 312 patients with pre-gestational diabetes (PGD) or gestational diabetes mellitus (GDM) with ultrasounds between 19w0d – 21w6d and 35w0d – 36w6d from 2013-2019 were collected. ACs at these intervals were used to calculate ACGV. ACGV ≤10th percentile was considered decelerated. Third trimester estimated fetal weight (tEFW)≤10th percentile was used as comparison. Chi square tests or Fisher’s exact tests were used for categorical variables. Of 312 patients included, 26 (8.3%) had dAGCV. A total of 39.4% had PGD and 60.6% had GDM. dACGV was not predictive of small for gestational age (SGA). However, dACGV was associated with increased risk of operative vaginal delivery [odds ratio (OR) 6.5, 95% confidence interval (CI) 2.1, 20.5], while comparable tEFW did not predict this outcome. Patients with dACGV were less likely to be using insulin compared to those with a normal ACGV (OR 0.2, 95% CI 0.1,0.6). Decelerated abdominal circumference growth velocity did not predict SGA in this diabetic cohort. However, dACGV was associated with a higher risk of operative vaginal delivery. This finding may be helpful in counseling patients with diabetes as they approach delivery.

929 Predictive performance of race/ethnicity based growth velocities in pregnancies complicated by diabetes

Recently, the NICHD published a race/ethnicity-based fetal growth velocity percentile calculator derived from a cohort of low-risk pregnancies. Fetal growth velocity is accelerated in pregnancies affected by diabetes. However, use of growth velocity percentiles are untested in this population. We sought to determine the test performance of growth velocity percentiles in pregnancies with diabetes. Retrospective cohort study of all women with pregestational and gestational diabetes with ultrasound data at two third trimester time points (28w0d-31w6d and 32w0d-35w6d) between 2009-2019 at a single academic institution. Self-reported race/ethnicity and fetal biometry were used to calculate abdominal circumference (AC) and estimated fetal weight (EFW) velocities between time points. Traditional AC and EFW percentiles were recorded for the second ultrasound for comparison. ROC curves and areas under the curve (AUC) were compared between parameters for prediction of composite neonatal outcome and LGA. Test statistics were calculated and compared at optimal cut points identified by the Youden J statistic. There were 1,093 pregnancies included in the analysis with 599 (54.8%) and 297 (27%) complicated by adverse composite outcome or LGA birthweight. No differences in AUCs for neonatal composite outcome were found (p=.234; Figure 1). Traditional EFW and AC biometric percentiles were significantly better predictors of LGA birthweight than either velocity parameter (Figure 2). The optimal cut point for EFW velocity (51%) had poor overall performance with a sensitivity 65.7% (CI 60.0%-71.0%) and positive predictive value (PPV) of 35.6% (CI 31.6-39.8%) for LGA. Results were similar for AC velocity (cut point 57%) with a sensitivity of 57.6% (CI 51.7%-63.3%) and PPV of 36.9% (CI 32.5%-41.4%). Neither traditional ultrasound biometry nor race/ethnicity-based growth velocity accurately predicted adverse neonatal outcomes in pregnancies complicated by diabetes. However, traditional ultrasound biometry was superior to both EFW and AC growth velocities for prediction of LGA birth weight.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Reduced growth velocity from the mid-trimester is associated with placental insufficiency in fetuses born at a normal birthweight

BackgroundFetal growth restriction (FGR) due to placental insufficiency is a major risk factor for stillbirth. While small-for-gestational-age (SGA; weight < 10th centile) is a commonly used proxy for FGR, detection of FGR among appropriate-for-gestational-age (AGA; weight ≥ 10th centile) fetuses remains an unmet need in clinical care. We aimed to determine whether reduced antenatal growth velocity from the time of routine mid-trimester ultrasound is associated with antenatal, intrapartum and postnatal indicators of placental insufficiency among term AGA infants.MethodsThree hundred and five women had biometry measurements recorded from their routine mid-trimester (20-week) ultrasound, at 28 and 36 weeks’ gestation, and delivered an AGA infant. Mid-trimester, 28- and 36-week estimated fetal weight (EFW) and abdominal circumference (AC) centiles were calculated. The EFW and AC growth velocities between 20 and 28 weeks, and 20–36 weeks, were examined as predictors of four clinical indicators of placental insufficiency: (i) low 36-week cerebroplacental ratio (CPR; CPR < 5th centile reflects cerebral redistribution—a fetal adaptation to hypoxia), (ii) neonatal acidosis (umbilical artery pH < 7.15) after the hypoxic challenge of labour, (iii) low neonatal body fat percentage (BF%) reflecting reduced nutritional reserve and (iv) placental weight < 10th centile.ResultsDeclining 20–36-week fetal growth velocity was associated with all indicators of placental insufficiency. Each one centile reduction in EFW between 20 and 36 weeks increased the odds of cerebral redistribution by 2.5% (odds ratio (OR) = 1.025, P = 0.001), the odds of neonatal acidosis by 2.7% (OR = 1.027, P = 0.002) and the odds of a < 10th centile placenta by 3.0% (OR = 1.030, P < 0.0001). Each one centile reduction in AC between 20 and 36 weeks increased the odds of neonatal acidosis by 3.1% (OR = 1.031, P = 0.0005), the odds of low neonatal BF% by 2.8% (OR = 1.028, P = 0.04) and the odds of placenta < 10th centile by 2.1% (OR = 1.021, P = 0.0004). Falls in EFW or AC of > 30 centiles between 20 and 36 weeks were associated with two–threefold increased relative risks of these indicators of placental insufficiency, while low 20–28-week growth velocities were not.ConclusionsReduced growth velocity between 20 and 36 weeks among AGA fetuses is associated with antenatal, intrapartum and postnatal indicators of placental insufficiency. These fetuses potentially represent an important, under-recognised cohort at increased risk of stillbirth. Encouragingly, this novel fetal assessment would require only one additional ultrasound to current routine care, and adds to the potential benefits of routine 36-week ultrasound.

Comparing fetal biometric growth velocity versus estimated fetal weight for prediction of neonatal small for gestational age

Objective Growth velocities derived from fetal biometrics have been proposed to improve prediction of small for gestational age (SGA) neonates. We sought to determine if ultrasound growth velocities for abdominal circumference (AC) and estimated fetal weight (EFW) improve the prediction of SGA infants when compared to using EFW alone. Study design This is a secondary analysis from a prospective study of women referred for growth ultrasounds during the third trimester. Growth velocities for AC and EFW were derived from the difference in Z-scores between measurements at the anatomy survey (18–22 weeks gestation) and later growth ultrasound (26–36 weeks gestation). Change in AC and EFW growth velocities <10th percentile were compared with prenatally suspected SGA from Hadlock EFW <10th percentile for prediction of SGA neonates. The primary outcome was defined as the sensitivity and specificity of the growth velocities and Hadlock EFW in predicting SGA neonates. Logistic regression modeling was used to determine if the growth velocities improved prediction of neonatal SGA. Area under the ROC curves (AUC) were determined and compared. Results Of 612 singleton pregnancies meeting inclusion criteria, 68 (11.1%) resulted in SGA neonates. Hadlock EFW <10th percentile had higher sensitivity and specificity when compared to AC growth velocity and EFW growth velocity. Only AC growth velocity and Hadlock EFW had significant odds ratios for association with neonatal SGA. The AUC were 0.54, 0.53, and 0.61 using AC growth velocity, EFW growth velocity, and Hadlock EFW, respectively. The AUC did not significantly improve when the growth velocities were combined with Hadlock EFW (0.63). Adjustment of Z-scores for gestational age at anatomy scan or third trimester growth scan did not significantly change these results (AUC = 0.69). Conclusion EFW determined by Hadlock formula has the highest predictive value in detecting SGA neonates when compared to both AC and EFW growth velocities.

VP40.03: Accelerated abdominal circumference growth velocity as a novel predictor of fetal macrosomia in diabetic pregnancies

VP40.03: Accelerated abdominal circumference growth velocity as a novel predictor of fetal macrosomia in diabetic pregnancies

The value of fetal growth biometry velocities to predict large for gestational age (LGA) infants

Objective The use of growth velocities derived from fetal biometrics have been suggested to improve prediction of large for gestational age (LGA). Our objective was to determine if ultrasonographic growth velocities (GV) for abdominal circumference (AC) and estimated fetal weight (EFW) improve the prediction of LGA infants when compared to Hadlock EFW. Methods This was a secondary analysis of data from a prospective study of women referred for growth ultrasounds during the 3rd trimester. Growth velocities (GV) for AC (AC − GV) and EFW (EFW − GV) were derived from the difference in Z-scores between measurements at the time of anatomy survey (18–24 week) and third trimester ultrasound (26–36 weeks). Change in AC − GV and EFW − GV >90th %ile alone or in combination with Hadlock EFW >90th%ile were compared for prediction of a LGA neonate. The primary outcome was the sensitivity and specificity of the (1) Hadlock EFW >90%ile, (2) AC − GV, (3) EFW − GV, (4) Hadlock EFW + AC − GV, and (5) Hadlock EFW + EFW − GV for the prediction of neonatal LGA. Test characteristics and area under the ROC curve (AUC) were determined. The association between the ultrasound predicted growth and adverse neonatal outcome was assessed using logistic regression. Results Of 630 women meeting inclusion criteria, 85 (13.5%) had LGA neonates. Hadlock EFW showed a better NPV (98.0%) and sensitivity (71.1%) when compared to AC − GV (NPV 87.5%, sensitivity 17.7%) and EFW − GV (NPV 88.0%, sensitivity 22.6%). Combining Hadlock EFW and AC-GV or EFW − GV did little to improve the test characteristics for the prediction of LGA (AUC 0.65 and 0.64, respectively). All five measurements were unable to predict a composite of adverse neonatal outcome or need for maternal cesarean delivery. Adjustment of the growth velocities for gestational age at anatomy scan or 3rd trimester growth scan did not change these results. Conclusion AC and EFW growth velocities do not appear to improve the prediction of LGA infants when compared to using the third trimester Hadlock EFW.

Altered cerebro-placental ratio is an early marker of adverse pregnancy outcome–a prospective study

Background: Fetal growth restriction (FGR) is a complex and common obstetric problem. It is associated with perinatal morbidity and mortality which accounts for about 10-15%. The diagnosis of FGR is made by clinical evaluation and ultrasonography. Objectives: To investigate the role of the efficacy of the cerebroplacental ratio as a marker of reduced fetal growth rate. To establish a relationship between Cerebro placental ratio at term with reduced fetal growth velocity and adverse pregnancy outcome. Methods: A Prospective study, in which study participants were subjected for Ultrasonography at 20 to 25 weeks for Abdominal Circumference and Ultrasonography above 35 weeks period of gestation were subjected to fetal biometry and Doppler studies. All Doppler indices will be converted into multiples of the median (MoM), correcting for gestational age using reference ranges, umbilical & middle cerebral arteries and birthweight values are converted into centiles. Results: Among 80 % of participants low cerebroplacental ratio were associated with low abdominal circumference and low growth velocity. The low cerebroplacental ratio risk is associated with the need for operative delivery. Conclusion: Altered Cerebroplacental ratio is the earlier marker of adverse fetal outcome than the biophysical profile. Low Cerebro placental ratio(<1) is associated with impaired fetal growth velocity and adverse pregnancy outcomes.

EP18.19: Abdominal circumference growth velocity as an independent predictor of small‐for‐gestational‐age fetuses and the relationship with adverse perinatal outcomes

EP18.19: Abdominal circumference growth velocity as an independent predictor of small‐for‐gestational‐age fetuses and the relationship with adverse perinatal outcomes

Prediction of large-for-gestational-age neonate by routine third-trimester ultrasound.

ABSTRACTObjectivesFirst, to evaluate and compare the performance of routine ultrasonographic estimated fetal weight (EFW) and fetal abdominal circumference (AC) at 31 + 0 to 33 + 6 and 35 + 0 to 36 + 6 weeks' gestation in the prediction of a large‐for‐gestational‐age (LGA) neonate born at ≥ 37 weeks' gestation. Second, to assess the additive value of fetal growth velocity between 32 and 36 weeks' gestation to the performance of EFW at 35 + 0 to 36 + 6 weeks' gestation for prediction of a LGA neonate. Third, to define the predictive performance for a LGA neonate of different EFW cut‐offs on routine ultrasound examination at 35 + 0 to 36 + 6 weeks' gestation. Fourth, to propose a two‐stage strategy for identifying pregnancies with a LGA fetus that may benefit from iatrogenic delivery during the 38th gestational week.MethodsThis was a retrospective study. First, data from 21 989 singleton pregnancies that had undergone routine ultrasound examination at 31 + 0 to 33 + 6 weeks' gestation and 45 847 that had undergone routine ultrasound examination at 35 + 0 to 36 + 6 weeks were used to compare the predictive performance of EFW and AC for a LGA neonate with birth weight &gt; 90th and &gt; 97th percentiles born at ≥ 37 weeks' gestation. Second, data from 14 497 singleton pregnancies that had undergone routine ultrasound examination at 35 + 0 to 36 + 6 weeks' gestation and had a previous scan at 30 + 0 to 34 + 6 weeks were used to determine, through multivariable logistic regression analysis, whether addition of growth velocity, defined as the difference in EFW Z‐score or AC Z‐score between the early and late third‐trimester scans divided by the time interval between the scans, improved the performance of EFW at 35 + 0 to 36 + 6 weeks in the prediction of delivery of a LGA neonate at ≥ 37 weeks' gestation. Third, in the database of the 45 847 pregnancies that had undergone routine ultrasound examination at 35 + 0 to 36 + 6 weeks' gestation, the screen‐positive and detection rates for a LGA neonate born at ≥ 37 weeks' gestation and ≤ 10 days after the initial scan were calculated for different EFW percentile cut‐offs between the 50th and 90th percentiles.ResultsFirst, the areas under the receiver–operating characteristics curves (AUC) of screening for a LGA neonate were significantly higher using EFW Z‐score than AC Z‐score and at 35 + 0 to 36 + 6 than at 31 + 0 to 33 + 6 weeks' gestation (P &lt; 0.001 for all). Second, the performance of screening for a LGA neonate achieved by EFW Z‐score at 35 + 0 to 36 + 6 weeks was not significantly improved by addition of EFW growth velocity or AC growth velocity. Third, in screening by EFW &gt; 90th percentile at 35 + 0 to 36 + 6 weeks' gestation, the predictive performance for a LGA neonate born at ≥ 37 weeks' gestation was modest (65% and 46% for neonates with birth weight &gt; 97th and &gt; 90th percentiles, respectively, at a screen‐positive rate of 10%), but the performance was better for prediction of a LGA neonate born ≤ 10 days after the scan (84% and 71% for neonates with birth weight &gt; 97th and &gt; 90th percentiles, respectively, at a screen‐positive rate of 11%). Fourth, screening by EFW &gt; 70th percentile at 35 + 0 to 36 + 6 weeks' gestation predicted 91% and 82% of LGA neonates with birth weight &gt; 97th and &gt; 90th percentiles, respectively, born at ≥ 37 weeks' gestation, at a screen‐positive rate of 32%, and the respective values of screening by EFW &gt; 85th percentile for prediction of a LGA neonate born ≤ 10 days after the scan were 88%, 81% and 15%. On the basis of these results, it was proposed that routine fetal biometry at 36 weeks' gestation is a screening rather than diagnostic test for fetal macrosomia and that EFW &gt; 70th percentile should be used to identify pregnancies in need of another scan at 38 weeks, at which those with EFW &gt; 85th percentile should be considered for iatrogenic delivery during the 38th week.ConclusionsFirst, the predictive performance for a LGA neonate by routine ultrasonographic examination during the third trimester is higher if the scan is carried out at 36 than at 32 weeks, the method of screening is EFW than fetal AC, the outcome measure is birth weight &gt; 97th than &gt; 90th percentile and if delivery occurs within 10 days than at any stage after assessment. Second, prediction of a LGA neonate by EFW &gt; 90th percentile is modest and this study presents a two‐stage strategy for maximizing the prenatal prediction of a LGA neonate. Copyright © 2019 ISUOG. Published by John Wiley &amp; Sons Ltd.

Prediction of small‐for‐gestational‐age neonates at 35–37 weeks' gestation: contribution of maternal factors and growth velocity between 20 and 36 weeks

To evaluate the performance of ultrasonographic estimated fetal weight (EFW) at 35 + 0 to 36 + 6 weeks' gestation in the prediction of delivery of a small-for-gestational-age (SGA) neonate and assess the additive value of, first, maternal risk factors and, second, fetal growth velocity between 20 and 36 weeks' gestation in improving such prediction. This was a prospective study of 44 043 singleton pregnancies undergoing routine ultrasound examination at 19 + 0 to 23 + 6 and at 35 + 0 to 36 + 6 weeks' gestation. Multivariable logistic regression analysis was used to determine whether addition of maternal risk factors and growth velocity, the latter defined as the difference in EFW Z-score or fetal abdominal circumference (AC) Z-score between the third- and second-trimester scans divided by the time interval between the scans, improved the performance of EFW Z-score at 35 + 0 to 36 + 6 weeks in the prediction of delivery of a SGA neonate with birth weight < 10th and < 3rd percentiles within 2 weeks and at any stage after assessment. Screening by EFW Z-score at 35 + 0 to 36 + 6 weeks' gestation predicted 63.4% (95% CI, 62.0-64.7%) of neonates with birth weight < 10th percentile and 74.2% (95% CI, 72.2-76.1%) of neonates with birth weight < 3rd percentile born at any stage after assessment, at a screen-positive rate of 10%. The respective values for SGA neonates born within 2 weeks after assessment were 76.8% (95% CI, 74.4-79.0%) and 81.3% (95% CI, 78.2-84.0%). For a desired 90% detection rate of SGA neonate delivered at any stage after assessment, the necessary screen-positive rate would be 33.7% for SGA < 10th percentile and 24.4% for SGA < 3rd percentile. Multivariable logistic regression analysis demonstrated that, in the prediction of a SGA neonate with birth weight < 10th and < 3rd percentiles, there was a significant contribution from EFW Z-score at 35 + 0 to 36 + 6 weeks' gestation, maternal risk factors and AC growth velocity, but not EFW growth velocity. However, the area under the receiver-operating characteristics curve for prediction of delivery of a SGA neonate by screening with maternal risk factors and EFW Z-score was not improved by addition of AC growth velocity. Screening for SGA neonates by EFW at 35 + 0 to 36 + 6 weeks' gestation and use of the 10th percentile as the cut-off predicts 63% of affected neonates. Prediction of 90% of SGA neonates necessitates classification of about 35% of the population as being screen positive. The predictive performance of EFW is not improved by addition of estimated growth velocity between the second and third trimesters of pregnancy. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Addition of sildenafil citrate for treatment of severe intrauterine growth restriction: a double blind randomized placebo controlled trial

Background: Severe intrauterine growth restriction complicates approximately 0.4% of the pregnancies. It increases the risk of perinatal morbidity and mortality.Subjects and methods: A double blind placebo controlled trial was conducted in Beni Suef University hospitals during 2017. It included 46 pregnant women with severe intrauterine growth restriction. Women were randomly allocated into two groups each included 23 patients. Intervention group received sildenafil citrate 20 mg orally three times a day, in addition to fish oil and zinc supplementation. Control group received tablets similar to sildenafil and the same treatment as intervention group. Primary outcomes included improvement in umbilical and middle cerebral arteries pulsatility indices and abdominal circumference.Results: Umbilical and middle cerebral arteries Doppler indices showed significant difference between groups after intake of sildenafil. Umbilical artery pulsatility index decreased significantly (p value = .001) while middle cerebral artery pulsatility index increased significantly in intervention group (p value0.001). Moreover, abdominal circumference growth velocity improved after two weeks of sildenafil intake (p value = .001).Conclusions: Sildenafil citrate may improve uteroplacental and fetal cerebral perfusion in pregnancies complicated by severe intrauterine growth restriction. It also improves abdominal circumference growth velocity. A wide scale randomized trials are needed for evaluation of neonatal and long term morbidity and mortality outcomes of pregnancies treated by sildenafil citrate.

Using fetal abdominal circumference growth velocity in the prediction of adverse outcome in near-term small-for-gestational-age fetuses.

To investigate whether abdominal circumference growth velocity (ACGV) improves the prediction of perinatal outcome in small-for-gestational-age (SGA) fetuses beyond that afforded by estimated fetal weight (EFW) and cerebroplacental ratio (CPR). A cohort of 235 singleton SGA fetuses at 36-38 weeks' gestation was examined. ACGV, EFW and CPR centiles were calculated. ACGV centile was determined using data from a large database of 19-21- and 36-38-week scans in an unselected population. Binary variables of ACGV < 10th , EFW < 3rd and CPR < 5th centiles were defined as abnormal. Two composite adverse outcomes (CAO) were explored: CAO-1 defined as at least one of umbilical artery pH < 7.10, 5-min Apgar score < 7 or neonatal unit admission, and CAO-2 that included in addition hypoglycemia, intrapartum fetal distress and perinatal death. Univariate and multivariate logistic regression analyses were performed to analyze the relationship between the three risk factors and their predictive value for CAO. The change in screening performance afforded by adding ACGV to EFW and CPR was assessed and receiver-operating characteristics (ROC) curves were calculated. ACGV < 10th centile was an independent risk factor for CAO. The sensitivity, specificity, positive and negative likelihood ratios of a predictive model based on EFW < 3rd centile and CPR < 5th centile were, respectively, 51%, 70%, 1.71 and 0.69 for CAO-1 and 41%, 70%, 1.39 and 0.83 for CAO-2. After addition of ACGV < 10th centile to the model, the respective values were 82%, 46%, 1.54 and 0.38 for CAO-1 and 71%, 47%, 1.34 and 0.62 for CAO-2. Using continuous variables, the areas under the ROC curves improved marginally from 0.669 (95% CI, 0.604-0.729) to 0.741 (95% CI, 0.677-0.798) for CAO-1 and from 0.646 (95% CI, 0.580-0.707) to 0.700 (95% CI, 0.633-0.759) for CAO-2 after addition of ACGV to the model. ACGV is a risk factor for adverse neonatal outcome that is independent of EFW and of CPR, although any improvement in the prediction of adverse outcome is not statistically significant. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.