Biophysical profile in the treatment of intrauterine growth-restricted fetuses who weigh <1000 g

Diagnostic Tests in the Prediction of Neonatal Outcome in Early Placental Fetal Growth Restriction

Background and Objectives: Monitoring pregnancies with fetal growth restriction (FGR) presents a challenge, especially concerning the time of delivery in cases of early preterm pregnancies below 32 weeks. The aim of our study was to compare different diagnostic parameters in growth-restricted preterm neonates with and without morbidity/mortality and to determine sensitivity and specificity of diagnostic parameters for monitoring preterm pregnancies with early preterm fetal growth restriction below 32 weeks. Materials and Methods: Our clinical study evaluated 120 cases of early preterm deliveries, with gestational age ≤ 32 + 0 weeks, with prenatally diagnosed placental FGR. All the patients were divided into three groups of 40 cases each based on neonatal condition,: I-Neonates with morbidity/mortality (NMM); II-Neonates without morbidity with acidosis/asphyxia (NAA); III-Neonates without neonatal morbidity/acidosis/asphyxia (NWMAA). Results: Amniotic fluid index (AFI) was lower in NMM, while NWMAA had higher biophysical profile scores (BPS). UA PI was lower in NWMAA. NWMAA had higher MCA PI and CPR and fewer cases with CPR <5th percentile. NMM had higher DV PI, and more often had ductus venosus (DV) PI > 95th‱ or absent/reversed A wave, and pulsatile blood flow in umbilical vein (UV). The incidence of pathological fetal heart rate monitoring (FHRM) was higher in NMM and NAA, although the difference was not statistically significant. ROC calculated by defining a bad outcome as NMM and a good outcome as NAA and NWMAA showed the best sensitivity in DV PIi. ROC calculated by defined bad outcome in NMM and NAA and good outcome in NWMAA showed the best sensitivity in MCA PI. Conclusions: In early fetal growth restriction normal cerebral blood flow strongly predicts good outcomes, while pathological venous blood flow is associated with bad outcomes. In fetal growth restriction before 32 weeks, individualized expectant management remains the best option for the optimal timing of delivery.

The role of the fetal biophysical profile in the management of fetal growth restriction

Growth-restricted fetuses are at risk of hypoxemia, acidemia, and stillbirth because of progressive placental dysfunction. Current fetal well-being, neonatal risks following delivery, and the anticipated rate of fetal deterioration are the major management considerations in fetal growth restriction. Surveillance has to quantify the fetal risks accurately to determine the delivery threshold and identify the testing frequency most likely to capture future deterioration and prevent stillbirth. From the second trimester onward, the biophysical profile score correlates over 90% with the current fetal pH, and a normal score predicts a pH >7.25 with a 100% positive predictive value; an abnormal score on the other hand predicts current fetal acidemia with similar certainty. Between 30% and 70% of growth-restricted fetuses with a nonreactive heart rate require biophysical profile scoring to verify fetal well-being, and an abnormal score in 8% to 27% identifies the need for delivery, which is not suspected by Doppler findings. Future fetal well-being is not predicted by the biophysical profile score, which emphasizes the importance of umbilical artery Doppler and amniotic fluid volume to determine surveillance frequency. Studies with integrated surveillance strategies that combine frequent heart rate monitoring with biophysical profile scoring and Doppler report better outcomes and stillbirth rates of between 0% and 4%, compared with those between 8% and 11% with empirically determined surveillance frequency. The variations in clinical behavior and management challenges across gestational age are better addressed when biophysical profile scoring is integrated into the surveillance of fetal growth restriction. This review aims to provide guidance on biophysical profile scoring in the in- and outpatient management of fetal growth restriction.

Society for Maternal-Fetal Medicine Consult Series #52: Diagnosis and management of fetal growth restriction: (Replaces Clinical Guideline Number 3, April 2012)

Fetal growth restriction can result from a variety of maternal, fetal, and placental conditions. It occurs in up to 10% of pregnancies and is a leading cause of infant morbidity and mortality. This complex obstetrical problem has disparate published diagnostic criteria, relatively low detection rates, and limited preventative and treatment options. The purpose of this Consult is to outline an evidence-based, standardized approach for the prenatal diagnosis and management of fetal growth restriction. The recommendations of the Society for Maternal-Fetal Medicine are as follows: (1) we recommend that fetal growth restriction be defined as an ultrasonographic estimated fetal weight or abdominal circumference below the 10th percentile for gestational age (GRADE 1B); (2) we recommend the use of population-based fetal growth references (such as Hadlock) in determining fetal weight percentiles (GRADE 1B); (3) we recommend against the use of low-molecular-weight heparin for the sole indication of prevention of recurrent fetal growth restriction (GRADE 1B); (4) we recommend against the use of sildenafil or activity restriction for in utero treatment of fetal growth restriction (GRADE 1B); (5) we recommend that a detailed obstetrical ultrasound examination (current procedural terminology code 76811) be performed with early-onset fetal growth restriction (<32 weeks of gestation) (GRADE 1B); (6) we recommend that women be offered fetal diagnostic testing, including chromosomal microarray analysis, when fetal growth restriction is detected and a fetal malformation, polyhydramnios, or both are also present regardless of gestational age (GRADE 1B); (7) we recommend that pregnant women be offered prenatal diagnostic testing with chromosomal microarray analysis when unexplained isolated fetal growth restriction is diagnosed at <32 weeks of gestation (GRADE 1C); (8) we recommend against screening for toxoplasmosis, rubella, or herpes in pregnancies with fetal growth restriction in the absence of other risk factors and recommend polymerase chain reaction for cytomegalovirus in women with unexplained fetal growth restriction who elect diagnostic testing with amniocentesis (GRADE 1C); (9) we recommend that once fetal growth restriction is diagnosed, serial umbilical artery Doppler assessment should be performed to assess for deterioration (GRADE 1C); (10) with decreased end-diastolic velocity (ie, flow ratios greater than the 95th percentile) or in pregnancies with severe fetal growth restriction (estimated fetal weight less than the third percentile), we suggest weekly umbilical artery Doppler evaluation (GRADE 2C); (11) we recommend Doppler assessment up to 2-3 times per week when umbilical artery absent end-diastolic velocity is detected (GRADE 1C); (12) in the setting of reversed end-diastolic velocity, we suggest hospitalization, administration of antenatal corticosteroids, heightened surveillance with cardiotocography at least 1-2 times per day, and consideration of delivery depending on the entire clinical picture and results of additional evaluation of fetal well-being (GRADE 2C); (13) we suggest that Doppler assessment of the ductus venosus, middle cerebral artery, or uterine artery not be used for routine clinical management of early- or late-onset fetal growth restriction (GRADE 2B); (14) we suggest weekly cardiotocography testing after viability for fetal growth restriction without absent/reversed end-diastolic velocity and that the frequency be increased when fetal growth restriction is complicated by absent/reversed end-diastolic velocity or other comorbidities or risk factors (GRADE 2C); (15) we recommend delivery at 37 weeks of gestation in pregnancies with fetal growth restriction and an umbilical artery Doppler waveform with decreased diastolic flow but without absent/reversed end-diastolic velocity or with severe fetal growth restriction with estimated fetal weight less than the third percentile (GRADE 1B); (16) we recommend delivery at 33-34 weeks of gestation for pregnancies with fetal growth restriction and absent end-diastolic velocity (GRADE 1B); (17) we recommend delivery at 30-32 weeks of gestation for pregnancies with fetal growth restriction and reversed end-diastolic velocity (GRADE 1B); (18) we suggest delivery at 38-39 weeks of gestation with fetal growth restriction when the estimated fetal weight is between the 3rd and 10th percentile and the umbilical artery Doppler is normal (GRADE 2C); (19) we suggest that for pregnancies with fetal growth restriction complicated by absent/reversed end-diastolic velocity, cesarean delivery should be considered based on the entire clinical scenario (GRADE 2C); (20) we recommend the use of antenatal corticosteroids if delivery is anticipated before 33 6/7 weeks of gestation or for pregnancies between 34 0/7 and 36 6/7 weeks of gestation in women without contraindications who are at risk of preterm delivery within 7 days and who have not received a prior course of antenatal corticosteroids (GRADE 1A); and (21) we recommend intrapartum magnesium sulfate for fetal and neonatal neuroprotection for women with pregnancies that are <32 weeks of gestation (GRADE 1A).

Intrauterine Growth Restriction. Guideline of the German Society of Gynecology and Obstetrics (S2k-Level, AWMF Registry No. 015/080, October 2016)

AIMS

The aim of this official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG) was to provide consensus-based recommendations obtained by evaluating the relevant literature for the diagnostic treatment and management of women with fetal growth restriction.

METHODS

This S2k guideline represents the structured consensus of a representative panel of experts with a range of different professional backgrounds commissioned by the Guideline Committee of the DGGG.

RECOMMENDATIONS

Recommendations for diagnostic treatment, management, counselling, prophylaxis and screening are presented.

Preventing deaths due to the hypertensive disorders of pregnancy

In this chapter, taking a life cycle and both civil society and medically oriented approach, we will discuss the contribution of the hypertensive disorders of pregnancy (HDPs) to maternal, perinatal and newborn mortality and morbidity. Here we review various interventions and approaches to preventing deaths due to HDPs and discuss effectiveness, resource needs and long-term sustainability of the different approaches. Societal approaches, addressing sustainable development goals (SDGs) 2.2 (malnutrition), 3.7 (access to sexual and reproductive care), 3.8 (universal health coverage) and 3c (health workforce strengthening), are required to achieve SDGs 3.1 (maternal survival), 3.2 (perinatal survival) and 3.4 (reduced impact of non-communicable diseases (NCDs)). Medical solutions require greater clarity around the classification of the HDPs, increased frequency of effective antenatal visits, mandatory responses to the HDPs when encountered, prompt provision of life-saving interventions and sustained surveillance for NCD risk for women with a history of the HDPs.

A practical approach to fetal growth restriction

Fetal growth restriction is one of the most complex problems encountered by obstetricians. Ultrasound-estimated fetal weight less than the 10th percentile for the gestational age is the most widely accepted diagnostic criterion. Management protocols vary from institution to institution. Doppler velocimetry provides valuable information about fetal status. We offer a practical approach to management and timing of delivery based on available data in the literature.

Pre-eclampsia: an update

Pre-eclampsia remains the second leading direct cause of maternal death, >99 % of which occurs in less developed countries. Over 90 percent of the observed reduction in pre-eclampsia-related maternal deaths in the UK (1952-2008) occurred with antenatal surveillance and timed delivery. In this review, we discuss the pathogenesis, diagnostic criteria, disease prediction models, prevention and management of pre-eclampsia. The Pre-eclampsia Integrated Estimate of RiSk (PIERS) models and markers of angiogenic imbalance identify women at incremental risk for severe pre-eclampsia complications. For women at high risk of developing pre-eclampsia, low doses of aspirin (especially if started <17 weeks) and calcium are evidence-based preventative strategies; heparin is less so. Severe hypertension must be treated and the Control of Hypertension In Pregnancy (CHIPS) Trial (reporting: 2014) will guide non-severe hypertension management. Magnesium sulfate prevents and treats eclampsia; there is insufficient evidence to support alternative regimens. Pre-eclampsia predicts later cardiovascular disease; however, at this time we do not know what to do about it.

Maternal and fetal outcome in de novo preeclampsia in comparison to superimposed preeclampsia: a two-year observational study

AIM

To assess the maternal and fetal outcome in women with de novo preeclampsia (PE) in comparison to superimposed PE.

STUDY DESIGN

This was a prospective 2-year observational study carried out at Menoufia University Hospital, Egypt, in which 164 patients out of 6472 pregnant women were diagnosed with PE (78 with de novo PE and 86 with superimposed PE). Enrolled patients were followed to assess the maternal and fetal outcome.

RESULTS

There was a significant higher women with liver impairment and delivery by caesarean section in the de novo PE group (p < 0.05), with more women with renal impairment and ECG changes in the superimposed PE group (p < 0.05). No significant difference between the two groups regarding the occurrence of eclampsia, blood transfusion, admission to ICU and venous thromboembolism (p > 0.05). There was a significantly higher small for gestational age, prematurity, NICU admission and perinatal mortality in the superimposed PE group (p < 0.05). No significant difference between the two groups regarding the occurrence of placental abruption and intrauterine fetal demise (p > 0.05).

CONCLUSIONS

Women with de novo PE have higher risks of liver impairment and delivery by cesarean section. On the other hand, women with superimposed PE have higher risks of poorer fetal outcome.

Survey on the current trends in managing intrauterine growth restriction

OBJECTIVE

To provide a snapshot of the current trends in managing intrauterine growth restriction (IUGR) and to assess the agreement on the gestational age and the way of delivery in different clinical scenarios.

METHODS

A PubMed search was performed to identify all original articles on IUGR in the last 6 years. The most active 20 authors were selected as experts and were invited to respond to a survey on their preferred gestational age for elective delivery in several IUGR cases depending on Doppler measurements (including umbilical artery (UA), middle cerebral artery, cerebroplacental ratio, uterine artery and ductus venosus), biophysical profile and cardiotocography.

RESULTS

15 of the 20 selected experts agreed to participate in the survey, of which 3 failed to meet the deadline to complete the survey. Management of IUGR was relatively uniform for abnormal UA, uterine artery or cerebroplacental ratio. Although average gestational age at delivery reflected a clear progression with accepted markers of severity, discrepancies of up to 4 weeks were found for abnormal middle cerebral artery Doppler and absent end-diastolic velocity in the UA, and of up to 8 weeks for reverse end-diastolic velocity in the UA and abnormalities in the ductus venosus Doppler.

CONCLUSIONS

Management of IUGR is still far from being uniform among centers, with most controversy surrounding the management of early-onset IUGR. There is a need of prospective studies to address this issue.

Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy

OBJECTIVE

This guideline summarizes the quality of the evidence to date and provides a reasonable approach to the diagnosis, evaluation and treatment of the hypertensive disorders of pregnancy (HDP).

EVIDENCE

The literature reviewed included the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines from 2008 and their reference lists, and an update from 2006. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT) and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2006 and March 2012. Articles were restricted to those published in French or English. Recommendations were evaluated using the criteria of the Canadian Task Force on Preventive Health Care and GRADE.

Combined sonographic testing index and prediction of adverse outcome in preterm fetal growth restriction

OBJECTIVE

We sought to test the hypothesis that a combined sonographic scoring system (CSTI) that incorporates features of the biophysical profile (BPP) and multivessel Doppler evaluation improves prediction of adverse outcomes in preterm intrauterine growth restriction.

METHODS

This was a prospective cohort study of growth-restricted fetuses with abnormal umbilical artery (UA) Doppler studies, defined as pulsatility index (PI) > 95 th percentile for gestational age or absent/reversed end diastolic flow. Fetuses were followed with weekly BPP and Doppler evaluation of the UA, middle cerebral artery (MCA), and ductus venosus (DV) until the time of delivery. The cerebroplacental Doppler ratio (CPR) was then calculated (MCA PI/UA PI). MCA PI < 5 th percentile, MCA peak systolic velocity (PSV) > 1.5 multiples of the median, DV PI > 95 th percentile with or without absent/reversed flow, and CPR < 1.08 were considered abnormal. Using logistic regression modeling, a weighted scoring index for the prediction of a composite fetal vulnerability index (FVI), which included 5-minute Apgar score < 3, cord pH < 7.2, seizures, necrotizing enterocolitis, grade 4 intraventricular hemorrhage, periventricular leukomalacia, and neonatal death, was developed. A receiver operating characteristic (ROC) curve was used to identify the best score associated with the FVI.

RESULTS

Of 66 patients meeting inclusion criteria over a 5-year period, 17 (25.8%) had a positive FVI. Abnormal BPP (< 8), MCA PI, MCA PSV, DV PI, and CPR were observed in 6, 27.3, 13.6, 56.1, and 33.3% of patients, respectively. From the logistic regression model, a CSTI was developed including a score of 1 for abnormal BPP, 3 for MCA PSV, 1 for DV, 6 for CPR, and 3 for oligohydramnios. The ROC curve identified a score of ≥ 7 to be the best predictor of FVI with sensitivity of 35.1% and specificity of 91.8% and a positive likelihood ratio of 4.3 (area under ROC curve 0.73). These test characteristics were better than those for any of the individual component antenatal tests.

CONCLUSION

Although this novel scoring system performs modestly in predicting adverse outcomes in FGR, it appears to perform better than any individual antenatal test currently available.

Predicting pH at birth in pregnancies with abnormal pulsatility index and positive end-diastolic velocity in the umbilical artery

OBJECTIVES

To identify potential associations between fetal surveillance tests and acidosis at birth in pregnancies with abnormal but positive end-diastolic velocity in the umbilical artery.

METHODS

A prospective case-control study [group 1: pH < 7.2; group 2: pH ≥ 7.2] including 46 fetuses with abnormal but positive end-diastolic velocity in the umbilical artery was conducted between February 2007 and March 2009. Outcome variables were evaluated by univariate analysis and compared between the two groups. Clinically relevant and statistically significant variables were analyzed by logistic regression.

RESULTS

Abnormal nonstress test, presence of deceleration, and absent fetal breathing movements were statistically significant. Logistic regression analysis revealed that fetal heart rate (FHR) deceleration in the nonstress test is the only predictor of fetal acidosis at birth (p = 0.024; OR = 8.2; 95%CI: 1.2-52).

CONCLUSIONS

In fetuses with positive end-diastolic flow velocity, acute variables of the antenatal surveillance tests are correlated with acidosis at birth and FHR deceleration in the nonstress test is the only predictor of fetal acidosis.

Intrauterine growth restriction: new concepts in antenatal surveillance, diagnosis, and management

Intrauterine growth restriction (IUGR) remains one of the main challenges in maternity care. Improvements have to start from a better definition of IUGR, applying the concept of the fetal growth potential. Customized standards for fetal growth and birthweight improve the detection of IUGR by better distinction between physiological and pathological smallness and have led to internationally applicable norms. Such developments have resulted in new insights in the assessment of risk and surveillance during pregnancy. Serial fundal height measurement plotted on customized charts is a useful screening tool, whereas fetal biometry and Doppler flow are the mainstay for investigation and diagnosis of IUGR. Appropriate protocols based on available evidence as well as individualized clinical assessment are essential to ensure good management and timely delivery.

Antepartum fetal testing: a critical appraisal

PURPOSE OF REVIEW

Recognition of the fetus at risk for death or damage in utero, quantifying the risk, balancing fetal risk against the risk of neonatal complications from immaturity and determining optimal time and mode of intervention, is a cornerstone of modern perinatal medicine. Antepartum fetal testing is essential in making these crucial decisions. The art and science of fetal assessment is fluid. In this treatise, the evolution of testing is reviewed, test accuracy results examined and suggestions for future applications are considered.

RECENT FINDINGS

Composite testing of a range of fetal biophysical variables is an excellent predictor of fetal acidemia and risk of death or damage. Confusion regarding the optimal means of measuring one of these variables, amniotic fluid volume, has been addressed in the literature and contemporary studies from several independent sources indicate that the amniotic fluid index method should be abandoned in favor of the maximal vertical pocket method. It is becoming increasingly more evident that a spectrum of fetal testing modalities based on interrogation of different aspects of fetal adaptive responses to adversity is preferable in fetal testing. Further it is evident that in some fetal diseases, such as intrauterine growth restriction, fetal condition may change acutely and accordingly best outcome is achieved by much more frequent testing. The question of whether intervention for fetal compromise can prevent subsequent neurological sequelae remains open.

SUMMARY

There has been remarkable advancement in identifying the fetus at risk. The concept of multispectral combined fetal testing including acute biophysical variables, amniotic fluid volume and arterial and venous Doppler flow velocity waveforms is established.

Doppler ultrasonography in obstetrics: from the diagnosis of fetal anemia to the treatment of intrauterine growth-restricted fetuses

After the adoption of the use of umbilical artery and middle cerebral artery peak systolic velocity in high-risk pregnancies and in pregnancies that are at risk of having an anemic fetus, the main focus of Doppler ultrasonography in obstetrics today is intrauterine growth-restricted fetuses. What is most needed at this time are (1) training of sonographers and sonologists on how to perform a Doppler study, (2) an international classification of intrauterine growth-restricted fetuses, and (3) a study of the natural history of intrauterine growth-restricted fetuses that might contribute to a better understanding of the intrauterine growth-restriction process and to standard treatment of intrauterine growth-restricted fetuses. Future investigations, which would include randomized studies, could be designed from the results of such studies.