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Hocquette A, Pulakka A, Metsälä J, Heikkilä K, Zeitlin J, Kajantie E. Association between risk of infant death and birth-weight z scores according to gestational age: A nationwide study using the Finnish Medical Birth Register. Int J Gynaecol Obstet 2024. [PMID: 38993143 DOI: 10.1002/ijgo.15772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 06/14/2024] [Accepted: 06/19/2024] [Indexed: 07/13/2024]
Abstract
OBJECTIVE To investigate the association between infant mortality and birth weight using estimated fetal weight (EFW) versus birth-weight charts, by gestational age (GA). METHODS This nationwide population-based study used data from the Finnish Medical Birth Register from 2006 to 2016 on non-malformed singleton live births at 24-41+6 weeks of gestation (N = 563 630). The outcome was death in the first year of life. Mortality risks by birth-weight z score, defined as a continuous variable using Maršál's EFW and Sankilampi's birth-weight charts, were assessed using generalized additive models by GA (24-27+6, 28-31+6, 32-36+6, 37-38+6, 39-41+6 weeks). We calculated z score thresholds associated with a two- and three-fold increased risk of infant death compared with newborns with a birth weight between 0 and 0.675 standard deviations. RESULTS The z score thresholds (with corresponding centiles in parentheses) associated with a two-fold increase in infant mortality were: -3.43 (<0.1) at 24-27+6 weeks, -3.46 (<0.1) at 28-31+6 weeks, -1.29 (9.9) at 32-36+6 weeks, -1.18 (11.9) at 37-38+6 weeks, and - 1.34 (9.0) at 39-41+6 weeks according to the EFW chart. These values were - 2.43 (0.8), -2.62 (0.4), -1.34 (9.0), -1.37 (8.5), and - 1.43 (7.6) according to the birth-weight chart. CONCLUSION The association between birth weight and infant mortality varies by GA whichever chart is used, suggesting that different thresholds for the screening of growth anomalies could be used across GA to identify high-risk newborns.
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Affiliation(s)
| | - Anna Pulakka
- Population Health Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
- Research Unit of Population Health, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - Johanna Metsälä
- Population Health Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Katriina Heikkilä
- Population Health Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
- Department of Public Health, University of Turku and Turku University Hospital, Turku, Finland
- Center for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland
| | | | - Eero Kajantie
- Population Health Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
- Clinical Medicine Research Unit, MRC Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Ramirez Zegarra R, Carbone IF, Angeli L, Gigli F, Di Ilio C, Barba O, Cassardo O, Valentini B, Ferrazzi E, Ghi T. Association of umbilical vein flow with abnormal fetal growth and adverse perinatal outcome in low-risk population: multicenter prospective study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:627-634. [PMID: 37963279 DOI: 10.1002/uog.27534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/09/2023] [Accepted: 11/08/2023] [Indexed: 11/16/2023]
Abstract
OBJECTIVE To investigate the relationship of umbilical vein flow (UVF) measured close to term with abnormal fetal growth and adverse perinatal outcome in a cohort of pregnancies at low risk of placental insufficiency. METHODS This was a prospective multicenter observational study conducted across two tertiary maternity units. Patients with a singleton appropriate-for-gestational-age fetus between 35 and 38 weeks' gestation were included. Pregnancies at higher risk of placental insufficiency or with fetal anomalies were excluded. At ultrasound examination, the abdominal circumference (AC), umbilical vein diameter and peak velocity of the umbilical vein were measured, and, using these variables, a new variable, UVF/AC, was calculated. The primary outcome was the occurrence of severely stunted fetal growth, defined as a greater than 40-percentile drop between estimated fetal weight at the third-trimester ultrasound and birth weight. The occurrence of adverse perinatal outcome (defined as one of the following: neonatal acidosis (umbilical artery pH < 7.15 and/or base excess > 12 mmol/L) at birth, 5-min Apgar score < 7, neonatal resuscitation or neonatal intensive care unit admission) was analyzed as a secondary outcome. RESULTS Between April 2021 and March 2023, 365 women were included in the study. The mean UVF/AC at enrolment was 6.4 ± 2.6 mL/min/cm, and 35 (9.6%) cases were affected by severely stunted fetal growth. Severely stunted fetal growth was associated with a lower mean UVF/AC (5.4 ± 2.6 vs 6.5 ± 2.6 mL/min/cm; P = 0.02) and a higher frequency of UVF/AC < 10th percentile (8/35 (22.9%) vs 28/330 (8.5%); P = 0.01). Moreover, UVF/AC showed an area under the receiver-operating-characteristics curve (AUC) of 0.65 (95% CI, 0.55-0.75; P = 0.004) in predicting the occurrence of severely stunted fetal growth, and the optimal cut-off value of UVF/AC for discriminating between normal and severely stunted fetal growth was 7.2 mL/min/cm. This value was associated with a sensitivity and specificity of 0.77 (95% CI, 0.60-0.90) and 0.33 (95% CI, 0.28-0.39), and positive and negative predictive values of 0.11 (95% CI, 0.07-0.15) and 0.93 (95% CI, 0.87-0.97), respectively. Regarding the occurrence of adverse perinatal outcome, this was associated independently with maternal age (adjusted odds ratio (aOR), 0.93 (95% CI, 0.87-0.99); P = 0.04), UVF/AC Z-score (aOR, 0.53 (95% CI, 0.30-0.87); P = 0.01) and augmentation of labor (aOR, 2.69 (95% CI, 1.28-5.69); P = 0.009). UVF/AC showed an AUC of 0.65 (95% CI, 0.56-0.73; P = 0.005) in predicting the occurrence of adverse perinatal outcome, and the optimal cut-off value of UVF/AC for discriminating between normal and adverse perinatal outcome was 6.7 mL/min/cm. This value was associated with a sensitivity and specificity of 0.70 (95% CI, 0.54-0.83) and 0.40 (95% CI, 0.34-0.45), and positive and negative predictive values of 0.14 (95% CI, 0.09-0.19) and 0.91 (95% CI, 0.85-0.95), respectively. CONCLUSIONS Our data demonstrate an association between reduced UVF close to term, severely stunted fetal growth and adverse perinatal outcome in a cohort of low-risk pregnant women, with a moderate ability to rule out and a poor ability to rule in either outcome. Further studies are needed to establish whether the assessment of UVF can improve the identification of fetuses at risk of subclinical placental insufficiency and adverse perinatal outcome. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R Ramirez Zegarra
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - I F Carbone
- Unit of Obstetrics, Department of Woman, Child and Neonate, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - L Angeli
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - F Gigli
- Unit of Obstetrics, Department of Woman, Child and Neonate, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - C Di Ilio
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
- Department Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - O Barba
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - O Cassardo
- Unit of Obstetrics, Department of Woman, Child and Neonate, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - B Valentini
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - E Ferrazzi
- Unit of Obstetrics, Department of Woman, Child and Neonate, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - T Ghi
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
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Dall'Asta A, Frusca T, Rizzo G, Ramirez Zegarra R, Lees C, Figueras F, Ghi T. Assessment of the cerebroplacental ratio and uterine arteries in low-risk pregnancies in early labour for the prediction of obstetric and neonatal outcomes. Eur J Obstet Gynecol Reprod Biol 2024; 295:18-24. [PMID: 38325239 DOI: 10.1016/j.ejogrb.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/28/2024] [Accepted: 02/02/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND The evidence-based management of human labor includes the antepartum identification of patients at risk for intrapartum hypoxia. However, available evidence has shown that most of the hypoxic-related complications occur among pregnancies classified at low-risk for intrapartum hypoxia, thus suggesting that the current strategy to identify the pregnancies at risk for intrapartum fetal hypoxia has limited accuracy. OBJECTIVE To evaluate the role of the combined assessment of the cerebroplacental ratio (CPR) and uterine arteries (UtA) Doppler in the prediction of obstetric intervention (OI) for suspected intrapartum fetal compromise (IFC) within a cohort of low-risk singleton term pregnancies in early labor. METHODS Prospective multicentre observational study conducted across four tertiary Maternity Units between January 2016 and September 2019. Low-risk term pregnancies with spontaneous onset of labor were included. A two-step multivariable model was developed to assess the risk of OI for suspected IFC. The baseline model included antenatal and intrapartum characteristics, while the combined model included antenatal and intrapartum characteristics plus Doppler anomalies such as CPR MoM < 10th percentile and mean UtA Doppler PI MoM ≥ 95th percentile. Predictive performance was determined by receiver-operating characteristics curve analysis. RESULTS 804 women were included. At logistic regression analysis, CPR MoM < 10th percentile (aOR 1.269, 95 % CI 1.188-1.356, P < 0.001), mean UtA PI MoM ≥ 95th percentile (aOR 1.012, 95 % CI 1.001-1.022, P = 0.04) were independently associated with OI for suspected IFC. At ROC curve analysis, the combined model including antenatal characteristics plus abnormal CPR and mean UtA PI yielded an AUC of 0.78, 95 %CI(0.71-0.85), p < 0.001, which was significantly higher than the baseline model (AUC 0.61, 95 %CI(0.54-0.69), p = 0.007) (p < 0.001). The combined model was associated with a 0.78 (95 % CI 0.67-0.89) sensitivity, 0.68 (95 % CI 0.65-0.72) specificity, 0.15 (95 % CI 0.11-0.19) PPV, and 0.98 (0.96-0.99) NPV, 2.48 (95 % CI 2.07-2.97) LR + and 0.32 (95 % CI 0.19-0.53) LR- for OI due to suspected IFC. CONCLUSIONS A predictive model including antenatal and intrapartum characteristics combined with abnormal CPR and mean UtA PI has a good capacity to rule out and a moderate capacity to rule in OI due to IFC, albeit with poor predictive value.
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Affiliation(s)
- Andrea Dall'Asta
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy; Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, United Kingdom.
| | - Tiziana Frusca
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
| | - Giuseppe Rizzo
- Department of Obstetrics and Gynaecology, Fondazione Policlinico di Tor Vergata, University of Rome Tor Vergata, Rome, Italy
| | - Ruben Ramirez Zegarra
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
| | - Christoph Lees
- Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, United Kingdom; Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Francesc Figueras
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, Spain
| | - Tullio Ghi
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
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Dall'Asta A, Ramirez Zegarra R, Figueras F, Rizzo G, Lees C, Frusca T, Ghi T. Association between uterine artery Doppler in early spontaneous labor and adverse peripartum outcome in relation to birth weight. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:303-304. [PMID: 37326975 DOI: 10.1002/uog.26287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/19/2023] [Accepted: 06/01/2023] [Indexed: 06/17/2023]
Affiliation(s)
- A Dall'Asta
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
- Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, London, UK
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - R Ramirez Zegarra
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - F Figueras
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, Barcelona, Spain
| | - G Rizzo
- Department of Obstetrics and Gynecology, Fondazione Policlinico di Tor Vergata, University of Rome Tor Vergata, Rome, Italy
| | - C Lees
- Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, London, UK
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - T Frusca
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - T Ghi
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
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Peasley R, Rangel LAA, Casagrandi D, Donadono V, Willinger M, Conti G, Seminara Y, Marlow N, David AL, Attilakos G, Pandya P, Zaikin A, Peebles D, Napolitano R. Management of late-onset fetal growth restriction: pragmatic approach. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:106-114. [PMID: 36864542 DOI: 10.1002/uog.26190] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 02/08/2023] [Accepted: 02/15/2023] [Indexed: 07/02/2023]
Abstract
OBJECTIVES There is limited prospective evidence to guide the management of late-onset fetal growth restriction (FGR) and its differentiation from small-for-gestational age. The aim of this study was to assess prospectively a novel protocol in which ultrasound criteria were used to classify women with suspected late FGR into two groups: those at low risk, who were managed expectantly until the anticipated date of delivery, and those at high risk, who were delivered soon after 37 weeks of gestation. We also compared the outcome of this prospective cohort with that of a historical cohort of women presenting similarly with suspected late FGR, in order to evaluate the impact of the new protocol. METHODS This was a prospective study of women with a non-anomalous singleton pregnancy at ≥ 32 weeks' gestation attending a tertiary hospital in London, UK, between February 2018 and September 2019, with estimated fetal weight (EFW) ≤ 10th centile, or EFW > 10th centile in addition to a decrease in fetal abdominal circumference of ≥ 50 centiles compared with a previous scan, umbilical artery Doppler pulsatility index > 95th centile or cerebroplacental ratio < 5th centile. Women were classified as low or high risk based on ultrasound and Doppler criteria. Women in the low-risk group were delivered by 41 weeks of gestation, unless they subsequently met high-risk criteria, whereas women in the high-risk group (EFW < 3rd centile, umbilical artery Doppler pulsatility index > 95th centile or EFW between 3rd and 10th centiles (inclusive) with abdominal circumference drop or abnormal Dopplers) were delivered at or soon after 37 weeks. The primary outcome was adverse neonatal outcome and included hypothermia, hypoglycemia, neonatal unit admission, jaundice requiring treatment, suspected infection, feeding difficulties, 1-min Apgar score < 7, hospital readmission and any severe adverse neonatal outcome (perinatal death, resuscitation using inotropes or mechanical ventilation, 5-min Apgar score < 7, metabolic acidosis, sepsis, and cerebral, cardiac or respiratory morbidity). Secondary outcomes were adverse maternal outcome (operative delivery for abnormal fetal heart rate) and severe adverse neonatal outcome. Women managed according to the new protocol were compared with a historical cohort of 323 women delivered prior to the implementation of the new protocol, for whom management was guided by individual clinician expertise. RESULTS Over 18 months, 321 women were recruited to the prospective cohort, of whom 156 were classified as low risk and 165 were high risk. Adverse neonatal outcome was significantly less common in the low-risk compared with the high-risk group (45% vs 58%; adjusted odds ratio (aOR), 0.6 (95% CI, 0.4-0.9); P = 0.022). There was no significant difference in the rate of adverse maternal outcome (18% vs 24%; aOR, 0.7 (95% CI, 0.4-1.2); P = 0.142) or severe adverse neonatal outcome (3.8% vs 8.5%; aOR, 0.5 (95% CI, 0.2-1.3); P = 0.153) between the low- and high-risk groups. Compared with women in the historical cohort classified retrospectively as low risk, low-risk women managed under the new protocol had a lower rate of adverse neonatal outcome (45% vs 58%; aOR, 0.6 (95% CI, 0.4-0.9); P = 0.026). CONCLUSIONS Appropriate risk stratification to guide management of late FGR was associated with a reduced rate of adverse neonatal outcome in low-risk pregnancies. In clinical practice, a policy of expectantly managing women with a low-risk late-onset FGR pregnancy at term could improve neonatal and long-term development. Randomized controlled trials are needed to assess the effect of an evidence-based conservative management protocol for late FGR on perinatal morbidity and mortality and long-term neurodevelopment. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R Peasley
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - L A Abrego Rangel
- Department of Women's Cancer, Institute for Women's Health, University College London, London, UK
- Department of Mathematics, University College London, London, UK
| | - D Casagrandi
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - V Donadono
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - M Willinger
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - G Conti
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - Y Seminara
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - N Marlow
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - A L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
- National Institute for Health Research, University College London Hospitals Biomedical Research Centre, University College London, London, UK
| | - G Attilakos
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - P Pandya
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - A Zaikin
- Department of Women's Cancer, Institute for Women's Health, University College London, London, UK
- Department of Mathematics, University College London, London, UK
| | - D Peebles
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
- National Institute for Health Research, University College London Hospitals Biomedical Research Centre, University College London, London, UK
| | - R Napolitano
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
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Dinu M, Stancioi-Cismaru AF, Gheonea M, Luciu ED, Aron RM, Pana RC, Marinas CM, Degeratu S, Sorop-Florea M, Carp-Veliscu A, Hodorog AD, Tudorache S. Intrauterine Growth Restriction-Prediction and Peripartum Data on Hospital Care. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040773. [PMID: 37109731 PMCID: PMC10145525 DOI: 10.3390/medicina59040773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 04/04/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023]
Abstract
Background and Objectives: We aimed to prospectively obtain data on pregnancies complicated with intrauterine growth restriction (IUGR) in the Prenatal Diagnosis Unit of the Emergency County Hospital of Craiova. We collected the demographic data of mothers, the prenatal ultrasound (US) features, the intrapartum data, and the immediate postnatal data of newborns. We aimed to assess the detection rates of IUGR fetuses (the performance of the US in estimating the actual neonatal birth weight), to describe the prenatal care pattern in our unit, and to establish predictors for the number of total hospitalization days needed postnatally. Materials and Methods: Data were collected from cases diagnosed with IUGR undergoing prenatal care in our hospital. We compared the percentile of estimated fetal weight (EFW) using the Hadlock 4 technique with the percentile of weight at birth. We retrospectively performed a regression analysis to correlate the variables predicting the number of hospitalization days. Results: Data on 111 women were processed during the period of 1 September 2019-1 September 2022. We confirmed the significant differences in US features between early- (Eo) and late-onset (Lo) IUGR cases. The detection rates were higher if the EFW was lower, and Eo-IUGR was associated with a higher number of US scans. We obtained a mathematical formula for estimating the total number of hospitalization days needed postnatally. Conclusion: Early- and late-onset IUGR have different US features prenatally and different postnatal outcomes. If the US EFW percentile is lower, a prenatal diagnosis is more likely to be made, and a closer follow-up is offered in our hospital. The total number of hospitalization days may be predicted using intrapartum and immediate postnatal data in both groups, having the potential to optimize the final financial costs and to organize the neonatal department efficiently.
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Affiliation(s)
- Marina Dinu
- 8th Department, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | | | - Mihaela Gheonea
- 8th Department, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Obstetrics and Gynecology Department, Emergency County Hospital, 200349 Craiova, Romania
| | - Elinor Dumitru Luciu
- Obstetrics and Gynecology Department, Emergency County Hospital, 200349 Craiova, Romania
| | - Raluca Maria Aron
- Obstetrics and Gynecology Department, Emergency County Hospital, 200349 Craiova, Romania
| | - Razvan Cosmin Pana
- 8th Department, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Obstetrics and Gynecology Department, Emergency County Hospital, 200349 Craiova, Romania
| | - Cristian Marius Marinas
- Obstetrics and Gynecology Department, Emergency County Hospital, 200349 Craiova, Romania
- 1st Department, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Stefan Degeratu
- Obstetrics and Gynecology Department, Targu-Jiu County Hospital, 210218 Targu-Jiu, Romania
| | - Maria Sorop-Florea
- Obstetrics and Gynecology Department, Targu-Jiu County Hospital, 210218 Targu-Jiu, Romania
| | - Andreea Carp-Veliscu
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Panait Sarbu Clinical Hospital of Obstetrics and Gynecology, 060251 Bucharest, Romania
| | | | - Stefania Tudorache
- 8th Department, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Obstetrics and Gynecology Department, Emergency County Hospital, 200349 Craiova, Romania
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7
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Burger RJ, Gordijn SJ, Mol BW, Ganzevoort W, Ravelli ACJ. Birth-weight centile at term and school performance at 12 years of age: linked cohort study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:458-465. [PMID: 36647332 DOI: 10.1002/uog.26160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/02/2022] [Accepted: 12/30/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE Birth weight, fetal growth and placental function influence cognitive development. The gradient of these associations is understudied, especially among those with a birth weight considered appropriate-for-gestational age. The aim of this study was to evaluate the associations between birth-weight centile and intellectual development in term/near-term infants across the entire birth-weight spectrum, in order to provide a basis for better understanding of the long-term implications of fetal growth restriction and reduced placental function. METHODS This was a population-based cohort study of 266 440 liveborn singletons from uncomplicated pregnancies, delivered between 36 and 42 weeks of gestation. Perinatal data were obtained from the Dutch Perinatal Registry over the period 2003-2008 and educational data for children aged approximately 12 years were obtained from Statistics Netherlands over the period 2016-2019. Regression analyses were conducted to assess the association of birth-weight centile with school performance. The primary outcomes were mean school performance score, on a scale of 501-550, and proportion of children who reached higher secondary school level. RESULTS Mean school performance score increased gradually with increasing birth-weight centile, from 533.6 in the 1st -5th birth-weight-centile group to 536.8 in the 81st -85th birth-weight-centile group. Likewise, the proportion of children at higher secondary school level increased with birth-weight centile, from 43% to 57%. Compared with the 81st -85th birth-weight-centile group, mean school performance score and proportion of children at higher secondary school level were significantly lower in all birth-weight-centile groups below the 80th centile, after adjusting for confounding factors. CONCLUSIONS Birth-weight centile is associated positively with school performance at 12 years of age across the entire birth-weight spectrum, well beyond the conventional and arbitrary cut-offs for suspected fetal growth restriction. This underlines the importance of developing better tools to diagnose fetal growth restriction and reduced placental function, and to identify those at risk for associated short- and long-term consequences. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R J Burger
- Department of Obstetrics and Gynaecology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - S J Gordijn
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - B W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
- Aberdeen Centre for Women's Health Research, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, King's College, Aberdeen, UK
| | - W Ganzevoort
- Department of Obstetrics and Gynaecology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - A C J Ravelli
- Department of Obstetrics and Gynaecology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Department of Medical Informatics, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
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8
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Stampalija T, Wolf H, Mylrea-Foley B, Marlow N, Stephens KJ, Shaw CJ, Lees CC. Reduced fetal growth velocity and weight loss are associated with adverse perinatal outcome in fetuses at risk of growth restriction. Am J Obstet Gynecol 2023; 228:71.e1-71.e10. [PMID: 35752304 DOI: 10.1016/j.ajog.2022.06.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/15/2022] [Accepted: 06/16/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Although fetal size is associated with adverse perinatal outcome, the relationship between fetal growth velocity and adverse perinatal outcome is unclear. OBJECTIVE This study aimed to evaluate the relationship between fetal growth velocity and signs of cerebral blood flow redistribution, and their association with birthweight and adverse perinatal outcome. STUDY DESIGN This study was a secondary analysis of the TRUFFLE-2 multicenter observational prospective feasibility study of fetuses at risk of fetal growth restriction between 32+0 and 36+6 weeks of gestation (n=856), evaluated by ultrasound biometry and umbilical and middle cerebral artery Doppler. Individual fetal growth velocity was calculated from the difference of birthweight and estimated fetal weight at 3, 2, and 1 week before delivery, and by linear regression of all available estimated fetal weight measurements. Fetal estimated weight and birthweight were expressed as absolute value and as multiple of the median for statistical calculation. The coefficients of the individual linear regression of estimated fetal weight measurements (growth velocity; g/wk) were plotted against the last umbilical-cerebral ratio with subclassification for perinatal outcome. The association of these measurements with adverse perinatal outcome was assessed. The adverse perinatal outcome was a composite of abnormal condition at birth or major neonatal morbidity. RESULTS Adverse perinatal outcome was more frequent among fetuses whose antenatal growth was <100 g/wk, irrespective of signs of cerebral blood flow redistribution. Infants with birthweight <0.65 multiple of the median were enrolled earlier, had the lowest fetal growth velocity, higher umbilical-cerebral ratio, and were more likely to have adverse perinatal outcome. A decreasing fetal growth velocity was observed in 163 (19%) women in whom the estimated fetal weight multiple of the median regression coefficient was <-0.025, and who had higher umbilical-cerebral ratio values and more frequent adverse perinatal outcome; 67 (41%; 8% of total group) of these women had negative growth velocity. Estimated fetal weight and umbilical-cerebral ratio at admission and fetal growth velocity combined by logistic regression had a higher association with adverse perinatal outcome than any of those parameters separately (relative risk, 3.3; 95% confidence interval, 2.3-4.8). CONCLUSION In fetuses at risk of late preterm fetal growth restriction, reduced growth velocity is associated with an increased risk of adverse perinatal outcome, irrespective of signs of cerebral blood flow redistribution. Some fetuses showed negative growth velocity, suggesting catabolic metabolism.
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Affiliation(s)
- Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, Istituto di Ricovero e Cura a Carattere Scientifico Burlo Garofolo, Trieste, Italy; Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Hans Wolf
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center (Location AMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Bronacha Mylrea-Foley
- Institute of Developmental and Reproductive Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom; Department of Fetal Medicine, Queen Charlotte's and Chelsea Hospital, Imperial College National Health Service Trust, London, United Kingdom
| | - Neil Marlow
- Institute for Womens Health, University College London, London, United Kingdom
| | - Katie J Stephens
- Department of Fetal Medicine, Queen Charlotte's and Chelsea Hospital, Imperial College National Health Service Trust, London, United Kingdom
| | - Caroline J Shaw
- Institute of Developmental and Reproductive Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom; Department of Fetal Medicine, Queen Charlotte's and Chelsea Hospital, Imperial College National Health Service Trust, London, United Kingdom
| | - Christoph C Lees
- Institute of Developmental and Reproductive Biology, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom; Department of Fetal Medicine, Queen Charlotte's and Chelsea Hospital, Imperial College National Health Service Trust, London, United Kingdom.
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9
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Gordijn SJ, Ganzevoort W. Search for the best prediction model, definition and growth charts for fetal growth restriction using a composite of adverse perinatal outcomes: a catch-22? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:305-306. [PMID: 35869942 DOI: 10.1002/uog.26037] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 06/15/2023]
Affiliation(s)
- S J Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - W Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
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10
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Fetal Growth Restriction: Mechanisms, Epidemiology, and Management. MATERNAL-FETAL MEDICINE 2022. [DOI: 10.1097/fm9.0000000000000161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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11
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Preventing Stillbirth: A Review of Screening and Prevention Strategies. MATERNAL-FETAL MEDICINE 2022. [DOI: 10.1097/fm9.0000000000000160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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12
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Morales-Roselló J, Khalil A, Loscalzo G, Buongiorno S, Brik M, Mendoza M, Di Fabrizio C, Scarinci E, Salvi S, Lanzone A, Perales Marín A. Cerebroplacental ratio prediction of intrapartum fetal compromise according to the interval to delivery. Fetal Diagn Ther 2022; 49:196-205. [DOI: 10.1159/000525162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 04/26/2022] [Indexed: 11/19/2022]
Abstract
Objectives
To evaluate whether the interval to delivery modifies the predictive accuracy of the cerebroplacental ratio (CPR) for the prediction of cesarean section for intrapartum fetal compromise (CS-IFC), either as a single marker or combined with estimated fetal weight centile (EFWc), type of labor onset (TLO) and other clinical variables.
Material and methods
This was a multicenter retrospective study of 5193 women with singleton pregnancies who underwent an ultrasound scan at 35+0- 41+0 weeks and gave birth within one month of examination, at any of the participating hospitals in Spain, UK, and Italy. CS-IFC was diagnosed in case of abnormal intrapartum fetal heart rate or intrapartum fetal scalp pH<7.20, requiring urgent cesarean section. The diagnostic ability of CPR in multiples of the median (CPR MoM) was evaluated at different intervals to delivery, alone and combined with EFWc, TLO, and other pregnancy data such as maternal age, maternal body mass index, parity, and fetal sex, for the prediction of CS-IFC by means of ROC curves and logistic regression analysis.
Results
The predictive ability of CPR MoM for CS-IFC worsened with the interval to delivery. In general, the best prediction was obtained prior to labor, and adding information related with EFWc and TLO [AUC 0.71 (95% CI 0.64-0.79), 0.73 (95% CI 0.66-0.80) and 0.75 (95% CI 0.69-0.81); P<0.0001]. Addition of more clinical data did not improve prediction. In addition, results did not vary when only cases with spontaneous onset of labor were studied.
Conclusion
CPR MoM prediction of CS-IFC at the end of pregnancy worsens with the interval to delivery. Accordingly, it should be done in the short term and considering EFWc and TLO.
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13
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Lees CC, Romero R, Stampalija T, Dall'Asta A, DeVore GA, Prefumo F, Frusca T, Visser GHA, Hobbins JC, Baschat AA, Bilardo CM, Galan HL, Campbell S, Maulik D, Figueras F, Lee W, Unterscheider J, Valensise H, Da Silva Costa F, Salomon LJ, Poon LC, Ferrazzi E, Mari G, Rizzo G, Kingdom JC, Kiserud T, Hecher K. Clinical Opinion: The diagnosis and management of suspected fetal growth restriction: an evidence-based approach. Am J Obstet Gynecol 2022; 226:366-378. [PMID: 35026129 PMCID: PMC9125563 DOI: 10.1016/j.ajog.2021.11.1357] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 11/22/2021] [Accepted: 11/22/2021] [Indexed: 11/01/2022]
Abstract
This study reviewed the literature about the diagnosis, antepartum surveillance, and time of delivery of fetuses suspected to be small for gestational age or growth restricted. Several guidelines have been issued by major professional organizations, including the International Society of Ultrasound in Obstetrics and Gynecology and the Society for Maternal-Fetal Medicine. The differences in recommendations, in particular about Doppler velocimetry of the ductus venosus and middle cerebral artery, have created confusion among clinicians, and this review has intended to clarify and highlight the available evidence that is pertinent to clinical management. A fetus who is small for gestational age is frequently defined as one with an estimated fetal weight of <10th percentile. This condition has been considered syndromic and has been frequently attributed to fetal growth restriction, a constitutionally small fetus, congenital infections, chromosomal abnormalities, or genetic conditions. Small for gestational age is not synonymous with fetal growth restriction, which is defined by deceleration of fetal growth determined by a change in fetal growth velocity. An abnormal umbilical artery Doppler pulsatility index reflects an increased impedance to flow in the umbilical circulation and is considered to be an indicator of placental disease. The combined finding of an estimated fetal weight of <10th percentile and abnormal umbilical artery Doppler velocimetry has been widely accepted as indicative of fetal growth restriction. Clinical studies have shown that the gestational age at diagnosis can be used to subclassify suspected fetal growth restriction into early and late, depending on whether the condition is diagnosed before or after 32 weeks of gestation. The early type is associated with umbilical artery Doppler abnormalities, whereas the late type is often associated with a low pulsatility index in the middle cerebral artery. A large randomized clinical trial indicated that in the context of early suspected fetal growth restriction, the combination of computerized cardiotocography and fetal ductus venosus Doppler improves outcomes, such that 95% of surviving infants have a normal neurodevelopmental outcome at 2 years of age. A low middle cerebral artery pulsatility index is associated with an adverse perinatal outcome in late fetal growth restriction; however, there is no evidence supporting its use to determine the time of delivery. Nonetheless, an abnormality in middle cerebral artery Doppler could be valuable to increase the surveillance of the fetus at risk. We propose that fetal size, growth rate, uteroplacental Doppler indices, cardiotocography, and maternal conditions (ie, hypertension) according to gestational age are important factors in optimizing the outcome of suspected fetal growth restriction.
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Affiliation(s)
- Christoph C Lees
- Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom.
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI
| | - Tamara Stampalija
- Department of Obstetrics and Gynecology, Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, Scientific Institute for Research, Hospitalization and Healthcare Burlo Garofolo, Trieste, Italy; Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Andrea Dall'Asta
- Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Greggory A DeVore
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Federico Prefumo
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Tiziana Frusca
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Gerard H A Visser
- Department of Obstetrics, University Medical Center, Utrecht, The Netherlands
| | - John C Hobbins
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO
| | - Ahmet A Baschat
- Department of Gynecology and Obstetrics, John Hopkins Center for Fetal Therapy, Johns Hopkins University, Baltimore, MD
| | - Caterina M Bilardo
- Amsterdam UMC, University of Amsterdam, Department of Obstetrics and Gynaecology, Amsterdam, the Netherlands
| | - Henry L Galan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital of Colorado, Aurora, CO
| | | | - Dev Maulik
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Francesc Figueras
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Pavilion for Women, Houston, TX
| | - Julia Unterscheider
- Department of Maternal-Fetal Medicine, Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Australia
| | - Herbert Valensise
- University of Rome Tor Vergata, Rome, Italy; Department of Surgery, Policlinico Casilino, Rome, Italy
| | - Fabricio Da Silva Costa
- Maternal-Fetal Medicine Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia; School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Laurent J Salomon
- Obstétrique et Plateforme LUMIERE, Hôpital Necker-Enfants Malades (AP-HP) et Université de Paris, Paris, France
| | - Liona C Poon
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Hong Kong, Special Administrative Region of China
| | - Enrico Ferrazzi
- Department of Woman, Child and Neonate, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giancarlo Mari
- Department of Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Giuseppe Rizzo
- Università di Roma Tor Vergata, Department of Obstetrics and Gynecology, Fondazione Policinico Tor Vergata, Rome, Italy; The First I.M. Sechenov Moscow State Medical University, Department of Obstetrics and Gynaecology, Moscow, Russian Federation
| | - John C Kingdom
- Placenta Program, Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Torvid Kiserud
- Department of Obstetrics and Gynecology, Haukeland University Hospital, and Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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14
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Bruin C, Damhuis S, Gordijn S, Ganzevoort W. Evaluation and Management of Suspected Fetal Growth Restriction. Obstet Gynecol Clin North Am 2021; 48:371-385. [PMID: 33972072 DOI: 10.1016/j.ogc.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Impaired fetal growth owing to placental insufficiency is a major contributor to adverse perinatal outcomes. No intervention is available that improves outcomes by changing the pathophysiologic process. Monitoring in early-onset fetal growth restriction (FGR) focuses on optimizing the timing of iatrogenic preterm delivery using cardiotocography and Doppler ultrasound. In late-onset FGR, identifying the fetus at risk for immediate hypoxia and who benefits from expedited delivery is challenging. It is likely that studies in the next decade will provide evidence how to best integrate different monitoring variables and other prognosticators in risk models that are aimed to optimize individual treatment strategies.
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Affiliation(s)
- Claartje Bruin
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, University of Amsterdam, Room H4-205, PO Box 22660, Amsterdam 1105 AZ, The Netherlands.
| | - Stefanie Damhuis
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, University of Amsterdam, Room H4-205, PO Box 22660, Amsterdam 1105 AZ, The Netherlands; Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Huispostcode CB20, Hanzeplein 1, Groningen 9700 RB, The Netherlands
| | - Sanne Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Huispostcode CB20, Hanzeplein 1, Groningen 9700 RB, The Netherlands
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, University of Amsterdam, Room H4-205, PO Box 22660, Amsterdam 1105 AZ, The Netherlands
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15
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Dall'Asta A, Kumar S. Prelabor and intrapartum Doppler ultrasound to predict fetal compromise. Am J Obstet Gynecol MFM 2021; 3:100479. [PMID: 34496306 DOI: 10.1016/j.ajogmf.2021.100479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/23/2021] [Accepted: 08/30/2021] [Indexed: 12/17/2022]
Abstract
According to current estimates, over 20% of the 4 million neonatal deaths occurring globally every year are related to intrapartum hypoxic complications that happen as a result of uterine contractions against a background of inadequate placental function. Most of such intrapartum complications occur among apparently uncomplicated term pregnancies. Available evidence suggests that current risk-assessment strategies do not adequately identify many of the fetuses vulnerable to periods of intermittent hypoxia that characterize human labor. In this review, we discuss the data available on Doppler ultrasound for the evaluation of placental function before and during labor in appropriately grown fetuses; we also discuss the current strategies for ultrasound-based risk stratification, the physiology of intrapartum compromise, and the potential future treatments to prevent fetal distress in labor and reduce perinatal complications related to birth asphyxia.
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Affiliation(s)
- Andrea Dall'Asta
- Obstetrics and Gynecology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy (Dr Dall'Asta); Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, London, United Kingdom (Dr Dall'Asta).
| | - Sailesh Kumar
- Mater Research Institute, University of Queensland, Queensland, Australia (Dr Kumar); Faculty of Medicine, The University of Queensland, Queensland, Australia (Dr Kumar)
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16
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Lees C, Stampalija T, Hecher K. Re: Outcome-based comparison of SMFM and ISUOG definitions of fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:493-494. [PMID: 34468059 DOI: 10.1002/uog.23747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 07/06/2021] [Indexed: 06/13/2023]
Affiliation(s)
- C Lees
- Imperial College School of Medicine, Imperial College London, London, UK
- Department of Fetal Medicine, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - T Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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17
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Fernandez-Rodriguez B, de Alba C, Galindo A, Recio D, Villalain C, Pallas CR, Herraiz I. Obstetric and pediatric growth charts for the detection of late-onset fetal growth restriction and neonatal adverse outcomes. J Perinat Med 2021; 49:216-224. [PMID: 33027055 DOI: 10.1515/jpm-2020-0210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/11/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Late-onset fetal growth restriction (FGR) has heterogeneous prenatal and postnatal diagnostic criteria. We compared the prenatal and postnatal diagnosis of late-onset FGR and their ability to predict adverse perinatal outcomes. METHODS Retrospective cohort study of 5442 consecutive singleton pregnancies that delivered beyond 34 + 0 weeks. Prenatal diagnosis of FGR was based on customized fetal growth standards and fetal Doppler while postnatal diagnosis was based on a birthweight <3rd percentile according to newborn charts (Olsen's charts and Intergrowth 21st century programme). Perinatal outcomes were analyzed depending on whether the diagnosis was prenatal, postnatal or both. RESULTS A total of 94 out of 5442 (1.7%) were diagnosed as late-onset FGR prenatally. Olsen's chart and Intergrowth 21st chart detected that 125/5442 (2.3%) and 106/5442 (2.0%) of infants had a birthweight <3rd percentile, respectively. These charts identified 35/94 (37.2%) and 40/94 (42.6%) of the newborns with a prenatal diagnosis of late-onset FGR. Prenatally diagnosed late-onset FGR infants were at a higher risk for hypoglycemia, jaundice and polycythemia. Both prenatally and postnatally diagnosed as late-onset FGR had a higher risk for respiratory distress syndrome when compared to non-FGR. The higher risks for intensive care admission and composite adverse outcomes were observed in those with a prenatal diagnosis of late-onset FGR that was confirmed after birth. CONCLUSIONS Current definitions of pre- and postnatal late-onset FGR do not match in more than half of cases. Infants with a prenatal or postnatal diagnosis of this condition have an increased risk of neonatal morbidity even if these diagnoses are not coincident.
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Affiliation(s)
| | - Concepción de Alba
- Department of Neonatology, University Hospital 12 de Octubre, 12 de Octubre Research Institute (imas12), Complutense University of Madrid, Madrid, Spain
| | - Alberto Galindo
- Department of Obstetrics and Gynaecology, Fetal Medicine Unit-SAMID, University Hospital 12 de Octubre, 12 de Octubre Research Institute (imas12), Complutense University of Madrid, Madrid, Spain
| | - David Recio
- Department of Neonatology, University Hospital 12 de Octubre, 12 de Octubre Research Institute (imas12), Complutense University of Madrid, Madrid, Spain
| | - Cecilia Villalain
- Department of Obstetrics and Gynaecology, Fetal Medicine Unit-SAMID, University Hospital 12 de Octubre, 12 de Octubre Research Institute (imas12), Complutense University of Madrid, Madrid, Spain
| | - Carmen Rosa Pallas
- Department of Neonatology, University Hospital 12 de Octubre, 12 de Octubre Research Institute (imas12), Complutense University of Madrid, Madrid, Spain
| | - Ignacio Herraiz
- Department of Obstetrics and Gynaecology, Fetal Medicine Unit-SAMID, University Hospital 12 de Octubre, 12 de Octubre Research Institute (imas12), Complutense University of Madrid, Madrid, Spain
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18
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Visser GHA, Nicholson WK, Barnea ER, Ramasauskaite D, Nassar AH. FIGO position paper on reference charts for fetal growth and size at birth: Which one to use? Int J Gynaecol Obstet 2020; 152:148-151. [PMID: 33247958 DOI: 10.1002/ijgo.13500] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/27/2020] [Accepted: 11/24/2020] [Indexed: 11/06/2022]
Abstract
Publication of the Intergrowth-21st and WHO growth charts raises the question of which growth data prenatal providers should use in clinical practice. Is it better to use a universal chart applied globally, or metrics based on local or regional growth patterns? And what about customized charts versus local charts? FIGO has reviewed the different growth charts and studies assessing their reproducibility and predictive values for small- and large-for-gestational age newborns and, where available, adverse fetal outcomes. It concludes that local or regional charts are likely to be best for identifying the 10th percentile of newborns at highest risk. However, international standards for growth may also be used when coupled with locally appropriate thresholds for risk interpretation.
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Affiliation(s)
- Gerard H A Visser
- Department of Obstetrics, University Medical Center, Utrecht, The Netherlands
| | - Wanda K Nicholson
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, USA
| | - Eytan R Barnea
- SIEP, The Society for the Investigation of Early Pregnancy, New York, NY, USA
| | - Diana Ramasauskaite
- Center of Obstetrics and Gynaecology, Vilnius University Medical Faculty, Vilnius, Lithuania
| | - Anwar H Nassar
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
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- Committee for Safe Motherhood and Newborn Health, FIGO, London, UK
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19
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Kennedy LM, Tong S, Robinson AJ, Hiscock RJ, Hui L, Dane KM, Middleton AL, Walker SP, MacDonald TM. Reduced growth velocity from the mid-trimester is associated with placental insufficiency in fetuses born at a normal birthweight. BMC Med 2020; 18:395. [PMID: 33357243 PMCID: PMC7758928 DOI: 10.1186/s12916-020-01869-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 11/24/2020] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Fetal growth restriction (FGR) due to placental insufficiency is a major risk factor for stillbirth. While small-for-gestational-age (SGA; weight < 10th centile) is a commonly used proxy for FGR, detection of FGR among appropriate-for-gestational-age (AGA; weight ≥ 10th centile) fetuses remains an unmet need in clinical care. We aimed to determine whether reduced antenatal growth velocity from the time of routine mid-trimester ultrasound is associated with antenatal, intrapartum and postnatal indicators of placental insufficiency among term AGA infants. METHODS Three hundred and five women had biometry measurements recorded from their routine mid-trimester (20-week) ultrasound, at 28 and 36 weeks' gestation, and delivered an AGA infant. Mid-trimester, 28- and 36-week estimated fetal weight (EFW) and abdominal circumference (AC) centiles were calculated. The EFW and AC growth velocities between 20 and 28 weeks, and 20-36 weeks, were examined as predictors of four clinical indicators of placental insufficiency: (i) low 36-week cerebroplacental ratio (CPR; CPR < 5th centile reflects cerebral redistribution-a fetal adaptation to hypoxia), (ii) neonatal acidosis (umbilical artery pH < 7.15) after the hypoxic challenge of labour, (iii) low neonatal body fat percentage (BF%) reflecting reduced nutritional reserve and (iv) placental weight < 10th centile. RESULTS Declining 20-36-week fetal growth velocity was associated with all indicators of placental insufficiency. Each one centile reduction in EFW between 20 and 36 weeks increased the odds of cerebral redistribution by 2.5% (odds ratio (OR) = 1.025, P = 0.001), the odds of neonatal acidosis by 2.7% (OR = 1.027, P = 0.002) and the odds of a < 10th centile placenta by 3.0% (OR = 1.030, P < 0.0001). Each one centile reduction in AC between 20 and 36 weeks increased the odds of neonatal acidosis by 3.1% (OR = 1.031, P = 0.0005), the odds of low neonatal BF% by 2.8% (OR = 1.028, P = 0.04) and the odds of placenta < 10th centile by 2.1% (OR = 1.021, P = 0.0004). Falls in EFW or AC of > 30 centiles between 20 and 36 weeks were associated with two-threefold increased relative risks of these indicators of placental insufficiency, while low 20-28-week growth velocities were not. CONCLUSIONS Reduced growth velocity between 20 and 36 weeks among AGA fetuses is associated with antenatal, intrapartum and postnatal indicators of placental insufficiency. These fetuses potentially represent an important, under-recognised cohort at increased risk of stillbirth. Encouragingly, this novel fetal assessment would require only one additional ultrasound to current routine care, and adds to the potential benefits of routine 36-week ultrasound.
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Affiliation(s)
- Lucy M Kennedy
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Stephen Tong
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Alice J Robinson
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Richard J Hiscock
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Lisa Hui
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Kirsten M Dane
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Anna L Middleton
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Susan P Walker
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Teresa M MacDonald
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia. .,Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia.
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Preventing term stillbirth: benefits and limitations of using fetal growth reference charts. Curr Opin Obstet Gynecol 2020; 31:365-374. [PMID: 31634162 DOI: 10.1097/gco.0000000000000576] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review examines the variation in clinical practice with regards to ultrasound estimation of fetal weight, as well as calculation of fetal weight centiles. RECENT FINDINGS Placental dysfunction is associated with fetal smallness from intrauterine malnutrition as well as fetal disability and even stillbirth from hypoxemia. Although estimating fetal weight can be done accurately, the issue of which fetal weight centile chart should be used continues to be a contentious topic. The arguments against local fetal growth charts based on national borders and customization for variables known to be associated with disease are substantial. As for other human diseases such as hypertension and diabetes, there is a rationale for the use of an international fetal growth reference standard. Irrespective of the choice of fetal growth reference standard, a significant limitation of small for gestational age (SGA) detection programs to prevent stillbirth is that the majority of stillborn infants at term were not SGA at the time of demise. SUMMARY Placental dysfunction can present with SGA from malnutrition and/or stillbirth from hypoxemia depending on the gestational age of onset. Emerging data show that at term, fetal Doppler arterial redistribution is associated more strongly with perinatal death than fetal size. Properly conducted trials of the role for maternal characteristics, fetal size, placental biomarkers, and Doppler assessing fetal well-being are required urgently.
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21
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Deter RL, Lee W, Dicker P, Tully EC, Cody F, Malone FD, Flood KM. Growth patterns and cardiovascular abnormalities in SGA fetuses: 3. Late, adaptive and recovering growth restriction. J Matern Fetal Neonatal Med 2020; 35:2808-2817. [PMID: 32938245 DOI: 10.1080/14767058.2020.1803262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To characterize abnormal growth processes and their associated cardiovascular abnormalities in SGA fetuses using Individualized Growth Assessment (IGA). METHODS This longitudinal investigation utilized a SGA cohort [EFW and BW <10th percentile] derived from the PORTO study. Fetuses categorized by their Fetal Growth Pathology Score [FGPS1] patterns [Pattern 2 {n = 12}, Pattern 3 {n = 11}, Pattern 5 {n = 13}] were evaluated. Growth pathology was measured using the -FGPS1 and the individual composite Prenatal Growth Assessment Score {-icPGAS]. Paired cardiovascular assessments utilized measurements of the Pulsatility Index [umbilical artery {UA}, middle cerebral artery {MCA}, ductus venosus {DV}] and the myocardial performance index [MPI; heart]. Outcome variables were birth age [preterm or, term] and birth weight [small or normal (IGA criteria)]. RESULTS Pattern 2 was usually characterized by a single, growth abnormality (67% of cases) of variable magnitude that occurred within two weeks of delivery {median onset age: 37.6 weeks}. The incidence of UA abnormalities was low (25%) while those of MCA and DV/MPI were high {60%, 42%}. Most neonates were of normal size (67%) and delivered at term (67%). Pattern 3 had an initial progressive growth restriction phase, followed by constant but abnormally low growth. Growth pathology had an early onset (median age: 31.6 weeks), was moderate but persistently abnormal. The incidences of cardiovascular abnormalities were moderate [30-50%]. Most neonates were abnormally small (80%) but delivered at term (90%). Pattern 5 had an initial progressive phase with an early onset [onset age {median}: 31.6 weeks]. However, this process was arrested and returned toward normal. Growth pathology magnitudes were minor as were the incidences of cardiovascular abnormalities. Neonatal size was usually normal and all fetuses delivered at term. CONCLUSIONS Characteristics of SGA Growth Restricted, Patterns 2, 3 and 5 are clearly different from those found in SGA Normal or SGA Growth Restricted Pattern 1 groups. They also differed from one another, indicating that growth restriction can manifest itself in several different ways. Pattern 2 is similar to "late" growth restriction reported previously. Patterns 3 and 5 are novel and have been designated as "adaptive" and "recovering" types of growth restriction.
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Affiliation(s)
- Russell L Deter
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Patrick Dicker
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Elizabeth C Tully
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fiona Cody
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fergal D Malone
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Karen M Flood
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
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Deter RL, Dicker P, Lee W, Tully EC, Cody F, Malone FD, Flood KM. Growth patterns and cardiovascular abnormalities in SGA fetuses: 2. Normal growth and progressive growth restriction. J Matern Fetal Neonatal Med 2020; 35:2818-2827. [PMID: 32924675 DOI: 10.1080/14767058.2020.1807506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To characterize growth processes and their associated cardiovascular abnormalities in SGA fetuses with normal growth and progressive growth restriction patterns as defined by Individualized Growth Assessment (IGA). METHODS A SGA cohort (EFW and BW < 10th percentile) was derived from the PORTO study that included 47 fetuses with normal growth outcome (SGA Normal) and 34 fetuses with progressive growth restriction (SGA Growth Restricted, Pattern 1). Composite fetal size parameters were used to quantify growth pathology at individual third trimester time points (individual composite Prenatal Growth Assessment Score {icPGAS}) and calculated cumulatively during the third trimester (Fetal Growth Pathology Score 1{FGPS1}). Paired Doppler evaluations of the umbilical artery (UA), middle cerebral artery (MCA), ductus venosus (DV) and myocardial performance index (MPI) were used to detect cardiovascular anomalies. Outcome variables were birth age and birth weight. RESULTS Ranking fetuses with respect to the severity of the 3rd trimester growth pathology (-FGPS1) revealed three subgroups in each of these two groups. In SGA Normal, no (51%), minimal (19%) or minor (30%) growth abnormalities were present. Although vascular flow abnormalities occurred without growth abnormalities (UA: 38%; MCA: 35%), they increased with minor growth disturbances (UA: 64%; MCA: 50%). All fetuses delivered at term and in only 7 cases (minor growth abnormalities subgroup) were the neonates abnormally small based on IGA criteria. In SGA Growth Restricted, Pattern 1, the progression of growth restriction was slow (47%), moderate (21%) and rapid (32%). Corresponding median -FGPS1 values were -1.34%, -2.67% and -4.88%, respectively. The median age of onset was 33.6, 29.7 and 29.7 weeks in these three subgroups. UA abnormalities occurred infrequently in the first two subgroups but were found in all cases of rapidly progressing pathology. Similar results were found for the MCA and DV + MPI Doppler parameters (rapid progression: MCA = 50%; DV + MPI = 50%). Premature delivery occurred less frequently with slow progression but was nearly 100% in the moderately and rapidly progressive subgroups. CONCLUSIONS Negative FGPS1 growth restriction patterns can be used to classify SGA fetuses. Subgroups, based on ranked -FGPS1 values in both SGA Normal and SGA Growth Restricted Pattern 1 groups had marked differences in cardiovascular abnormalities and neonatal outcomes. The characteristics of these two groups are consistent with small, normally growing fetuses and fetuses with "early" growth restriction, respectively.
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Affiliation(s)
- Russell L Deter
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Patrick Dicker
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Elizabeth C Tully
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fiona Cody
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fergal D Malone
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Karen M Flood
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
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Stampalija T, Ghi T, Rosolen V, Rizzo G, Ferrazzi EM, Prefumo F, Dall'Asta A, Quadrifoglio M, Todros T, Frusca T. Current use and performance of the different fetal growth charts in the Italian population. Eur J Obstet Gynecol Reprod Biol 2020; 252:323-329. [PMID: 32653605 DOI: 10.1016/j.ejogrb.2020.06.059] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 06/25/2020] [Accepted: 06/26/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The choice of growth charts impacts on screening, diagnosis and clinical management of fetal growth abnormalities. The objectives of the study were to evaluate: 1) the clinical practice at a national level among tertiary referral centers in the use of fetal biometric growth charts; and 2) the impact on fetal growth screening of existing national and international growth charts. STUDY DESIGN A questionnaire was sent to 14 Italian tertiary referral centers to explore biometric reference growth charts used in clinical practice. National and international (Intergrowth-21st and World Health Organization) fetal growth charts were tested on a large national cohort of low risk women with singleton uneventful pregnancy derived from a retrospective cross-sectional multicenter study (21 centers). The percentage of fetuses with biometric measurements below and above the 10th and 90th percentile for each biometric parameter and gestational week were calculated for each growth chart. The percentile curves of the study population were calculated by non-linear quantile regressions. RESULTS Twelve Italian centers (86 %) answered to the questionnaire showing a wide discrepancy in the use of growth charts for fetal biometry. The cohort included 7347 pregnant women. By applying Intergrowth-21st growth charts the percentage of fetuses with head circumference, abdominal circumference and femur length below the 10th centile was 3.9 %, 3.6 % and 2.3 %, and above the 90th centile 29.9 %, 32.5 % and 46 %, respectively. The percentages for the World Health Organization growth charts for head and abdominal circumferences and femur length were: below the 10th centile 6.3 %, 7.2 % and 5.3 %, and above 90th centile 22.8 %, 21.3 % and 31.9 %, respectively. CONCLUSIONS The wide discrepancy in clinical use of fetal growth charts in Italian centers warrants the adoption of an uniform set of charts. Our data suggest that immediate application into clinical practice of international growth charts might result into an under-diagnosis of small for gestational age fetuses and, especially, in an over-diagnosis of large for gestational age fetuses with major consequences for clinical practice. On these grounds, there is an urgent need for a nationwide study for the prospective evaluation of international growth charts and, if needed, the construction and adoption of methodologically robust national growth charts.
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Affiliation(s)
- Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Via dell'Istria 65, 34100 Trieste, Italy; Department of Medicine, Surgery and Health Sciences, University of Trieste, Strada di Fiume 447, 34149 Trieste, Italy.
| | - Tullio Ghi
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Via Gramsci 14, 43125 Parma, Italy.
| | - Valentina Rosolen
- Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Via dell'Istria 65, 34100 Trieste, Italy.
| | - Giuseppe Rizzo
- Division of Maternal Fetal Medicine, Ospedale Cristo Re, University of Rome Tor Vergata, Viale Montpelier 1, 00133 Rome, Italy; Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia.
| | - Enrico Maria Ferrazzi
- IRCCS Fondazione Ca' Granda, Policlinico di Milano, Via Francesco Sforza 28, 20122 Milano, Italy.
| | - Federico Prefumo
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, University of Brescia, Piazza del Mercato 15, 25121 Brescia, Italy; Division of Obstetrics and Gynecology, ASST Spedali Civili, P.le Spedali Civili 1, 25123 Brescia, Italy.
| | - Andrea Dall'Asta
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Via Gramsci 14, 43125 Parma, Italy.
| | - Mariachiara Quadrifoglio
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Via dell'Istria 65, 34100 Trieste, Italy.
| | - Tullia Todros
- Department of Obstetrics and Gynaecology, Ultrasound Centre, University of Turin, Sant'Anna Hospital, Corso Spexzia 60, 10126 Turin, Italy.
| | - Tiziana Frusca
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Via Gramsci 14, 43125 Parma, Italy.
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24
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Lee W, Mack LM, Sangi-Haghpeykar H, Gandhi R, Wu Q, Kang L, Canavan TP, Gatina R, Schild RL. Fetal Weight Estimation Using Automated Fractional Limb Volume With 2-Dimensional Size Parameters: A Multicenter Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1317-1324. [PMID: 32022946 DOI: 10.1002/jum.15224] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 12/08/2019] [Accepted: 12/28/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To develop new fetal weight prediction models using automated fractional limb volume (FLV). METHODS A prospective multicenter study measured fetal biometry within 4 to 7 days of delivery. Three-dimensional data acquisition included the automated FLV that was based on 50% of the humerus diaphysis (fractional arm volume [AVol]) or 50% of the femur diaphysis (fractional thigh volume [TVol]) length. A regression analysis provided population sample-specific coefficients to develop 4 weight estimation models. Estimated and actual birth weights (BWs) were compared for the mean percent difference ± standard deviation of the percent differences. Systematic errors were analyzed by the Student t test, and random errors were compared by the Pitman test. RESULTS A total of 328 pregnancies were scanned before delivery (BW range, 825-5470 g). Only 71.3% to 72.6% of weight estimations were within 10% of actual BW using original published models by Hadlock et al (Am J Obstet Gynecol 1985; 151:333-337) and INTERGROWTH-21st (Ultrasound Obstet Gynecol 2017; 49:478-486). All predictions were accurate by using sample-specific model coefficients to minimize bias in making these comparisons (Hadlock, 0.4% ± 8.7%; INTERGROWTH-21st, 0.5% ± 10.0%; AVol, 0.3% ± 7.4%; and TVol, 0.3% ± 8.0%). Both AVol- and TVol-based models improved the percentage of correctly classified BW ±10% in 83.2% and 83.9% of cases, respectively, compared to the INTERGROWTH-21st model (73.8%; P < .01). For BW of less than 2500 g, all models slightly overestimated BW (+2.0% to +3.1%). For BW of greater than 4000 g, AVol (-2.4% ± 6.5%) and TVol (-2.3% ± 6.9%) models) had weight predictions with small systematic errors that were not different from zero (P > .05). For these larger fetuses, both AVol and TVol models correctly classified BW (±10%) in 83.3% and 87.5% of cases compared to the others (Hadlock, 79.2%; INTERGROWTH-21st, 70.8%) although these differences did not reach statistical significance. CONCLUSIONS In this cohort, the inclusion of automated FLV measurements with conventional 2-dimensional biometry was generally associated with improved weight predictions.
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Affiliation(s)
- Wesley Lee
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Lauren M Mack
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | | | - Rajshi Gandhi
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Qingqing Wu
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Li Kang
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Timothy P Canavan
- Magee-Women's Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Coutinho CM, Melchiorre K, Thilaganathan B. Stillbirth at term: Does size really matter? Int J Gynaecol Obstet 2020; 150:299-305. [PMID: 32438457 DOI: 10.1002/ijgo.13229] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/06/2020] [Accepted: 05/14/2020] [Indexed: 01/22/2023]
Abstract
Placental dysfunction has a deleterious influence on fetal size and is associated with higher rates of perinatal morbidity and mortality. This association underpins the strategy of fetal size evaluation as a mechanism to identify placental dysfunction and prevent stillbirth. The optimal method of routine detection of small for gestational age (SGA) remains to be clarified with choices between estimation of symphyseal-fundal height versus routine third-trimester ultrasound, various formulae for fetal weight estimation by ultrasound, and the variable use of national, customized, or international fetal growth references. In addition to these controversies, the strategy for detecting SGA is further undermined by data demonstrating that the relationship between fetal size and adverse outcome weakens significantly with advancing gestation such that near term, the majority of stillbirths and adverse perinatal outcomes occur in normally sized fetuses. The use of maternal serum biochemical and Doppler parameters near term appears to be superior to fetal size in the identification of fetuses compromised by placental dysfunction and at increased risk of damage or demise. Multiparameter models and predictive algorithms using maternal risk factors, and biochemical and Doppler parameters have been developed, but need to be prospectively validated to demonstrate their effectiveness.
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Affiliation(s)
- Conrado Milani Coutinho
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.,Department of Obstetrics and Gynaecology, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Karen Melchiorre
- Department of Obstetrics and Gynaecology, Spirito Santo Tertiary Level Hospital of Pescara, Pescara, Italy
| | - Basky Thilaganathan
- Department of Obstetrics and Gynaecology, St. George's University Hospitals NHS Foundation Trust, London, UK.,Molecular and Clinical Sciences Research Institute, St. George's University of London, London, UK
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Hansen DN, Odgaard HS, Uldbjerg N, Sinding M, Sørensen A. Screening for small-for-gestational-age fetuses. Acta Obstet Gynecol Scand 2019; 99:503-509. [PMID: 31670396 DOI: 10.1111/aogs.13764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 10/24/2019] [Accepted: 10/29/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION It is well established that correct antenatal identification of small-for-gestational-age (SGA) fetuses reduces their risk of adverse perinatal outcome with long-term consequences. Ultrasound estimates of fetal weight (EFWus ) are the ultimate tool for this identification. It can be conducted as a "universal screening", that is, all pregnant women at a specific gestational age. However, in Denmark it is conducted as "selective screening", that is, only on clinical indication. The aim of this study was to assess the performance of the Danish national SGA screening program and the consequences of false-positive and false-negative SGA cases. MATERIAL AND METHODS In this retrospective cohort study, we included 2928 women with singleton pregnancies with due dates in 2015. We defined "risk of SGA" by an EFWus ≤ -15% of expected for the gestational age and "SGA" as birthweight ≤-22% of expected for gestational age. RESULTS At birth, the prevalence of SGA was 3.3%. The overall sensitivity of the Danish screening program was 62% at a false-positive rate of 5.6%. Within the entire cohort, 63% had an EFWus compared with 79% of the SGA cases. The sensitivity was 79% for those born before 37 weeks of gestation but only 40% for those born after 40 weeks of gestation. The sensitivity was also associated with birthweight deviation; 73% among extreme SGA cases (birthweight deviation ≤-33%) and 55% among mild SGA (birthweight deviation between -22% and -27%). False diagnosis of SGA was associated with an increased rate of induction of labor (ORadj = 2.51, 95% CI 1.70-3.71) and cesarean section (ORadj = 1.44, 95% CI 0.96-2.18). CONCLUSIONS The performance of the Danish national screening program for SGA based on selective EFWus on clinical indication has improved considerably over the last 20 years. Limitations of the program are the large proportion of women referred to ultrasound scan and the low performance post-term.
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Affiliation(s)
- Ditte N Hansen
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Helle S Odgaard
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark
| | - Niels Uldbjerg
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Marianne Sinding
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne Sørensen
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Chatzakis C, Papaioannou GK, Eleftheriades M, Makrydimas G, Dinas K, Sotiriadis A. Perinatal outcome of appropriate-weight fetuses with decelerating growth. J Matern Fetal Neonatal Med 2019; 34:3362-3369. [PMID: 31718357 DOI: 10.1080/14767058.2019.1684470] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION To assess the perinatal outcome of fetuses dropping by ≥50 estimated fetal weight (EFW) centiles between the second and third trimester. METHODS Singleton pregnancies progressing after 32 + 0 weeks, who had their second- and third-trimester scans at our institutions were enrolled in the study. The perinatal outcome of AGA fetuses crossing more than 50 centiles was compared to that of fetuses with FGR, small for gestational age (SGA) and nondecelerating appropriate for gestational age (AGA). The primary perinatal outcomes were perinatal death, neonatal intensive care (NICU) admission and emergency cesarean section (CS). The rates of these outcomes were compared between the four groups and regression analysis was performed to account for maternal and fetal confounders. RESULTS Our analysis included 4394 cases. Compared to nondecelerating SGA, fetuses crossing ≥50 centiles had higher rates of NICU admission (odds ratio [OR] 1.8, 95% confidence interval [CI] CI 1.1-3.1) and perinatal death (OR 3.8, 95%CI 1.3-11.4). Regression analysis showed that significant independent predictors for NICU admission included maternal age, gestational age at birth and FGR (area under the curve [AUC] 0.851), whereas significant predictors for perinatal death included maternal age, gestational age at birth, decelerating growth ≥50 centiles, conception through ART and third-trimester CPR centile (AUC 0.801). CONCLUSION AGA fetuses that cross >50 EFW centiles between the second and third trimester are at increased risk of adverse perinatal outcome and it seems advisable that they are followed up as typical FGR cases.
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Affiliation(s)
- Christos Chatzakis
- 2nd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | | | - Makarios Eleftheriades
- 2nd Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - George Makrydimas
- Department of Obstetrics and Gynecology, University of Ioannina Medical School, Ioannina, Greece
| | - Konstantinos Dinas
- 2nd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Alexandros Sotiriadis
- 2nd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
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Karaaslan O, Islamova G, Soylemez F, Kalafat E. Ultrasound in labor admission to predict need for emergency cesarean section: a prospective, blinded cohort study. J Matern Fetal Neonatal Med 2019; 34:1991-1998. [PMID: 31718351 DOI: 10.1080/14767058.2019.1687682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To assess whether assessment with ultrasound could improve the detection of emergency cesarean section (ECS) in laboring women. METHODS Women who presented with symptoms of active labor or women in need of labor induction were invited to participate in the study. Women included in the study were evaluated with ultrasonography for fetal biometry and vaginal examinations for Bishop score assessment. The main aim in this study was determining factors associated with ECS due to fetal distress and obstructed labor. RESULTS No fetal biometry variable was associated with ECS due to any indication (fetal distress and obstructed labor combined) in the univariate analysis. In multivariate analyses, biometry variables were adjusted for Bishop score at admission and only abdominal circumference percentile showed a significant association with the odds of ECS due to any indication (OR:1.02, 95% CI: 1.01-1.03). Biparietal diameter and abdominal circumference variables were associated with the odds of ECS due to obstructed labor in both univariate and multivariate analyses (p < .05 for all). However, the predictive accuracy of biparietal diameter percentile (area under the curve (AUC): 0.55, 95% CI: 0.46-0.63) and abdominal circumference percentile (AUC: 0.56, 95% CI: 0.48-0.64) without adjunct variables were poor. Moreover, the addition of fetal biometry parameters to Bishop score did not improve the predictive accuracy of Bishop score. CONCLUSION Ultrasound assessment at admission, in addition to Bishop score assessment, did not significantly improve the prediction of ECS. Also, the fetal biometry alone had poor predictive capability for ECS. Routine ultrasound assessment at labor admission appears to be ineffective for predicting ECS.PrecisFetal biparietal diameter and abdominal circumference showed an association with emergency cesarean due to obstructed labor but the predictive accuracy of fetal biometry was low. Routine ultrasound examination at admission, in addition to Bishop score assessment, may not useful for assessing the risk of emergency section in unselected populations.
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Affiliation(s)
- Onur Karaaslan
- Obstetrics and Gynecology Clinic, Hakkari State Hospital, Hakkari, Turkey
| | - Gunel Islamova
- Department of Obstetrics and Gynecology, Ankara University, Ankara, Turkey
| | - Feride Soylemez
- Department of Obstetrics and Gynecology, Ankara University, Ankara, Turkey
| | - Erkan Kalafat
- Obstetrics and Gynecology Clinic, Hakkari State Hospital, Hakkari, Turkey.,Department of Obstetrics and Gynecology, Ankara University, Ankara, Turkey.,Department of Statistics, Middle East Technical University, Ankara, Turkey
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Correlation of Ultrasonographic Estimation of Fetal Weight with Actual Birth Weight as Seen in a Private Specialist Hospital in South East Nigeria. Int J Reprod Med 2019; 2019:3693797. [PMID: 31781589 PMCID: PMC6854978 DOI: 10.1155/2019/3693797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 08/04/2019] [Indexed: 11/17/2022] Open
Abstract
Background Ultrasound estimation of fetal weight at term provides vital information for the skilled birth attendants to make decisions on the possible best route of delivery of the fetus. This is more pertinent in a setting where women book late for antenatal care. Aim and Objectives The study evaluated the accuracy of estimation of fetal weight with ultrasound machine at term. Methods This was a cross sectional study conducted at a private specialist hospital in Nigeria. A coded questionnaire was used to retrieve relevant information which included the last menstrual period, gestational age, parity, and birth weight. Other information obtained includes Ultrasound-delivery interval, maternal weight, and route of delivery. The ultrasound was used to estimate the fetal weight. The actual birth weight was determined using a digital baby weighing scale. The data were inputted into Microsoft excel and analyzed using STATA version 14. Statistical significance was considered at p-values less than 0.05. Measures of accuracy evaluated in the statistical analysis included mean error, mean absolute error, mean percentage error, and mean absolute percentage error. Pearson correlation was done between the estimated ultrasound fetal weight and the actual birth weight. The proportion of estimates within ±10% of actual birth weight was also determined. Result A total of 170 pregnant women participated in the study. The mean maternal age was 30.77 years ± 5.54. The mean birth weight was 3.47 kg ± 0.47, while the mean estimated ultrasound weight was 3.43 kg ± 0.8. There was positive correlation between the ultrasound estimated weight and the actual birth weight. The mean ultrasound scan to delivery interval was 0.8 days (with range of 0–2 days). The study recorded a mean error of estimation of 41.17 grams and mean absolute error of 258.22 grams. The mean percentage error was 0.65%, while the mean absolute error of estimation was 7.56%. About 72.54% of the estimated weights were within 10% of the actual birth weight. Conclusion The ultrasound estimated fetal weight correlated with the actual birth weight. Ultrasound estimation of fetal weight should be done when indicated to aid the clinician in making decisions concerning routes of delivery.
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30
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Deter RL, Lee W, Dicker P, Tully EC, Cody F, Malone FD, Flood KM. Growth patterns and cardiovascular abnormalities in small for gestational age fetuses: 1. Pattern characteristics. J Matern Fetal Neonatal Med 2019; 34:3029-3038. [PMID: 31630585 DOI: 10.1080/14767058.2019.1677592] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Fetal growth restriction is being defined as either "early" or "late" depending on age of onset. A recent investigation using individualized assessment has identified five different growth restriction patterns. No previous study has related these patterns to cardiovascular abnormalities. OBJECTIVES To determine growth patterns in small fetuses (BW < 10th percentile) using Individualized Growth Assessment (IGA) and to relate cardiovascular abnormalities found with Doppler ultrasound to these patterns. STUDY DESIGN A secondary analysis was carried out in 126 fetuses from the PORTO data set having both estimated weights and birth weights below the 10th percentile. Only fetuses with 2nd and 3rd trimester biometry scans appropriate for IGA and cardiovascular assessments were studied. There was one-to-one matching of biometry and Doppler evaluations in the 3rd trimester. Composite growth parameters were used to quantify growth pathology at individual time points (individual composite Prenatal Growth Assessment Score (icPGAS)) and during the 3rd trimester (Fetal Growth Pathology Score {FGPS1}). Normal and growth restriction patterns were identified using plots of FGPS1 values. Doppler measurements were classified as normal or abnormal based on published cross-sectional standards. Outcome variables were birth weight and birth age. RESULTS In these SGA cases, 38.2% showed normal fetal growth and 61.8% had growth restriction. In the latter, seven different patterns were observed. Pattern 1 was most common (43.5%), followed by Patterns 5 (16.7%), 2 (15.4%) and 3 (14.1%). The characteristics of Pattern 1 indicated progressive growth restriction while Pattern 5 demonstrated recovery from an initial growth abnormality. Cardiovascular abnormalities were quite variable, with those in the umbilical artery being most frequent in Patterns 1 and 3. Pattern 2 had the highest incidence of middle cerebral artery abnormalities. Umbilical artery abnormalities were similar in the Normal and Pattern 5 groups as were those for the middle cerebral artery. Other cardiovascular abnormalities had low frequencies except in Pattern 2 where the ductus venosus incidence was high. Abnormally small neonates, as identified with IGA, were seen primarily in Patterns 1, 3 and 6 (80-88%). Premature deliveries occurred most frequently in Pattern 1 (56%), followed by Pattern 2 (33%). CONCLUSIONS Growth in this SGA Group was very heterogeneous with a significant proportion of these small fetuses growing normally. Growth restriction did not appear to be a single process but was manifest as seven different FGPS1 patterns. Both growth pathology and cardiovascular abnormalities differed among patterns. Further investigation will be required to determine how specific growth abnormalities are related to fetal cardiovascular changes over time.
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Affiliation(s)
- Russell L Deter
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Patrick Dicker
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Elizabeth C Tully
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fiona Cody
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fergal D Malone
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Karen M Flood
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
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31
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Gyselaers W, Thilaganathan B. Preeclampsia: a gestational cardiorenal syndrome. J Physiol 2019; 597:4695-4714. [PMID: 31343740 DOI: 10.1113/jp274893] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 06/13/2019] [Indexed: 12/12/2022] Open
Abstract
It is generally accepted today that there are two different types of preeclampsia: an early-onset or placental type and a late-onset or maternal type. In the latent phase, the first one presents with a low output/high resistance circulation eventually leading in the late second or early third trimester to an intense and acutely aggravating systemic disorder with an important impact on maternal and neonatal mortality and morbidity; the other type presents initially as a high volume/low resistance circulation, gradually evolving to a state of circulatory decompensation usually in the later stages of pregnancy, with a less severe impact on maternal and neonatal outcome. For both processes, numerous dysfunctions of the heart, kidneys, arteries, veins and interconnecting systems are reported, most of them presenting earlier and more severely in early- than in late-onset preeclampsia; however, some very specific dysfunctions exist for either type. Experimental, clinical and epidemiological observations before, during and after pregnancy are consistent with gestation-induced worsening of subclinical pre-existing chronic cardiovascular dysfunction in early-onset preeclampsia, and thus sharing the pathophysiology of cardiorenal syndrome type II, and with acute volume overload decompensation of the maternal circulation in late-onset preeclampsia, thus sharing the pathophysiology of cardiorenal syndrome type 1. Cardiorenal syndrome type V is consistent with the process of preeclampsia superimposed upon clinical cardiovascular and/or renal disease, alone or as part of a systemic disorder. This review focuses on the specific differences in haemodynamic dysfunctions between the two types of preeclampsia, with special emphasis on the interorgan interactions between heart and kidneys, introducing the theoretical concept that the pathophysiological processes of preeclampsia can be regarded as the gestational manifestations of cardiorenal syndromes.
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Affiliation(s)
- Wilfried Gyselaers
- Department of Obstetrics & Gynaecology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.,Department Physiology, Hasselt University, Agoralaan, 3590, Diepenbeek, Belgium
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, UK.,Molecular and Clinical Sciences Research Institute, St George's University of London, UK
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Budunoglu MD, Yapca OE, Yldildiz GA, Atakan Al R. Fetal renal blood flow velocimetry and cerebro-placental ratio in patients with isolated oligohydramnios. J Gynecol Obstet Hum Reprod 2019; 48:495-499. [PMID: 31176048 DOI: 10.1016/j.jogoh.2019.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 05/20/2019] [Accepted: 06/04/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE It's proposed that oligohydramnios is caused by decreased renal perfusion due to redistribution of fetal blood at fetal growth restriction. Isolated oligohydramnios refers to the presence of oligohydramnios without fetal structural and chromosomal abnormalities, without fetal growth restriction, without intrauterine infection, and in the absence of known maternal disease. It's unknown whether the redistribution or decreased renal perfusion cause isolated oligohydramnios. The aim of the study was to evaluate fetal renal artery Doppler blood velocimetry and cerebro-placental ratio (CPR) among women with isolated oligohydramnios between 25-40 weeks of gestational age. STUDY DESIGN The middle cerebral artery, umbilical artery and, renal artery pulsatility index (PI) values were measured in 45 fetuses with isolated oligohydramnios and 65 fetuses with normal amniotic fluid. Oligohydramnios was defined as deepest vertical amniotic fluid being measured lower than 1cm. The CPR (middle cerebral artery PI/umbilical artery PI) and renal artery PI values were expressed as multiples of the normal median (MoM) and were compared between the two groups. RESULTS There was no difference in MoM of CPR PI (p=0.167) and MoM of renal artery PI values (right p=0.253, left p=0.353) between the groups. CONCLUSION The renal artery Doppler velocimetry and CPR were not significantly different in the women with isolated oligohydramnios, compared to the women with normal amniotic fluid.
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Affiliation(s)
| | - Omer Erkan Yapca
- Department of Obstetrics and Gynecology, Ataturk University, Faculty of Medicine, Turkey
| | | | - Ragip Atakan Al
- Department of Obstetrics and Gynecology, Ataturk University, Faculty of Medicine, Turkey.
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Rolnik DL, Wang Y, Hyett J, Silva Costa FD, Nie G. Serum podocalyxin at 11-13 weeks of gestation in the prediction of small for gestational age neonates. J Perinatol 2019; 39:784-790. [PMID: 30952947 DOI: 10.1038/s41372-019-0370-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/09/2019] [Accepted: 02/15/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To investigate a potential new marker for the prediction of small for gestational age (SGA) infants. STUDY DESIGN Nested case-control study involving 280 uncomplicated pregnancies and 70 cases of SGA without pre-eclampsia. Serum podocalyxin was measured at 11-13 weeks of gestation and results were expressed in multiples of the median (MoM). The performance of screening by a combination of maternal history and podocalyxin levels was assessed with ROC curves. RESULTS SGA was predicted by maternal age, height, South Asian ethnicity, and previous delivery without pre-eclampsia. Median podocalyxin levels were higher in affected than uncomplicated pregnancies (1.303 versus 0.994 MoM, p < 0.001). At a 10% false-positive rate, maternal history identified 40.0% of the cases (AUC = 0.74, 95%CI 0.671-0.809). The addition of podocalyxin increased the detection to 54.3% (AUC = 0.78, 95%CI 0.771-0.842, p = 0.027 for the difference in ROC curves). CONCLUSION First-trimester podocalyxin may be useful in screening for SGA infants.
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Affiliation(s)
- Daniel Lorber Rolnik
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Yao Wang
- Implantation and Placental Development Laboratory, Centre for Reproductive Health, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Molecular and Translational Science, Monash University, Melbourne, VIC, Australia
| | - Jonathan Hyett
- University of Sydney, Sydney, NSW, Australia.,RPA Women and Babies, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Fabricio da Silva Costa
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia.,Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Guiying Nie
- Implantation and Placental Development Laboratory, Centre for Reproductive Health, Hudson Institute of Medical Research, Melbourne, VIC, Australia. .,Department of Molecular and Translational Science, Monash University, Melbourne, VIC, Australia. .,Department of Biochemistry and Molecular Biology, Monash University, Melbourne, VIC, Australia.
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Alavifard S, Meier K, Shulman Y, Tomlinson G, D’Souza R. Derivation and validation of a model predicting the likelihood of vaginal birth following labour induction. BMC Pregnancy Childbirth 2019; 19:130. [PMID: 30991983 PMCID: PMC6469110 DOI: 10.1186/s12884-019-2232-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 02/28/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND There is high-quality evidence supporting induction of labour (IOL) for a number of maternal and fetal indications. However, one fifth of inductions fail to result in vaginal births, requiring cesarean deliveries. This has negative clinical, emotional and resource implications. The importance of predicting the success of labour induction to enable shared decision-making has been recognized, but existing models are limited in scope and generalizability. Our objective was to derive and internally validate a clinical prediction model that uses variables readily accessible through maternal demographic data, antenatal history, and cervical examination to predict the likelihood of vaginal birth following IOL. METHODS Data was extracted from electronic medical records of consecutive pregnant women who were induced between April and December 2016, at Mount Sinai Hospital, Toronto, Canada. A multivariable logistic regression model was developed using 16 readily accessible variables identified through literature review and expert opinion, as predictors of vaginal birth after IOL. The final model was internally validated using 10-fold cross-validation. RESULTS Of the 1123 cases of IOL, 290 (25.8%) resulted in a cesarean delivery. The multivariable logistic regression model found maternal age, parity, pre-pregnancy body mass index and weight, weight at delivery, and cervical dilation at time of induction as significant predictors of vaginal delivery following IOL. The prediction model was well calibrated (Hosmer-Lemeshow χ2 = 5.02, p = 0.76) and demonstrated good discriminatory ability (area under the receiver operating characteristic (AUROC) curve, 0.81 (95% CI 0.78 to 0.83)). Finally, the model showed good internal validity [AUROC 0.77 (95% CI 0.73 to 0.82)]. CONCLUSIONS We have derived and internally validated a well-performing clinical prediction model for IOL in a large and diverse population using variables readily accessible through maternal demographic data, antenatal history, and cervical examination. Once prospectively validated in diverse settings, and if shown to be acceptable to pregnant women and healthcare providers as well as clinically and cost-effective, this model has potential for widespread use in clinical practice and research for enhancing patient autonomy, improving induction outcomes, and optimizing allocation of resources.
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Affiliation(s)
- Sepand Alavifard
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON Canada
- Faculty of Medicine, University of Toronto, Toronto, ON Canada
| | - Kennedy Meier
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON Canada
- Faculty of Medicine, University of Toronto, Toronto, ON Canada
| | - Yonatan Shulman
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON Canada
| | - George Tomlinson
- Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON Canada
| | - Rohan D’Souza
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON Canada
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON Canada
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Preyer O, Husslein H, Concin N, Ridder A, Musielak M, Pfeifer C, Oberaigner W, Husslein P. Fetal weight estimation at term - ultrasound versus clinical examination with Leopold's manoeuvres: a prospective blinded observational study. BMC Pregnancy Childbirth 2019; 19:122. [PMID: 30971199 PMCID: PMC6458793 DOI: 10.1186/s12884-019-2251-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 03/18/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fetal weight estimation is of key importance in the decision-making process for obstetric planning and management. The literature is inconsistent on the accuracy of measurements with either ultrasound or clinical examination, known as Leopold's manoeuvres, shortly before term. Maternal BMI is a confounding factor because it is associated with both the fetal weight and the accuracy of fetal weight estimation. The aim of our study was to compare the accuracy of fetal weight estimation performed with ultrasound and with clinical examination with respect to BMI. METHODS In this prospective blinded observational study we investigated the accuracy of clinical examination as compared to ultrasound measurement in fetal weight estimation, taking the actual birth weight as the gold standard. In a cohort of all consecutive patients who presented in our department from January 2016 to May 2017 to register for delivery at ≥37 weeks, examination was done by ultrasound and Leopold's manoeuvres to estimate fetal weight. All examiners (midwives and physicians) had about the same level of professional experience. The primary aim was to compare overall absolute error, overall absolute percent error, absolute percent error > 10% and absolute percent error > 20% for weight estimation by ultrasound and by means of Leopold's manoeuvres versus the actual birth weight as the given gold standard, namely separately for normal weight and for overweight pregnant women. RESULTS Five hundred forty-three patients were included in the data analysis. The accuracy of fetal weight estimation was significantly better with ultrasound than with Leopold's manoeuvres in all absolute error calculations made in overweight pregnant women. For all error calculations performed in normal weight pregnant women, no statistically significant difference was seen in the accuracy of fetal weight estimation between ultrasound and Leopold's manoeuvres. CONCLUSIONS Data from our prospective blinded observational study show a significantly better accuracy of ultrasound for fetal weight estimation in overweight pregnant women only as compared to Leopold's manoeuvres with a significant difference in absolute error. We did not observe significantly better accuracy of ultrasound as compared to Leopold's manoeuvres in normal weight women. Further research is needed to analyse the situation in normal weight women.
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Affiliation(s)
- Oliver Preyer
- Department of Obstetrics and Gynaecology, University Teaching Hospital Tauernklinikum Zell am See, Paracelsusstrasse 8, A-5700, Zell am See, Austria.
| | - Heinrich Husslein
- Department of Obstetrics and Gynaecology, Division of General Gynaecology and Gynaecologic Oncology, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Nicole Concin
- Department of Obstetrics and Gynaecology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Anna Ridder
- Paracelsus Medical University, Strubergasse 21, A-5020, Salzburg, Austria
| | - Maciej Musielak
- Department of Obstetrics and Gynaecology, University Teaching Hospital Tauernklinikum Zell am See, Paracelsusstrasse 8, A-5700, Zell am See, Austria
| | - Christian Pfeifer
- Department of Clinical Epidemiology of the Tyrolean State Hospitals Ltd, Cancer Registry of Tyrol, Tirolkliniken GmbH, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Willi Oberaigner
- Department of Clinical Epidemiology of the Tyrolean State Hospitals Ltd, Cancer Registry of Tyrol, Tirolkliniken GmbH, Anichstrasse 35, A-6020, Innsbruck, Austria
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and HTA, UMIT The Health & Life Sciences University, Eduard-Wallnöfer-Zentrum 1, A-6060, Hall in Tirol, Austria
| | - Peter Husslein
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
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