Outcome In Fetal Growth Restriction Research Articles

538: Ductus venosus (DV) doppler waveform patterns predict adverse fetal outcome in fetal growth restriction (FGR)

538: Ductus venosus (DV) doppler waveform patterns predict adverse fetal outcome in fetal growth restriction (FGR)

The incidence rate, high-risk factors, and short- and long-term adverse outcomes of fetal growth restriction: a report from Mainland China.

To investigate the incidence and high-risk factors of fetal growth restriction (FGR) in Mainland China and determine the adverse effects of this condition on fetal-neonatal health.This study was a retrospective chart review. We investigated the incidence rate of FGR using a retrospective analysis of clinical data obtained from mothers and newborns from 7 hospitals in Mainland China from January 1 to December 31, 2011. The short-term outcomes of FGR were analyzed based on data obtained from the neonatal intensive-care unit (NICU) of Bayi Children's Hospital. The long-term outcomes of FGR were determined after a follow-up study of 125 cases of FGR in children at 18 months. The physical development index, mental development index (MDI), and psychomotor development index (PDI) were compared between FGR patients and controls.The incidence of FGR was 8.77%. The incidence of FGR was significantly higher in females than in males (9.80% vs 7.84%, P < 0.05). The incidence of FGR in preterm infants was higher than that in full-term infants (16.43% vs 7.87%, P < 0.01). Chronic hypertension, abnormal amniotic fluid, and umbilical cord abnormalities were independent factors of FGR. A significantly higher incidence of complications, including hypoglycemia, asphyxia, hypoxic-ischemic encephalopathy, gastrointestinal bleeding, congenital malformations, polycythemia, lung hemorrhage, apnea, congenital heart disease, and disseminated intravascular coagulation, was observed in FGR patients than in controls. The FGR prolonged the duration of the hospital stay and markedly increased hospitalization expenses (P < 0.05). Children with FGR showed catch-up growth, which reached the level of the control group after 1.5 years, but these individuals still had lower MDI and PDI scores.The incidence rate of FGR in Mainland China was 8.77%. It has a significantly adverse effect on fetal-neonatal health and cognitive development.

Resultados perinatales en fetos con flujo umbilical diastólico ausente

SUMMARY Objective: To determine the perinatal outcome in fetal growth restriction were umbilical artery Doppler end diastolic flow was absent. Methods: A retrospective study performed at the Canary Islands University Hospital. All consecutive cases between 2004 and 2011 were included. We excluded twin pregnancies. Data was abstracted for maternal age, gestational age at diagnosis and delivery, mode of delivery, Apgar and perinatal adverse outcomes. Results: Fifty seven patients were included. Forty three percent had a pregnancy complicated by hypertension and 19% diabetes. Mean gestational age at diagnosis was 30+4 weeks. We found 89% and 21% absent umbilical artery end diastolic flow and reverse flow respectively. Oligohydram nios was seen in 28% of the cases. Fetal weight was below the third percentile in 26% of the cases. Fetal demise occurred in 3 cases. Mode of delivery was cesarean section in 80% of the cases. We found a rate of 17% perinatal mortality. At 1 to 6 years follow up 35% of the children had no sequelae. Conclusion: Absent end diastolic umbilical flow is associated with a high risk of perinatal mortality. Up to 65% of the children will show some type of sequelae. The optimal gestational date for fetal extraction should be individualized after multidisciplinary counseling.

Defining the residual risk of adverse perinatal outcome in growth-restricted fetuses with normal umbilical artery blood flow

We sought to determine the cause of adverse perinatal outcome in fetal growth restriction (FGR) where umbilical artery (UA) Doppler was normal, as identified from the Prospective Observational Trial to Optimize Pediatric Health (PORTO). We compared cases of adverse outcome where UA Doppler was normal and abnormal. The PORTO study was a national multicenter study of >1100 ultrasound-dated singleton pregnancies with an estimated fetal weight <10th centile. Each pregnancy underwent intensive ultrasound, including multivessel Doppler. UA Doppler was considered abnormal when the pulsatility index was >95th centile or end-diastolic flow was absent/reversed. Adverse perinatal outcome was defined as a composite of intraventricular hemorrhage, periventricular leukomalacia, hypoxic ischemic encephalopathy, necrotizing enterocolitis, bronchopulmonary dysplasia, sepsis, or death. In all, 57 (5.0%) of the 1116 fetuses had an adverse perinatal outcome. Nine (1.3%) of 698 fetuses with normal UA Doppler had an adverse outcome, compared with 48 (11.5%) of 418 with abnormal UA Doppler (P < .0001). There were 2 perinatal deaths in the normal group and 6 in the abnormal group (P = .01). The perinatal deaths in the normal group were 1 case of pulmonary hypoplasia after prolonged preterm rupture of the membranes from 12 weeks' gestation and a case of placental abruption. Gestation at delivery was 33 ± 3 vs 31 ± 4 weeks (P = .05) and mean birthweight was 1830 ± 737 vs 1146 ± 508 g (P = .001) in the respective groups. Neonatal sepsis was the commonest adverse outcome in both groups: 0.1% and 0.4%, respectively (P = .01). Adverse perinatal outcome is uncommon in FGR with normal UA Doppler. The cases we identified were associated with heterogenous pathologies. FGR with normal UA blood flow is a largely benign condition.

PFM.67 Can fetal renal artery Dopplers predict perinatal outcome in fetal growth restriction?

Severe intra-uterine growth restriction (IUGR) is significantly associated with intra-uterine and perinatal morbidity and mortality. There are no reliable screening tools and currently, monitoring is with Doppler ultrasound after the...

Prospective cohort study about the lymphocyte subpopulations’ change and impact on the pregnancy outcome in fetal growth restriction

Objective: To evaluate lymphocyte subpopulations’ change and impact on the pregnancy outcome in fetal growth restriction (FGR) through a prospective cohort study. Methods: Sixty singleton pregnancies with FGR and 20 normal pregnant women were enrolled at the third trimester of pregnancy in this study. FGR was defined according to fundal height and abdominal circumference through obstetric examination and ultrasound examination. Third trimester peripheral blood and umbilical cord blood lymphocyte subpopulations were analysed by flow cytometry. The cytotoxic activity of lymphocytes using umbilical cord blood mononuclear activated kill cells as the effector cells, K562 cells as the target cells was measured by MTT deoxidation assay. Results: There were no significant differences about the age, parity, gestational age enrolled, BMI before pregnancy between the FGR and control group. The birth weight, length and head circumference of the neonates from FGR group were less than that from normal control. The percentages of B-lymphocytes in peripheral blood at the third trimester were significantly increased in FGR group compared to that in control group (P < 0.05). In umbilical cord blood, FGR group had a higher percentage of both CD3 and CD4 lymphocyte, lower absolute cell counts and percentage of B-lymphocyte, and higher CD4/CD8 ratio than control group (P < 0.05). Most importantly, the kill cell activity of the lymphocytes in cord blood from FGR group was significantly higher than that from control group (P < 0.05). The significant positive correlations were also found that the percentage and number of B lymphocytes in umbilical cord blood with birthweight, birthlength and birth head circumference, but CD4/CD8 ratio, the kill cell activity in umbilical cord blood had negative correlations with that. The percentage of B lmyphocyte in third trimester and CD4/CD8 ratio, kill cell activity in umbilical cord blood are associated with an increased risk of prematurity and SGA birth, but contrary result was found with the percentage and number of B lmyphocyte in cord blood. Conclusions: Fetal immunological rejection could be involved in the pathogenesis of FGR. The changes of T lymphocyte subpopulations and B-cells, enhanced kill cell activity might cause FGR and preterm birth.

Perinatal outcomes of fetal growth restriction between late preterm and term birth infants

Objective To estimate the absolute increase in the risk for adverse neonatal outcomes of fetal growth restriction between late preterm and term birth and to identify risk factors for neonatal morbidity among late preterm and term birth infants. Methods A retrospective review of 2,954 singleton infant between 34 and 42 weeks of gestation born at our hospital over the 5 years were enrolled and they were divided into four groups as late preterm small for gestational age (SGA), late preterm adequate for gestational age (AGA), term SGA and term AGA, respectively. The prenatal ultrasonographic findings between SGA and AGA in late preterm birth were assessed. Maternal and neonatal complications were compared with SGA and AGA between late preterm and term birth infants. The statistical analyses for frequencies and relative risks in each group were calculated by SPSS ver. 19.0. Results In prenatal evaluation between SGA and AGA in late preterm birth, amniotic fluid volume, abdominal circumference and umbilical artery Doppler resistance index value were different significantly ( P<0.001). Preeclampsia and oligohydramnios were found more common in SGA of late preterm birth compared with AGA of term birth. Jaundice, respiratory distress syndrome, necrotizing enterocolitis, sepsis, congenital anomalies, hypoglycemia, and germinal matrix`s hemorrhage, occurred more frequent in SGA of late preterm birth than in AGA of term birth. Conclusion Not only adequate prenatal evaluation and obstetrical decision-making but also long-term evaluation are needed to improve perinatal outcomes of growth restricted infants in late preterm birth.

Duration of persistent abnormal ductus venosus flow and its impact on perinatal outcome in fetal growth restriction

To study if the duration of individual Doppler abnormalities is an independent predictor of adverse outcome in fetal growth restriction (FGR) caused by placental dysfunction. This was a secondary analysis of patients with FGR (abdominal circumference < 5(th) percentile and umbilical artery (UA) pulsatility index (PI) elevation) who had at least three examinations before delivery. Days of duration of absent/reversed UA end-diastolic velocity (UA-AREDV), low middle cerebral artery PI (brain sparing), ductus venosus (DV) and umbilical vein Doppler abnormalities were related to stillbirth, major neonatal morbidity and intact survival. One hundred and seventy-seven study participants underwent a total of 1069 examinations. The duration of an absent/reversed a-wave in the DV (DV-RAV) was significantly higher in stillbirths (median, 6 days) compared with intact survivors and those with major morbidity (median, 0 days for both; P = 0.006 and P = 0.001, respectively). Duration of brain sparing was also longer in stillbirth cases compared with intact survivors (median, 19 days vs. 9 days, P = 0.02). Stepwise multinomial logistic regression showed that gestational age at delivery was a significant codeterminant of outcome for all arterial Doppler abnormalities when the DV a-wave was antegrade. However, when present, the duration of DV-RAV was the only contributor to stillbirth (probability of stillbirth = 1/(1 + exp - (interval to delivery × 1.03 - 2.28)), r2 = 0.73). Receiver-operating characteristics curve statistics showed that a DV-RAV for > 7 days predicted stillbirth (100% sensitivity, 80% specificity, likelihood ratio = 5.0, P < 0.0001). In contrast, neither neonatal death nor neonatal morbidity was predicted by the days of persistent DV-RAV. The duration of absent or reversed flow during atrial systole in the DV is a strong predictor of stillbirth that is independent of gestational age. While prematurity remains the strongest predictor of neonatal risks it is unlikely that pregnancy can be prolonged by more than 1 week in this setting.

Placental pathologies associated with intra-uterine fetal growth restriction complicated with and without oligohydramnios

To compare the placental pathologies and perinatal outcomes in fetal growth restriction (FGR) pregnancies with and without oligohydramnios. A retrospective cohort study, comparing placental findings in all singleton deliveries with FGR. Macroscopic placental findings were available for 1,104 singleton FGR pregnancies. A total of 397 placentas were microscopically examined; of which 89 placentas were of FGR neonates who had oligohydramnios. No significant differences in placental vascular mal-perfusion were found between pregnancies with and without oligohydramnios (69.3 vs. 74.3%; P = 0.357). Likewise, no significant differences were noted between the groups regarding diffuse villous fibrosis (10.1 vs. 4.9%; P = 0.573), and amnion cell metaplasia (65.9 vs. 64.3%; P = 0.779). Cases of FGR complicated with oligohydramnios had significantly higher rates of perinatal mortality (9.9 vs. 5.9%; P = 0.028), preterm deliveries (34.9 +/- 3.4 vs. 35.4 +/- 3.1 weeks of pregnancy; P = 0.041), and lower birth weight (1,737 +/- 542 vs. 1,845 +/- 467 g; P = 0.002) compared to FGR without oligohydramnios. Oligohydramnios is a significant risk factor for adverse perinatal outcome in FGR pregnancies; nevertheless, no significant differences in placental pathologies were noted.

139: Role of middle cerebral artery (MCA) doppler for prediction of adverse neonatal outcome in fetal growth restriction (FGR)

139: Role of middle cerebral artery (MCA) doppler for prediction of adverse neonatal outcome in fetal growth restriction (FGR)

OP14.13: Prediction of adverse outcome in fetal growth restriction (FGR)—the role of middle cerebral artery peak systolic velocity (MCA PSV)

OP14.13: Prediction of adverse outcome in fetal growth restriction (FGR)—the role of middle cerebral artery peak systolic velocity (MCA PSV)

Prediction and perinatal outcomes of fetal growth restriction

Assessment of fetal growth and wellbeing is one of the major purposes of antenatal care. Some fetuses have smaller than expected growth in utero and while some of these fetuses are constitutionally small, others have failed to meet their growth potential, that is they are growth restricted. While severe growth restriction is uncommon, the consequences of it being undetected may include perinatal death or severe morbidity. It is, therefore, important to have strategies in place to detect the fetus at risk of growth restriction. These would include an assessment of 'prior risk' from maternal history and examination combined with the results of biochemical and ultrasound investigations, the most promising of which are uterine artery Doppler and biochemistry. We discuss some of the factors to consider when stratifying the obstetric population into degrees of likelihood for growth restriction, and discuss aspects of the management and outcome of pregnancies complicated by growth restriction.

Biophysical profile score (BPS) as a predictor of poor outcome in preterm fetal growth restriction (FGR): A multicenter study

Arteriovenous Doppler is key to identifying severe FGR, but recent trials suggest delivery may be provoked earlier than ideal, when Doppler is used alone. Our study assessed utility of Biophysical Profile Scoring in predicting poor neonatal outcome in FGR fetuses delivered <32 weeks gestational age (GA). Multicenter prospective study. FGR fetuses (abdominal circumference <5%, elevated umbilical artery Doppler) had serial BPS (Manning). In those delivered <32 weeks, BPS at delivery was related to acidosis, Apgar score, neonatal outcome including respiratory distress (RDS), bronchopulmonary dysplasia (BPD), retinopathy (ROP), intraventricular hemorrhage (IVH), leukomalacia (PVL) enterocolitis (NEC)) and composite morbidity. Chi-square assessment of distribution and Mantel-Haenzel test for dichotomous outcomes, were used. Among 224 FGR neonates mean birth GA was 28.6 (±1.8) weeks, birthweight 851 (±254) g. Normal BPS (>6) significantly reduced the likelihood of pH <7.2 (Odds ratio (OR) 0.13, 95% confidence interval (CI) 0.07-0.025), 5 minute Apgar <7 (OR 0.14, CI 0.07-0.29), IVH (OR 0.32, CI 0.7-0.62), NEC (OR 0.30, CI 0.13-0.72) and perinatal mortality (OR 0.23, CI 0.11-0.49, all p<0.001). Abnormal BPS (<6) significantly increased chances of pH < 7.2 (OR 8.93, CI 4.87 – 16.37), 5 minute Apgar <7 (OR 7.58, CI 4.10- 14.01), IVH (OR 4.33, CI 2.37 – 7.88), PVL (OR 6.16, CI 1.32 – 28.78) and perinatal mortality (OR 5.42, CI 2.82- 10.40, all p<0.05). Equivocal BPS (6/10) did not discriminate outcome classes. Biophysical profile scoring is an accurate predictor of adverse outcome in early onset FGR. Risks of adverse outcome are reliably stratified by individual scores, allowing confident patient counseling. Safe prolongation of pregnancy in presence of a normal BPS may optimize gestational time, and improve perinatal outcome. Conversely, high likelihood of poor outcome validates delivery for abnormal scores. Demonstration of these BPS principles in early severe IUGR provides strong impetus for a randomized management trial.

Can we predict adverse neonatal outcome in fetal growth restriction near term?

NEAR TERM? PATRIZIA VERGANI, NADIA RONCAGLIA, ALESSANDRO GHIDINI, ISABELLA CRIPPA, CAMILLA ANDREOTTI, FRANCESCA SALA, JOHN PEZZULLO, University of Milano-Bicocca, Monza, Italy, Georgetown University, Pharmacology and Biostatistics, Washington, District of Columbia OBJECTIVE: To assess whether we can identify cases of fetal growth restriction (FGR) approaching term who are at risk for adverse neonatal outcome. STUDY DESIGN: From a cohort of 508 FGR cases delivered at R34 weeks, fetal biometry, Doppler indices at uterine, umbilical and middle cerebral arteries, in addition to demographic and obstetrical variables available within 2 weeks of delivery were related to adverse neonatal outcome, defined as admission to the NICU for indications other than low birth weight alone. RESULTS: Stepwise regression analysis showed that gestational age at delivery (OR= 0.62, 95% CI 0.53-0.72), fetal abdominal circumference centile (OR = 0.72, 95% CI 0.62-0.84) , and umbilical artery pulsatility index centile (OR = 1.02, 95% CI 1.01-1.04) independently predicted occurrence of adverse neonatal outcome. Receiver operating characteristic curve analysis demonstrated that a formula inclusive of these variables predicted 80% of adverse outcomes with 22% false positive rate. CONCLUSION: In FGR cases delivered at R34 weeks, a formula inclusive of gestational age at delivery, abdominal circumference centile and umbilical artery Doppler achieves 80% sensitivity for the prediction of neonatal morbidity.

Antenatal predictors of neonatal outcome in fetal growth restriction with absent end-diastolic flow in the umbilical artery

Absent end-diastolic blood flow in the umbilical artery identifies growth-restricted fetuses at high risk of perinatal mortality and severe morbidity. We explored antenatal variables predictive of perinatal mortality or severe neonatal morbidity in such fetuses. We accessed a cohort of 39 singleton, non-malformed, growth-restricted fetuses with absent end-diastolic blood flow at less than 34 weeks between January 1995 and December 2004. The ratio of umbilical artery pulsatility index to middle cerebral artery pulsatility index was calculated to assess redistribution of the fetal arterial circulation. Prenatal and neonatal variables were compared between subjects with versus those without perinatal mortality or severe morbidity using unpaired Student t test or Fisher exact test. Statistical analysis included stepwise logistic regression and receiver operating characteristic curve analysis. P < .05 was considered significant. Stepwise logistic regression analysis demonstrated that the last umbilical artery/middle cerebral artery ratio (P = .02) and estimated fetal weight before delivery (P = .02) were independent predictors of adverse neonatal outcome, with an umbilical artery/middle cerebral artery ratio 1.9 or greater having a sensitivity of 75% and a 13% false-positive rate. Umbilical artery/middle cerebral artery ratio alone accounted for 54% of the variability in outcome. Among preterm growth-restricted fetuses with absent end-diastolic blood flow in the umbilical artery, the umbilical artery/middle cerebral artery ratio is the best predictor of neonatal mortality or severe morbidity.