Does antenatal identification of small-for-gestational age fetuses significantly improve their outcome?

Histomorphometric characteristics of first trimester chorionic villi in pregnancies with low serum pregnancy-associated plasma protein-A levels: relationship with placental three-dimensional power doppler ultrasonographic vascularization

OBJECTIVE

To evaluate histomorphometric vascular characteristics from samples obtained by chorionic villus sampling (CVS) in pregnancies with low serum pregnancy-associated plasma protein-A (PAPP-A) levels and to relate these findings to three-dimensional (3D) placental volume and power Doppler vascularization.

METHODS

Immediately before CVS, placental 3D-power Doppler ultrasonography was performed at 11 + 0 to 13 + 6 weeks in 12 pregnancies with PAPP-A concentrations <0.3 multiples of median (MoM) as well as in 11 control women. Using a standardized setting placental volume, vascularization index (VI), flow index (FI), and vascularization flow index (VFI) were measured. Histomorphometric parameters of villi were blindly evaluated with a video-computerized-image-analysis system.

RESULTS

Pregnancies with low PAPP-A showed a significantly reduced number of capillary vessels per villus cross-section (p = 0.005) and a smaller capillary diameter (p = 0.041). Placental vascular indices were significantly related to the number of fetal capillary vessels per villus (VI: r = 0.51, p = 0.03; FI: r = 0.48, p = 0.04; VFI: r = 0.56, p = 0.01).

CONCLUSIONS

Differences in placental vascularization are present in first trimester in pregnancies with low PAPP-A and they are associated to altered 3D placental Doppler indices.

Use of fetal colon thickness for auxiliary term dating of pregnancy

OBJECTIVE

To verify whether fetal colon thickness can be used as a marker for estimating, independent of biometrics and fetal weight percentile, the gestational age (GA) of fetuses between 37 and 40 weeks.

METHODS

The study group was 1296 fetuses aged between 33 and 40 weeks. The correlation between GA and colon thickness was assessed by the Pearson correlation test. For term fetuses (≥ 37 weeks), comparisons among the mean colon thickness for different weight percentiles at each GA (in weeks) were made with an analysis of variance test.

RESULTS

A significant relationship was observed between GA and colon thickness (P < 0.001, r(2) = 0.6). For term fetuses, significant differences were observed among the mean colon thickness values for different weight percentiles at 38 and 39 weeks. Of the 157 term fetuses for which biometrics would have underestimated GA by 2 weeks or more, 126 (80.3%) had a colon thickness equal to, or greater than, 14 mm. This colon thickness was also observed in 52 (70.3%) of term fetuses weighing less than the 10th percentile (n = 74).

CONCLUSION

The present study suggested that colon thickness might be a good marker for 37 weeks of gestation, and might identify term fetuses for which biometrics has underestimated the GA.

Stillbirth among foreign-born women in Sweden

BACKGROUND

The aims of this study were: (i) to investigate stillbirth risk in offspring to foreign-born women by region of birth; (ii) if disparities in risks can be explained by socio-economic factors, pregnancy complications or maternal morbidity; and (iii) if the risk varies by time since immigration.

METHODS

This was a population-based register study with data from the Swedish Medical Birth Register and socio-economic variables from national income and population registers. We studied single births from 1992 to 2005, and included 219,832 births to foreign-born women and 1,094,146 births to Swedish-born women. Logistic regression analysis was used to calculate odds ratios (ORs), using 95% confidence intervals (CIs).

RESULTS

In all, 4104 antepartal and 255 intrapartal stillbirths occurred. Compared with births to Swedish women, the OR of stillbirth was 2.27 (95% CI 1.84-2.80) for births to women from Africa and 1.41 (95% CI 1.22-1.64) for births to women from Middle East, after adjustment for confounding factors. The risk of stillbirth was higher in immigrants who had been in Sweden for a short time period (<5 years) compared with those who had been in Sweden for a longer period, OR 1.21 (95% CI 1.05-1.40).

CONCLUSIONS

The risk of stillbirth in immigrant women varies by region of birth and time since immigration, being highest in women from Africa and the Middle East, and the recently settled. Further studies are needed to identify the mechanisms behind these patterns.

The customised growth potential: an international research tool to study the epidemiology of fetal growth

Customised centiles based on individual fetal growth potential enhance our ability to differentiate between physiological and pathological smallness. A series of studies in different maternity populations has found striking similarities in the way fetal growth varies with maternal and pregnancy related characteristics, and has established the clear advantages of this method over generic, population-based birthweight or fetal weight standards. The method opens up many new avenues for the retrospective study of risk factors and fetal growth. The findings quantify the strength of association between fetal growth restriction and perinatal outcome, and therefore also highlight the clinical imperative to improve antenatal detection of the at-risk fetus. Applied prospectively as customised charts, the concept improves the detection of fetal growth restriction and reduces the need for unnecessary investigations.

A hospital-based birth weight analysis using computerized perinatal data base for a Chinese population

OBJECTIVES

We aimed to construct birth weight-for-gestational age nomograms based on a computerized perinatal data base in a hospital-based Chinese population.

METHODS

Retrospectively collected 28,052 singleton deliveries at Women and Children's Medical Center, Guangzhou, China. Standard curves of birth weight from 27 to 43 week's gestation were computed. The nomograms included the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles and standard deviations.

RESULTS

79.9% pregnant women delivered between 38, 39, and 40 gestational week, and the mean birth weights are 3160, 3282, and 3388 g, respectively. Preterm birth is 5.7%. In general, male birth weights are greater than females at each gestational week. The hospital-based Chinese population birth weight is lower than that of North American and Scandinavian population.

CONCLUSIONS

A different standard birth weight is needed for different population. A hospital-based birth weight curve by gestational week is established, which can be a useful tool to estimate intrauterine fetal growth to define SGA or LGA fetuses.

Relative growth estimated from self-administered symphysis fundal measurements

OBJECTIVE

To establish absolute- and relative-growth reference curves for the detection of intrauterine growth restriction from weekly self-administered symphysis-fundus (SF) measurements and to assess the influence of fetal sex, maternal obesity and parity.

DESIGN

Prospective longitudinal study.

SETTING

Pregnant women from six primary antenatal care centres.

POPULATION

Three hundred women with singleton ultrasound dated pregnancies.

METHODS

Weekly self-administered SF measurements from gestational week 25 until delivery were obtained. A linear mixed longitudinal model was used to estimate the absolute SF growth using the natural logarithm (lnSF). Relative lnSF growth was calculated as the lnSF measurement in one gestational week subtracted by the lnSF measurement in the previous gestational week. The influence of fetal sex, maternal obesity and parity was assessed in regression models and by a graphical display.

MAIN OUTCOME MEASURES

Absolute lnSF and relative lnSF growth curves and influence of fetal sex, maternal obesity and parity on these.

RESULTS

SF measurements from 191 women were used to establish an SF-growth reference. The absolute lnSF growth was influenced by maternal obesity, and for fetal sex and parity, borderline significance was recorded; while there was no evidence that the relative lnSF growth could depend on these variables.

CONCLUSIONS

Weekly self-administered SF measurements can be obtained and used to estimate SF growth. Relative growth of the lnSF height seems to be independent of fetal sex, maternal obesity and parity.

Symphysis-fundal height curve in the diagnosis of fetal growth deviations

OBJECTIVE

To validate a new symphysis-fundal curve for screening fetal growth deviations and to compare its performance with the standard curve adopted by the Brazilian Ministry of Health.

METHODS

Observational study including a total of 753 low-risk pregnant women with gestational age above 27 weeks between March to October 2006 in the city of João Pessoa, Northeastern Brazil. Symphisys-fundal was measured using a standard technique recommended by the Brazilian Ministry of Health. Estimated fetal weight assessed through ultrasound using the Brazilian fetal weight chart for gestational age was the gold standard. A subsample of 122 women with neonatal weight measurements was taken up to seven days after estimated fetal weight measurements and symphisys-fundal classification was compared with Lubchenco growth reference curve as gold standard. Sensitivity, specificity, positive and negative predictive values were calculated. The McNemar χ2 test was used for comparing sensitivity of both symphisys-fundal curves studied.

RESULTS

The sensitivity of the new curve for detecting small for gestational age fetuses was 51.6% while that of the Brazilian Ministry of Health reference curve was significantly lower (12.5%). In the subsample using neonatal weight as gold standard, the sensitivity of the new reference curve was 85.7% while that of the Brazilian Ministry of Health was 42.9% for detecting small for gestational age.

CONCLUSIONS

The diagnostic performance of the new curve for detecting small for gestational age fetuses was significantly higher than that of the Brazilian Ministry of Health reference curve.

First-trimester umbilical vein blood flow in pregnancies with low serum pregnancy-associated plasma protein-A levels: an early predictor of fetal growth restriction

OBJECTIVE

To investigate umbilical vein blood flow (UVBF) during the first trimester in pregnancies with low serum pregnancy-associated plasma protein-A (PAPP-A) levels and to relate umbilical vein (UV) diameter, time-averaged maximum velocity (TAMXV) and UVBF values to the subsequent development of fetal intrauterine growth restriction (IUGR).

METHODS

UVBF assessment was performed at 11 + 0 to 13 + 6 weeks' gestation in 102 singleton pregnancies with PAPP-A concentrations of < 0.3 multiples of the median. UV diameter, UV-TAMXV and UVBF were calculated and analyzed in relation to pregnancy outcome.

RESULTS

Pregnancy outcomes were: 51 pregnancies with birth weight ≥ 10(th) centile (Group A), 30 pregnancies with birth weight < 10(th) centile with normal Doppler in the umbilical artery throughout gestation (Group B) and 21 pregnancies with birth weight < 10(th) centile and abnormal umbilical artery Doppler later in gestation (Group C). No differences were found in PAPP-A levels between groups. Group C fetuses exhibited significantly lower values of UV-TAMXV (z-score - 1.99 SDs, t = 8.527, P ≤ 0.0001) and UVBF (z-score - 0.97 SDs, t = 7.420, P ≤ 0.0001) in comparison with normal reference ranges, while no differences were found in Groups A or B.

CONCLUSIONS

Decreased UV-TAMXV and UVBF at 11 + 0 to 13 + 6 weeks' gestation identify fetuses at risk of developing IUGR among pregnancies with low levels of PAPP-A.

Clinical and ultrasound work-up and follow-up of preeclampsia

Hypertensive disorders are frequent during pregnancy and are related with an important morbidity and mortality worldwide. In this review we aim to provide the reader with a comprehensive overview of the clinical aspects of and the diagnostic tools used in the primary assessment and the (long term) follow-up of preeclampsia. The focus in this review will lay on the clinical follow-up of both the mother and the fetus aiming at the prevention of severe maternal complications as well as preventing growth restriction and prematurity in the child.

The proform of eosinophil major basic protein: a new maternal serum marker for adverse pregnancy outcome

OBJECTIVE

To establish the first trimester serum levels of the proform of eosinophil major basic protein (proMBP) in pregnancies with adverse outcome. Furthermore, to determine the screening performance using proMBP alone and in combination with other first trimester markers.

METHODS

A case-control study was conducted in a primary hospital setting. The proMBP concentration was measured in cases with small-for-gestational age (SGA) (n = 150), spontaneous preterm delivery (n = 88), preeclampsia (n = 40), gestational hypertension (n = 10) and in controls (n = 500). Concentrations were converted to multiples of the median (MoM) in controls and groups were compared using Mann-Whitney U-test. Logistic regression analysis was used to determine significant factors for predicting adverse pregnancy outcome. Screening performance was assessed using receiver operating characteristic curves.

RESULTS

The proMBP median was significantly reduced in pregnancies with SGA (0.81 MoM), spontaneous preterm delivery (0.83 MoM), preeclampsia (0.88 MoM) and gestational hypertension (0.60 MoM). The best screening performance was found for preeclampsia including the covariates proMBP and nulliparity yielding an area under the curve equal to 0.737 (p < 0.0005) and a 75% detection rate for a 30% false positive rate.

CONCLUSION

The proMBP is a novel first trimester serum marker for adverse pregnancy outcome.

First-trimester placental volume and vascularization measured by 3-dimensional power Doppler sonography in pregnancies with low serum pregnancy-associated plasma protein a levels

OBJECTIVE

The purpose of this study was to investigate the first-trimester placental volume and 3-dimensional (3D) power Doppler vascularization of pregnancies with low serum pregnancy-associated plasma protein A (PAPP-A) levels and to relate these findings to pregnancy outcomes.

METHODS

Three-dimensional power Doppler sonography of the placenta was performed at gestational ages of 11 weeks to 13 weeks 6 days in 84 pregnancies with PAPP-A concentrations of less than 0.4 multiple of the median (MoM). With a standardized setting, the placental volume and vascularization index (VI), flow index (FI), and vascularization-flow index (VFI) were calculated and related to pregnancy outcomes.

RESULTS

Pregnancy outcomes were as follows: 57 pregnancies with birth weights at or above the 10th percentile (group A), 16 pregnancies with birth weights below the 10th percentile and normal Doppler findings in the umbilical artery throughout gestation (group B), and 11 pregnancies with birth weights below the 10th percentile and abnormal umbilical Doppler findings later in gestation (group C). No differences were found in PAPP-A levels among groups. Placental volume values were significantly lower than reference limits, but no differences were found between groups. In groups A and B, there were no significant differences in 3D Doppler indices. However, these indices were significantly lower in group C (VI mean difference, -1.904; P < .001; FI mean difference, -1.939; P < .001; VFI mean difference, -1.944; P < .001). Placental vascular indices were significantly related to the severity of intrauterine growth restriction (IUGR; VI, r = 0.438; P < .001; FI, r = 0.482; P < .001; VFI, r = 0.497; P < .001) but not to the PAPP-A MoM and placental volume values.

CONCLUSIONS

Low serum maternal PAPP-A levels are associated with altered 3D placental Doppler indices, and these changes are related to subsequent development of IUGR and adverse pregnancy outcomes.

Obstetric management of intrauterine growth restriction

The aim of obstetric management is to identify growth-restricted foetuses at risk of severe intrauterine hypoxia, to monitor their health and to deliver when the adverse outcome is imminent. After 30-32 gestational weeks, a Doppler finding of absent or reverse end-diastolic flow in the umbilical artery of a small-for-gestational age foetus is in itself an indication for delivery. In very preterm foetuses, the intrauterine risks have to be balanced against the risk of prematurity. All available diagnostic information (e.g., Doppler velocimetry of umbilical artery, foetal central arteries and veins and of maternal uterine arteries; foetal heart rate with computerised analysis of short-term variability; amniotic fluid amount; and foetal gestational age-related weight) should be collected to support the timing of delivery. If possible, the delivery should optimally take place before the onset of late signs of foetal hypoxia (pathological foetal heart rate pattern, severely abnormal ductus venosus blood velocity waveform, pulsations in the umbilical vein).

Leptin in first trimester pregnancy serum: no reduction associated with small-for-gestational-age infants

Leptin is an adipocytokine that is also synthesized by the placenta. Leptin and its receptor, which is also expressed by the placenta, are believed to play an auto- and paracrine role in trophoblast invasion and placental development. The leptin concentration in first trimester maternal serum and its relation to fetal growth disturbances were examined in this study. The study is a case-control study with 36 small-for-gestational-age (SGA) (<5th percentile) pregnancies and 108 appropriate-for-gestational-age (AGA) (> or =5th percentile) pregnancies. The groups were matched by maternal age, gestational age and body mass index (BMI). All were non-smokers. Leptin was measured in maternal serum in weeks 8-13 and was normalized for BMI with concentrations expressed as multiples of the median for the actual BMI. It was found that maternal serum leptin increased strongly (r = 0.7, P < 10(-4))with maternal BMI. There was no significant difference in maternal serum leptin concentrations between SGA and AGA pregnancies. In conclusion, SGA pregnancies are not associated with a lower maternal serum leptin concentration in first trimester. The maternal serum leptin concentration is largely determined by maternal BMI. Variation in the leptin concentration in maternal serum in first trimester does not seem to be associated with impaired fetal growth.

First-trimester uterine artery Doppler indices in the prediction of small-for-gestational age pregnancy and intrauterine growth restriction

OBJECTIVES

To assess the relationship of first-trimester uterine artery Doppler indices with subsequent delivery of small-for-gestational age (SGA) neonates or intrauterine growth restriction (IUGR).

METHODS

This was a prospective study in which uterine artery Doppler assessment was performed at 11-14 weeks in 3010 women with singleton pregnancies. Resistance indices (RI) and incidence of bilateral notching were compared between women with normal pregnancies (n = 2445) and those who delivered: SGA neonates (birth weight < 10th centile) (n = 377); SGA neonates who had been affected by pre-eclampsia (n = 27); IUGR neonates (birth weight < 10th centile and abnormal Doppler indices) with delivery > or = 37 weeks (n = 62); and IUGR neonates requiring preterm delivery (delivery < 37 weeks) (n = 36).

RESULTS

The first-trimester uterine artery mean RI and prevalence of bilateral notching were significantly higher in women destined to deliver SGA neonates than in women with normal pregnancies (median uterine artery RI, 0.74 vs. 0.70, P < 0.001; prevalence of bilateral notches, 56% vs. 43%, P < 0.001). The areas under the receiver-operating characteristics curves for the prediction of SGA without pre-eclampsia, IUGR, preterm IUGR and SGA with pre-eclampsia were 0.602, 0.687, 0.776 and 0.708, respectively. There was a statistically significant inverse relationship between mean uterine artery RI and gestational age at delivery in the SGA pregnancies without pre-eclampsia (R = - 0.329, P = 0.01).

CONCLUSIONS

There is a significant relationship between first-trimester uterine artery Doppler RI and the subsequent development of SGA. The sensitivity of first-trimester uterine artery Doppler is greater for SGA with pre-eclampsia than it is for IUGR alone. This could be because these two entities may have different underlying placental abnormalities that are detected variably on first-trimester uterine artery Doppler evaluation.

Low maternal awareness of fetal movement is associated with small for gestational age infants

Our aim was to identify associations between information given to pregnant women about fetal activity, level of maternal awareness of fetal activity, maternal concern about decreased fetal movement, and pregnancy outcomes. This was a population-based cross-sectional study. Mothers with a singleton delivery were invited to answer an anonymous structured questionnaire before discharge from the delivery unit. Six hundred and ninety-one mothers participated (60.4% of eligible women). Women were highly aware of fetal activity. Yet, 25% did not receive any information from care providers about expected normal fetal activity. Receiving information about fetal activity was associated with increased maternal awareness (odds ratio, 2.0; 95% confidence interval [CI], 1.2-3.4). Low maternal awareness of fetal activity was associated with an increased risk of having a small for gestational age infant (odds ratio, 6.5; 95% CI, 3.5-12.3). Expectations about the normal frequency of fetal movements, as reported by the mothers, varied from 25 kicks/hour to 3 kicks/24 hours. Receiving information about expected fetal activity was associated with maternal concerns about decreased fetal movement, but not with improved outcomes. We conclude that receiving information about expected fetal activity was associated with maternal concerns, but not with improved outcomes.

Routine ultrasound in late pregnancy (after 24 weeks' gestation)

BACKGROUND

Diagnostic ultrasound is used selectively in late pregnancy where there are specific clinical indications. However, the value of routine late pregnancy ultrasound screening in unselected populations is controversial. The rationale for such screening would be the detection of clinical conditions which place the fetus or mother at high risk, which would not necessarily have been detected by other means such as clinical examination, and for which subsequent management would improve perinatal outcome.

OBJECTIVES

To assess the effects on obstetric practice and pregnancy outcome of routine late pregnancy ultrasound, defined as greater than 24 weeks' gestation, in women with either unselected or low-risk pregnancies.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2008).

SELECTION CRITERIA

All acceptably controlled trials of routine ultrasound in late pregnancy (defined as after 24 weeks).

DATA COLLECTION AND ANALYSIS

All three review authors were involved in assessing trial quality and data extraction.

MAIN RESULTS

Eight trials recruiting 27,024 women were included. The quality of trials overall was satisfactory. There was no difference in antenatal, obstetric and neonatal intervention or morbidity in screened versus control groups. There was a slightly higher caesarean section rate in the screened group, but this difference did not reach statistical significance. Routine late pregnancy ultrasound was not associated with improvements in overall perinatal mortality. Placental grading as an adjunct to third trimester examination scan was associated with a significant reduction in the stillbirth rate in the one trial that assessed it. There is little information on long-term substantive outcomes such as neurodevelopment. There is a lack of data on maternal psychological effects.

AUTHORS' CONCLUSIONS

Based on existing evidence, routine late pregnancy ultrasound in low-risk or unselected populations does not confer benefit on mother or baby. It may be associated with a small increase in caesarean section rates. There is a lack of data about the potential psychological effects of routine ultrasound in late pregnancy, and limited data about its effects on both short- and long-term neonatal and childhood outcome. Placental grading in the third trimester may be valuable, but whether reported results are reproducible remains to be seen, and future research of late pregnancy ultrasound should include evaluation of placental textural assessment.

Intrauterine restriction (IUGR)

Perinatal mortality and morbidity is markedly increased in intrauterine growth restricted (IUGR) fetuses. Prenatal identification of IUGR is the first step in clinical management. For that purpose a uniform definition and criteria are required. The etiology of IUGR is multifactorial and whenever possible it should be assessed. When the cause is of placental origin, it is possible to identify the affected fetuses. The major complication is chronic fetal hypoxemia. By monitoring the changes of fetal vital functions it is thus possible to improve both management and outcome. The timing of delivery is crucial but the optimal management scheme has not yet been identified. When IUGR is identified at very early gestational ages, serial assessments of the risk of continuing the in utero fetal life under adverse conditions versus the risks of the prematurity should be performed. Delivery of IUGR fetuses should take place in centers where appropriate neonatal assistance can be provided. Careful monitoring of the IUGR fetus during labor is crucial as the IUGR fetus can quickly decompensate once uterine contractions have started.

Management of decreased fetal movements

Maternal perception of decreased fetal activity is a common complaint, and one of the most frequent causes of unplanned visits in pregnancy. No proposed definitions of decreased fetal movements have ever been proven to be superior to a subjective maternal perception in terms of identifying a population at risk. Women presenting with decreased fetal movements do have higher risk of stillbirth, fetal growth restriction, fetal distress, preterm birth, and other associated outcomes. Yet, little research has been conducted to identify optimal management, and no randomized controlled trials have been performed. The strong associations with adverse outcome suggest that adequate management should include the exclusion of both acute and chronic conditions associated with decreased fetal movements. We propose guidelines for management of decreased fetal movements that include both a nonstress test and an ultrasound scan and report findings in 3014 cases of decreased fetal movements.

Expected day of delivery from ultrasound dating versus last menstrual period--obstetric outcome when dates mismatch

OBJECTIVE

To analyse the association between fetal size at time of dating ultrasound and risk for preterm delivery and small-for-gestational-age (SGA) birth and to evaluate if timing of ultrasound, that is before 14 weeks of gestation or after 16 weeks affects this association.

DESIGN

Retrospective cohort study.

SETTING

Ultrasound departments of Ultragyn, Stockholm, Sweden.

POPULATION

A total of 28,776 singleton pregnancies dated between 1998 and 2004.

METHODS

Obstetric outcome was assessed through linkage of the cohort to the Swedish Medical Birth Register.

MAIN OUTCOME MEASURES

Risks of preterm delivery, low birthweight for gestational age, pre-eclampsia, asphyxia, respiratory distress, instrumental delivery, caesarean section, and postterm birth were calculated for the groups dated early and late.

RESULTS

When the expected date of delivery was postponed after ultrasound dating by 7 days or more, there was an increased risk for preterm delivery and pre-eclampsia in the late dating group (OR 1.49, 95% CI 1.27-1.73 and OR 1.27, 95% CI 1.02-1.60, respectively) but not in the early dating group. In both dating groups, there was an increased risk for SGA birth (OR 1.77, 95% CI 1.13-2.78 and OR 2.09, 95% CI 1.59-2.73, respectively) There was no increased risk for any of the other diagnoses.

CONCLUSION

Our study gives further support to the notion that intrauterine growth restriction may be present as early as the first trimester. Accordingly, our study also suggests that surveillance of pregnancies with postponed estimated date of delivery may provide means for increased detection of fetal growth restriction.

Predictiveness of antenatal umbilical artery Doppler for adverse pregnancy outcome in small-for-gestational-age babies according to customised birthweight centiles: population-based study

OBJECTIVE

To examine the relationship between smallness at birth and the predictive value of umbilical artery Doppler.

DESIGN

Retrospective cohort.

SETTING

Tertiary referral university hospital, Barcelona.

POPULATION

A total of 7645 singleton pregnancies delivered between January 2002 and June 2004.

METHODS

The associations with adverse outcome were assessed for small-for-gestational-age (SGA) babies according to customised standards who had normal and abnormal umbilical artery Doppler.

MAIN OUTCOME MEASURES

Neonatal morbidity and perinatal mortality.

RESULTS

Of the 369 SGA fetuses that had been identified antenatally, 70 (19%) had an abnormal umbilical artery Doppler and the babies from these pregnancies had a higher risk for neonatal morbidity when compared with babies with normal birthweight (OR 3.99, 95% CI 1.04-11.03). However, the remaining 299 (81%) fetuses with normal umbilical artery Doppler also had an elevated risk of neonatal morbidity (OR 2.26, 95% CI 1.04-4.39). Overall, many of the instances of adverse outcome associated with smallness for gestational age were attributable to the group with normal Doppler than to the group with abnormal Doppler.

CONCLUSION

Normal antenatal umbilical artery Doppler cannot be taken as an indicator of low risk in pregnancies where the fetus is SGA according to customised percentiles.

First-trimester biochemical markers of aneuploidy and the prediction of small-for-gestational age fetuses

OBJECTIVES

To examine the clinical utility of the first-trimester biochemical markers of aneuploidy in their ability to predict subsequent delivery of a small-for-gestational age (SGA) infant.

METHODS

We examined singleton pregnancies with no chromosomal abnormality and with complete outcome data that had undergone screening for trisomy 21 by a combination of fetal nuchal translucency (NT) thickness and maternal serum free beta-human chorionic gonadotropin (beta-hCG) and pregnancy-associated plasma protein-A (PAPP-A) at 11 + 0 and 13 + 6 weeks' gestation. The biochemical markers were converted to multiples of the expected normal median (MoM) for a pregnancy of the same gestation. The association between free beta-hCG and PAPP-A and the incidence of SGA were assessed by comparing the relative incidence at MoM cut-offs and birth-weight centile cut-offs. At various marker levels the likelihood ratios (LR) for SGA were also calculated after excluding other adverse pregnancy complications.

RESULTS

There were 46,262 pregnancies resulting in live births with birth weight at or above the 10(th) centile, and 3,539 below the 10(th) centile for gestation (SGA). There was a significant inverse association between the risk for SGA and maternal serum PAPP-A MoM but not free beta-hCG MoM. At the 5(th) centile of the normal outcome group for PAPP-A (0.415 MoM) the odds ratios for SGA below the 10(th), 5(th) and 3(rd) centiles of normal were 2.70, 3.21 and 3.66 and the respective detection rates for SGA were 12.0%, 14.0% and 16.0%.

CONCLUSIONS

Low levels of maternal serum PAPP-A are associated, in the absence of an abnormal karyotype, with an increased risk for subsequent delivery of an SGA infant.

Customised birthweight standards accurately predict perinatal morbidity

OBJECTIVE

Fetal growth restriction is associated with adverse perinatal outcome but is often not recognised antenatally, and low birthweight centiles based on population norms are used as a proxy instead. This study compared the association between neonatal morbidity and fetal growth status at birth as determined by customised birthweight centiles and currently used centiles based on population standards.

DESIGN

Retrospective cohort study.

SETTING

Referral hospital, Barcelona, Spain.

PATIENTS

A cohort of 13 661 non-malformed singleton deliveries.

INTERVENTIONS

Both population-based and customised standards for birth weight were applied to the study cohort. Customised weight centiles were calculated by adjusting for maternal height, booking weight, parity, ethnic origin, gestational age at delivery and fetal sex.

MAIN OUTCOME MEASURES

Newborn morbidity and perinatal death.

RESULTS

The association between smallness for gestational age (SGA) and perinatal morbidity was stronger when birthweight limits were customised, and resulted in an additional 4.1% (n=565) neonates being classified as SGA. Compared with non-SGA neonates, this newly identified group had an increased risk of perinatal mortality (OR 3.2; 95% CI 1.6 to 6.2), neurological morbidity (OR 3.2; 95% CI 1.7 to 6.1) and non-neurological morbidity (OR 8; 95% CI 4.8 to 13.6).

CONCLUSION

Customised standards improve the prediction of adverse neonatal outcome. The association between SGA and adverse outcome is independent of the gestational age at delivery.

Small-for-gestational-age fetuses with normal umbilical artery Doppler have suboptimal perinatal and neurodevelopmental outcome

OBJECTIVE

To evaluate the perinatal and neurodevelopmental outcome of small-for-gestational-age fetuses with normal umbilical artery Doppler managed expectantly during pregnancy and delivery.

STUDY DESIGN

Perinatal and neurodevelopmental outcome was assessed from a cohort of singleton small-for-gestational-age fetuses with normal umbilical artery Doppler and normally grown controls matched by gestational age at delivery, parity and parental socio-economic level. Neurodevelopmental outcome was prospectively evaluated by means of the 24-month Age&Stage Questionnaire (ASQ).

RESULTS

A total of 129 small-for-gestational-age fetuses and 259 controls were included. Small-for-gestational-age fetuses had a higher risk for neonatal intensive care unit admission (15.5% versus 3.9%; p<0.001) and significant neonatal morbidity (2.3% versus 0%; p=0.04) than controls. At 24-months, these fetuses showed significantly lower neurodevelopmental centile in the problem solving (42.8 versus 52.1; p=0.001) and personal-social (44.4 versus 54.6; p<0.001) areas than controls.

CONCLUSION

Perinatal and neurodevelopmental outcome in small-for-gestational-age fetuses with normal umbilical artery Doppler is suboptimal, which may challenge the role of umbilical artery Doppler to discriminate between normal-SGA and growth-restricted fetuses.

Ultrasound detection of placental insufficiency in women with 'unexplained' abnormal maternal serum screening results

Serious placental insufficiency results in perinatal death or preterm birth from ischemic-thrombotic pathology, a process which has its origins in placental maldevelopment in the first trimester. A proportion of at-risk pregnancies may be identified from abnormalities in first or second trimester serum screening data, uterine artery Doppler waveforms or placental shape and texture at the time of the 18-20-week anatomical examination. In combination, these tests may be capable of recognizing a subset of at-risk pregnancies with 50% positive predictive values. Early recognition before fetal viability affords opportunities to direct women to regional perinatal care centres for enhanced maternal-fetal surveillance, corticosteroids to enhance fetal lung maturation, prophylactic measures to prevent pre-eclampsia and optimal decision making around the time of delivery. The creation of regional screening programs to use screening data with a placental focus is likely to be cost-effective, because existing patterns of care are utilized. More importantly, this strategy can direct women to participate in clinical research programs designed to reduce morbidity and mortality from this common group of conditions.