Small For Gestational Age Pregnancies Research Articles

Maternal vascular indices at 36 weeks' gestation in pregnancy with small or growth-restricted fetus.

To compare maternal vascular indices and hemodynamic parameters at 35-37 weeks' gestation in pregnancies complicated by delivery of a small-for-gestational-age (SGA) or growth-restricted (FGR) neonate. This was a prospective observational study of women with a singleton pregnancy attending for a routine hospital visit at 35 + 0 to 36 + 6 weeks' gestation. The visit included recording of maternal demographic characteristics, medical history, vascular indices and hemodynamic parameters, which were obtained using a non-invasive operator-independent device and included pulse-wave velocity, augmentation index, cardiac output, stroke volume, central systolic and diastolic blood pressure, total peripheral resistance and heart rate. Women with hypertensive disorders of pregnancy were excluded. SGA was diagnosed if birth weight was < 10th percentile. FGR was diagnosed if, in addition to birth weight < 10th percentile, at the 35-37-week scan, uterine artery or umbilical artery pulsatility index (PI) was > 95th percentile or fetal middle cerebral artery PI was < 5th percentile. Among the 6413 women included in the study, there were 605 (9.4%) cases of SGA, 133 (2.1%) cases of FGR and 5675 (88.5%) cases that were unaffected by SGA or FGR. Women with SGA or FGR, compared to unaffected pregnancies, had increased peripheral vascular resistance and reduced cardiac output. Central systolic and diastolic blood pressure were increased in the FGR group compared with the unaffected group. Aortic stiffness, as assessed by pulse-wave velocity, and augmentation index did not differ between affected and unaffected pregnancies. In the FGR group, compared with the SGA group, central systolic and diastolic blood pressure were higher, whereas heart rate was lower. SGA and FGR pregnancies exhibit deranged maternal hemodynamic responses compared with unaffected pregnancies. Pregnancies with FGR have higher central blood pressure compared to those with SGA, but it remains unclear whether these differences are driven by the size of the fetus or pathological fetal growth. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Metformin and small for gestational age babies: findings of a randomised placebo-controlled clinical trial of metformin in gestational diabetes (EMERGE).

Gestational diabetes mellitus (GDM) is associated with adverse perinatal outcomes because of suboptimal glucose management and glucose control and excessive weight gain. Metformin can offset these factors but is associated with small for gestational age (SGA) infants. We sought to identify risk factors for SGA infants, including the effect of metformin exposure on SGA status. In this prespecified secondary analysis of the EMERGE trial, which evaluated the effectiveness of metformin vs placebo in treating GDM and found reduced gestational weight gain and longer time to insulin initiation with metformin use, we included women with a live-born infant and known infant birthweight and gestational age at delivery. We compared the numbers of SGA infants in both groups and explored baseline predictive factors to help identify those at highest risk of delivering an SGA infant. Baseline maternal characteristics were similar between SGA and non-SGA pregnancies. On multivariable-adjusted regression, no baseline maternal variables were associated with SGA status. Mothers of SGA infants were more likely to develop pre-eclampsia or gestational hypertension (18.2% vs 2.0%, p=0.001; 22.7% vs 5.4%, p=0.005, respectively); after multivariable adjustment, pre-eclampsia was positively associated with SGA status). Among SGA pregnancies, important perinatal outcomes including preterm birth, Caesarean delivery and neonatal care unit admission did not differ between the metformin and placebo groups (20.0% vs 14.3%, p=1.00; 50.0% vs 28.6%, p=0.25; 13.3% vs 42.9%, p=0.27, respectively). Pre-eclampsia was strongly associated with SGA infants. Metformin-exposed SGA infants did not display a more severe SGA phenotype than infants treated with placebo. Clinical Trials.gov NCT02980276; EudraCT number: 2016-001644-19.

Leukocyte-associated immunoglobulin-like receptor 1 (LAIR1) is reduced with preeclampsia and small for gestational aged fetuses

Leukocyte-associated immunoglobulin-like receptor 1 (LAIR1) is an inhibitory receptor expressed on immune cells. We evaluated LAIR1 in placentas from preeclamptic or small for gestational age (SGA) pregnancies, and placental explant model (1 % O2, IL6 and TNFα, or control). LAIR1 mRNA was reduced in placentas from preeclamptic (p < 0.0001, n = 78) and SGA (p < 0.0001, n = 32) pregnancies. LAIR1 protein expression was reduced in placentas from preeclampsia (p < 0.0001, n = 43) and SGA (p = 0.009, n = 10) pregnancies. Hypoxia (1 % O2) reduced LAIR1 mRNA expression in placental explants (p = 0.008). These findings suggest hypoxia modulates LAIR1 expression in the placenta.

The Relationship between Placental Shear Wave Elastography and Fetal Weight-A Prospective Study.

Background/Objectives: The utility of shear wave elastography (SWE) as an adjunct to ultrasound biometry and Doppler velocimetry for the examination of placental dysfunction and suboptimal fetal growth is unclear. To date, limited data exist correlating the mechanical properties of placentae with fetal growth. This study aimed to investigate the relationship between placental shear wave velocity (SWV) and ultrasound estimated fetal weight (EFW), and to ascertain if placental SWV is a suitable proxy measure of placental function in the surveillance of small-for-gestational-age (SGA) pregnancies. Methods: This prospective, observational cohort study compared the difference in placental SWV between SGA and appropriate-for-gestational-age (AGA) pregnancies. There were 221 women with singleton pregnancies in the study cohort-136 (61.5%) AGA and 85 (38.5%) SGA. Fetal biometry, Doppler velocimetry, the deepest vertical pocket of amniotic fluid, and mean SWV were measured at 2-4-weekly intervals from recruitment to birth. Results: There was no difference in mean placental SWV in SGA pregnancies compared to AGA pregnancies, nor was there any relationship to EFW. Conclusions: Although other studies have shown some correlation between increased placental stiffness and SGA pregnancies, our investigation did not support this. The mechanical properties of placental tissue in SGA pregnancies do not result in placental SWVs that are apparently different from those of AGA controls. As this study did not differentiate between constitutionally or pathologically small fetuses, further studies in growth-restricted cohorts would be of benefit.

Stillbirth risk by fetal size among 126.5 million births in 15 countries from 2000 to 2020: A fetuses-at-risk approach.

To compare stillbirth rates and risks for small for gestational age (SGA), large for gestational age (LGA) and appropriate for gestational age (AGA) pregnancies at 24-44 completed weeks of gestation using a birth-based and fetuses-at-risk approachs. Population-based, multi-country study. National data systems in 15 high- and middle-income countries. Live births and stillbirths. A total of 151 country-years of data, including 126 543 070 births across 15 countries from 2000 to 2020, were compiled. Births were categorised into SGA, AGA and LGA using INTERGROWTH-21st standards. Gestation-specific stillbirth rates, with total births as the denominator, and gestation-specific stillbirth risks, with fetuses still in utero as the denominator, were calculated from 24 to 44 weeks of gestation. Gestation-specific stillbirth rates and risks according to size at birth. The overall stillbirth rate was 4.22 per 1000 total births (95% CI 4.22-4.23) across all gestations. Applying the birth-based approach, the stillbirth rates were highest at 24 weeks of gestation, with 621.6 per 1000 total births (95% CI 620.9-622.2) for SGA pregnancies, 298.4 per 1000 total births (95% CI 298.1-298.7) for AGA pregnancies and 338.5 per 1000 total births (95% CI 337.9-339.0) for LGA pregnancies. Applying the fetuses-at-risk approach, the gestation-specific stillbirth risk was highest for SGA pregnancies (1.3-1.4 per 1000 fetuses at risk) prior to 29 weeks of gestation. The risk remained stable between 30 and 34 weeks of gestation, and then increased gradually from 35 weeks of gestation to the highest rate of 8.4 per 1000 fetuses at risk (95% CI 8.3-8.4) at ≥42 weeks of gestation. The stillbirth risk ratio (RR) was consistently high for SGA compared with AGA pregnancies, with the highest RR observed at ≥42 weeks of gestation (RR 9.2, 95% CI 15.2-13.2), and with the lowest RR observed at 24 weeks of gestation (RR 3.1, 95% CI 1.9-4.3). The stillbirth RR was also consistently high for SGA compared with AGA pregnancies across all countries, with national variability ranging from RR 0.70 (95% CI 0.43-0.97) in Mexico to RR 8.6 (95% CI 8.1-9.1) in Uruguay. No increased risk for LGA pregnancies was observed. Small for gestational age (SGA) was strongly associated with stillbirth risk in this study based on high-quality data from high- and middle-income countries. The highest RRs were seen in preterm gestations, with two-thirds of the stillbirths born as preterm births. To advance our understanding of stillbirth, further analyses should be conducted using high-quality data sets from low-income settings, particularly those with relatively high rates of SGA.

Association between Doppler assessment and secondary cesarean delivery for intrapartum fetal compromise in small-for-gestational-age fetuses

PurposeTo elucidate the association between arterial and venous Doppler ultrasound parameters and the risk of secondary cesarean delivery for intrapartum fetal compromise (IFC) and neonatal acidosis in small-for-gestational-age (SGA) fetuses.MethodsThis single-center, prospective, blinded, cohort study included singleton pregnancies with an estimated fetal weight (EFW) < 10th centile above 36 gestational weeks. Upon study inclusion, all women underwent Doppler ultrasound, including umbilical artery (UA) pulsatility index (PI), middle cerebral artery (MCA) PI, fetal aortic isthmus (AoI) PI, umbilical vein blood flow (UVBF), and modified myocardial performance index (mod-MPI). Primary outcome was defined as secondary cesarean section due to IFC.ResultsIn total, 87 SGA pregnancies were included, 16% of which required a cesarean section for IFC. Those fetuses revealed lower UVBF corrected for abdominal circumference (AC) (5.2 (4.5–6.3) vs 7.2 (5.5–8.3), p = 0.001). There was no difference when comparing AoI PI, UA PI, ACM PI, or mod-MPI. No association was found for neonatal acidosis. After multivariate logistic regression, UVBF/AC remained independently associated with cesarean section due to IFC (aOR 0.61 [0.37; 0.91], p = 0.03) and yielded an area under the curve (AUC) of 0.78 (95% CI, 0.67–0.89). A cut-off value set at the 50th centile of UVBF/AC reached a sensitivity of 86% and specificity of 58% for the occurrence of cesarean section due to IFC (OR 8.1; 95% CI, 1.7–37.8, p = 0.003).ConclusionLow levels of umbilical vein blood flow (UVBF/AC) were associated with an increased risk among SGA fetuses to be delivered by cesarean section for IFC.

Doppler ultrasound of umbilical and middle cerebral artery in third trimester small-for-gestational age fetuses to decide on timing of delivery for suspected fetal growth restriction: A cohort with nested RCT (DRIGITAT).

To assess the association of the umbilicocerebral ratio (UCR) with adverse perinatal outcome in late preterm small-for-gestational age (SGA) fetuses and to investigate the effect on perinatal outcomes of immediate delivery. Multicentre cohort study with nested randomised controlled trial (RCT). Nineteen secondary and tertiary care centres. Singleton SGA pregnancies (estimated fetal weight [EFW] or fetal abdominal circumference [FAC] <10th centile) from 32 to 36+6 weeks. Women were classified: (1) RCT-eligible: abnormal UCR twice consecutive and EFW below the 3rd centile at/or below35 weeks or below the 10th centile at 36 weeks; (2) abnormal UCR once or intermittent; (3) never abnormal UCR. Consenting RCT-eligible patients were randomised for immediate delivery from 34 weeks or expectant management until 37 weeks. A composite adverse perinatal outcome (CAPO), defined as perinatal death, birth asphyxia or major neonatal morbidity. The cohort consisted of 690 women. The study was halted prematurely for low RCT-inclusion rates (n = 40). In the RCT-eligible group, gestational age at delivery, birthweight and birthweight multiple of the median (MoM) (0.66, 95% confidence interval [CI] 0.59-0.72) were significantly lower and the CAPO (n = 50, 44%, p < 0.05) was more frequent. Among patients randomised for immediate delivery there was a near-significant lower birthweight (p = 0.05) and higher CAPO (p = 0.07). EFW MoM, pre-eclampsia, gestational hypertension and Doppler classification were independently associated with the CAPO (area under the curve 0.71, 95% CI 0.67-0.76). Perinatal risk was effectively identified by low EFW MoM and UCR. Early delivery of SGA fetuses with an abnormal UCR at 34-36 weeks should only be performed in the context of clinical trials.

Lipid profile of circulating placental extracellular vesicles during pregnancy identifies foetal growth restriction risk.

Small-for-gestational age (SGA) neonates exhibit increased perinatal morbidity and mortality, and a greater risk of developing chronic diseases in adulthood. Currently, no effective maternal blood-based screening methods for determining SGA risk are available. We used a high-resolution MS/MSALL shotgun lipidomic approach to explore the lipid profiles of small extracellular vesicles (sEV)released from the placenta into the circulation of pregnant individuals. Samples were acquired from 195 normal and 41 SGA pregnancies. Lipid profiles were determined serially across pregnancy. We identified specific lipid signatures of placental sEVs that define the trajectory of a normal pregnancy and their changes occurring in relation to maternal characteristics (parity and ethnicity) and birthweight centile. We constructed a multivariate model demonstrating that specific lipid features of circulating placental sEVs, particularly during early gestation, are highly predictive of SGA infants. Lipidomic-based biomarker development promises to improve the early detection of pregnancies at risk of developing SGA, an unmet clinical need in obstetrics.

Night work during pregnancy and small for gestational age: a Danish nationwide register-based cohort study

ObjectiveThe aim was to investigate the association between night work during pregnancy and risk of having a small for gestational age (SGA) child.MethodsThis cohort study had payroll data with detailed...

AHA stage 1 hypertension and risk of small for gestational infants in nulliparous women

Non-Obstetric guidelines by the American Heart Association (AHA) have redefined hypertension (HTN) into stages with a systolic blood pressure (BP) of 130-139 mmHg and/or diastolic BP of 80-89 mmHg defined as stage 1. It is well known that stage 1 HTN confers a significantly elevated risk of hypertensive disorders of pregnancy, but less is known regarding effects on placental function and subsequent birth weight. This study aims to assess risk of small for gestational age (SGA) birth weight in women stratified by non-Obstetric HTN cut points. This was a secondary analysis of a large prospective observational study investigating birth outcomes in nulliparous women (nuMoM2b). Subjects were excluded from the current analysis for incomplete outcome data, lack of first trimester blood pressure, structural fetal anomaly, and pregestational diabetes. Women were stratified based on documented first trimester blood pressure defined as normotensive (< 120/< 80), elevated (120-129/< 80), stage 1 HTN (130-139/80-89), or stage 2 HTN (either by medical history or BP ≥140/≥90). Logistic regression was used to generate adjusted odds ratio (aOR) and 95% confidence intervals (CI) for SGA birth weight (< 10%) and pregnancy induced HTN ([PIH], gestational HTN or preeclampsia). 7,951 pregnancies were included in the analysis with 601 (7.6%) meeting criteria for stage 1 hypertension based on AHA guidelines and 754 (9.5%) delivered SGA neonates. There were no significant differences in rates of SGA among groups < 10% (p=0.184) or < 3% (p=.920), Figure 1. There were also no differences in SGA after regression analysis (Table 1). Women with stage 1 HTN had the highest risk of PIH (aOR 2.1, CI 1.7-2.6) while stage 2 HTN was not significant after adjustment (aOR 1.3, CI 0.92-1.8). Nulliparous women with stage 1 hypertension by non-obstetric guidelines do not have an elevated risk of SGA despite and increased risk of hypertensive disorders of pregnancy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Assessment of Fetal Thymus Size in Small for Gestational Age and Growth Restricted Fetuses

Objective: The purpose of this study was to analyze the fetal thymus size by sonography in healthy, small for gestational age (SGA), and fetal growth restriction (FGR) pregnancies and investigate if there is a difference between healthy fetuses and those with growth restriction. &#x0D; Study Design: The thymic-thoracic ratio (TTR), transverse diameter, and perimeter of the fetal thymus were prospectively measured in SGA and FGR pregnancies between the gestational ages of 20 and 37 weeks and compared with healthy controls. Fetal abdominal circumference (AC) or estimated fetal weight (EFW)

First-Trimester Screening for Fetal Growth Restriction and Small-for-Gestational-Age Pregnancies without Preeclampsia Using Cardiovascular Disease-Associated MicroRNA Biomarkers.

The goal of the study was to determine the early diagnostical potential of cardiovascular disease-associated microRNAs for prediction of small-for-gestational-age (SGA) and fetal growth restriction (FGR) without preeclampsia (PE). The whole peripheral venous blood samples were collected within 10 to 13 weeks of gestation from singleton Caucasian pregnancies within the period November 2012 to March 2020. The case-control retrospective study, nested in a cohort, involved all pregnancies diagnosed with SGA (n = 37) or FGR (n = 82) without PE and 80 appropriate-for-gestational age (AGA) pregnancies selected with regard to equality of sample storage time. Gene expression of 29 cardiovascular disease-associated microRNAs was assessed using real-time RT-PCR. Upregulation of miR-16-5p, miR-20a-5p, miR-146a-5p, miR-155-5p, miR-181a-5p, and miR-195-5p was observed in SGA or FGR pregnancies at 10.0% false positive rate (FPR). Upregulation of miR-1-3p, miR-20b-5p, miR-126-3p, miR-130b-3p, and miR-499a-5p was observed in SGA pregnancies only at 10.0% FPR. Upregulation of miR-145-5p, miR-342-3p, and miR-574-3p was detected in FGR pregnancies at 10.0% FPR. The combination of four microRNA biomarkers (miR-1-3p, miR-20a-5p, miR-146a-5p, and miR-181a-5p) was able to identify 75.68% SGA pregnancies at 10.0% FPR in early stages of gestation. The detection rate of SGA pregnancies without PE increased 4.67-fold (75.68% vs. 16.22%) when compared with the routine first-trimester screening for PE and/or FGR based on the criteria of the Fetal Medicine Foundation. The combination of seven microRNA biomarkers (miR-16-5p, miR-20a-5p, miR-145-5p, miR-146a-5p, miR-181a-5p, miR-342-3p, and miR-574-3p) was able to identify 42.68% FGR pregnancies at 10.0% FPR in early stages of gestation. The detection rate of FGR pregnancies without PE increased 1.52-fold (42.68% vs. 28.05%) when compared with the routine first-trimester screening for PE and/or FGR based on the criteria of the Fetal Medicine Foundation. Cardiovascular disease-associated microRNAs represent promising early biomarkers with very suitable predictive potential for SGA or FGR without PE to be implemented into the routine screening programs.

Circulating SPINT1 Is Reduced in a Preeclamptic Cohort with Co-Existing Fetal Growth Restriction.

Fetal growth restriction (FGR), when undetected antenatally, is the biggest risk factor for preventable stillbirth. Maternal circulating SPINT1 is reduced in pregnancies, which ultimately deliver small for gestational age (SGA) infants at term (birthweight < 10th centile), compared to appropriate for gestational age (AGA) infants (birthweight ≥ 10th centile). SPINT1 is also reduced in FGR diagnosed before 34 weeks’ gestation. We hypothesised that circulating SPINT1 would be decreased in co-existing preterm preeclampsia and FGR. Plasma SPINT1 was measured in samples obtained from two double-blind, randomised therapeutic trials. In the Preeclampsia Intervention with Esomeprazole trial, circulating SPINT1 was decreased in women with preeclampsia who delivered SGA infants (n = 75, median = 18,857 pg/mL, IQR 10,782–29,890 pg/mL, p < 0.0001), relative to those delivering AGA (n = 22, median = 40,168 pg/mL, IQR 22,342–75,172 pg/mL). This was confirmed in the Preeclampsia Intervention 2 with metformin trial where levels of SPINT1 in maternal circulation were reduced in SGA pregnancies (n = 95, median = 57,764 pg/mL, IQR 42,212–91,356 pg/mL, p < 0.0001) compared to AGA controls (n = 40, median = 107,062 pg/mL, IQR 70,183–176,532 pg/mL). Placental Growth Factor (PlGF) and sFlt-1 were also measured. PlGF was significantly reduced in the SGA pregnancies, while ratios of sFlt-1/SPINT1 and sFlt1/PlGF were significantly increased. This is the first study to demonstrate significantly reduced SPINT1 in co-existing FGR and preeclamptic pregnancies.

Rates of small for gestational age and low birth weight among underweight and normal weight women.

Prepregnancy underweight, and gestational weight gain has been associated with increased risk of adverse pregnancy outcomes, including preterm birth, low birthweight (LBW) and small for gestational age (SGA), but with conflicting results. The objectives were to compare the incidence of SGA, LBW, and other pregnancy outcomes between prepregnancy underweight and normal weight women and to evaluate possible associated risk factors. A retrospective cohort study was conducted in 220 underweight women (prepregnancy BMI of <18.5 kg/m2) and 440 normal weight women (prepregnancy BMI 18.5-24.9 kg/m2). Data were extracted from medical records and compared between the 2 groups, including baseline and obstetric characteristics, labor and delivery data, pregnancy, and neonatal outcomes. Underweight women were significantly younger and more likely to be nulliparous. They were significantly more likely to have weight gain below recommendation (33.6% vs. 23.2%, P<0.001). SGA and LBW were significantly more common in underweight compared to normal weight women (10.9% vs. 7%, P=0.034 and 13.2 vs. 7.3%, P=0.013, respectively). Other adverse neonatal outcomes were comparable. Logistic regression analysis showed that inadequate weight gain was the independent risk for both SGA and LBW (adjusted OR 2.20, 95%CI 1.19-4.09, P=0.012) and adjusted OR 2.31, 95%CI 1.28-4.159, P=0.005, respectively). Risk of both SGA and LBW were significantly increased in underweight compared to normal weight women. Inadequate weight gain was independently associated with increased risk of both SGA and LBW.

Cardiovascular outcome of former late-onset small-for-gestational-age children at 1year of age: CURIOSA study.

Late-onset small-for-gestational-age (SGA) fetuses usually show normal uterine artery Doppler and were long considered to have a good peri- and postnatal outcome. Recently, these fetuses were identified to have a risk factor for cardiovascular disease. The aim of our study was to evaluate former SGA children concerning their cardiovascular risk and nutrition behavior at the age of 1year. We performed a prospective longitudinal cohort study at the University Hospital "Klinikum rechts der Isar" of the Technical University of Munich. Singleton pregnancies from 32weeks with suspicion of SGA and healthy control pregnancies were included. A total of 100 former SGA children and 113 controls with normal weight (AGA) were examined at 1year of age. Drop-out for 1-year follow-up was 27%. SGA children had significantly higher systolic (92.8 ± 9.8mmHg vs. 87.5 ± 10.7mmHg, p = 0.001), diastolic (63.1 ± 8.5mmHg vs. 60.0 ± 10.3mmHg, p = 0.028) and mean (73.0 ± 7.8 vs. 69.2 ± 9.7mmHg, p = 0.004) blood pressure than AGA children. Comparing two breastfeeding periods (0-4months vs. > 7months), a downward trend in blood pressure values for longer breastfeeding periods was shown. Our study showed that even late-onset small-for-gestational-age fetuses seem to have cardiovascular problems, although they were previously thought to be "healthy". Up to now, blood pressure measurement is not part of indicated health checks in former SGA or even fetal growth-restricted children which should be changed. Further studies are needed to investigate cardiovascular prevention programs in children.

Effects of Mediterranean Diet or Mindfulness-Based Stress Reduction on Prevention of Small-for-Gestational Age Birth Weights in Newborns Born to At-Risk Pregnant Individuals

Being born small for gestational age (SGA) is a leading cause of perinatal morbidity and mortality with no effective prevention or therapy. Maternal suboptimal nutrition and high stress levels have been associated with poor fetal growth and adverse pregnancy outcomes. To investigate whether structured interventions based on a Mediterranean diet or mindfulness-based stress reduction (stress reduction) in high-risk pregnancies can reduce the percentage of newborns who were born SGA and other adverse pregnancy outcomes. Parallel-group randomized clinical trial conducted at a university hospital in Barcelona, Spain, including 1221 individuals with singleton pregnancies (19-23 weeks' gestation) at high risk for SGA. Enrollment took place from February 1, 2017, to October 10, 2019, with follow-up until delivery (final follow-up on March 1, 2020). Participants in the Mediterranean diet group (n = 407) received 2 hours monthly of individual and group educational sessions and free provision of extra-virgin olive oil and walnuts. Individuals in the stress reduction group (n = 407) underwent an 8-week stress reduction program adapted for pregnancy, consisting of weekly 2.5-hour sessions and 1 full-day session. Individuals in the usual care group (n = 407) received pregnancy care per institutional protocols. The primary end point was the percentage of newborns who were SGA at delivery, defined as birth weight below the 10th percentile. The secondary end point was a composite adverse perinatal outcome (at least 1 of the following: preterm birth, preeclampsia, perinatal mortality, severe SGA, neonatal acidosis, low Apgar score, or presence of any major neonatal morbidity). Among the 1221 randomized individuals (median [IQR] age, 37 [34-40] years), 1184 (97%) completed the trial (392 individuals assigned to the Mediterranean diet group, 391 to the stress reduction group, and 401 to the usual care group). SGA occurred in 88 newborns (21.9%) in the control group, 55 (14.0%) in the Mediterranean diet group (odds ratio [OR], 0.58 [95% CI, 0.40-0.84]; risk difference [RD], -7.9 [95% CI, -13.6 to -2.6]; P = .004), and 61 (15.6%) in the stress reduction group (OR, 0.66 [95% CI, 0.46-0.94]; RD, -6.3 [95% CI, -11.8 to -0.9]; P = .02). The composite adverse perinatal outcome occurred in 105 newborns (26.2%) in the control group, 73 (18.6%) in the Mediterranean diet group (OR, 0.64 [95% CI, 0.46-0.90]; RD, -7.6 [95% CI, -13.4 to -1.8]; P = .01), and 76 (19.5%) in the stress reduction group (OR, 0.68 [95% CI, 0.49-0.95]; RD, -6.8 [95% CI, -12.6 to -0.3]; P = .02). In this randomized trial conducted at a single institution in Spain, treating pregnant individuals at high risk for SGA with a structured Mediterranean diet or with mindfulness-based stress reduction, compared with usual care, significantly reduced the percentage of newborns with birth weight below the 10th percentile. Due to important study limitations, these findings should be considered preliminary and require replication, as well as assessment in additional patient populations, before concluding that these treatments should be recommended to patients. ClinicalTrials.gov Identifier: NCT03166332.

Placental MRI: Longitudinal relaxation time (T1) in appropriate and small for gestational age pregnancies.

The antenatal detection of small for gestational age (SGA) pregnancies is a challenge, which may be improved by placental MRI. The longitudinal relaxation time (T1) is a tissue constant related to tissue morphology and tissue oxygenation, thereby placental T1 may be related to placental function. The aim of this study is to investigate placental T1 in appropriate for gestational age (AGA) and SGA pregnancies. A total of 132 singleton pregnancies were retrieved from our MRI research database. MRI and ultrasound estimated fetal weight (EFW) was performed at gestational week 20.6-41.7 in a 1.5T system. SGA was defined as BW≤-15% of the expected for gestational age (≤10th centile). A subgroup of SGA pregnancies underwent postnatal placental histological examination (PHE) and abnormal PHE was defined as vascular malperfusion. The placental T1 values were converted into Z-scores adjusted for gestational age at MRI. The predictive performance of placental T1 and EFW was compared by receiver operating curves (ROC). In AGA pregnancies, placental T1 showed a negative linear correlation with gestational age (r=-0.36, p=0.004) Placental T1 was significantly reduced in SGA pregnancies (mean Z-score=-0.34) when compared to AGA pregnancies, p=0.03. Among SGA pregnancies placental T1 was not reduced in cases with abnormal PHE, p=0.84. The predictive performance of EFW (AUC=0.84, 95% CI, 0.77-0.91) was significantly stronger than placental T1 (AUC=0.62, 95% CI, 0.52-0.72) (p=0.002). A low placental T1 relaxation time is associated with SGA at birth. However, the predictive performance of placental T1 is not as strong as EFW.

Detection of small for gestational age in preterm prelabor rupture of membranes by Hadlock versus the Fetal Medicine Foundation growth charts.

ObjectiveThe primary outcome was to compare the diagnostic accuracy of neonatal small for gestational age (SGA) by the Hadlock and Fetal Medicine Foundation (FMF) charts in our cohort, followed by the ability to predict composite severe neonatal outcomes (SNO) in pregnancies with preterm prelabor rupture of membranes (PPROM).MethodsThis study was a secondary analysis of a prospective cohort of pregnancies with PPROM from 2015 to 2018, from 23 to 36 completed weeks of gestation. Sensitivity, specificity, and positive and negative predictive values for the primary and secondary outcomes of the Hadlock and FMF fetal charts were calculated. The discriminatory ability of each chart was compared using the area under the receiver’s operating curves of clinical characteristics.ResultsOf the 106 women who met the inclusion criteria, 48 (45%) were screened positive using the FMF fetal growth chart and 22 (21%) were screened positive using the Hadlock chart. SGA was diagnosed in 12 infants (11%). Both fetal growth charts had comparable diagnostic accuracies and were statistically significant predictors of SGA (Hadlock: area under the receiver operating characteristic curves [AUC], 0.76, risk ratio [RR], 7.6, 95% confidence interval [CI], 2.5–23; and FMF: AUC, 0.76 RR, 13.3 95%CI 1.8–99.3). Both growth standards were poor predictors of SNO.ConclusionThe Hadlock and FMF fetal growth charts have a similar accuracy to predict SGA in pregnancies complicated by PPROM. The FMF fetal growth chart may result in a 2-fold increase in positive screens, potentially increasing fetal surveillance.

Ten-year experience of protocol-based management of small-for-gestational-age fetuses: perinatal outcome in late-pregnancy cases diagnosed after 32 weeks.

To report our 10-year experience of protocol-based management of small-for-gestational-age (SGA) fetuses, based on standardized clinical and Doppler criteria, in late-pregnancy cases. A retrospective cohort was constructed of consecutive singleton pregnancies referred for late-onset (> 32 weeks) SGA (defined as estimated fetal weight (EFW) < 10th centile) that were classified as fetal growth restriction (FGR) or low-risk SGA, based on the severity of smallness (EFW < 3rd centile) and the presence of Doppler abnormalities (uterine artery pulsatility index (UtA-PI) ≥ 95th centile or cerebroplacental ratio (CPR) < 5th centile). Low-risk SGA pregnancies were followed at 2-week intervals and delivered electively at 40 weeks. FGR pregnancies were followed at 1-week intervals, or more frequently if there were signs of fetal deterioration, and were delivered electively after 37 + 0 weeks' gestation. The occurrence of stillbirth and composite adverse outcome (CAO; defined as neonatal death, metabolic acidosis, need for endotracheal intubation or need for admission to the neonatal intensive care unit) was analyzed in low-risk SGA and FGR pregnancies. A total of 1197 pregnancies with EFW < 10th centile were identified and classified at diagnosis as low-risk SGA (n = 619; 51.7%) or FGR (n = 578; 48.3%). Of these, 160 were delivered before 37 weeks' gestation; for obstetric reasons in 93 (58.1%) cases, severe pre-eclampsia in 33 (20.6%), FGR with severe hypoxia in 47 (29.4%) and stillbirth in four (2.5%) (indications are non-exclusive). During follow-up, 52/574 (9.1%) low-risk SGA pregnancies were reclassified as FGR, whereas 22/463 (4.8%) FGR pregnancies were reclassified as low-risk SGA. Overall, there were no stillbirths in the low-risk SGA group and four in the FGR group, all of which occurred before 37 weeks. There were no instances of neonatal death in pregnancies delivered ≥ 37 weeks. The risk of CAO was higher in those meeting antenatal criteria for FGR at 37 weeks than in those classified as low-risk SGA (32/493 (6.5%) vs 15/544 (2.8%); odds ratio, 2.5 (95%CI, 1.3-4.6)). In FGR pregnancies, the adjusted odds ratio (95% CI) for CAO was 6.3 (1.8-21.1) in those with EFW < 3rd centile, while it was 3.2 (1.5-6.8) and 4.2 (1.9-8.9) in those with UtA-PI ≥ 95th centile and CPR < 5th centile, respectively, as compared to FGR pregnancies without each of these criteria. Protocol-based risk stratification with different management and monitoring schemes for late pregnancy with a suspected SGA baby, based on clinical and Doppler criteria, enables identification and tailored assessment of high-risk FGR, while allowing expectant management with safe perinatal outcome for low-risk SGA fetuses. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Increasing Obstetric Intervention for Fetal Growth Restriction Is Shifting Birthweight Centiles: A Retrospective Cohort Study

(Abstracted from BJOG 2020;127:1074–1080) One way to reduce the risk of stillbirths is to focus on improving the detection of fetal growth restriction (FGR) and providing timely delivery of the small-for-gestational-age (SGA) fetus. Detecting and delivering the SGA pregnancy at less than 40 weeks of gestation are the recommended best practice.