Small For Gestational Age Fetuses Research Articles

Right and left ventricular 24-segment sphericity index is abnormal in small-for-gestational-age fetuses.

Fetuses with growth restriction have been reported to have an abnormal sphericity index (SI), which is indicative of the shape of the ventricular chambers of the heart. Our aim was to evaluate the SI for 24 transverse segments distributed from base to apex of the right (RV) and left (LV) ventricles to determine whether, in small-for-gestational-age (SGA) fetuses, the SI is abnormal at locations other than the basal segment. We evaluated 30 SGA fetuses between 25 and 37 weeks of gestation. SI was computed for both ventricles by dividing the end-diastolic mid-basal-apical length by each of 24 end-diastolic transverse segmental widths, from base (Segment 1) to apex (Segment 24). For each ventricle, the Z-score and centile for the SI from each of the 24 segments were computed using the mean and SD from published equations. The 24-segment method, defining abnormal SI as values < 10th centile or > 90th centile, was compared with that of using only the basal segment by chi-square analysis to determine the number of fetuses identified with an abnormal SI. In 23 of the 30 (77%) SGA fetuses, at least one of the 24 transverse segments in one or both ventricles had an abnormal SI; in 17% of cases, both ventricles were affected, in 23% of cases only the RV was involved and in 37% of cases only the LV was involved. Compared with the 24-segment model, significantly fewer fetuses with an abnormal SI were identified using only basal Segment 1, from the RV base (58%, 7/12; P< 0.01) or only Segment 12, in the mid portion of the RV (50%, 6/12; P< 0.005). Combining measurements of Segment 1 and Segment 12 from the RV identified 83% of fetuses with at least one abnormal SI and was not significantly different from using the 24-segment model. Similarly, significantly fewer fetuses with an abnormal SI were identified using only LV basal Segment 1 (63%, 10/16; P< 0.006) or only Segment 12, in the mid portion of the LV (75%, 12/16; P< 0.03), when compared with the 24-segment model. Combining measurements of both LV Segment 1 and Segment 12 identified 81% (13/16) of fetuses with an abnormal SI and was not significantly different from using the 24-segment model. The 24-segment SI of RV and LV provides a comprehensive method with which to examine the shape of the ventricular chambers and identifies more SGA fetuses with an abnormal SI than are identified using only the basal segment SI. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Peak systolic velocity Doppler of middle cerebral artery in small for gestational age (SGA) fetus

Small for gestational age (SGA) has high frequency which increases the risk of long-term adverse outcomes. Thus the aim of this study was to evaluate peak systolic velocity Doppler of middle cerebral artery (MCA) in SGA fetus in order to find appropriate method to diagnosis SGA sooner. This prospective longitudinal study was conducted on 90 pregnant women with a diagnosis of SGA fetus and 90 pregnant women with normal fetus. Then MCA and umbilical artery assessment were performed for all subjects and compared between two groups. Doppler assessment showed that umbilical artery PI was significantly higher in SGA group as compared to normal group (1.11±0.37 vs 0.98±0.18, P = 0.003), while MCA PI was significantly lower in SGA group (1.77±0.44 vs 1.92±0.47, P = 0.028). On the other hand, PSV did not differ between the groups (P = 0.592). Moreover, we found that PSV was more in SGA group by grouping maternal age ( 34 weeks) (P<0.001). The results of this study suggest that MCA PI decreased significantly in SGA fetuses, while UA PI increased in this group. Moreover, PSV increased in this group when evaluated in different subgroups (based on maternal age and gestational age).

Weight discordance and perinatal mortality in twin pregnancy: systematic review and meta-analysis.

The primary aim of this systematic review was to explore the strength of association between birth-weight (BW) discordance and perinatal mortality in twin pregnancy. The secondary aim was to ascertain the contribution of gestational age and growth restriction in predicting mortality in growth-discordant twins. MEDLINE, EMBASE, CINAHL and ClinicalTrials.gov databases were searched. Only studies reporting on the risk of mortality in twin pregnancies affected compared with those not affected by BW discordance were included. The primary outcomes explored were incidence of intrauterine death (IUD), neonatal death (NND) and perinatal death. Outcome was assessed separately for monochorionic (MC) and dichorionic (DC) twin pregnancies. Analyses were stratified according to BW discordance cut-off (≥ 15%, ≥ 20%, ≥ 25% and ≥ 30%) and selected gestational characteristics, including incidence of IUD or NND before and after 34 weeks' gestation, presence of at least one small-for-gestational age (SGA) fetus in the twin pair and both twins being appropriate-for-gestational age. Risk of mortality in the larger vs smaller twin was also assessed. Meta-analyses using individual data random-effects logistic regression and meta-analyses of proportion were used to analyze the data. Twenty-two studies (10 877 twin pregnancies) were included in the analysis. In DC pregnancies, a higher risk of IUD, but not of NND, was observed in twins with BW discordance ≥ 15% (odds ratio (OR) 9.8, 95% CI, 3.9-29.4), ≥ 20% (OR 7.0, 95% CI, 4.15-11.8), ≥ 25% (OR 17.4, 95% CI, 8.3-36.7) and ≥ 30% (OR 22.9, 95% CI, 10.2-51.6) compared with those without weight discordance. For each cut-off of BW discordance explored in DC pregnancies, the smaller twin was at higher risk of mortality compared with the larger one. In MC twin pregnancies, excluding cases affected by twin-twin transfusion syndrome, twins with BW discordance ≥ 20% (OR 2.8, 95% CI, 1.3-5.8) or ≥ 25% (OR 3.2, 95% CI, 1.5-6.7) were at higher risk of IUD, compared with controls. MC pregnancies with ≥ 25% weight discordance were also at increased risk of NND (OR 4.66, 95% CI, 1.8-12.4) compared with those with concordant weight. The risk of IUD was higher when considering discordant pregnancies involving at least one SGA fetus. The overall risk of mortality in MC pregnancies was similar between the smaller and larger twin, except in those with BW discordance ≥ 20%. DC and MC twin pregnancies discordant for fetal growth are at higher risk of IUD but not of NND compared with pregnancies with concordant BW. The risk of IUD in BW-discordant DC and MC twins is higher when at least one fetus is SGA. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Small-for-gestational-age babies after 37 weeks: impact study of risk-stratification protocol.

Although no clear evidence exists, many international guidelines advocate early-term delivery of small-for-gestational-age (SGA) fetuses. The aim of this study was to determine whether a risk-stratification protocol in which low-risk SGA fetuses are managed expectantly beyond 37 weeks affects perinatal and maternal outcomes. This was an impact study examining data collected over a 39-month period (1 January 2013 to 30 April 2016) at a tertiary referral unit. The study included women who were referred to the fetal medicine unit with a singleton non-anomalous fetus diagnosed antenatally as SGA (estimated fetal weight < 10th centile) from 36 + 0 weeks' gestation. In 2014, a protocol for management of SGA was introduced, which included risk stratification with surveillance and expectant management after 37 weeks for lower-risk babies (protocol group). This was compared with the previous strategy, which recommended delivery at around 37 weeks (pre-protocol group). Primary outcome was neonatal composite adverse outcome. In the pre-protocol group, there were 138 SGA babies; in the protocol group there were 143. Mean gestational ages at delivery were 37.4 weeks in the pre-protocol group and 38.2 weeks in the protocol group (P = 0.04). The incidence of neonatal composite adverse outcome was lower in the protocol group (9% vs 22%; P < 0.01), as was neonatal unit admission (13% vs 39%; P < 0.01). Induction of labor and Cesarean section rates were lower, and vaginal delivery rate (83% vs 60%; P < 0.01) was higher, in the protocol group. Most of the differences were as a result of delayed delivery of SGA babies that were stratified as low risk. The findings of this study suggest that protocol-based management of SGA babies may improve outcome, and that identification of moderate SGA should not in isolation prompt delivery. Larger numbers are required to assess any impact on perinatal mortality. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Is prenatal identification of small-for-gestational-age fetuses useful?

Introduction Small-for-gestational-age (SGA) neonates have an increased risk of neonatal mortality. The utility of prenatal detection of these fetuses ( Methods This historical cohort study included women giving birth at 247 French maternity units. Women with a singleton delivery (≥ 32 weeks), in cephalic presentation were eligible for the study. Medically-indicated terminations of pregnancy, pregnancies with intrauterine fetal deaths, and women with missing delivery data were excluded. Among the SGA infants, we compared those who had been identified as such in utero (i.e., exposed group) (n = 4525) with those who were not (n = 18,516). The term “SGA” at birth describes a neonate whose birth weight is at least 1.64 standard deviations (SD) lower than the mean for the infant's gestational age and sex, that is, the 5th percentile for gestational age, based on data derived from the reference population included in our national database. The principal outcome was measured by a composite variable, defined as resuscitation in the delivery room, or death in the delivery room or the immediate postpartum period, or transfer to a neonatal intensive care unit. The secondary outcomes were the 5-minute Apgar score, and the rates of neonatal traumatic lesions, operative vaginal deliveries, and cesareans. Study ethics approval was obtained on June 30, 2017 (CECIC Rhone-Alpes-Auvergne, Grenoble, IRB 5921). A log-binomial model was used to adjust for covariates previously reported in the literature as either a risk factor or a confounding factor for each outcome we studied. Results The mean birthweight in the cohort was 2472 ± 343 g. Risk of resuscitation in the delivery room or of death in the delivery room or the immediate postpartum period or of neonatal transfer to the NICU was higher for the babies in the prenatally suspected group: RR = 2.31 (95% CI: 2.20–2.42). The adjusted RR was 1.22 (95% CI: 1.09–1.36) (39.7% in the group identified prenatally as SGA vs. 17.2% in the other group). The 5-min. Apgar scores, and the rates of neonatal traumatic lesions, operative vaginal deliveries, and global and elective cesarean deliveries did not differ significantly between the 2 groups. The a posteriori study power with a = 0.05 was 99%. Conclusions Contrary to what we expected, among children born SGA, prenatal identification did not improve neonatal or maternal outcomes. Therefore, we cannot currently recommend the systematic screening of SGA fetuses to improve their neonatal prognosis. More particularly, this strategy improved the diagnosis of SGA fetuses, but paradoxically this diagnosis was not followed by improved fetal outcome. Further studies on this topic should be based on customized in utero weight estimates.

Association between arterial stiffness and wave reflection with subsequent development of placental-mediated diseases during pregnancy: findings of a systematic review and meta-analysis.

We present a comprehensive systematic review of published literature to examine, whether arterial stiffness and wave reflection measurements during pregnancy differed between healthy patients and patients with placental-mediated diseases including preeclampsia (PET), small for gestational age (SGA), fetal death, and placental abruption, and a quantitative assessment of the findings using the meta-analysis approach. We searched Medline, Embase, and The Cochrane Library for studies of arterial stiffness in pregnancy, analyzed pregnancy outcomes and conducted the meta-analysis of data evaluated by trimesters of pregnancy. Hemodynamic parameters evaluated included: pulse wave velocity (PWV), augmentation index (AIx), and augmentation index-75 (AIx-75). We screened 2806 citations, reviewed 36 studies and included nine (n = 15 923) studies for further quantitative assessment. Compared with healthy pregnancy, measures of arterial stiffness and wave reflection were consistently increased among pregnant women who subsequently developed PET during all trimesters. In the first trimester, mean AIx-75 (%) in the PET group was significantly higher with estimated standardized mean difference (SMD) of 0.90 [95% confidence intervals (95% CI) 0.07-1.73; P = 0.034]. In the second trimester, the PET group had significantly higher PWV (m/s) with estimated SMD of 1.26 (95% CI 0.22-2.30; P = 0.018). Concerning the SGA group, mean AIx (%) was greater during the second trimester only: 65.5 (SD 15.6) vs. 57.0 (11.2), P < 0.01. There is significant increase in arterial stiffness and wave reflection parameters among pregnant women who subsequently developed PET and SGA fetuses. Larger studies with consistent methodological designs are required to evaluate the role and usefulness of arterial stiffness and wave reflection measurements as a screening tool for placental-mediated diseases during pregnancy.

Falling Third-Trimester Insulin Requirements and Adverse Pregnancy Outcomes: A Systematic Review [32E

INTRODUCTION: There is conflicting evidence on whether falling insulin requirements in the third-trimester are associated with adverse pregnancy outcomes. Our objective was to systematically review the literature to determine the association between a ≥15 percent fall in insulin dose (PFID) and adverse pregnancy outcomes. METHODS: We searched Medline, Embase and PubMed from inception until October 2016 for English language articles describing falling insulin requirements and pregnancy outcomes. Article screening and data extraction was performed in duplicate. As significant clinical and methodological heterogeneity was anticipated, no formal meta-analysis was planned. Outcomes were described as proportions. RESULTS: We identified 1011 publications, of which three observational studies met eligibility criteria. Two studies that used ≥15 PFID were included in the quantitative analysis. Pregnancies with ≥15 PFID were associated with small-for-gestational-age (SGA) fetuses (6/40 vs. 7/153, p=0.04; risk ratio (RR) 2.95 [1.08, 8.07]). There were no differences in large-for- gestational-age fetuses (14/40 vs. 58/153; RR 1.07 [0.68, 1.70]), low 5-minute Apgar scores (6/40 vs. 16/153; RR 1.93 [0.52, 7.14]), caesarean deliveries (25/40 vs. 105/153; RR 0.90 [0.70, 1.17]), extreme preterm (3/35 vs. 2/104) birth, stillbirths (1/35 vs. 1/104) or hypertensive disorders (9/35 vs. 19/104, p=0.34). CONCLUSION: This systematic review of observational studies found no association between ≥15 PFID and adverse pregnancy outcomes, except for a higher number of SGA fetuses. This was not causal. Early delivery based on ≥15 PFID cannot be recommended. Instead, clinical management should involve continued maternal-fetal surveillance, exploring possible obstetric and metabolic reasons for this PFID, and treatment of the primary cause.

The impact of different 75 g oral glucose tolerance test target ranges within normal limits on neonatal outcomes: A validation study.

Objective:To investigate the impact of different 75 g glucose tolerance test (OGTT) target ranges within normal limits on neonatal outcomes, thus to investigate the validity of 75 g OGTT thresholds.Materials and Methods:The normal 1-hour and 2-hour ranges of 75 g OGTT levels of 110 pregnant women with no gestational diabetes mellitus (GDM) were further divided into three different sub-groups; for the 1 hour as group 1 (<120 mg/dL), group 2 (120-140 mg/dL), group 3 (>140 mg/dL) and for the 2 hour as group 1 (<120 mg/dL), group 2 (120-135 mg/dL), and group 3 (>135 mg/dL).Results:For the 1-hour results, there was no statistically significant difference between groups in terms of age, body mass index, multiparity, neonatal hypoglycemia, hyperbilirubinemia, neonatal intensive care unit admission, birth weight, and LGT rates; however, the rate of small-for-gestational-age (SGA) infants was significantly higher in group 2 compared with those in group 3. For the 2-hour results, statistically similar results were found between the groups.Conclusion:A 2-hour 75 g OGTT has reliable threshold values for GDM screening. However, because there are still adverse neonatal outcomes in women with OGTT results below the current thresholds and the number of SGA fetuses is higher in the glucose range 120-140 mg/dL of the first hour, the validity of the 75 g OGTT thresholds still needs further investigation.

Risk of neonatal care unit admission in small for gestational age fetuses at term: a prediction model and internal validation

Objective: Small for gestational age (SGA) fetuses are at increased risk of admission to the neonatal unit, even at term. We aimed to develop and validate a predictive model for the risk of prolonged neonatal unit admission in suspected SGA fetuses at term.Methods: A single-center cohort study of singleton pregnancies with SGA fetus, defined as estimated fetal weight (EFW) less than the 10th centile, at term. The variables included known risk factors for neonatal unit admissions: maternal characteristics, EFW, abdominal circumference (AC), fetal Dopplers, gestational age (GA) at delivery, and intrapartum risk factors (meconium, pyrexia). Logistic regression analysis was used for model building and the prediction models were validated internally using bootstrapping.Results: Seven hundred and one SGA pregnancies at term were included; 5.9% had prolonged neonatal unit admission (>48 h). The multivariable model (AUC 0.71; 95% CI: 0.63–0.79) included GA at delivery <39 weeks (OR 2.76; 95% CI 1.23–6.04, p = .011), cerebroplacental ratio (CPR) multiples of median (MoM) (OR 0.21; 95% CI 0.05–0.79, p = .023), and EFW below the third centile (OR 2.43; 95% CI 1.26–4.68, p < .007). The combined model showed a sensitivity 30.9% (95% CI: 16.6–45.2%) for a fixed 10% false positive rate.Conclusion: The prediction model shows good accuracy and good calibration for assessing the risk of neonatal unit admission in suspected SGA fetuses. It has the potential to be used for patient counseling, determining the timing of delivery and the individual risk.Brief rationaleObjective: The objective of this study is to determine the factors associated with prolonged neonatal unit admissions in small for gestational age fetuses at term.What is already known: Fetal weight and Doppler parameters are associated with adverse outcome in small for gestational age fetuses. However, most studies use composite outcome criteria by combining neonatal unit admission with adverse delivery outcomes. A comprehensive model combining antenatal and intrapartum variables is also lacking.What this study adds: Our model describes the association of antenatal and intrapartum variables with prolonged neonatal unit admission without using a composite adverse outcome measure. Estimated fetal weight, gestational age at delivery, and the cerebroplacental ratio can be used to estimate the risk of prolonged neonatal unit admission. The risk estimation can be useful for patient counseling and to determine the time of delivery.

The profiles of soluble adhesion molecules in the “great obstetrical syndromes”

Objective: The objective of this study was to determine the profiles of maternal plasma soluble adhesion molecules in patients with preeclampsia, small-for-gestational-age (SGA) fetuses, acute pyelonephritis, preterm labor with intact membranes (PTL), preterm prelabor rupture of the membranes (preterm PROM), and fetal death.Materials and methods: A cross-sectional study was conducted to determine maternal plasma concentrations of sE-selectin, sL-selectin, and sP-selectin as well as sICAM-1, sVCAM-1, and sPECAM-1 in patients with (1) an uncomplicated pregnancy (control, n = 100); (2) preeclampsia (n = 94); (3) SGA fetuses (in women without preeclampsia/hypertension, n = 45); (4) acute pyelonephritis (n = 25); (5) PTL (n = 53); (6) preterm PROM (n = 24); and (7) fetal death (n = 34). Concentrations of soluble adhesion molecules and inflammatory cytokines (tumor necrosis factor (TNF)-α and interleukin (IL)-8) were determined with sensitive and specific enzyme-linked immunoassays.Results: In comparison to women with a normal pregnancy, (1) women with preeclampsia had higher median concentrations of sE-selectin, sP-selectin, and sVCAM-1, and a lower concentration of sL-selectin (all p values < .001); (2) patients with SGA fetuses had higher median concentrations of sE-selectin, sP-selectin, and sVCAM-1 (all p values < .05); (3) patients with a fetal death had higher median concentrations of sE-selectin and sP-selectin (all p values < .05); (4) patients with acute pyelonephritis had higher median plasma concentrations of sE-selectin, sICAM-1, and sVCAM-1 (all p values < .001); (5) patients with preeclampsia and acute pyelonephritis, plasma concentrations of sVCAM-1, sE-selectin, and sP-selectin correlated with those of the proinflammatory cytokines TNF-α and interleukin (IL)-8 (all p values < .05); (6) patients with PTL had a higher median concentration of sP-selectin and a lower median concentration of VCAM-1 (all p values < .05); and (7) women with preterm PROM had lower median concentrations of sL-selectin and sVCAM-1 (all p values < .05).Conclusions: The results of this study show that endothelial cell activation/dysfunction reflected by the plasma concentration of sE-selectin is not specific to preeclampsia but is present in pregnancies complicated by SGA fetuses, acute pyelonephritis, and fetal death. Collectively, we report that each obstetrical syndrome appears to have a stereotypical profile of soluble adhesion molecules in the peripheral circulation.

Impact de la détection anténatale d’un fœtus petit pour l’âge gestationnel sur le pronostic néonatal

ObjectiveWe sought to evaluate whether the antenatal identification of small for gestational age (SGA) fetuses could influence the neonatal and obstetric prognosis. MethodsThis was a retrospective cohort study. All liveborn singleton neonates with a birthweight<3rd centile, born>32 weeks of gestation between January 1, 2011 and December 31, 2012 were included. Fetuses were considered “suspected SGA” when the estimated fetal weight was<10th centile or when a diagnosis of clinical or ultrasound SGA was explicitly noted in the record. Obstetrical and neonatal follow-up and outcomes of suspected SGA (SGAS group) and non-suspected (SGANS group) were compared, with Chi2 and the Fisher exact test when appropriate. ResultsHundred and forty-seven neonates were included. Among these, 54% were suspected SGA before birth. Gestational age was lower (38.5 weeks gestation [WG] vs. 39.6 WG, P<0.001) and there was a higher preterm birth rate in the SGAS group (10% vs. 0%, P=0.005). The rate of elective cesarean sections (17% vs. 3%, P=0.005) was higher in the SGAS group, whereas the rate of nonelective cesarean sections was lower (20% vs. 33%, P=0.002). Neonatal morbidity was similar in both groups, as well as birth weight. ConclusionSGA fetal screening in our cohort was associated with a higher rate of medical intervention and preterm birth without neonatal benefit. Nevertheless, the study's power and methodology are not adequate to reduce the risk of fetal death in utero or severe asphyxia associated with non-identification of a SGA fetus.

356: Propensity score analysis of prostaglandin use and cesarean delivery for nonreassuring fetal status in small for gestational age fetuses at term

Growth restricted fetuses have been excluded from many randomized trials of prostaglandin use. The objective of this study was to estimate the association between use of prostaglandins for labor induction in term small for gestational age (SGA) fetuses and the risk of cesarean delivery for nonreassuring fetal status (NRFS). In a retrospective cohort study of consecutive deliveries ≥37 weeks, we analyzed induction of labor in patients with SGA fetuses defined as birthweight <10th%ile for gestational age. Patients with prior cesarean were excluded. Patients were categorized by exposure to prostaglandins. The primary outcome was cesarean delivery for NRFS. Secondary outcomes were any cesarean and a composite of 5-minute Apgar score <7 or admission to higher level nursery. Propensity scores for exposure were estimated using a logistic regression model including parity, comorbidities, and Bishop score. The propensity scores were trimmed at the non-overlapping tails to ensure positivity and were assessed for balance of covariates. Outcomes were compared between propensity score-matched exposed and unexposed patients. Of 1153 patients meeting inclusion criteria, 611 (53.0%) were exposed to prostaglandins and 542 (47.1%) were not. Misoprostol was the most common type of prostaglandin (73.6%). Prostaglandin use was strongly associated with nulliparity and low Bishop score (p<0.001). In unadjusted, non-propensity score-matched analysis, prostaglandin use was associated with an increased risk of cesarean for NRFS (OR 2.14, 95% CI 1.30, 3.50). In the propensity score-matched analysis of 290 exposed and 290 unexposed patients, use of prostaglandins was not associated with a significant risk of cesarean for NRFS (OR 1.32, 95%CI 0.68, 2.54). There was also no association between prostaglandin use and the secondary outcomes. We found no independent association between the use of prostaglandins for labor induction in term SGA fetuses and cesarean for NRFS after adjusting for factors associated with prostaglandin use. This suggests that withholding prostaglandins from patients with SGA fetuses may be unwarranted.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Fetal facial expressions in small-for-gestational-age and growth-restricted fetuses

Objective: To evaluate the frequencies of fetal facial expressions among appropriate-for-gestational-age (AGA), small-for-gestational-age (SGA), and growth-restricted (FGR) fetuses.Methods: Four-dimensional (4D) ultrasound was used to examine the facial expressions of 50 AGA, 25 SGA, and six FGR fetuses between 28 and 35 weeks of gestation. The frequencies of seven facial expressions during 15-minute recordings were assessed. Comparison of facial expressions among the three groups was performed.Results: Mouthing was the commonest facial expression at 28–35 weeks, and the frequency of mouthing was significantly higher than those of the other six facial expressions in AGA fetuses. Mouthing was the most frequent facial expression, but there was no significant difference in the frequency among mouthing, smiling and blinking in SGA fetuses. Moreover, mouthing displayed a significantly higher frequency than the other facial expressions, except for yawning, smiling, and blinking in FGR fetuses. However, there was no significant difference in the frequency of each facial expression among the three groups.Conclusions: Our results suggest that the frequencies of fetal facial expressions are not decreased in either SGA or FGR pregnancies. The absence of a decrease in the frequency of each fetal expression in FGR fetuses may be due to increased brain blood flow because of the brain-sparing effect. Moreover, accelerated maturation and development of the brain function, especially the central dopamine system, might be suspected in SGA and FGR fetuses.

Chromosomal and subchromosomal anomalies associated to small for gestational age fetuses with no additional structural anomalies.

To assess the chromosomal and subchromosomal anomalies in small for gestational age (SGA) fetuses with no additional structural anomalies and their clinical outcomes. This study retrospectively reviewed the 128 SGA fetuses with no additional anomalies and underwent genetic testing with karyotyping and chromosomal microarray analysis (CMA). Stratified analysis was performed according to the existence of maternal risk factors for SGA (yes or no), gestational age at onset (before or after 32weeks), presence of oligohydraminos (yes or no), and umbilical artery Doppler flow (normal or abnormal). Chromosomal anomalies were identified in 6 (4.7%) SGA fetuses and pathogenic subchromosomal anomalies in 4 (3.1%) by microarray analysis. Chromosomal and subchromosomal anomalies were more frequently observed in cases with oligohydraminos (P=.017) and with early-onset SGA (P=.042). No differences were observed in relation to the existence of maternal risk factors and abnormal umbilical artery Doppler flow. Overall survival rate was 75.0% with different rates in the early and the late onset group (P<.001). There is a 3.3% incremental yield of subchromosomal anomalies in CMA above karyotyping in SGA fetuses. Chromosomal microarray analysis is recommended in SGA fetuses with no additional structural anomalies, especially coexisting with oligohydraminos and being early onset.

Cord Blood Biomarkers of Cardiac Dysfunction and Damage in Term Growth-Restricted Fetuses Classified by Severity Criteria

Objective: To assess cardiovascular function and damage in term small-for-gestational-age (SGA) and intrauterine growth-restricted (IUGR) fetuses by echocardiography and biomarkers in cord blood. Methods: This was a cohort study including 60 normal fetuses and 47 term small fetuses subclassified as small for gestational age (SGA) with estimated fetal weight (EFW) between the 3rd and 9th centiles and normal fetoplacental Doppler (n = 14) or intrauterine growth restriction (IUGR, n = 33) if EFW <3rd centile or EFW <10th centile together with cerebroplacental ratio <5th and/or mean uterine artery pulsatility index >95th centile. Fetal echocardiography included left myocardial performance index (MPI) and annular plane systolic excursion. Fetal B-type natriuretic peptide (BNP), troponin-I, heart-type fatty acid-binding proteins (H-FABP), and homocysteine concentrations were measured in cord blood collected at delivery. Results: Both SGA and IUGR cases presented echocardiographic signs of systolic and diastolic dysfunction with increased MPI (mean controls 0.43 [SD 0.12], SGA 0.47 [0.03], and IUGR 0.57 [0.08], p < 0.01) and decreased mitral annular plane systolic excursion (controls 6.0 mm [1.0], SGA 5.5 mm [0.6], and IUGR 4.9 mm [0.8], p = 0 01). IUGR fetuses presented increased levels of cord blood BNP (controls 17.2 pg/mL [11.5], SGA 22.4 pg/mL [10.7], and IUGR 31.2 pg/mL [26.8], p < 0.01). Troponin I was increased in both SGA and IUGR cases (controls 0.004 ng/mL [0.007], SGA 0.012 ng/mL [0.02], and IUGR 0.018 ng/mL [0.05], p < 0.01). H-FABP and homocysteine showed similar values among groups. Conclusions: Cardiac dysfunction and cell damage is a common feature of term SGA and IUGR fetuses despite of the severity criteria for perinatal outcome. Further research is needed to evaluate the potential long-term consequences on their cardiovascular system.

Evolution of linear and nonlinear fetal heart rate indices throughout pregnancy in appropriate, small for gestational age and preterm fetuses: A cohort study

Background and objectivesTo assess the evolution of linear and nonlinear fetal heart rate (FHR) analysis throughout pregnancy in appropriate (AGA), small for gestational age (SGA) and preterm (PTB) fetuses. MethodsA prospective cohort study was carried out in 171 singleton pregnancies divided in three groups: AGA (n = 147), SGA (n = 13) fetuses and spontaneous PTB (n = 11). FHR was recorded with an external sensor from the 24th to the 40th week of gestation. Linear time- and frequency-domain and nonlinear FHR indices were computed on 10-min segments. Longitudinal analysis of indices throughout pregnancy was performed with generalized estimating equations, and receiver operating characteristic (ROC) curves were calculated for the prediction of SGA and PTB fetuses. ResultsIncreasing gestational age significantly affected most FHR indices, with a general increase in variability and entropy indices, and a decrease in mean FHR. The PTB group exhibited a significantly lower short-term variation, and no monotonic increase in the sympatho-vagal balance as observed in the AGA group. The SGA group exhibited higher long-term irregularity and lower short-term irregularity than the AGA group throughout gestation. In prediction of SGA and PTB, the largest areas under the ROC curves obtained were 0.76 and 0.78, respectively. ConclusionsLinear and nonlinear FHR analysis provides useful information on the evolution of fetal autonomic nervous and complexity control systems throughout pregnancy, in relation with AGA, SGA and PTB fetuses, which may be helpful in clinical practice.

Placental abnormalities differ between small for gestational age fetuses in dichorionic twin and singleton pregnancies

ObjectiveTwin fetuses grow slower during the third trimester compared with singletons. However, the extent to which the relative smallness of twins is the result of placenta-mediated factors similar to those associated with fetal growth restriction in singletons remains unclear. Our aim was to address this question by comparing placental findings between small for gestational age (SGA) twins and SGA singletons. MethodsRetrospective cohort study of all SGA non-anomalous newborns from singleton and dichorionic twin pregnancies in a single tertiary referral center between 2002 and 2015. SGA was defined as birth weight <10th percentile for gestational age according to sex-specific national reference charts. Placental findings were compared between SGA twins and SGA singletons and were classified into lesions associated with maternal vascular malperfusion, fetal vascular malperfusion, placental hemorrhage and chronic villitis. ResultsA total of 532 SGA twins and 954 SGA singletons met the inclusion criteria. SGA twins had a higher mean placental weight (371 ± 103 g vs. 319 ± 107, p < 0.001) and a lower fetal-placental ratio (6.0 ± 2.5 vs. 6.7 ± 3.2, p < 0.001) compared with SGA singletons. Compared with SGA singletons, SGA twins were less likely to have any placental pathology (aOR 0.37, 95%-CI 0.29–0.46), hypercoiled cord (aOR 0.45, 95%-CI 0.33–0.61), placental weight<10th% (aOR 0.13, 95%-CI 0.08–0.20), maternal vascular malperfusion pathology (aOR 0.24, 95%-CI 0.18–0.30) and fetal vascular malperfusion pathology (aOR 0.62, 95%-CI 0.48–0.82). By contrast, SGA twins had higher odds of a marginal or velamentous cord insertion compared with SGA singletons (aOR 13.82, 95%-CI 10.44–18.30). Similar significant associations were observed in subgroups of SGA fetuses with a birth weight below the 5th and 3rd percentile for gestational age. ConclusionsOur findings illustrate that the mechanisms underlying reduced fetal growth in dichorionic twins differ from those involved in singletons, and may provide support to the hypothesis that smallness in dichorionic twins may be more benign than in singletons.

EP14.35: The influence of fetal gender on the antenatal detection of small‐for‐gestational‐age fetuses

To evaluate the influence of fetal gender on the antenatal detection of small for gestational age (SGA) fetuses. This is a prospective observational cohort of women attending for pregnancy care at the John Radcliffe Hospital, Oxford, UK. 2062 unselected singleton pregnancies had ultrasound fetal biometry at 20 and 36 weeks; umbilical and middle cerebral artery Doppler at 36 weeks; and birthweight and gender assessed at birth. The abdominal circumference (AC) growth velocity was defined as the z-score difference between 20 and 36 weeks adjusted for the interval in days and the lowest decile derived from local data was used. Fetal SGA was defined as EFW < 10th centile; and SGA at birth was defined as birthweight < 10th centile adjusted for gender. Comparisons between categorical variables were performed using the chi-squared test. Quantitative variables were assessed for normality and comparisons were performed using the student t-test. Amongst 199 cases of fetal SGA there were more female (57.8%) than male (42.2%) fetuses (OR 1.443; p=0.017). AC growth velocity in the lowest decile was less common in girls (OR 0.390; p=0.002). There were no significant differences in CPR < 5th centile (OR 0.759; p=0.488) or EFW< 3rd centile (OR 0.64; p=0.159) between female and male fetuses. Overall detection rate of SGA at birth was 46%. The detection rate of SGA at birth for boys and girls was 41% and 51% respectively (p=0.1925); the positive predictive value of EFW < 10th centile for boys and girls was 50% and 40% respectively (p=0.1937). The use of a universal EFW centile threshold leads to over representation of female fetuses as fetal SGA. Female fetal SGA are less likely to have a clinically significant reduction of AC velocity than males and therefore may be at less risk. Antenatal adjustment for fetal gender could improve the detection of fetuses at risk.

P20.11: Small‐for‐gestational‐age (SGA) fetuses are at higher risk of neonatal unit (NNU) admission: we aimed to develop and validate a predictive model for the risk of NNU admission in SGA fetuses at term

Small-for-gestational-age (SGA) fetuses are at higher risk of neonatal unit (NNU) admission. We aimed to develop and validate a predictive model for the risk of NNU admission in SGA fetuses at term. A single-centre cohort study of SGA [estimated fetal weight (EFW) <10th centile using INTERGROWTH charts] singleton pregnancies at term. Major structural anomalies, aneuploidy, genetic syndromes, missing outcomes or stillbirth were excluded. Variables included known risk factors for NNU admission: maternal characteristics, EFW, abdominal circumference (AC), fetal Dopplers, gestational age (GA) at the ultrasound and delivery, induction of labour and intrapartum risk factors (meconium, augmentation using oxytocin, epidural, pyrexia, hemorrhage). Logistic regression, ROC curve analysis, and Hosmer-Lemeshow tests were used to analyse the data. Validation of the models was performed internally with bootstrapped datasets. 965 pregnancies were included in the analysis, of which 5.3% required NNU admission. The prediction model (AUC 0.73, 95% CI: 0.66-0.80) included maternal BMI [OR: 1.94 (95%CI: 1.05 to 3.54)], drug abuse [OR: 7.57 (95%CI: 2.48 to 20.62)], cerebroplacental ratio (CPR) MoM [OR: 0.26 (95%CI: 0.07 to 0.87)], GA at delivery [OR: 0.36 (95%CI: 0.19 to 0.65)] and intrapartum pyrexia [OR: 12.56 (95%CI: 3.58 to 39.74)]. The results indicate that the model has good precision and, according to Hosmer-Lemeshow test, also has good fit (p = 0.99). The prediction model shows modest precision and good calibration for assessing the risk of NNU admission in a cohort of suspected SGA fetuses. The predictive model can be useful for determining the need for NNU care in suspected SGA fetuses.

Differential effect of assisted reproductive technology and small‐for‐gestational age on fetal cardiac remodeling

Fetuses conceived by assisted reproductive technology (ART) and those that are small-for-gestational age (SGA) show cardiovascular remodeling in utero; however, these two conditions are often associated. We aimed to evaluate the differential effect of ART and SGA on fetal cardiac remodeling. This was a prospective cohort study of term singleton pregnancies seen at our department between April 2011 and September 2013. The cohort was divided according to fetal growth and mode of conception into the following four groups: 102 appropriate-for-gestational-age (AGA) fetuses conceived spontaneously (controls), 72 AGA fetuses conceived by ART (ART-AGA), 31 SGA fetuses conceived by ART (ART-SGA) and 28 SGA fetuses conceived naturally (Spont-SGA). SGA was defined as birth weight < 10th centile. Fetal echocardiography was performed at 28-32 weeks to assess cardiac dimensions, geometry and function. ART fetuses had dilated atria (mean left atrium-to-heart area ratio: controls, 15 ± 2.7%; ART-AGA, 18 ± 4.1%; Spont-SGA, 14 ± 3.7%) and more globular ventricles (left ventricular sphericity index: controls, 1.77 ± 0.2; ART-AGA, 1.68 ± 0.2; Spont-SGA, 1.72 ± 0.2), with normally sized hearts. In contrast, SGA fetuses had enlarged hearts (cardiothoracic ratio: controls, 24 ± 3%; ART-AGA, 24 ± 4%; Spont-SGA, 29 ± 6%), preserved atrial size, more globular and concentric hypertrophic ventricles (left ventricle relative wall thickness: controls, 0.48 ± 0.17; ART-AGA, 0.54 ± 0.13; Spont-SGA, 0.63 ± 0.23). Both ART and SGA fetuses had decreased longitudinal motion (tricuspid annular ring displacement: controls, 6.5 ± 0.8 mm; ART-AGA, 5.5 ± 0.7 mm; Spont-SGA, 5.9 ± 0.6 mm) and impaired relaxation (left isovolumetric relaxation time: controls, 47.0 ± 7.3 ms; ART-AGA, 50.0 ± 7.9 ms; Spont-SGA, 49.5 ± 9.3 ms). ART-SGA fetuses presented a combination of features from both ART and SGA groups. SGA and conception with ART were associated with distinct patterns of fetal cardiac remodeling, supporting the concept that they are independent causes of cardiac programming. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.