Diagnosis Of Fetal Growth Restriction Research Articles

Fetal Umbilical Vein Flow in the Classification of Fetuses with Growth Restriction

Objectives: To assess umbilical vein (UV) blood flow in fetal growth restriction (FGR) and in pregnancy with small for gestational age (SGA) fetus. To evaluate the predictive capacity of UV blood flow (QUV) in the discrimination of SGA fetuses from FGR before and after 32 weeks of pregnancy. Methods: Sixty-five women with a recent diagnosis of FGR or SGA fetuses were enrolled and underwent a complete fetal Doppler examination comprehending QUV. We collected SGA (n = 34), early-FGR (n = 9), and late-FGR (n = 22) fetuses. Results: UV diameter was lower in early and late-FGR compared to SGA, while time-averaged maximum velocity (TAMXV) was lower only in early-FGR. UV blood flow (QUV) and QUV corrected for estimated fetal weight (cQUV) were significantly lower in early-FGR and late-FGR compared to SGA. The receiver operating characteristic (ROC) curves analysis of cQUV showed a significant predictive capacity for SGA diagnosis before and after 32 weeks. Conclusions: The evaluation of UV blood flow allows distinguishing SGA fetuses from FGR. The assessment of UV flow should be taken into consideration in future research of new parameters to differentiate SGA from FGR.

Impact of Using Abdominal Circumference Independently in the Diagnosis of Fetal Growth Restriction.

Society for Maternal-Fetal Medicine guidelines for diagnosing fetal growth restriction (FGR) have broadened the definition to include abdominal circumference (AC) <10th percentile for gestational age (GA) regardless of estimated fetal weight (EFW). We aimed to compare the ability of three definitions of FGR to predict small for gestational age (SGA) neonates and adverse outcomes. We performed a secondary analysis of a prospective cohort of patients who underwent assessment of fetal growth between GA of 26 and 36 weeks. We compared three definitions of FGR: EFW <10th percentile; AC <10th percentile; either EFW or AC <10th percentile. The primary outcome was successful prediction of neonatal SGA. Secondary outcomes included a composite adverse neonatal outcome (CANO). We further compared these definitions of FGR using area under receiver operative curves (AUC) to measure their discriminatory abilities. About 1054 women met inclusion criteria. Ninety-one (8.6%) had EFW <10th percentile, 122 (11.6%) had AC <10th percentile, and 137 (12.9%) had either EFW or AC <10th percentile. SGA was seen in 139 (13.2%); CANO was seen in 139 (13.2%). Ability for detecting neonatal SGA was significantly better when the definition included both EFW or AC <10th percentile compared to either variable independently. The AUC were: 0.74, 0.73, 0.69; P= .0003. There was no statistical significance in ability for predicting CANO (AUC 0.51, 0.51, 0.50; P= .7447). Addition of AC as a criterion for diagnosing FGR improves our ability to predict neonatal SGA compared to using EFW alone. All three definitions were poorly predictive of neonates at risk for adverse outcomes.

FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction.

Fetal growth restriction (FGR) is defined as the failure of the fetus to meet its growth potential due to a pathological factor, most commonly placental dysfunction. Worldwide, FGR is a leading cause of stillbirth, neonatal mortality, and short- and long-term morbidity. Ongoing advances in clinical care, especially in definitions, diagnosis, and management of FGR, require efforts to effectively translate these changes to the wide range of obstetric care providers. This article highlights agreements based on current research in the diagnosis and management of FGR, and the areas that need more research to provide further clarification of recommendations. The purpose of this article is to provide a comprehensive summary of available evidence along with practical recommendations concerning the care of pregnancies at risk of or complicated by FGR, with the overall goal to decrease the risk of stillbirth and neonatal mortality and morbidity associated with this condition. To achieve these goals, FIGO (the International Federation of Gynecology and Obstetrics) brought together international experts to review and summarize current knowledge of FGR. This summary is directed at multiple stakeholders, including healthcare providers, healthcare delivery organizations and providers, FIGO member societies, and professional organizations. Recognizing the variation in the resources and expertise available for the management of FGR in different countries or regions, this article attempts to take into consideration the unique aspects of antenatal care in low-resource settings (labelled “LRS” in the recommendations). This was achieved by collaboration with authors and FIGO member societies from low-resource settings such as India, Sub-Saharan Africa, the Middle East, and Latin America.

574 Fetal abdominal circumference as an early marker in prediction of small for gestational age newborns

This study aims to evaluate the relationship of the fetal abdominal circumference (AC) and the subsequent development of fetal growth restriction (FGR) in small for gestational age (SGA) newborns. This is a retrospective cohort study of singleton fetuses diagnosed with antenatal FGR (EFW < 10th percentile) during ultrasound between 2012 and 2020. Time from diagnosis of AC < 10th percentile to time of diagnosis of FGR and time to delivery were calculated. Primary outcome was SGA newborns (birthweight < 5th percentile). Secondary outcomes included fetal umbilical artery Doppler, maternal comorbid disorders such as hypertension and autoimmune disease, and newborn outcomes. Abnormal umbilical artery Doppler was defined as an S/D ratio >95th percentile for GA, absent end diastolic flow or reverse end diastolic flow. Statistical analyses, including Chi square and logistic regression modeling, were performed with significance levels of <0.05. Of 231 women given an antenatal diagnosis of FGR, there were 182 (79%) SGA newborns and 49 (21%) non-SGA newborns. Both groups were similar in age, parity, ethnicity, substance use disorder, gestational age at delivery, oligohydramnios, preeclampsia, and maternal comorbidities. Fetal AC <10th percentile preceded ultrasound diagnosis of FGR in SGA newborns more frequently than non-SGA newborns (46% v 29%; p=0.03). Time from identification of an AC <10th percentile to diagnosis of FGR averaged 6.7±4.9 weeks. Antenatal abnormal umbilical artery Doppler occurred more frequently in SGA newborns compared with non-SGA newborns (92% v 8%; p=0.002). In logistic regression, the antenatal variables most likely to predict an SGA newborn included fetal AC <10th percentile preceding FGR (OR 2.27; 95%CI: 1.09-4.71) and abnormal umbilical artery Doppler (OR 4.41; 95%CI: 1.7 –11.4). (Table 1) Measurement of fetal AC <10th percentile on antenatal ultrasound independently predicts development of subsequent FGR and SGA newborns. When an ultrasound measurement of the AC is <10th percentile, further monitoring should be recommended.

782 Difference in ultrasound unit volume between birthweight and ultrasound derived definitions of fetal growth restriction

Recent guidelines recommend the use Hadlock rather than birth weight derived percentiles for diagnosis of fetal growth restriction (FGR). The objective of this study is to quantify the impact of changing from a birth weight (Williams et al.) to an ultrasound based (Hadlock et al.) percentile classification of FGR on ultrasound unit volume. We conducted a retrospective cohort study of all singleton pregnancies that presented for ultrasound ≥22 weeks’ gestation pre- and post an institutional change of FGR classification system from Williams et al. to Hadlock et al. between 2018-2020. Pregnancies with an estimated fetal weight <10% by either classification system were included in the analysis. The primary outcomes were the frequency of patient encounters, follow up examinations, biophysical profiles (BPP) ≥28 weeks, and umbilical artery (UA) Doppler assessments. Secondary outcomes were gestational age (GA) at delivery and rates of cesarean delivery, 5-minute Apgar <7, and fetal death between study years. 550 women met inclusion criteria over the study period. FGR diagnosis was discordant (FGR by Hadlock, but not Williams) in 77.6% of cases at diagnosis and in 46.9% at the last ultrasound before delivery. The median GA at FGR diagnosis was significantly earlier using Hadlock (31.9 vs 36.0 weeks; p<.001). Significant increases in the median number of encounters, BPP, UA Doppler, and total billed procedure codes were calculated between study years; Table 1. Fetal death was decreased (6.0% vs 2.1%; p=.043), but FGR diagnosis was discordant in only 4/15 cases that resulted in fetal death. No differences in GA at delivery, cesarean delivery and Apgar <7 at 5 minutes were identified between study years. Use of Hadlock results in increased rates of FGR and diagnosis at an earlier gestational age when compared to birth weight derived percentiles. This leads to a significant increase in overall ultrasound unit volume including use of UA Doppler surveillance.

824 Prediction of perinatal demise and severe adverse neonatal outcomes in pregnancies with fetal growth restriction

To evaluate our ability to use clinical factors available at the time of diagnosis of fetal growth restriction (FGR) to predict perinatal demise and severe adverse neonatal outcomes. Retrospective analysis of 907 singleton non-anomalous pregnancies at a single tertiary-care institution (2010-2020) that met Delphi procedure-based consensus (Gordijn 2016) criteria for fetal growth restriction. This secondary analysis of 423 pregnancies was limited to those that ended in either perinatal demise or neonatal intensive care unit (NICU) admission. Regression analysis incorporated factors available at time of FGR diagnosis to predict composite severe adverse outcomes: grade III-IV intraventricular hemorrhage or periventricular leukomalacia, necrotizing enterocolitis, bronchopulmonary dysplasia, sepsis, and perinatal demise or death prior to NICU discharge. Severe adverse outcome occurred in 168 (39.7%) cases; 54 (32.1%) ended in demise. Mean NICU admission duration was 69.4 compared to 26.5 days in those with and without the composite outcome, respectively (P < .0001). Factors at diagnosis of growth restriction positively correlated with adverse outcomes include: gestational age < 30 weeks (adjusted OR 7.75, 95% CI 4.63-13.45), absent/reversed umbilical artery end diastolic flow (aOR 3.56, 95% CI 2.15-5.97), and chronic hypertension (aOR 4.10, 95% CI 1.80-9.83). Umbilical artery pulsatility index >95th centile was associated with decreased odds of adverse outcome on univariate analysis (P < .001), but was not significant after adjustment. Superimposed preeclampsia was associated with a decreased odds of adverse outcome (aOR 0.30, 95% CI 0.11-0.75). Bias-corrected bootstrapped (1000 replicates) area under the curve for the 5-item predictive model was 0.81 (95% CI 0.76-0.84). A model comprised of five factors widely available in daily clinical practice at time of diagnosis of fetal growth restriction is predictive of perinatal demise and severe adverse neonatal outcomes. If validated, this model may aid in counseling patients and guide management.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

998 Fetal growth restriction and the association between abnormal placental changes and significant adverse neonatal outcomes

To evaluate the frequency of abnormal placental changes and significant adverse neonatal outcomes in pregnancies complicated by fetal growth restriction (FGR) as defined by the Delphi procedure. We performed a retrospective cohort study of 423 singleton, non-anomalous pregnancies at a tertiary care center from 2010-2020 that met the diagnosis of fetal growth restriction by the Delphi procedure-based consensus and resulted in either intrauterine fetal demise, neonatal demise, or NICU admission. Cases for which the postnatal course was unknown or placenta pathology was not performed were excluded. Chi-square bivariate analysis was performed to evaluate the association between abnormal placental findings and severe adverse neonatal outcomes, which included grade III-IV intraventricular hemorrhage (IVH) or periventricular leukomalacia, necrotizing enterocolitis (NEC), sepsis, bronchopulmonary dysplasia, perinatal demise, as well as a composite of all outcomes. Severe adverse perinatal outcomes occurred in 168 (39.7%) pregnancies; 54 (32.1%) ended in demise. Placental pathology was available for 401 cases. Placenta-to-birthweight ratio was greater for cases with severe adverse outcomes (0.27 vs 0.21, p< .001). 171 (43%) placentas exhibited maternal lesions and 30 (7%) had fetal lesions. Villous changes were noted in all categories with the exception of NEC; vascular lesions were found in all categories except for NEC and IVH. Perinatal demise was the only factor associated with fetal malperfusion lesions. NEC was the only outcome not individually associated with any placental pathology. Cases of severe adverse neonatal outcomes were associated with abnormal placental pathology, most commonly malperfusion lesions. Our findings support the conclusion that severe FGR and significant adverse outcomes are associated with poor placental perfusion attributed to maternal vascular disease. Future study is needed to determine how chronic maternal vascular disorders may be used to guide prognostic discussions on the likelihood of adverse outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

817 Utility of ultrasound and antenatal testing in women undergoing outpatient cervical ripening

To evaluate indications for exclusion in women who participated in outpatient cervical ripening studies (Outpatient Foley For Starting Induction at Term I and II). These data will assist in evaluating which parts of the scientific protocol are informative and should be retained in clinical application. This is a secondary analysis of women evaluated for enrollment in, but eventually excluded from, two randomized trials evaluating outpatient cervical ripening in low-risk parous (OFFSITE-I) and nulliparous (OFFSITE-II) women. Participants were considered low risk if they had no medical problems (other than well-controlled diabetes or hypertension), singleton pregnancies, and were 39-42 weeks gestation. Women identified as eligible at the time of pre-enrollment screening underwent an enrollment visit that included blood pressure (to rule out hypertensive disorders), ultrasound (to assess presentation, fluid, and growth), antenatal testing (to rule out non-reassuring fetal status), and a cervical exam (to determine need for ripening). In this analysis, we evaluate indications for exclusion based on the findings at the enrollment visit. Baseline maternal and pregnancy characteristics were balanced between groups. Among 354 women who presented for an enrollment visit, 98 were excluded from the trials at the study visit and included in this analysis. Of these, the majority (n=60, 17% of all women evaluated) were excluded for ultrasound findings. In this group, 49 women (14% of all women evaluated) were excluded due to a diagnosis of fetal growth restriction (regardless of antenatal testing), and 11 (3.1% of all women evaluated) were found to have polyhydramnios. (Fig 1). As we consider implementing outpatient cervical ripening into clinical practice, appropriate identification of low-risk patients is crucial. A third trimester ultrasound prior to outpatient cervical ripening identifies findings that may influence plans for outpatient cervical ripening and should be performed as part of clinical protocols.

68 Dichorionic twin-specific versus singleton growth standards for diagnosis of fetal growth restriction

To compare a twin-specific growth standard (NICHD) and a singleton growth curve (Hadlock) in diagnosing fetal growth restriction (FGR) associated with adverse neonatal outcomes in dichorionic diamniotic (DiDi) twin gestations. A retrospective cohort study of DiDi twin gestations ≥32 weeks delivered at a single institution between 2004-2019 with serial growth ultrasounds and neonatal outcomes data. Twins were classified based on last ultrasound before delivery with FGR: by both Hadlock and NICHD, by Hadlock only, and not by either curve, with FGR defined as estimated fetal weight <10%. Multivariate generalized linear mixed models were used to assess adverse neonatal outcomes via pairwise comparisons by FGR group, with a random effects component to account for twin-pair correlations. 1,460 twin infants were included with 8.1% FGR by both NICHD and Hadlock, 8.8% FGR by Hadlock only, and 83.1% with no FGR by either. Compared to twins with no FGR by either curve, twins with FGR by both curves were more likely to experience mild (aOR 2.38; CI 1.38-4.13) and severe (aOR 2.82; CI 1.16-6.88) composite neonatal morbidity. Compared to twins with FGR by Hadlock only, twins with FGR by both curves were more likely to experience mild (aOR 2.03; CI 1.00-4.14), but not severe (aOR 3.70; CI 0.72-18.90), composite neonatal morbidity. No significant differences were found for the studied outcomes between twins with FGR by Hadlock only and twins with no FGR by either curve (Table 1). The NICHD growth standard is a more sensitive marker of FGR that is associated with adverse neonatal outcomes in DiDi twin gestations. Use of Hadlock appears to identify more twins as FGR that are at low risk for neonatal morbidity, which could lead to unnecessary maternal anxiety, increased antenatal testing and possible iatrogenic preterm delivery.

725 Impact of using abdominal circumference independently in the diagnosis of fetal growth restriction

Recent updates to guidelines for diagnosing fetal growth restriction (FGR) have broadened the definition from estimated fetal weight (EFW)<10th percentile for gestational age to also include abdominal circumference (AC)<10th percentile for gestational age. The objective of this study is to compare these definitions of FGR to predict small for gestational age (SGA) neonates and adverse outcomes. We conducted a prospective cohort analysis of women presenting for fetal growth assessment between 26 and 36 weeks gestation (GA). We compared three definitions of FGR; EFW<10th percentile for GA by the Hadlock formula, abdominal circumference<10th percentile for GA, either EFW<10th percentile or AC<10th percentile. The primary outcome was prediction of neonatal SGA by the Alexander growth chart. Secondary outcomes included a neonatal outcome composite score. Of 1054 women meeting inclusion criteria, 91 (8.6%) were found to have EFW<10th percentile, 122 (11.6%) were found to have AC<10th percentile, and 137 (12.9%) were found to have either EFW or AC <10th percentile. SGA was seen in 139 (13.2%), and a composite adverse neonatal outcome was seen in 139 (13.2%). The overall ability for detecting neonatal SGA was significantly better when the definition included both EFW<10th percentile or AC<10th percentile compared to AC<10th percentile alone or EFW<10th percentile alone. The area under the curve and 95% confidence intervals were: 0.74, 0.70-0.78 vs 0.73, 0.68-0.77 vs 0.69, 0.65-0.73; respectively, p=0.0003. There was no statistical significance between the three definitions’ ability for predicting composite adverse neonatal outcomes (area under the curve 0.51, 95% confidence interval 0.48-0.54 vs 0.51 95% confidence interval 0.48-0.54 vs 0.50 95% confidence interval 0.47-0.53; p=0.7447). The new definition of FGR which now includes either AC or EFW <10th percentile improves our ability to detect neonatal SGA compared either parameter alone. All three definitions, however, were poor at detecting neonates who are at risk for neonatal adverse outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

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)

1159 Evaluation of fetal growth restriction in pregnancies complicated by buprenorphine therapy

To determine if a single growth ultrasound in the third trimester is as effective as serial growth ultrasounds to diagnose fetal growth restriction (FGR) in pregnancies exposed to buprenorphine therapy. This is a retrospective cohort study of pregnant women on buprenorphine opioid replacement therapy who delivered a singleton fetus at a tertiary care center between January 1, 2014 to December 31, 2019. Women were included if they had a growth ultrasound with MFM in the third trimester and at least one additional MFM ultrasound. Women served as their own control. The primary outcome was FGR, defined as estimated fetal weight less than the 10th percentile by Hadlock, on a single third trimester growth ultrasound compared to serial growth ultrasounds. Mantel-Haenszel Chi-square test was used to compare the proportion of patients diagnosed with FGR on a single ultrasound to serial ultrasounds. There were 294 pregnant women on buprenorphine therapy included in this study. The majority of the patients were single (81%), non-Hispanic white females (97%) who used tobacco (95%). Patients received an average of 3.7 ultrasounds > 20 weeks. When serial growth ultrasounds were performed, 79 fetuses were diagnosed with FGR (Table 1). Of the 79 cases, 73 fetuses were found to have FGR by evaluating a single third trimester growth ultrasound (p=0.57). The mean earliest gestational age of diagnosis of FGR was at 31w6d (SD±4w2d). In pregnant women on buprenorphine maintenance therapy, a single third trimester growth ultrasound is as effective in detecting fetal growth restriction when compared to serial growth ultrasounds. These data suggest that a single fetal growth assessment in the third trimester is sufficient for pregnant women on buprenorphine therapy. We recommend considering one growth ultrasound between 31-32 weeks to evaluate for fetal growth restriction in this population.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Fetal Outcomes Associated with the Sequence of Doppler Deterioration in Severely Growth-Restricted Fetuses.

Various patterns of Doppler deterioration exist in fetal growth restriction (FGR). However, the factors that differentiate these patterns are still unknown. The purpose of this study was to clarify the perinatal outcomes and factors to determine the pattern of Doppler deterioration in severe FGR. We conducted a retrospective cohort study of preterm severe FGR with Doppler abnormality, wherein the clinical features, including maternal characteristics, medical history, and sonographic findings, were compared between the patterns of Doppler deterioration. We used the multivariable logistic regression analyses to identify the factors associated with the pattern of Doppler deterioration. Of 322 eligible fetuses, 143 had Doppler abnormalities. Fetuses with Doppler deterioration from ductus venosus uniquely featured fetal and placental-umbilical abnormalities detected after birth. Gestational age (GA) at diagnosis of FGR and at the first diagnosis of Doppler abnormality in fetuses with Doppler deterioration from middle cerebral artery (MCA) were later than those from umbilical artery. In addition, the factor associated with Doppler deterioration from MCA was 31-week GA at the first diagnosis of Doppler abnormality (adjusted odds ratio [aOR]: 26.7; 95% CI: 8.35-103), not GA at diagnosis of FGR (aOR: 1.82; 95% CI: 0.50-5.96). Characteristics of each Doppler deterioration pattern might reflect FGR etiology. Undetectable anomalies and umbilical-placental abnormalities were found in fetuses with Doppler deterioration from the ductus venosus. Doppler deterioration from the MCA was observed after 31 weeks of gestation not only in the late-onset FGR but also in the early-onset FGR with normal umbilical artery Doppler findings.

Значение поперечного размера мозжечка плода в диагностике задержки роста плода

This study is an analysis of literary sources devoted to the use of transverse cerebellar diameter (TCD) and its relation to fetal abdominal circumference in the diagnosis of fetal growth restriction and determination of gestational age. All available research works on this subject were reviewed and a summary table with the results of the twenty-five most significant of them was compiled. The relevance of transferring TCD from the category of additional fetometry parameters to the category of standard fetometry parameters was indicated. Key words: fetal growth restriction, fetal growth retardation, transverse cerebellar diameter, gestational age, fetometry

Induction of labour with unfavourable local conditions for suspected fetal growth restriction after 36 weeks of gestation: Factors associated with the risk of caesarean

IntroductionInduction of labour in women with an unfavourable cervix is associated with a risk of caesarean delivery. When a diagnosis of fetal growth restriction (FGR) is also involved, the risk of intrapartum fetal acidosis increases. The main objective was to identify prognostic factors for the risk of caesarean delivery after induction for suspected FGR after 36 weeks of gestation with an unripe cervix. Material and methodsThis was a retrospective, single-centre (Port Royal, Paris, France) study of women with a singleton fetus in cephalic presentation, with labour induced at or after 36 weeks for suspected FGR diagnosed during second or third trimester of pregnancy with an unripe cervix (Bishop score under 6) who gave birth between 1 January 2015 and 31 December 2019. A multivariable analysis was performed to identify the factors related to an increased risk of caesarean section. ResultsOf the 146 women included, 56 (38.4 %) had caesarean deliveries. After adjustment, the factors significantly associated with the risk of caesarean were maternal age greater than 39 years (ORa = 4.33 [1.22−17.2], reference: 25−39 years), nulliparity (ORa = 3.49 [1.25−11.2]), and an abnormal fetal umbilical artery Doppler velocimetry (ORa = 3.50 [1.47–8.70]). The risk of poor neonatal condition did not differ significantly between women with vaginal and caesarean deliveries (2.3 % vs 7.3 %, P = 0.21). ConclusionWhen FGR is suspected at 36 weeks of gestation and later, induction of labour is a reasonable option, even if the cervix is unripe, as the risk of caesarean delivery appears acceptable and neonatal status is good and similar with both modes of delivery.

Evaluation of midtrimester ductus venosus diameter and peak systolic velocity to predict late onset small for gestational age fetuses

Objective The ductus venosus, a small blood vessel in the fetal venous system, has extraordinary physiologic significance because it connects the umbilical vein to the inferior vena cava in the fetus circulation system and transports highly oxygenated blood from the placenta to the fetus’ heart. Hence, assessment of ductus venosus flows is helpful in evaluating fetal hemodynamics. Considering the critical function of the ductus venosus, we hypothesized that the diameter of the midtrimester ductus venosus and its peak velocity index can be related to adequate fetal growth; therefore, the aim of this study was to evaluate the role of the midtrimester umbilical venous blood flow, ductus venosus diameter, and ductus venosus peak systolic velocity to help predict uncomplicated deliveries of late onset small for gestational age (SGA) fetuses. Methods In this prospective study we analyzed the pregnancies and deliveries of 398 pregnant women who met the inclusion criteria and divided them into three groups according to fetal birth weight as follows: birth weight <3 percentile SGA group (n = 16), birth weight 3–10 percentile SGA group (n = 42), and appropriate for the gestational age (AGA) group (n = 340). The midtrimester ductus venosus diameter and peak sistolic velocity, umbilical venous blood flow, and umbilical artery pulsatility index (PI) were recorded. In the absence of congenital anomalies, the diagnosis of fetal growth restriction (FGR) is made according to Delphi consensus criteria. In the absence of abnormal Doppler findings, late FGR was defined as occurring ≥32 weeks. Results Maternal age, nulliparity, mean gestational age at ultrasound evaluation, ethnicity, body mass index, and previous cesarean delivery rates were similar among the groups. In addition, mid-trimester fetal biometric measurements and amniotic fluid volume were similar among the groups. The gestational age at delivery, prematurity, fetal birth weight, vaginal delivery rates, and rate of admission to the neonatal intensive care unit were significantly different among the groups. The mean mid-trimester umbilical vein blood flow to abdominal circumference ratio (UVBF/AC) was similar among the groups (p=.740). In the <3 group, the mean peak systolic velocity of the ductus venosus was significantly lower and the mean diameter of the ductus venosus significantly higher than those in the 3–10 and AGA groups (both p<.001). Although the values are below the 95th percentile mid-trimester umbilical artery PI was significantly higher in the <3 percentile SGA group than in the 3–10 percentile SGA and AGA groups. Conclusion Our results suggest that the diameter and peak systolic velocity of the mid-trimester ductus venosus are useful noninvasive measurements that provide prediction of late onset SGA fetuses

Accuracy of Ultrasound to Predict Neonatal Birth Weight Among Fetuses With Gastroschisis: Impact on Timing of Delivery.

To determine the accuracy of ultrasound estimation of fetal weight among fetuses with gastroschisis and how the diagnosis of fetal growth restriction (FGR) affects the timing of delivery. This was a retrospective cohort study including all fetuses with a diagnosis of gastroschisis at our institution from November 2012 through October 2017. We excluded multiple gestations, pregnancies with major structural or chromosomal abnormalities, and those for which prenatal and postnatal follow-up were unavailable. Performance characteristics of ultrasound to predict being small for gestational age (SGA) were calculated for the first and last ultrasound estimations of fetal weight. Our cohort included 75 cases of gastroschisis. At the initial ultrasound estimation, 15 of 58 (25.9%) fetuses met criteria for FGR; 48 of 70 (68.6%) met criteria at the time of the last ultrasound estimation (median, 34.7 weeks). Cesarean delivery was performed for 37 of 75 (49.3%), with FGR and concern for fetal distress as the indication for delivery in 17 of 37 (45.9%). Only 6 of 17 (35.3%) of the neonates born by cesarean delivery for an indication of FGR and fetal distress were SGA. The initial ultrasound designation of FGR corresponded to SGA at birth in 8 of 15 (53.3%), whereas the last ultrasound estimation corresponded to SGA in 17 of 48 (35.4%). The initial ultrasound estimation agreed with the last ultrasound estimation before delivery with the diagnosis of FGR in 13 of 15 (86.7%). Ultrasound in the third trimester was sensitive but had a low positive predictive value and low accuracy for the diagnosis of SGA at birth for fetuses with gastroschisis. A large proportion of fetuses were born by cesarean delivery with indications related to FGR or fetal concerns.

Antenatal corticosteroids in the late preterm period for growth-restricted pregnancies

Recently, the Antenatal Late Preterm Steroids study reported that antenatal corticosteroids administered in the late preterm period (34.0-36.6 weeks' gestation) reduced the rate of neonatal respiratory complications at birth. The utility of this intervention in women with fetal growth restriction remains unclear. This study aimed to determine whether administration of antenatal corticosteroids in the late preterm period in pregnancies with growth restriction decreased the need for respiratory support at delivery and other neonatal morbidities. This was a single-center retrospective cohort study that included growth-restricted pregnancies delivered in the late preterm period. Growth restriction was defined as either a diagnosis of fetal growth restriction or small for gestational age by birthweight less than 10%. The primary composite outcome consisted of any 1 of the following occurring in a single neonate: requirement of continuous positive airway pressure or high-flow nasal cannula for 2 hours or more, oxygen requirement with fraction of inspired oxygen of ≥30% for 4 hours or more, mechanical ventilation at any time, stillbirth, or neonatal death. The primary outcome was compared between steroid naive pregnancies and pregnancies exposed to betamethasone in the late preterm period. Univariable and multivariable statistical analysis was performed and P<.05 was considered statistically significant. A total of 247 women with a diagnosis of growth restriction or small for gestational age metall inclusion criteria, 111 of whom did not receive antenatal corticosteroids and 136 received late preterm antenatal corticosteroids. Demographics were similar between the groups, with the exception of those who received betamethasone being more likely to be nulliparous (P=.01) and to receive a diagnosis of preeclampsia (P=.001). The primary outcome did not differ between the 2 groups (16.2% [18/111] vs 12.5% [17/136]; P=.41). Multivariable modeling controlling for parity and preeclampsia indicated that the rate of the primary composite respiratory outcome was similar between the exposure groups (adjusted odds ratio, 0.63; P=.29). Neonatal hypoglycemia (<40 mg/dL) was more common in newborns exposed to steroids (25.2% [28 /111] vs 40.4% [55/136]; P=.012). Administration of antenatal corticosteroids in the late preterm period for pregnancies with growth restriction did not significantly decrease the need for respiratory support in newborns at our institution. The rate of neonatal hypoglycemia increased after exposure to antenatal corticosteroids. This special population may not benefit from late preterm steroids.

Severity of fetal growth restriction stratified according to maternal obesity

Objective The primary objective of this study was to ascertain if among women with fetal growth restriction (FGR; estimated fetal weight [EFW] < 10th percentile) the frequency of severe FGR (sFGR; EFW < 3rd percentile for gestational age) differed among various classes of obesity. Study design This was a retrospective cohort study of all pregnancies complicated by FGR from August 2016- March 2019 at a single center, undergoing weekly antenatal surveillance (biophysical profiles and umbilical artery Doppler). Exclusion criteria included multiple gestation, prenatally diagnosed fetal anomalies, and unknown maternal body mass index (BMI) at the time of the ultrasound exam. We defined fetal growth restriction as an estimated fetal weight less than the 10th percentile for gestational age using Hadlock criteria. Severe FGR was defined as the estimated fetal weight below 3rd percentile for gestational age. Maternal BMI was categorized as non-obese (BMI ≤ 29.9), Class I obesity (30.0–34.9), and Class II or III obesity (≥35.0 kg/m2). Abnormal Dopplers were defined as absent or reversed end diastolic flow. Maternal characteristics and ultrasound findings were compared between groups. Categorical variables were compared by χ 2 or Fisher’s exact test and continuous variables were compared by t test or nonparametric Wilcoxon rank sum test. Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals by adjusting for potential confounders including maternal age, hypertensive disorders, pre-gestational and gestational diabetes, auto-immune disorders, and gestational age at diagnosis. Results Of 974 women that met the inclusion and exclusion criteria, 678 (70%) were not obese, 151 (15%) had class I obesity, and 145 (15%) had class II or III obesity. Obese women were significantly more likely to be multiparous and had a lower mean gestational age at diagnosis of FGR. Hypertensive disorders were more common with increasing BMI, as was type II diabetes mellitus (p < .01). There were no statistically significant differences between the obesity groups with regards to other comorbidities. Women with obesity classes I and II/III had significantly higher frequency of severe FGR (37.8%) as compared to non-obese women (29%; p < .05). The rates of abnormal Dopplers was more frequent with worsening obesity: 31.4%, 34.4%, and 46.2% for non-obese, class I obesity, and class II or III obesity, respectively (p < .01). There were no significant differences in amniotic fluid abnormalities or antenatal testing results. After adjustment for potential confounders, women with class I obesity had higher odds of having severe FGR (aOR = 1.4; 95% CI = 1.0–2.1). There was also an increased odds of abnormal Dopplers among women with class II/III obesity, as compared to non-obese women, after adjusting for confounders (aOR = 1.7; 95% CI = 1.2–2.6). Conclusion Among women with FGR, obese women were more likely to have severe FGR and abnormal Dopplers compared to non-obese women. These findings warrant further study into predictors of adverse outcomes among obese women with FGR. Such information could be useful in counseling patients as to the possible course of disease after diagnosis of fetal growth restriction.

False diagnosis of small for gestational age and macrosomia – clinical and sonographic predictors

Purpose To investigate clinical and sonographic features associated with sonographic accuracy for the prediction of small for gestational age (SGA) and macrosomia at birth. Methods The database of a tertiary medical center was retrospectively searched for women who gave birth at term to a singleton healthy neonate in 2007–2014 and underwent sonographic estimated fetal weight (sEFW) evaluation within 3 d before delivery. Fetal growth restriction (FGR) and SGA were defined as sEFW or birth weight <10th percentile for gestational age; macrosomia was defined as birth weight >4000 grams. Data on maternal age, parity, gestational age, fetal gender, presentation, placental location, diabetes, hypertension, and oligo/polyhydramnios were compared between pregnancies with a false-negative and false-positive diagnosis of SGA or macrosomia. Results Of the 5425 fetal weight evaluations, 254 (4.7%) deviated by >15% from the actual birth weight. Nulliparity, absence of diabetes, neonatal female gender, anterior placenta, lower birth weight, and oligohydramnios were associated with a high deviation. We identified 482 SGA neonates (8.9%) and 633 macrosomic neonates (11.7%). A false-positive diagnosis of FGR was associated with oligohydramnios, absence of diabetes, and posterior placenta, and a false-negative diagnosis, with older maternal age, nulliparity, and male gender. A false-positive diagnosis of macrosomia was associated with older maternal age, multiparity, polyhydramnios, anterior placenta, and lack of hypertensive complications, and a false-negative diagnosis, with diabetes, hypertension, oligohydramnios, and vertex presentation. Conclusion The accuracy of sEFW is affected by clinical and sonographic pregnancy characteristics. Further analyses should focus on improving accuracy especially at the fetal weight extremes.