Detection Of Fetal Growth Restriction Research Articles

Morphologic development of the first-trimester utero-placental vasculature is positively associated with embryonic and fetal growth: the Rotterdam Periconception Cohort.

Is morphologic development of the first-trimester utero-placental vasculature associated with embryonic growth and development, fetal growth, and birth weight percentiles? Using the utero-placental vascular skeleton (uPVS) as a new imaging marker, this study reveals morphologic development of the first-trimester utero-placental vasculature is positively associated with embryonic growth and development, fetal growth, and birth weight percentiles. First-trimester development of the utero-placental vasculature is associated with placental function, which subsequently impacts embryonic and fetal ability to reach their full growth potential. The attribution of morphologic variations in the utero-placental vascular development, including the vascular structure and branching density, on prenatal growth remains unknown. This study was conducted in the VIRTUAL Placental study, a subcohort of 214 ongoing pregnancies, embedded in the prospective observational Rotterdam Periconception Cohort (Predict study). Women were included before 10 weeks gestational age (GA) at a tertiary referral hospital in The Netherlands between January 2017 and March 2018. We obtained three-dimensional power Doppler volumes of the gestational sac including the embryo and the placenta at 7, 9, and 11 weeks of gestation. Virtual Reality-based segmentation and a recently developed skeletonization algorithm were applied to the power Doppler volumes to generate the uPVS and to measure utero-placental vascular volume (uPVV). Absolute vascular morphology was quantified by assigning a morphologic characteristic to each voxel in the uPVS (i.e. end-, bifurcation-crossing-, or vessel point). Additionally, total vascular length (mm) was calculated. The ratios of the uPVS characteristics to the uPVV were calculated to determine the density of vascular branching. Embryonic growth was estimated by crown-rump length and embryonic volume. Embryonic development was estimated by Carnegie stages. Fetal growth was measured by estimated fetal weight in the second and third trimester and birth weight percentiles. Linear mixed models were used to estimate trajectories of longitudinal measurements. Linear regression analysis with adjustments for confounders was used to evaluate associations between trajectories of the uPVS and prenatal growth. Groups were stratified for conception method (natural/IVF-ICSI conceptions), fetal sex (male/female), and the occurrence of placenta-related complications (yes/no). Increased absolute vascular morphologic development, estimated by positive random intercepts of the uPVS characteristics, is associated with increased embryonic growth, reflected by crown-rump length (endpoints β = 0.017, 95% CI [0.009; 0.025], bifurcation points β = 0.012, 95% CI [0.006; 0.018], crossing points β = 0.017, 95% CI [0.008; 0.025], vessel points β = 0.01, 95% CI [0.002; 0.008], and total vascular length β = 0.007, 95% CI [0.003; 0.010], and similarly with embryonic volume and Carnegie stage, all P-values ≤ 0.01. Density of vascular branching was negatively associated with estimated fetal weight in the third trimester (endpoints: uPVV β = -94.972, 95% CI [-185.245; -3.698], bifurcation points: uPVV β = -192.601 95% CI [-360.532; -24.670]) and birth weight percentiles (endpoints: uPVV β = -20.727, 95% CI [-32.771; -8.683], bifurcation points: uPVV β -51.097 95% CI [-72.257; -29.937], and crossing points: uPVV β = -48.604 95% CI [-74.246; -22.961])), all P-values < 0.05. After stratification, the associations were observed in natural conceptions specifically. Although the results of this prospective observational study clearly demonstrate associations between first-trimester utero-placental vascular morphologic development and prenatal growth, further research is required before we can draw firm conclusions about a causal relationship. Our findings support the hypothesis that morphologic variations in utero-placental vascular development play a role in the vascular mechanisms involved in embryonic and fetal growth and development. Application of the uPVS could benefit our understanding of the pathophysiology underlying placenta-related complications. Future research should focus on the clinical applicability of the uPVS as an imaging marker for the early detection of fetal growth restriction. This research was funded by the Department of Obstetrics and Gynecology of the Erasmus MC, University Medical Centre, Rotterdam, The Netherlands. There are no conflicts of interest. Registered at the Dutch Trial Register (NTR6854).

The impact of late pregnancy dating on the detection of fetal growth restriction at term.

The inaccuracy of late pregnancy dating is often discussed, and the impact on diagnosis of fetal growth restriction is a concern. However, the magnitude and direction of this effect has not previously been demonstrated. In this study, we aimed to investigate the effect of late pregnancy dating by head circumference on the detection of late onset growth restriction, compared to first trimester crown-rump length dating. This was a cohort study of 14 013 pregnancies receiving obstetric care at a tertiary center over a three-year period. Universal scans were performed at 12 weeks, including crown-rump length; at 20 weeks including fetal biometry; and at 36 weeks, where biometry, umbilical artery doppler and cerebroplacental ratio were used to determine the incidence of fetal growth restriction according to the Delphi consensus. For the entire cohort, the gestational age was first calculated using T1 dating; and was then recalculated using head circumference at 20 weeks (T2 dating); and at 36 weeks (T3 dating). The incidence of fetal growth restriction following T2 and T3 dating was compared to T1 dating using four-by-four sensitivity tables. When the cohort was redated from T1 to T2, the median gestation at delivery changed from 40 + 0 to 40 + 2 weeks (p < 0.001). When the cohort was redated from T1 to T3, the median gestation at delivery changed from 40 + 0 to 40 + 3 weeks (p < 0.001). T2 dating resulted in fetal growth restriction sensitivity of 80.2% with positive predictive value of 78.8% compared to T1 dating. T3 dating resulted in sensitivity of 8.6% and positive predictive value of 27.7%, respectively. The sensitivity of abnormal CPR remained high despite T2 and T3 redating; 98.0% and 89.4%, respectively. Although dating at 11-14 weeks is recommended, late pregnancy dating is sometimes inevitable, and this can prolong the estimated due date by an average of two to three days. One in five pregnancies which would be classified as growth restricted if the pregnancy was dated in the first trimester, will be reclassified as nongrowth restricted following dating at 20 weeks, whereas nine out of 10 pregnancies will be reclassified as non-growth restricted with 36-week dating.

Implementation of Uterine Artery Doppler Scanning: Improving the Care of Women and Babies High Risk for Fetal Growth Restriction.

While stillbirth rates have declined in many countries, these declines are less marked in the UK. Fetal growth restriction (FGR) affects about 3% to 7% of all pregnancies and is by far the single strongest risk factor for stillbirth. FGR implies a pathological restriction of the genetic growth potential and is not synonymous with small-for-gestational age (SGA). The Royal College of Obstetricians and Gynaecologists (RCOG) defines SGA as an estimated fetal weight (EFW) or abdominal circumference (AC) less than the 10th centile. The likelihood of FGR is higher in severe SGA defined as an EFW or AC less than the 3rd centile. The second version of Saving Babies' Lives Care Bundle (SBLCBv2) recommends the second trimester uterine artery Doppler (UtAD) pulsatility index (PI) screening for pregnancies at high risk of FGR. This study was aimed at determining the prevalence of FGR and assess pregnancy outcomes following the implementation of UtAD at the United Lincolnshire Hospitals NHS Trust (ULHT). One-year retrospective cohort study (1st September 2020-31st August 2021) was conducted across both ULHT hospitals in the UK (Lincoln County Hospital in Lincoln and Pilgrim Hospital in Boston). During the study period, 5197 women were booked at ULHT. Of 5197, 349 were identified as high risk for FGR. When numbers were compared for the two hospitals, FGR rate was higher in Lincoln 8.10% vs. 4.51% in Boston. In addition, an increased proportion of abnormal UtAD scans was observed in Lincoln (35.7%) vs. in Boston (22%) (P = 0.014). Of the 349 UtAD scans, 237 were normal (67.9%), 41 showed unilateral notching (11.7%), 43 bilateral notching (12.3%), and 28 raised PI (8%). Babies in the bilateral notching group exhibited the lowest birth weight (P = 0.005), born at an earlier gestation (P = 0.029), and with low Apgar scores at 1 (P = 0.007) and 5 minutes (P < 0.001). Discussion. UtAD is a useful second trimester screening tool for women identified as high risk for FGR and helps stratify the intensity of surveillance. However, the findings call into question a focus solely on the UtAD PI for improving FGR detection without taking into account bilateral notching.

Is bigger better? A comparison of growth restriction rates using the crown-rump length derived due date from the smaller versus larger twin

Although the smaller twin's crown-rump length is most accurate in establishing the estimated due date in dichorionic gestations, societal guidelines favor the use of the larger twin measurements based on concern for missing a diagnosis of fetal growth restriction. This study aimed to compare the accuracy of the diagnosis of early- and late-onset fetal growth restriction in dichorionic twin gestations conceived by assisted reproductive technology using the estimated due date as established by the crown-rump length of the smaller vs larger twin. This was a 10-year retrospective cohort study of nonanomalous, dichorionic gestations conceived with assisted reproductive technology at 2 institutions. The incidence of early-onset (<32 weeks of gestation) and late-onset (≥32 weeks of gestation) growth restriction derived from the Hadlock formula using the smaller and larger crown-rump length estimated due date was compared with the true estimated due date by assisted reproductive technology. Statistical significance was determined using the Fisher exact test. The incidence of missed fetal growth restriction cases, false-positive rate, and error were calculated along with the relative risk for a missed diagnosis using the smaller crown-rump length. A total of 176 subjects were screened: 81 had a fetal growth ultrasound at 24 to <32 weeks of gestation, and 58 had a fetal growth ultrasound at ≥32 weeks of gestation. There was a significant difference in the incidence of fetal growth restriction using the 3 dating strategies in both gestational age ranges (P<.001) with the smaller crown-rump length estimated due date more closely approximating the true rate. Before 32 weeks of gestation, the smaller crown-rump length estimated due date missed 2.5% of fetal growth restriction cases, whereas the larger crown-rump length estimated due date missed 0.6% of fetal growth restriction cases, with false-positive and error rates of 1.2% and 3.7% and 5.5% and 6.2%, respectively. After 32 weeks of gestation, the smaller crown-rump length estimated due date missed 1.8% of cases, whereas the larger crown-rump length estimated due date missed 0% of cases, with false-positive and error rates of 2.6% and 4.4% and 5.3% and 5.3%, respectively. The relative risk for a missed diagnosis of fetal growth restriction using the smaller crown-rump length estimated due date was 1.77 for early-onset growth restriction and 1.22 for late-onset growth restriction. Using the estimated due date derived from the smaller twin led to a more accurate detection of fetal growth restriction at a cost of a higher missed diagnosis rate.

Perinatal survival among very preterm singletons born after detection of early-onset fetal growth restriction with or without maternal hypertensive disorders: A population-based study in France

ObjectiveTo investigate the management and survival of very preterm singletons born because of fetal growth restriction (FGR) with or without maternal hypertensive disorders in France. Study designFrom a population-based cohort of very preterm births between 22 and 31 weeks in France in 2011, the study population included all non-anomalous singleton pregnancies delivered because of detected FGR with or without maternal hypertensive disorders. Antenatal detection of FGR was defined as an estimated fetal weight <10th percentile with or without fetal Doppler abnormalities or growth arrest. All fetuses were alive at the time of detection of FGR. Indicators of active perinatal management (antenatal steroids, pre-labor cesarean and birth in level 3 maternity unit) and fetal/neonatal outcomes (terminations of pregnancy (TOP), stillbirths, neonatal deaths and survival to discharge) were compared by gestational age between FGR associated with maternal hypertensive disorders and isolated FGR. ResultsOverall, 398 pregnancies delivered before 32 weeks for FGR associated with hypertensive disorders and 234 for isolated FGR. Active perinatal care was rare before 26 weeks in both groups and about one in five cases associated with maternal hypertensive disorders received steroids and was born by prelabor cesarean compared to none for isolated FGR. Before 25 weeks of gestation age, more pregnancies resulted in TOP when FGR was associated with hypertensive disorders compared to isolated FGR (respectively, 76.2 % vs 28.0 % at 22–23 weeks, P = 0.002 and 57.9 % vs 21.1 % at 24 weeks, P = 0.028) whereas stillbirths were more common among isolated FGR (respectively, 23.8 % vs 72.0 % at 22–23 weeks, P = 0.002 and 36.8 % vs 73.7 % at 24 weeks, P = 0.030). Survival to discharge was higher at any gestational age when the cause of birth was FGR associated with hypertensive disorders compared to isolated FGR. ConclusionThe management and pregnancy outcomes differed when FGR was associated with maternal hypertensive disorders or isolated. The proportion of TOP was higher when FGR was associated with hypertensive disorders and the proportion of stillbirths was higher in isolated FGR.

Prediction of pre-eclampsia complicated by fetal growth restriction and its perinatal outcome based on an artificial neural network model.

Objective: Pre-eclampsia (PE) complicated by fetal growth restriction (FGR) increases both perinatal mortality and the incidence of preterm birth and neonatal asphyxia. Because ultrasound measurements are bone markers, soft tissues, such as fetal fat and muscle, are ignored, and the selection of section surface and the influence of fetal position can lead to estimation errors. The early detection of FGR is not easy, resulting in a relative delay in intervention. It is assumed that FGR complicated with PE can be predicted by laboratory and clinical indicators. The present study adopts an artificial neural network (ANN) to assess the effect and predictive value of changes in maternal peripheral blood parameters and clinical indicators on the perinatal outcomes in patients with PE complicated by FGR. Methods: This study used a retrospective case-control approach. The correlation between maternal peripheral blood parameters and perinatal outcomes in pregnant patients with PE complicated by FGR was retrospectively analyzed, and an ANN was constructed to assess the value of the changes in maternal blood parameters in predicting the occurrence of PE complicated by FGR and adverse perinatal outcomes. Results: A total of 15 factors-maternal age, pre-pregnancy body mass index, inflammatory markers (neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio), coagulation parameters (prothrombin time and thrombin time), lipid parameters (high-density lipoprotein, low-density lipoprotein, and triglyceride counts), platelet parameters (mean platelet volume and plateletcrit), uric acid, lactate dehydrogenase, and total bile acids-were correlated with PE complicated by FGR. A total of six ANNs were constructed with the adoption of these parameters. The accuracy, sensitivity, and specificity of predicting the occurrence of the following diseases and adverse outcomes were respectively as follows: 84.3%, 97.7%, and 78% for PE complicated by FGR; 76.3%, 97.3%, and 68% for provider-initiated preterm births,; 81.9%, 97.2%, and 51% for predicting the severity of FGR; 80.3%, 92.9%, and 79% for premature rupture of membranes; 80.1%, 92.3%, and 79% for postpartum hemorrhage; and 77.6%, 92.3%, and 76% for fetal distress. Conclusion: An ANN model based on maternal peripheral blood parameters has a good predictive value for the occurrence of PE complicated by FGR and its adverse perinatal outcomes, such as the severity of FGR and preterm births in these patients.

Performance of a risk factor-based approach in the detection of small for gestational age neonates: A cohort study.

Antenatal detection of fetal growth restriction allows the opportunity to increase surveillance and initiate intervention to prevent adverse outcomes. Detection of small for gestational age (SGA) fetuses with risk factor screening and selective ultrasonography is the standard of care in Australia, but evidence regarding performance is lacking. To evaluate the diagnostic performance of a risk factor-based screening approach in detection of SGA neonates. Retrospective cohort study conducted in a metropolitan maternity service, including all consecutive singleton deliveries over 20 weeks gestation from July 2016 to December 2017, and excluding terminations of pregnancy. An SGA neonate was defined by birthweight below the tenth percentile according to Australian reference ranges. Antenatally detected SGA cases were defined by estimated fetal weight or abdominal circumference below the tenth percentile for gestational age, or abnormal symphysio-fundal height. The diagnostic accuracy of the screening protocol was calculated using detection rates and false-positive rates. There were 13 384 singleton pregnancies included. There were 1330 infants (10.0%) who were SGA at birth. Antenatal detection rate of SGA neonates was 39.6% (95% confidence interval (CI) 37.0-42.3%), with a false-positive rate of 10.2% (95% CI 9.6-10.7%). There were 10 266 pregnancies (77.0%) which had at least one risk factor for an SGA infant. Of these, 6650 (64.8%) underwent at least one fetal growth ultrasound after 24 weeks gestation. Antenatal recognition of poor fetal growth is suboptimal using our current screening protocol. Three-quarters of pregnancies demonstrated risk factors for delivering an SGA infant, but growth ultrasonography may be underutilised.

Application of Prospect Theory in Obstetrics by Evaluating Mode of Delivery and Outcomes in Neonates Born Small or Appropriate for Gestational Age

(Abstracted from JAMA Network Open 2022;5(3):e222177) The antenatal diagnosis of fetal weight is a challenge that relies on sonographic estimations and the clinical assessment of fetal and maternal status. Meanwhile, the rate of detection of fetal growth restriction (FGR) is &lt;40%.

Impact of a Hybrid Model of Prenatal Care on the Diagnosis of Fetal Growth Restriction.

Fetal growth restriction (FGR) is associated with poor neonatal outcomes and stillbirth, and screening via fundal height or ultrasound is routinely performed. During the novel coronavirus disease 2019 (COVID-19) pandemic, we developed a hybrid model of prenatal care which decreased the frequency of in-person visits and incorporated telemedicine visits. We sought to determine if prenatal FGR diagnoses decreased with this hybrid model compared with routine prenatal care. This was a retrospective cohort study of singleton nonanomalous neonates with birth weights <10th percentile at term. The "routine care" group was consisted of those who born between April and July 2019 with in-person prenatal care, and the "hybrid care" group was consisted of those who born between April and July 2020 with both in-person and telemedicine prenatal cares at a collaborative academic practice. The primary outcome was the rate of diagnosis of small for gestational age (SGA) as defined as infant birth weight <10th percentile without a prenatal diagnosis of FGR. The secondary outcome was timing of diagnosis of FGR. Overall, 1,345 and 1,296 women gave birth in the routine and hybrid groups, respectively. The number of in-person prenatal care visits decreased from 15,024 in the routine period to 7,727 in the hybrid period; 3,265 telemedicine visits occurred during the hybrid period. The total number of prenatal patients remained relatively stable at 3,993 and 3,753 between periods. Third trimester ultrasounds decreased from 2,929 to 2,014 between periods. Birth weights <10 percentile occurred in 115 (8.6%) births during the routine period and 79 (6.1%) births during the hybrid period. Of 115, 44 (38.3%) cases were prenatally diagnosed with FGR in the routine versus 28 of 79 (35.4%) in the hybrid group (p = 0.76). Median gestational age at diagnosis did not vary between groups (36 vs. 37 weeks, p = 0.44). A hybrid prenatal care model did not alter the detection of FGR. Future efforts should further explore the benefits of incorporating telemedicine into prenatal care. · Telemedicine visits can provide comprehensive prenatal care.. · FGR was diagnosed equally with hybrid versus routine prenatal care.. · FGR diagnosis was not delayed with hybrid care..

Comparative Diagnostic Performance of Estimated Fetal Weight and Isolated Abdominal Circumference for the Detection of Fetal Growth Restriction.

To describe the comparative incidence, detection of small-for-gestational age (SGA), and composite perinatal morbidity (CPM) associated with diagnostic criteria of fetal growth restriction (FGR) by estimated fetal weight (EFW) <10% with those with isolated abdominal circumference (AC) measurements <10%. We performed a retrospective cohort study of 1587 patients receiving prenatal care and delivery at our institution. We included all patients with ultrasounds and delivery outcomes available, and excluded terminations, second trimester losses, and pregnancies without ultrasounds. EFW was calculated from Hadlock and use of the Duryea centiles, and AC from Hadlock's reference curves. We determined SGA at birth and defined CPM as birthweight less than 3% or birthweight less than 10% with neonatal morbidity. Of 1587 patients, 28 (1.8%) were classified as FGR by EFW <10%. Three of 12 patients with isolated AC <10% developed EFW <10% later in pregnancy (25%). The performance of each diagnostic criteria were comparable for the outcomes of SGA and CPM, with similar sensitivities, but with decreased specificity for SGA outcome, and an increased false positive rate for patients classified as FGR by isolated AC <10, with a tradeoff of decreased false negatives. Broadening the diagnosis of FGR to include patients with isolated AC <10 did not significantly increase the detection of pregnancies at risk for SGA or CPM. Our conclusions may be limited by a lack of statistical power given a low frequency of SGA and CPM.

Long-term monitoring of blood biomarkers related to intrauterine growth restriction using AgNPs SERS tags-based lateral flow assay.

Sensitive and accurate early detection of fetal growth restriction (FGR) is of vital importance in the development of the fetus during pregnancy and even the health of future life. Here, an ultrasensitive and straightforward surface-enhanced Raman scattering (SERS)-based double targets detection in pregnancy is implemented by utilizing functionalized Ag nanoparticles (AgNPs). Through fabricating 4-MPA antibody-modified AgNPs on the lateral flow assay (LFA) strips as the SERS nanotags, the target proteins in blood samples from pregnancy were accurately captured, which further quantizing PI3K and CRAF in unprocessed blood. This strategy warrant excellent selectivity and sensitivity with the limits of detection (LODs) are 0.76fgmL-1 for PI3K and 0.61fgmL-1 for CRAF, leading reliable quantification for these two targets. Meanwhile, the feasibility of this assembly was testified by comparing with conventional ELISA method, and the results showed that a high degree of consistency was obtained in these two detection assays. This SERS-colorimetric dual-signal LFA strip can provide a novel strategy for early diagnosis of fetal-related disorders, which is essential for disease diagnosis and treatment guidance during pregnancy.

Perinatal and 2-year neurodevelopmental outcome in late preterm fetal compromise: the TRUFFLE 2 randomised trial protocol

IntroductionFollowing the detection of fetal growth restriction, there is no consensus about the criteria that should trigger delivery in the late preterm period. The consequences of inappropriate early or late...

The Diagnostic Utility of Growth Ultrasound for the Indication of Maternal Overweight or Obesity.

The objective of this study was to evaluate the diagnostic utility of serial growth ultrasounds for the indication of maternal overweight or obesity. This is a retrospective cohort study of all women with a body mass index ≥25 kg/m2 who underwent at least one growth ultrasound at ≥24 weeks gestation and delivered at a single tertiary care institution between January 2010 and December 2013. Women were excluded if they had other medical indications for growth ultrasounds. Ultrasounds were divided into three gestational age epochs: 24 to 316/7 weeks, 32 to 356/7 weeks, and ≥36 weeks. Outcomes examined included the accuracy of sonographic detection of fetal growth restriction (FGR) and fetal overgrowth compared with diagnoses of small for gestational age (SGA) and large for gestational age (LGA) based on the birth weight. The test characteristics of ultrasound and the number needed to screen (NNS) to detect growth abnormalities at the time of birth were estimated for each condition and gestational age epoch. The NNS for the detection of fluid abnormalities was also assessed. During the study period, 3,945 eligible sonograms were performed in 2,928 women. FGR was identified on ultrasound in 42 (1.4%) women, fetal overgrowth in 94 (3.2%) women, oligohydramnios in 35 (1.2%) women, and hydramnios in 41 (1.4%) women. The NNS for the diagnoses of SGA, LGA, oligohydramnios, and hydramnios at delivery was at least 137 prior to 32 weeks of gestation and decreased (i.e., at least 45 and 16, for 32 to 356/7 weeks and ≥36 weeks, respectively) with advancing gestational age epochs. If growth ultrasounds are to be performed for the sole indication of maternal overweight or obesity, consideration should be given to delaying initiation until at least 32 weeks of gestation given the infrequency of growth and fluid abnormalities identified earlier. · There are limited data to support serial growth ultrasounds in overweight and obese women.. · The sensitivity of ultrasound for growth abnormalities at <32 weeks is low in women with BMI ≥25. · Consideration should be given to delaying initiation of growth ultrasounds until at least 32 weeks.

National perinatal mortality audits and resultant initiatives in four countries

BackgroundIt is important to examine perinatal deaths as part of a national mortality audit to identify risk factors. Implementing and re-evaluating recommendations from perinatal mortality audits completes the audit cycle, preventing similar deaths in the future. Lack of implementation results in recommendations recurring. ObjectivesIn this study we examine national perinatal mortality audits’ methodology in four high-income countries (United Kingdom, New Zealand, Ireland, Netherlands) to highlight different approaches taken. We compare the recommendations made in these audits’ reports over the last five years, as well as review national initiatives and programmes addressing them. Study DesignThis study is an integrative review where two comprehensive literature searches were completed: on established national perinatal mortality audits in high-income countries; and on national initiatives addressing recommendations from these audits. Content analysis of the audits’ recommendations was performed organising them into themes according to topics these focused on. ResultsThough the methodology of the national perinatal mortality audits varied, all four were state-funded and had standardised online data collection forms to report deaths.The recommendations themes included: Raising public awareness of perinatal mortality risk factors, Detection of fetal growth restriction, Prevention of preterm birth, Resources for data collection and review.Only the UK had various initiatives addressing perinatal mortality risk factors directly. New Zealand included stakeholders in the audit recommendations’ development and provided updates on their implementation. The Netherlands developed a programme for audit recommendation implementation. Ireland created a group which is progressing some recommendations from the audit. ConclusionsNational perinatal mortality audits are important in identifying contributory factors and making recommendations to address these. Recurring recommendations suggest a failure to resolve the identified issues. This study shows how some challenges are common to high-income countries’ audits, highlighting the need for shared learning of successful initiatives.

Fetal growth restriction: underdiagnosed condition with non-optimal screening

Background Fetal Growth restriction (FGR) is the pathological failure of a fetus to reach its biologically determined growth potential. Detection of FGR fetuses is a universally agreed key objective of antenatal care. Antenatal detection of FGR has undeniable benefits, juggling between intensive fetal surveillance and optimized timing of delivery; it reduces adverse perinatal outcomes by up to four-fold. However, FGR is still widely underdiagnosed. We aimed to identify the prevalence of FGR diagnosis in our wards and study the impact of the 2013 published French guidelines on the detection rate of FGR. The secondary objective aimed to highlight the factors of suboptimal screening in the population of non-diagnosed FGR fetuses and emphasize the screening method that led to antenatal diagnosis of FGR. Materials and methods We conducted a retrospective study at a single tertiary maternity center in Lyon-France, the Femme Mère Enfant Hospital, including the exhaustive population of FGR born after 24 + 0 weeks of gestation from 1 January 2011 to 31 December 2017. FGR was defined combining the neonatal and antenatal consensus-based definitions for early and late FGR in absence of congenital anomalies, excluding small for gestational age fetuses. For all FGR fetuses, we compared the antenatal detection rate of FGR during 2011–2013 to 2015–2017, since the French guidelines were published in December 2013. When FGR fetuses underwent an antenatal diagnosis of FGR, we retrospectively collected the characteristics that led to the diagnosis. When fetuses were not diagnosed as FGR, we retrospectively reviewed the implementation of the recommended screening method, enabling to evaluate whether screening was optimal or not. Statistical analysis was performed in July 2018, and statistical significance was regarded as a p-value <.05. Results Over the seven-year period, and among 31,052 newborns, 1020 (3.3%) infants were identified as FGR and met the inclusion criteria. The detection rate of FGR was similar before and after publication of the French Guidelines related to FGR in 2013. Indeed, 50.8% (201/395) FGR were diagnosed between 2011 and 2013 versus 52.6% (245/465) between 2015 and 2017 (p = .59). In the population of non-diagnosed FGR infants, screening was suboptimal in 80%. Symphysis-fundal height (SFH) was not measured in 10.7%, with no difference before and after 2014 (7.3 versus 11.8% p = .11). Ultrasound examination for fetal biometry had not been prescribed in spite of abnormal SFH in 47.7% of undiagnosed FGR infants. Diagnosis has been missed in 11.5% of infants because of misinterpretation of the estimated fetal weight’s centile. Conclusion FGR is widely underdiagnosed. However, the limited performances can partially be explained by the regular misuse of screening method in clinical practice. Despite the systematic third trimester ultrasound screening, the detection rate of FGR was similar to the one reported in the medical literature. The timing of routine third trimester ultrasound in low-risk women may be rethought.

Prediction of Fetal Growth Restriction Using Combined Fetal Biometry and Maternal Serum( Inhibin A) in Pregnant Women with Type 1 Diabetes.

Prediction of Fetal Growth Restriction using Combined Fetal Biometry and Maternal Serum [Inhibin A] in Pregnant Women with Type 1 DiabetesAbstractBackground: FGR is a major determinant of perinatal and childhood morbidity and mortality and is associated with the risk of chronic diseases in later life.Objective: to assess the diagnostic value of early detection of fetal growth restriction using combined fetal biometry and maternal serum biomarker inhibin A in type 1 diabetic patients.Patients and Methods: A prospective study on 100 diabetic pregnant women. Maternal Serum Inhibin A, Hemoglobin AIC, fasting glucose serum levels, all done for each patient once in second trimester. Serial fetal ultrasound biometry done as one assessment in second trimester and two assessments in third trimester. Ultrasonic markers for fetal growth restriction were performed. Follow-up was done for 3 antenatal care visits.Results: The IUGR was [66%] and non-IUGR was [34%]. Mean serum inhibin A level in IUGR cases 673.83± 470.43, mean serum inhibin A in NON- IUGR cases 102.06 ± 106.29) P value

Preventing harm: A balance measure for improving the detection of fetal growth restriction

Increasing the detection of fetal growth restriction (FGR), while reducing stillbirth, also leads to unnecessary early intervention, and associated morbidity, for normally grown babies who are incorrectly suspected of FGR. We sought to design a balance measure that addresses the specificity of FGR detection. A retrospective cohort study on all singleton births ≥32weeks gestation in 2016 and 2017 in Victoria. We compared two balance measures for the detection of FGR, defined as the proportion of all babies iatrogenically delivered before 39weeks gestation for suspected FGR that had a birthweight ≥10th centile (balance measure 1) or ≥25th centile (balance measure 2). Hospital level performance on each balance measure was derived and compared to an existing performance measure for severe FGR detection in Victoria. Of the 38 hospitals analysed, 12 (32%) had a favourable performance on an existing indicator of FGR detection, seven (18%) hospitals had a favourable performance on balance measure 1, and 15 (39%) had a favourable performance on balance measure 2. There was a moderate correlation between hospital performance on the existing indicator and on balance measure 1 (r=0.447, P=0.005) but not balance measure 2 (r=-0.063, P=0.71). There was no difference in perinatal mortality between high performing hospitals and low performing hospitals. Introducing a balance measure into routine reporting may bring greater awareness to the unintended harm associated with increased detection of FGR.

Biosensor for Detecting Fetal Growth Restriction in a Low-Resource Setting

One strategy for improving detection of fetal growth restriction (FGR) is developing biosensors identifying placental dysfunction as a leading pathogenesis for FGR. The aim of this pilot study was to investigate the performance of a biosensor specified to detect placental dysfunction by means of maternal arterial turbulence acoustics in a low-resource setting. A cohort of 147 singleton pregnant women were prospectively followed with double-blinded biosensor tests, sonographic estimation of fetal weight (EFW) and Doppler flow at 26–28, 32–34 and 37–39 weeks of pregnancy. Full term live births with recorded birth weights (BWs) and without major congenital malformations were included. Outcomes were defined as (A) a solitary biometric measure (BW &lt; 3rd centile) and as (B) a biometric measure and contributory functional measure (BW &lt; 10th centile and antenatally detected umbilical artery pulsatility index &gt; 95th centile). Data from 118 women and 262 antenatal examinations were included. Mean length of pregnancy was 40 weeks (SD ± 8 days), mean BW was 3008 g (SD ± 410 g). Outcome (A) was identified in seven (6%) pregnancies, whereas outcome (B) was identified in one (0.8%) pregnancy. The biosensor tested positive in five (4%) pregnancies. The predictive performance for outcome (A) was sensitivity = 0.29, specificity = 0.97, p = 0.02, positive predictive value (PPV) was 0.40 and negative predictive value (NPV) was 0.96. The predictive performance was higher for outcome (B) with sensitivity = 1.00, specificity = 0.97, p = 0.04, PPV = 0.20 and NPV = 1.00. Conclusively, these pilot-study results show future potential for biosensors as screening modality for FGR in a low-resource setting.

514 Impact of a hybrid model of prenatal care on the diagnosis of fetal growth restriction

Fetal growth restriction (FGR) is associated with poor neonatal outcomes and stillbirth, and antenatal screening via fundal height or ultrasound is routinely performed. During the COVID-19 pandemic, we developed a prenatal care schedule that limited in-person care. We sought to determine if FGR diagnoses decreased with this model of care. This was a retrospective cohort study of singleton non-anomalous neonates with birthweights <10%ile. Birthweight was defined using curves by Oken et al. The routine group were those born April-July 2019 with routine prenatal care, and the hybrid group were those born April-July 2020 with both in-person and telemedicine prenatal care dictated by risk (Table 1). The primary outcome was the rate of missed FGR diagnosis. A secondary outcome was time of diagnosis. Neonatal adverse events were also reviewed. Data were abstracted via REDCap. 1345 routine and 1296 hybrid births occurred in the study periods. The number of in-person prenatal care visits decreased from 15,024 in the routine period to 7727 during the hybrid period. 3265 telemedicine visits occurred during the hybrid period. The total number of prenatal care patients remained stable at 3993 and 3753 over the time periods. Third trimester ultrasounds decreased from 2929 to 2014 between periods. FGR occurred in 115 (8.6%) births during the routine and 79 (6.1%) births during the hybrid period. 44/115 (38.5%) cases of FGR were detected in the routine group vs 28/79 (35.4%) in the hybrid group (p=0.76) (Figure 1). Among all births affected by FGR, the median number of in-person visits differed routine vs hybrid groups (11 vs 9 p=<0.001) as did the number of telemedicine visits (0 vs 1 p=<0.001). Median gestational age at diagnosis did not vary between groups (36 vs 37 weeks, p=0.44). Neonatal outcomes (NICU admission, hypoglycemia, and Apgar scores <7) were similar between groups, though limited by sample size. Our hybrid prenatal care protocol did not alter the detection of FGR. Future efforts should explore the benefits of incorporating telemedicine into prenatal care.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Effect of regular third-trimester ultrasound examination on antenatal detection and perinatal outcomes of small for gestational age infants.

ObjectiveTo assess the effect of regular third-trimester ultrasound on antenatal detection and perinatal outcomes of small for gestational age (SGA) infants.MethodsData from SGA infants delivered at ≥28 weeks’ gestation were retrospectively studied. Each pregnancy had undergone three regular third-trimester ultrasound examinations, and data were grouped according to with or without antenatal ultrasound suspicion of fetal growth restriction (FGR). Adjusted risk ratios (aRRs) of perinatal outcomes were analysed.ResultsA total of 407 infants were included, comprising 268 (65.85%) with antenatal ultrasound suspicion of FGR. Antenatal suspicion of FGR was associated with increased risk of iatrogenic delivery (aRR 2.03, 95% confidence interval [CI] 1.31, 3.14) that included risk of preterm birth (aRR 10.61, 95% CI 1.35, 83.62) and elective caesarean section (aRR 1.306, 95% CI 1.051, 1.623). Differences in fetal death, 1-min Apgar score, and admission to neonatal intensive care unit were not statistically significant. Resuscitation risk was reduced (aRR 0.22, 95% CI 0.06, 0.79).ConclusionsRegular use of third-trimester ultrasound in one teaching hospital in China showed satisfactory antenatal detection of FGR among SGA infants. Ultrasound suspicion of FGR was associated with higher incidence of iatrogenic deliveries, but not improved neonatal outcomes, except for reduced perinatal resuscitation.