Prévalence, facteurs de risque et morbi-mortalité materno-fœtale des troubles de la croissance fœtale

Current Status of Maternal Gestational Weight Gain and Obstetric Outcomes in Japan

Introduction In 2021, the Japanese Ministry of Health, Labour and Welfare (JMHLW) revised the standard optimal gestational weight gain (GWG) to reduce the incidence of low-birth-weight infants (LBWI) in Japan. In this study, we examined whether maternal GWG increased and LBWI decreased after the revision. Materials and methods We reviewed the obstetric records of singleton pregnant Japanese women who delivered at our institute at ≥37 weeks' gestation in 2020 (before revision) and 2022 (after revision). Results The maternal GWG was significantly increased after the revision of the JMHLW guideline; however, the expected decrease in the incidence of LBWI was not achieved. Conclusion The maternal GWG met the new criteria in the revised guidelines and did not appear to contribute to the reduced incidence of LBWI.

The burden of inappropriate birth weight on neonatal survival in term newborns: a population-based study in a middle-income setting

Introduction

Premature birth, perinatal asphyxia, and infections are the main causes of neonatal death. Growth deviations at birth also affect neonatal survival according to week of gestation at birth, particularly in developing countries. The purpose of this study was to verify the association between inappropriate birth weight and neonatal death in term live births.

Methods

This is an observational follow-up study with all term live births from 2004 to 2013 in Sao Paulo State, Brazil. Data were retrieved with the deterministic linkage of death and birth certificates. The definition of very small for gestational age (VSGA) and very large for gestational age (VLGA) used the 10th percentile of 37 weeks and the 90th percentile of 41 weeks + 6 days, respectively, based on the Intergrowth-21st. We measured the outcome in terms of time to death and the status of each subject (death or censorship) in the neonatal period (0-27 days). Survival functions were calculated using the Kaplan-Meier method stratified according to the adequacy of birth weight into three groups (normal, very small, or very large). We used multivariate Cox regression to adjust for proportional hazard ratios (HRs).

Results

The neonatal death rate during the study period was 12.03/10,000 live births. We found 1.8% newborns with VSGA and 2.7% with VLGA. The adjusted analysis showed a significant increase in mortality risk for VSGA infants (HR = 4.25; 95% CI: 3.89-4.65), independent of sex, 1-min Apgar score, and five maternal factors.

Discussion

The risk of neonatal death in full-term live births was approximately four times greater in those with birth weight restriction. The development of strategies to control the factors that determine fetal growth restriction through planned and structured prenatal care can substantially reduce the risk of neonatal death in full-term live births, especially in developing countries such as Brazil.

Effects of Non-Essential "Toxic" Trace Elements on Pregnancy Outcomes: A Narrative Overview of Recent Literature Syntheses

Adverse pregnancy outcomes and their complications cause increased maternal and neonatal morbidity and mortality and contribute considerably to the global burden of disease. In the last two decades, numerous narrative and systematic reviews have emerged assessing non-essential, potentially harmful, trace element exposure as a potential risk factor. This narrative review summarizes the recent literature covering associations between exposure to cadmium, lead, arsenic, and mercury and pregnancy outcomes and highlights common limitations of existing evidence that may hinder decision-making within public health. Several initial scoping searches informed our review, and we searched PubMed (latest date July 2022) for the literature published within the last five years reporting on cadmium, lead, arsenic, or mercury and pre-eclampsia, preterm birth, or prenatal growth. Pre-eclampsia may be associated with cadmium and strongly associated with lead exposure, and exposure to these metals may increase risk of preterm birth. Many reviews have observed cadmium to be negatively associated with birth weight. Additionally, lead and arsenic exposure may be negatively associated with birth weight, with arsenic exposure also adversely affecting birth length and head circumference. These findings should be interpreted with caution due to the limitations of the reviews summarized in this paper, including high heterogeneity due to different exposure assessment methods, study designs, and timing of sampling. Other common limitations were the low quality of the included studies, differences in confounding variables, the low number of studies, and small sample sizes.

Is accuracy of estimated fetal weight improved by better image quality scores?

OBJECTIVE

To assess in a group of ultrasound operators of various levels of experience the predictive value of systematic quality scoring to assess estimated fetal weight (EFW) validity.

METHODS

Screenshots, sonographer experience, and neonate birth weight were collected for 131 ultrasound examinations in the 7 days before birth. The difference (EFW error) between projected birth weight (EFW + [30 g × interval in days to birth]) and actual birth weight was then assessed (absolute value). Three senior sonographers rated all the screenshots (International Society of Ultrasound in Obstetrics and Gynecology 16-point score for image quality) and interobserver reproducibility was assessed concomitantly. The impact of the score on EFW accuracy was then assessed (univariate analysis). Receiver operating characteristic curves allowed us to assess the score's positive predictive value (PPV) for accurate EFW.

RESULTS

Mean birth weight was 2998 ± 954 g and mean EFW error was 8.6% ± 7.1%. Both the sonographer's experience and score significantly impacted the EFW error (P < 0.05). The PPVs of systematic image scores for identifying an EFW error greater than 10% and greater than 15% were appropriate for clinical use (areas under the curve 0.61 and 0.70, respectively). Score reproducibility was modest.

CONCLUSION

Low image scores and limited ultrasound expertise are associated with an increased risk of inaccurate EFW.

Contribution of amniocentesis in fetuses small for gestational age without other sonographic signs

OBJECTIVE

Our study evaluated the contribution of amniocentesis in the diagnostic approach of small-for-gestational-age fetuses (SGA) without morphological abnormality identified on ultrasound by studying FISH (fluorescence in situ hybridization) for chromosomes 13, 18 and 21, CMV PCR (cytomegalovirus polymerase chain reaction), karyotype and CGH (genomic hybridization array) METHODS: Our single-center retrospective cohort study included pregnant women referred for prenatal diagnosis for a SGA fetus in whom amniocentesis was performed between 2016 and 2019. A SGA fetus was defined as a fetus with an estimated fetal weight (EFW) below the 10th percentile according to referral growth curves in use. We evaluated the number of amniocenteses with an abnormal result and identified factors that may be associated with this outcome.

RESULTS

Among the 79 amniocenteses performed, there were 5 (6.3%) abnormalities: karyotype (1.3%) and CGH (5.1%). No complications were described. We did not find any statistically significant factors associated with abnormal amniocentesis findings even if some elements seemed reassuring such as late discovery (p = 0.31), moderate SGA (p = 0.18), normal head, abdomen and femur measurements (p = 0.57), but without statistically significant difference.

CONCLUSION

Our study found 6.3% pathological analysis of amniocenteses, of which several would have been missed by conventional karyotyping. Patients must be informed about the risk of detecting abnormalities of low severity, with low penetrance or with unknown fetal consequences that could be source of anxiety.

Fetal growth restriction, low birth weight, and preterm birth: Effects of active or passive smoking evaluated by maternal expired CO at delivery, impacts of cessation at different trimesters

INTRODUCTION

The objectives of this study were to evaluate the effect of cessation of active smoking during the 1st, 2nd, and 3rd trimesters of pregnancy on the risk of reduced birth weight and prematurity using an exhaled carbon monoxide biomarker with a cut-off value ≥3 ppm as well as the effects of passive smoking.

METHODS

This was a multicenter prospective cohort study involving pregnant smokers and non-smokers. Pregnant smokers were identified at the first prenatal visit before 15 weeks of amenorrhea by the number of cigarettes smoked per day and by the carbon monoxide breath test. Women were classified into 6 groups: non-smokers, passive smokers, first trimester cessation, second trimester cessation, third trimester cessation, and smoking throughout pregnancy. Smoking cessation was defined if the pregnant woman reported quitting smoking and if she achieved an exhaled CO level of <3 ppm. The association between smoking cessation and fetal growth restriction or prematurity was assessed by multivariate logistic regression. Passive smoking was defined for non-smoking women on declarative smoking status and exhaled CO ≥3 ppm. The association between passive smoking and fetal growth restriction or prematurity was assessed by multivariate logistic regression.

RESULTS

The number of patients included was 5244. The incidence of fetal growth restriction below the 10th percentile was 10.6%, 12.1%, 8.5%, 9.1%, 21.1%, and 22.9%, respectively, for the non-smoking, passive smoking, first, second, third trimester cessation, and full-pregnancy smoking, groups. The risk of FGR compared to non-smokers was OR=2.3 (95% CI: 1.18–4.30, p=0.014) for patients who quit smoking in the third trimester, OR=2.5 (95% CI: 2.03–3.12, p<0.001) for women who smoked throughout pregnancy. After logistic regression, FGR (AOR=1.9; 95% CI: 0.96–3.82) for women who quit smoking in the 3rd trimester (AOR=1.8; 95% CI: 1.38–2.31, p<0.001). The risk of FGR <5th percentile was AOR=1.96 (95% CI: 1.36–2.48, p<0.001).

CONCLUSIONS

Active or passive smoking during pregnancy is associated with an increased risk of intrauterine growth restriction and low birth weight. Cessation in the 1st and 2nd trimester reduces the risk of intrauterine growth restriction or low birth weight. Passive smoking has a deleterious impact on fetal development, intermediate to that of active smoking.

Maternal Low Volume Circulation Relates to Normotensive and Preeclamptic Fetal Growth Restriction

This narrative review summarizes current evidence on the association between maternal low volume circulation and poor fetal growth. Though much work has been devoted to the study of cardiac output and peripheral vascular resistance, a low intravascular volume may explain why high vascular resistance causes hypertension in women with preeclampsia (PE) that is associated with fetal growth restriction (FGR) and, at the same time, presents with normotension in FGR itself. Normotensive women with small for gestational age babies show normal gestational blood volume expansion superimposed upon a constitutionally low intravascular volume. Early onset preeclampsia (EPE; occurring before 32 weeks) is commonly associated with FGR, and poor plasma volume expandability may already be present before conception, thus preceding gestational volume expansion. Experimentally induced low plasma volume in rodents predisposes to poor fetal growth and interventions that enhance plasma volume expansion in FGR have shown beneficial effects on intrauterine fetal condition, prolongation of gestation and birth weight. This review makes the case for elevating the maternal intravascular volume with physical exercise with or without Nitric Oxide Donors in FGR and EPE, and evaluating its role as a potential target for prevention and/or management of these conditions.

Topical sertaconazole during pregnancy and risk of adverse pregnancy outcome and major congenital anomalies: comparative study in the EFEMERIS database

INTRODUCTION

Topical sertaconazole is indicated in the treatment of vaginal or mucocutaneous fungal infections due to Candida and dermatophytosis. To our knowledge, there is no data available in the literature on the potential effects of sertaconazole during pregnancy. The aim of this study was to evaluate the potential risks of topical sertaconazole use during pregnancy for the fetus and pregnancy.

MATERIALS AND METHODS

The EFEMERIS database was used, which contained medications prescribed and dispensed to pregnant women in the Haute-Garonne region whose pregnancy ended between July 2004 and December 2018. We compared pregnant women exposed to sertaconazole at least once during pregnancy to unexposed. Crude and adjusted odds ratios (OR) of major congenital anomalies were estimated using logistic regression models. For other outcomes, hazard ratios (HR) were estimated by Cox regression models.

RESULTS

The study included 16,222 pregnant women (15.0%) who were given sertaconazole and 91,976 who were not. Exposure to sertaconazole during pregnancy was not associated with increased risks of any of the investigated outcomes, including natural pregnancy termination (HR_a =0.92 [0.78-1.08]), preterm birth (HR_a =1.06 [0.95-1.17]) and small for gestational age at birth (OR_a =0.78 [0.66-0.92]). No association between risk of major congenital anomalies overall and maternal exposure to sertaconazole during the first trimester was observed (OR_a =1.01 [0.84-1.21]).

DISCUSSION

This is the first study involving a large number of pregnant women to assess the potential risks of sertaconazole during pregnancy. This study does not indicate an increased risk of adverse pregnancy outcome and major congenital anomalies from exposure to topical sertaconazole.

Maternal Signatures of Cortisol in First Trimester Small-for-Gestational Age

The objective of this study was to identify predictable maternal serum signatures of cortisol metabolism during the first trimester of women who are expected to deliver small-for-gestational-age (SGA) neonates. This prospective cohort study included 112 pregnant women (with and without SGA, n = 56 each). Maternal serum samples were collected at 10-14 gestational weeks to quantify the levels of cortisol and its precursors and metabolites by liquid chromatography-mass spectrometry. Increased maternal serum levels of tetrahydrocortisol (11.82 ± 8.16 ng/mL vs. 7.51 ± 2.90 ng/mL, P < 0.005) and decreased 21-deoxycortisol (2.98 ± 1.36 ng/mL vs. 4.33 ± 2.06 ng/mL, P < 0.0001) were observed in pregnant women carrying SGA fetus. In conjunction with individual steroid levels, metabolic ratios corresponding to the activity of related enzymes were calculated. In addition to increased tetrahydrocortisol/cortisol ratio (P < 0.006), the SGA group showed a significant increase in the two metabolic ratios including cortisol/11-deoxycortisol (P < 0.03) and cortisol/21-deoxycortisol (P < 0.0003). The receiver operating characteristic (ROC) curve generated in combination with three variables of 21-deoxycortisol concentration and two metabolic ratios of cortisol/21-deoxycortisol and tetrahydrocortisol/cortisol resulted in an area under the ROC curve = 0.824 (95% confidence interval, 0.713-0.918). A significant decrease in maternal serum levels of 21-deoxycortisol and an increase in two metabolic ratios of cortisol/21-deoxycortisol and tetrahydrocortisol/cortisol, indicating cortisol biosynthetic rate, represent potential biomarkers for the prediction of SGA in the first trimester.

FoxO1 Regulates Neuropeptide Y and Pro-opiomelanocortin in the Hypothalamus of Rat Offspring Small for Gestational Age

Adulthood obesity, diabetes, and metabolic diseases are associated with small for gestational age (SGA) newborns. This association could be related to abnormal appetite signaling pathways in the hypothalamus. This study investigated the appetite regulation by the hypothalamus of SGA newborns by establishing an SGA rat model and culturing SGA neural progenitor cells (NPCs) in vitro. Models of SGA were established by maternal food restriction embryonic day 10 (E10). At E18, postpartum day 1 (P1), and P5, hypothalamic neural precursor cells (NPCs) of offspring were cultured in vitro. Immunofluorescence, Western blot (WB), and qRT-PCR were used to assess NPY, POMC, and FoxO1 expression levels. The effects on mRNA expression of the FoxO1-specific inhibitor AS1842856 were examined. The results indicated that compared with controls, NPY was higher, and POMC was lower at embryonic day 18 (E18), postpartum day 1 (P1), and P5. The proliferation and migration of NPCs in the third ventricle of SGA hypothalami were lower than in controls. After treatment with the FoxO1 inhibitor AS1842856, the differences in the mRNA expression of NPY and POMC between the two groups disappeared. NPY and POMC mRNA levels in the SGA group treated with AS1842856 were not significantly different compared with the control group without AS1842856 treatment. In conclusion, SGA pups showed an increase in appetite-promoting NPY and a decrease in appetite-reducing POMC, probably contributing to adulthood weight gain, obesity, and endocrine disorders.

[Unadjusted and customized fetal growth curves: a comparative study in a sub-Saharan population]

Le but de notre étude était de comparer la courbe non ajustée EPOPé M0 à la courbe personnalisée de Gardosi, dans le diagnostic des fœtus petits pour l´âge gestationnel (PAG) au sein d´une population du Sud du Sahara. Les classements des courbes de Gardosi et al. et EPOPé M0 étaient comparée. Les différences de classement ont été analysées selon les caractéristiques des patientes et des pathologies obstétricales. Les données recueillies à partir d´un logiciel Filemaker étaient analysées à l´aide des logiciels SPSS 20.0 et R Studio. Les tests statistiques étaient réalisés selon les conditions d´applicabilité. Le risque d´erreur alpha était fixé à 0,05. Avec la courbe de Gardosi, le taux de nouveau-nés PAG était plus élevé (31,4% contre 28,9%) et le taux de PAG ne différait pas entre les femmes en surpoids et celles de poids normal. Le taux de PAG sévères chez les prématurés était aussi plus élevé (23,6 versus 19,7%). Les pathologies étaient plus fréquentes chez les nouveau-nés classés PAG sévères par la courbe personnalisée. La courbe personnalisée est plus adaptée dans la population d´Afrique Sub-saharienne.

Use of the 50-g glucose challenge test to predict small-for-gestational-age neonates

BACKGROUND

To determine a cutoff value for the 50-g glucose challenge test (50-g GCT) for the prediction of small-for-gestational-age (SGA) neonates.

METHODS

This retrospective cohort study was conducted among pregnant women who were screened with the 50-g GCT at Hacettepe University Hospital between 1 January 2016 and 31 March 2019. Patients with 50-g GCT values <74 mg/dL (<10th percentile) served as the study group (n = 244), while patients with 50-g GCT values between 74 to 139 mg/dL served as the control group (n = 3104). Groups were compared in terms of demographic features, clinical characteristics, and obstetric outcomes. Logistic regression analysis was used to determine independent predictors of SGA. Receiver operating characteristic curves were used to assess the performance of 50-g GCT values in predicting SGA.

RESULTS

Lower birthweight, birthweight percentile, and 5th-minute Apgar values, together with higher rates of SGA, were observed in the study group (P < .001 for all). A 50-g GCT value below the 10th percentile (odds ratio: 3.29, 95% CI: 2.31-4.69, P < .001) was a significant independent factor for SGA. A cutoff value of 89.5 mg/dL (84.9% sensitivity, 85.6% specificity) was determined for SGA.

CONCLUSIONS

Low 50-g GCT values (<89.5 mg/dL) may be an early indicator for SGA.

Surgery during pregnancy - results of a German questionnaire

Objectives

Worldwide, not only the number of female medical students, but also of female surgeons increases. Simultaneously, younger generations take a closer look to their work-life balance. With this in mind, it seems necessary to evaluate the expectations of female surgeons in particular with respect to pregnancy during their surgical career.

Methods

Therefore, a nationwide survey was conducted in Germany from July to December 2016 under the auspices of the German Society of Surgery as well as the Professional Board of German Surgeons. The questionnaire involved 2,294 female surgeons and 1,843 complete records were evaluated.

Results

Of the analyzed answers, 62% of the women (n=781) were operating during pregnancy. The joy of surgery (91.6%), followed by team spirit (57.1%), were the main motivations to perform operations while pregnant. Operative activity decreased from 30.8% in the first 3 months of pregnancy to 21.5% during the last three months. Regarding the possible complaints, e.g., leg edema, back pain, premature labor and vaginal bleeding, there were no significant differences between the women with or without activity in the operating room. Sick leave due to pregnancy (1–10 days) was stated by 40.4% of respondents.

Conclusion

Despite strong legal regulations for pregnant surgeons, the survey showed that most female surgeons are eager to operate despite their pregnancy. The results also demonstrate no significant differences regarding complications during pregnancy- or pregnant-dependent absence from work. Hospitals and surgical departments are asked to establish proper working conditions for pregnant surgeons and pregnancy should not be an obstacle for a career in surgery.

Evaluating the Effect of Utrogestan on Idiopathic Intrauterine Growth Retardation

Background:

Intrauterine growth factor (IUGR) is one of the most important causes of neonatal mortality. The aim of this study was to evaluate the therapeutic effect of utrogestan on the treatment of IUGR and its complications.

Materials and Methods:

In this clinical trial, 66 pregnant women with idiopathic IUGR embryos were enrolled. Patients in the intervention group, in addition to receiving routine treatment of control group (high-protein diet, resting), took utrogestan capsules (100 mg) twice daily. The primary and secondary outcomes of the disease were recorded in a checklist. Data were analyzed using SPSS 18 using an independent t-test, Chi-square test, and Fisher's exact test.

Results:

In the intervention group, mean neonatal weight (P = 0.003), mean neonatal Apgar score (P = 0.001), and mean gestational age at birth (P = 0.001) were significantly higher than those in the control group. There was no neonatal death in the intervention group, whereas in the control group, four cases of neonatal death were observed (P = 0.03). In the majority of subjects in the intervention group, resistance index, and pulsatility index of the umbilical artery decreased (P = 0.002). The difference in abdominal circumference and gestational age in the intervention group decreased (P = 0.01). In the intervention group, the diastolic flow of the umbilical artery increased (P = 0.002).

Conclusion:

Utrogestan was effective as an inexpensive and effective way to treat IUGR and improve pregnancy outcomes.

Placental Histopathology and Pregnancy Outcomes in "Early" vs. "Late" Placental Abruption

Placenta-associated pregnancy complications (fetal growth restriction and preeclampsia) are traditionally classified as "early" and "late" due to their different pathophysiology, histopathology, and pregnancy outcomes. As placental abruption (PA) represents another placenta-associated complication, we aimed to study if this categorization can be applied to PA as well. Pregnancy and placental reports of all pregnancies complicated by PA between November 2008 and January 2019 were reviewed. Maternal background, pregnancy outcomes, and placental histopathology were compared between cases of PA < 34 weeks (early PA group) vs. > 34 weeks (late PA group). Placental lesions were classified according to the "Amsterdam" criteria. The primary outcome was severe neonatal morbidity (≥ 1 severe neonatal complications: seizures, IVH, HIE, PVL, blood transfusion, NEC, or death). Included were 305 cases of PA, 71 (23.3%) in the early group and 234 (76.7%) in the late group. The early PA group was characterized by higher rates of vaginal bleeding upon presentation (p = 0.003), DIC (p = 0.018), and severe neonatal morbidity (p < 0.001). The late PA group was characterized by a higher rate of urgent Cesarean deliveries (p < 0.001). The early PA group was characterized by higher rates of placental maternal vascular malperfusion (MVM) lesions (p < 0.001), maternal inflammatory response (MIR) lesions (p < 0.001), placental hemorrhage (p < 0.001), and a lower feto-placental ratio (p < 0.001). Using regression analysis, we found that severe neonatal morbidity was independently associated with early abruption (aOR = 5.3, 95% CI = 3.9-7.6), placental MVM (aOR = 1.5, 95% CI = 1.2-1.9), placental MIR (aOR = 1.9, 95% CI = 1.4-2.3), and inversely associated with antenatal corticosteroids (aOR = 0.9, 95% CI = 0.6-0.98). "Early" and "late" PA significantly differ in their presentation, placental pathology, and pregnancy outcomes.

Mobile phone use during pregnancy: Which association with fetal growth?

INTRODUCTION

Few studies have investigated the effect of electromagnetic waves on the human fetus whereas nowadays mobile phone use is ubiquitous. The aim of this study was to evaluate the association between mobile phone use by pregnant women and fetal development during pregnancy in the general population.

MATERIAL AND METHODS

Data came from the NéHaVi cohort ("prospective follow-up, from intrauterine development to the age of 18 years, for children born in Haute-Vienne"), a prospective, longitudinal, multicenter (three maternity units in Haute-Vienne) observational cohort focusing on children born between April 2014 and April 2017. Main objective was to investigate the association of mobile phone use on fetal growth. Univariate and multivariate models were generated adjusted for the socioprofessional category variables of the mother, and other variables likely to influence fetal growth.

RESULTS

For the analysis 1378 medical charts were considered from which 1368 mothers (99.3 %) used their mobile phones during pregnancy. Mean phone time was 29.8 min (range: 0.0-240.0 min) per day. After adjustment, newborns whose mothers used their mobile phones for more than 30 min/day were significantly more likely to have an AUDIPOG score ≤ 10th percentile than those whose mothers used their mobile phones for less than 5 min/day during pregnancy (aOR = 1.54 [1.03; 2.31], p = 0.0374). For women using their cell phones 5-15 min and 15-30 min, there wasn't a significant association with an AUDIPOG score ≤ 10th, respectively aOR = 0.98 [0.58; 1.65] and aOR = 1.68 [0.99; 2.82].

CONCLUSION

Using a mobile phone for calls for more than 30 min per day during pregnancy may have a negative impact on fetal growth. A prospective study should be performed to further evaluate this potential link.

Children Born with Congenital Heart Defects and Growth Restriction at Birth: A Systematic Review and Meta-Analysis

Newborns with congenital heart defects tend to have a higher risk of growth restriction, which can be an independent risk factor for adverse outcomes. To date, a systematic review of the relation between congenital heart defects (CHD) and growth restriction at birth, most commonly estimated by its imperfect proxy small for gestational age (SGA), has not been conducted. Objective: To conduct a systematic review and meta-analysis to estimate the proportion of children born with CHD that are small for gestational age (SGA). Methods: The search was carried out from inception until 31 March 2019 on Pubmed and Embase databases. Studies were screened and selected by two independent reviewers who used a predetermined data extraction form to obtain data from studies. Bias was assessed using the Critical Appraisal Skills Programme (CASP) checklist. The database search identified 1783 potentially relevant publications, of which 38 studies were found to be relevant to the study question. A total of 18 studies contained sufficient data for a meta-analysis, which was done using a random effects model. Results: The pooled proportion of SGA in all CHD was 20% (95% CI 16%–24%) and 14% (95% CI 13%–16%) for isolated CHD. Proportion of SGA varied across different CHD ranging from 30% (95% CI 24%–37%) for Tetralogy of Fallot to 12% (95% CI 7%–18%) for isolated atrial septal defect. The majority of studies included in the meta-analysis were population-based studies published after 2010. Conclusion: The overall proportion of SGA in all CHD was 2-fold higher whereas for isolated CHD, 1.4-fold higher than the expected proportion in the general population. Although few studies have looked at SGA for different subtypes of CHD, the observed variability of SGA by subtypes suggests that growth restriction at birth in CHD may be due to different pathophysiological mechanisms.

Placental pathology in pregnancies complicated by fetal growth restriction: recurrence vs. new onset

OBJECTIVE

In an attempt to shed new light on the pathogenesis of fetal growth restriction (FGR), we aimed to study pregnancy characteristics, neonatal outcomes, and placental histopathological lesions of FGR pregnancies in two different subgroups: when developed after appropriate for gestational age (AGA) pregnancy and when developed after previous pregnancy with FGR.

STUDY DESIGN

Pregnancy and placental reports of all singleton pregnancies complicated by FGR (defined as actual birthweight below the 10th percentile according to local birthweight nomograms) between 2008 and 2018 were reviewed. Included were only cases with previous delivery. Maternal background, neonatal outcomes, and placental histopathology were compared between FGR that occurred after FGR (recurrent FGR group) and FGR that occurred after an AGA pregnancy (FGR after AGA group). Placental lesions were classified according to the current "Amsterdam" criteria. Continuous variables were compared using the Student's t test or the Mann-Whitney test as appropriate. Categorical variables were compared using Chi-square or Fisher's exact test as appropriate.

RESULTS

A total of 334 FGR cases with a previous delivery were included in the study. Of them, 111 cases constituted the recurrent FGR group and 223 constituted the FGR after AGA group. The recurrent FGR group was characterized by higher rates of maternal diabetes during pregnancy and hypertensive diseases (9% versus 2.7%, p = 0.01 and 19.8% versus 11.6%, p = 0.04). The FGR after AGA group was characterized by a higher rate of fetal vascular malperfusion (FVM) lesions (29.6% versus 18.0%, p = 0.02), and by lower mean birthweight (1842 ± 424.9 versus 1977.4 ± 412.2, p = 0.005), as compared to the recurrent FGR group.

CONCLUSION

Recurrent FGR was associated with maternal background morbidities during pregnancy which represents a chronic repeated insult, while "new" FGR cases (those followed an AGA pregnancy) were characterized by a higher rate of FVM lesions and lower birthweight which probably represent an "accident" in placentation. These findings may suggest that different mechanisms of placental dysfunction exist in the two subgroups of FGR.

Does parity affect pregnancy outcomes in the elderly gravida?

PURPOSE

To identify whether older primiparas have more complications than do women who continue to deliver children into their late reproductive age. Patients of at least 35 years of age at delivery were included. Within this cohort, data from primiparous and multiparous women were compared.

METHODS

This retrospective study was based on electronic medical records from a single academic center, with more than 7000 deliveries annually. The impact of parity on maternal complications was assessed using a multivariate logistic regression model that adjusted for baseline maternal characteristics and medical history.

RESULTS

During the study period, there were 54 283 deliveries in our medical center. A total of 13,982 (25.7%) patients were at least 35 years old at delivery. The rate of twin pregnancy was higher in the primiparous group (1.9%) as compared to the multiparous group (0.8%, 95% CI 0.30-0.64, P < 0.001), as was the incidence of delivery prior to 34 weeks (6.1% of the primiparas versus 2.9% of the multiparas, P < 0.001, OR 2.16, 95% CI 1.75-2.68); hypertensive disorders (3.9% versus 1.7%, P < 0.001, 95% CI 0.33-0.57); diabetes (4.6% versus 3.2%, P = 0.003, 95% CI 0.55-0.88); and IUGR (10.5% versus 4.7%, P < 0.001, 95% CI 0.35-049), respectively. The increased risk for pre-term delivery, hypertensive disorders, diabetes, and IUGR was maintained after logistic regression analysis.

CONCLUSION

We found that pregnancy complications typical to older parous women are significantly more common among primiparas, indicating that not only older age, but also having a first child relatively late in the reproductive period contributes to adverse pregnancy outcomes.

Maternal plasma fetuin-A levels in fetal growth restriction: A case-control study

Background

Higher Fetuin-A (FA) concentrations were found to be associated with obesity and there is an interest to the relation between maternal FA and pregnancy outcomes.

Objective

In this study, our aim was to evaluate the association of maternal plasma levels of FA with fetal growth restriction (FGR).

Materials and Methods

41 pregnant women with FGR and 40 controls were recruited in this case-control study between July and November 2015. At the diagnosis of FGR, venous blood samples (10 cc) were obtained for FA analysis.

Results

Maternal plasma FA levels were significantly higher in fetal growth-restricted pregnant women compared with controls (19.3 ± 3.0 ng/ml vs 25.9 ± 6.8 ng/ml, p = 0.001). Area under receiver operating characteristic curve analysis of FA in FGR was 0.815 (95% confidence interval (CI): 0.718-0.912, p < 0.001). The maternal FA levels with values more than 22.5 ng/ml had a sensitivity of about 73.17% (95% CI: 56.79-85.25) and a specificity of about 82.5% (95% CI: 66.64-92.11) with positive and negative predictive values of about 81.08% (95% CI: 64.29-91.45) and 75% (95% CI: 59.35-86.30), respectively. Therefore, the diagnostic accuracy was obtained about 77.78%.

Conclusion

The results of this study show higher maternal plasma levels of FA in FGR. Further studies are needed in order to demonstrate the long-term effects of FA in pregnancies complicated with FGR and early prediction of FGR.

Maternal occupational exposures to nanoscale particles and small for gestational age outcome in the French Longitudinal Study of Children

OBJECTIVES

To investigate the association between maternal occupational exposures to nanoscale particles (NPs) during pregnancy and small for gestational age (SGA).

METHODS

This study included 11,224 mothers and singleton birth pairs from the French Longitudinal Study of Children (ELFE cohort), which included infants born after 33 weeks of gestation or more in continental France in 2011. Mothers who did not work during pregnancy were excluded from the analyses. Maternal occupational exposures to NPs was estimated using a job-exposure matrix for the probability (>50%: occupationally exposed group, n = 569; 0%: occupationally non-exposed group, n = 9113; between these two thresholds: uncertain group, n = 1542) and frequency of exposure. Associations were estimated from multivariate logistic regression models for occupationally exposed vs occupationally unexposed groups in a first analysis, and with the frequency-weighted duration of work for the occupationally exposed group only in a second analysis.

RESULTS

Among working mothers, 5.1% were occupationally exposed to NPs. Maternal occupational exposures to NPs was associated with SGA (ORa = 1.63, 95% CI: 1.22, 2.18). The frequency-weighted duration of work for the occupationally exposed group (n = 569) was not associated with SGA (ORa = 1.02, 95% CI: 0.97, 1.08) in adjusted analyses.

CONCLUSIONS

These results, showing a significant association between occupational exposures to NPs and SGA, should encourage further studies to examine the adverse effect of NPs exposure on fetal development.

Maternal dietary consumption of legumes, vegetables and fruit during pregnancy, does it protect against small for gestational age?

BACKGROUND

Different diets during pregnancy might have an impact on the health, reflected in the birthweight of newborns. The consumption of fruits and vegetables during pregnancy and the relationship with newborn health status have been studied by several authors. However, these studies have shown inconsistent results.

PURPOSE

We assessed whether certain foods were related to the risk of small for gestational age (SGA).

METHODS

A matched by age (± 2 years) and hospital 1:1 case-control study of 518 pairs of pregnant Spanish women in five hospitals was conducted. The cases were women with an SGA newborn at delivery (neonates weighting less than the 10th percentile, adjusted for gestational age at delivery and sex, were diagnosed as SGA). The control group comprised women giving birth to babies adequate for gestational age (AGA). Mothers who gave birth to babies large for gestational age (LGA) were excluded. Data were gathered concerning demographic characteristics, socioeconomic status, toxic habits and diet. A food frequency questionnaire (FFQ) comprising 137 items was completed by all participants. The intake of vegetables, legumes and fruits was categorized in quintiles (Q1-Q5). Crude values and and adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were estimated using conditional logistic regression. The variables for adjustment were as follows: preeclampsia, education, smoking, weight gain per week during pregnancy, fish intake and previous preterm/low birthweight newborns.

RESULTS

Total pulse intake showed an inverse association with the risk of SGA (trend p = 0.02). Women with an intake of fruits above 420 g/day (Q5), compared with women in Q1 (≤ 121 g/day) showed a decreased risk of SGA (AOR = 0.63, 95% CI = 0.40-0.98). The total consumption of vegetables was not associated with the risk of SGA. The intake of selenium was assessed: a protective association was observed for Q3-5; a daily intake above 60 μg was associated with a lower risk of SGA (AOR = 0.39, 95% CI: 0.22-0.69).

CONCLUSIONS

Fruits, pulses and selenium reduce the risk of SGA in Spanish women.

Can certain factors for recurrence of placenta-mediated pregnancy complications be identified after an initial small-for-gestational-age birth?

Introduction: After a small-for-gestational-age (SGA) birth, recurrence of placenta-mediated pregnancy complications (PMPCs) is a cause for anxiety when contemplating another pregnancy. We sought to identify factors potentially associated with this recurrence.Material and methods: This retrospective single-center observational study was conducted in a tertiary maternity unit between 1 January 2010 and 31 December 2017. We included all women having experienced a non-syndromic SGA birth and who were subsequently monitored for at least one other pregnancy in our institution. PMPCs were defined as recurrent SGA births, three consecutive first-trimester miscarriages, or preeclampsia.Results: Ninety-four women were included over a 7-year study period. Recurrent PMPCs were recorded in 30 (32%) cases, of which 29 featured recurrent SGA births. None of the following characteristics were significantly associated with recurrence: presence of preeclampsia during the initial pregnancy (six [20%] versus 25 [39%] cases in the recurrent PMPCs and non-recurrent PMPCs groups, respectively; p = .11), results of the histopathologic placental examination or thrombophilia screen, or implemented treatment during subsequent pregnancies.Conclusions: PMPCs recur frequently. No risk factor for recurrence was identified in our study. Results of etiologic assessments and treatments implemented after an initial SGA birth should therefore not modify level of clinical and ultrasound monitoring provided during subsequent pregnancies.Rationale: Recurrence of placenta-mediated pregnancy complications is a cause for anxiety when contemplating another pregnancy. We did not identify any risk factor after an initial small-for-gestational-age birth in our study; surveillance should therefore not be modified by the etiologic assessments' results.

Three-dimensional Doppler ultrasonography for the assessment of fetal liver vascularization in fetuses with intrauterine growth restriction

OBJECTIVE

To demonstrate changes in hepatic volume and vascular indices in fetuses with intrauterine growth restriction (IUGR) compared with normal-growth fetuses, using a noninvasive method (three-dimensional power Doppler ultrasound).

METHODS

The present cross-sectional study was conducted between September 1 and November 30, 2014, at a maternal-fetal medicine unit in Bogotá, Colombia; it included consecutive women at 24-34 weeks of pregnancy. The fetal liver volume and indices of hepatic vascularization were determined with three-dimensional power Doppler ultrasonography and compared between fetuses with and without a diagnosis of IUGR. Results A total of 119 women met study inclusion criteria; 97 fetuses had no growth restriction, whereas 22 fetuses had IUGR. The latter group had decreased liver volume (57.85 ± 29.71 mL vs 86.99 ± 31.24 mL; P=0.010) and increased vascular indices (vascularization index, 47.92 ± 34.44 versus 22.46 ± 18.95; flow index, 71.39 ± 42.01 versus 41.11 ± 23.24; vascularization flow index, 47.94 ± 47.96 versus 13.67 ± 22.38; P=0.003 for all comparisons).

CONCLUSION

Liver volume was decreased and liver vascular indices values were increased in fetuses with IUGR. These findings imply that evaluation of hepatic vascularization with three-dimensional hepatic Doppler could be useful in the diagnosis of IUGR.

Pathways linking socioeconomic status to small-for-gestational-age (SGA) infants among primiparae: a birth cohort study in China

OBJECTIVES

Evidence about the relationship between socioeconomic status (SES) and small-for-gestational-age (SGA) infants was insufficient among Chinese primiparae. In addition, factors that may mediate this relationship are poorly understood. The purpose of this study was to investigate the risk of and mediators between SES and SGA.

DESIGN

Retrospective cohort study.

SETTING

Wuhan, Hubei, China.

METHOD

Participants were recruited from patients who gave birth in the maternity care hospital of Wuhan between September 2012 and October 2014. Logistic regression models were used to estimate the association between SES and SGA. Pathway analysis was performed to examine the contribution of maternal lifestyles and pregnancy-induced hypertension syndrome (PIH) to the relationship between SES and SGA. Total effect, direct effect and indirect effect of SES on SGA were measured. Effect sizes were evaluated by unstandardised estimates (B) and standardised estimates (ß).

RESULTS

Among 8737 primiparae, 927 (10.61%) pregnant women had babies with SGA. High SES was inversely associated with risk of SGA (OR 0.856; 95% CI 0.737 to 0.995) after adjustment for potential confounders. Maternal obstetric characteristics, lifestyles and PIH completely mediated SES and SGA (indirect effect: B=-0.067, 95% CI -0.108 to -0.026). The indirect effect of SES was strengthened by PIH (B=-0.029), a multivitamin supplement (B=-0.021), prepregnancy body mass index (BMI) ≥18.50 (B=-0.009) and prepregnancy BMI ≥18.50 to gestational weight gain (GWG) not below the Institute of Medicine (IOM) recommendations (B=-0.003).

CONCLUSIONS

Women from high SES predicted lower risk of PIH, more chances to take a multivitamin supplement during early pregnancy, keeping prepregnancy BMI ≥18.50 kg/cm² and gaining adequate gestational weight which was not below IOM recommendations. Furthermore, lower risk of PIH, more chances to take a multivitamin supplement, prepregnancy BMI ≥18.50 kg/cm² and GWG not below IOM recommendations were associated with a lower risk of SGA infants.

Confined placental mosaicism revisited: Impact on pregnancy characteristics and outcome

OBJECTIVES

We wanted to re-evaluate the influence of confined placental mosaicism subtypes (type 2 and type 3) on pregnancy characteristics and outcome.

MATERIAL AND METHODS

From July 2009 to December 2015, 5512 chorionic villus samplings were performed in our Fetal Medicine Center. Conventional karyotyping was performed after long-term and short-term cultured villi to define type 2 or type 3 confined placental mosaicisms. Karyotype after amniocentesis was performed to exclude true fetal mosaicism, when appropriate. Pregnancy characteristics and outcomes were collected and compared to a control population.

RESULTS

Thirty-six (0.65%) confined placental mosaicisms were observed (13 type 2 and 23 type 3). Nuchal translucency was not increased for type 2 and type 3 confined placental mosaicisms. Pregnancy characteristics and outcomes were comparable between type 2 confined placental mosaicisms and the control population. In type 3 confined placental mosaicisms, median first trimester serum pregnancy-associated plasma protein A was lower than for the control population (p<0.001), preterm births were noticed in 56% (p<0.001), small for gestational age newborns in 74% (p<0.001), and adverse pregnancy outcome was reported in 35% (p<0.01).

CONCLUSION

Although type 2 confined placental mosaicisms appeared to have no influence on pregnancy characteristics and outcome, type 3 confined placental mosaicisms were associated with low levels of first trimester serum pregnancy-associated plasma protein A, preterm birth, small for gestational age newborns, and adverse pregnancy outcomes.

Pre-pregnancy endothelial dysfunction and birth outcomes: The Coronary Artery Risk Development in Young Adults (CARDIA) Study

Endothelial dysfunction is a form of subclinical cardiovascular disease that may be involved in preterm birth and small-for-gestational-age deliveries. However, concentrations of biomarkers of endothelial dysfunction before pregnancy have rarely been measured. We hypothesized that higher levels of biomarkers of endothelial dysfunction (cellular adhesion molecules and selectins) would be associated with odds of preterm birth and/or small-for-gestational-age deliveries. We included 235 women from the Coronary Artery Risk Development in Young Adults (CARDIA) study who were nulliparous at Y7, reported ≥1 live birth through Y25, and had ≥1 biomarker measured at Y7. We tested for associations between individual biomarkers and an averaged z-score representing total endothelial dysfunction with preterm birth and/or small-for-gestational-age deliveries using Poisson regression, adjusted for demographic and clinical characteristics at the exam immediately preceding index birth. At Y7, total evidence of  endothelial dysfunction was similar in women who did (n = 59) and did not have (n = 176) preterm birth and/or small-for-gestational-age deliveries. There was no association between biomarkers of endothelial dysfunction (either individual biomarker or total score) with odds of preterm birth and/or small-for-gestational-age deliveries after adjustment: IRR = 1.01, 95% CI: 0.74, 1.39, p = 0.93 for total endothelial biomarker score. Associations were not modified by race. We conclude that biomarkers of endothelial dysfunction in nulliparous women, measured ~3 years before pregnancy, did not identify women at risk for preterm birth and/or small-for-gestational-age deliveries. This suggests that the maternal endothelial dysfunction that is believed to contribute to these birth outcomes may not be detectable before pregnancy.

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.

Impact of customized growth curves on screening for small for gestational age twins

OBJECTIVE

The choice of a growth curve determines the screening for small-for-gestational-age (SGA) fetuses and little data is available on SGA twins. Our aim was to evaluate small-for-gestational-age (SGA) detection rate in twin pregnancies and assess whether the use of a customized curve allowed better identification of SGA fetuses.

STUDY DESIGN

Retrospective study including all twins between 2010 and 2013. Two groups were formed: the SGA and the non-SGA group. Four curves were compared: Hadlock's curve, a customized curve, EPOPé M0 and EPOPé M1. We defined a composite neonatal complication criterion (transfer to intensive care unit, respiratory distress and death).

RESULT

472 fetuses were included with a 34.3% prevalence of SGA. Hadlock's curve showed better sensitivity for the detection of SGA <10th percentile (67.3% vs. 63%, 59.9% and 57.4% respectively). Diagnostic Odd Ratio were comparable for the detection of SGA. For the composite variable, there was a significant difference between the 2 groups using a customized curve adjusted for fetal sex (EPOPé M1).

CONCLUSION

The EPOPé (M0 and M1) and customized curves do not improve screening for SGA infants below the 10th percentile. The reduced effectiveness of customized curves can be related to the greater impact of placentation or cord insertion on the potential for fetal growth.

Adverse Birth Outcomes and Maternal Neisseria gonorrhoeae Infection: A Population-Based Cohort Study in Washington State

BACKGROUND

Neisseria gonorrhoeae (gonorrhea) remains an important cause of reproductive and obstetric complications. There has been limited population-based research to evaluate the association between maternal gonorrhea and adverse birth outcomes.

METHODS

A population-based retrospective cohort study was conducted of women with singleton pregnancies in Washington State from 2003 to 2014 using linked birth certificate and birth hospitalization discharge data. The exposed cohort consisted of women with gonorrhea diagnosed during pregnancy. The unexposed group, defined as pregnant women without gonorrhea, was selected by frequency-matching by birth year in a 4:1 ratio. Logistic regression was used to determine crude and adjusted odds ratios (OR) for the association of maternal gonorrhea and adverse birth outcomes.

RESULTS

Women with gonorrhea during pregnancy (N = 819) were more likely to be younger, black, single, less educated, multiparous, and smokers compared with women without gonorrhea (N = 3276). Maternal gonorrhea was significantly associated with a 40% increased odds (adjusted OR, 1.4; 95% confidence interval [CI], 1.0-1.8) of low birth weight infants compared with women without gonorrhea when adjusted for marital and smoking status. Maternal gonorrhea was associated with a 60% increased odds (OR, 1.6; 95% CI, 1.3-2.0) of small for gestational age infants compared with women without gonorrhea.

CONCLUSIONS

This analysis showed that pregnant women with gonorrhea were more likely to have low birth weight infants, consistent with prior literature, and provided new evidence that maternal gonorrhea is associated with small for gestational age infants. These findings support increased public health efforts to prevent, identify, and treat gonorrhea infection during pregnancy.

Social correlates of term small for gestational age babies in a Russian Arctic setting

BACKGROUND

Small for gestational age (SGA) births have been associated with both short- and long-term adverse health outcomes. Although social risk factors for SGA births have been studied earlier, such data are limited from Northern Russia.

OBJECTIVE

We assessed maternal social risk factors for term SGA births based on data from the population-based Murmansk County Birth Registry (MCBR).

DESIGN

Data on term live-born singleton infants born between 2006 and 2011 in Murmansk County were obtained from the MCBR. We applied the 10th percentile for only birth weight (SGAW) or for both birth weight and birth length (SGAWL). Binary logistic regression was used to estimate the effect of independent variables on SGA males and females with adjustment for known risk factors and potential confounders. Both crude and adjusted odds ratios with 95% confidence intervals for the studied risk factors were calculated.

RESULTS

The proportions of term SGAW and SGAWL births were 9.7 and 4.1%, respectively. After adjustment for potential confounders, the risk of term SGA births among less educated, unemployed, unmarried, smoking and underweight women was higher compared with women from the reference groups. Evidence of alcohol abuse was also associated with birth of SGAWL and SGAW boys. Maternal overweight and obesity decreased the risk of SGA.

CONCLUSIONS

Maternal low education, unemployment, unmarried status, smoking, evidence of alcohol abuse and underweight increased the risk of term SGA births in a Russian Arctic setting. This emphasizes the importance of both social and lifestyle factors for pregnancy outcomes. Public health efforts to reduce smoking, alcohol consumption and underweight of pregnant women may therefore promote a decrease in the prevalence of SGA births.

Novel 3D light microscopic analysis of IUGR placentas points to a morphological correlate of compensated ischemic placental disease in humans

The villous tree of the human placenta is a complex three-dimensional (3D) structure with branches and nodes at the feto-maternal border in the key area of gas and nutrient exchange. Recently we introduced a novel, computer-assisted 3D light microscopic method that enables 3D topological analysis of branching patterns of the human placental villous tree. In the present study we applied this novel method to the 3D architecture of peripheral villous trees of placentas from patients with intrauterine growth retardation (IUGR placentas), a severe obstetric syndrome. We found that the mean branching angle of branches in terminal positions of the villous trees was significantly different statistically between IUGR placentas and clinically normal placentas. Furthermore, the mean tortuosity of branches of villous trees in directly preterminal positions was significantly different statistically between IUGR placentas and clinically normal placentas. We show that these differences can be interpreted as consequences of morphological adaptation of villous trees between IUGR placentas and clinically normal placentas, and may have important consequences for the understanding of the morphological correlates of the efficiency of the placental villous tree and their influence on fetal development.

Environmental and socio-economic determinants of infant mortality in Poland: an ecological study

BACKGROUND

Health status of infants is related to the general state of health of women of child-bearing age; however, women's occupational environment and socio-economic conditions also seem to play an important role. The aim of the present ecological study was to assess the relationship between occupational environment, industrial pollution, socio-economic status and infant mortality in Poland.

METHODS

Data on infant mortality and environmental and socio-economic characteristics for the 66 sub-regions of Poland for the years 2005-2011 were used in the analysis. Factor analysis was used to extract the most important factors explaining total variance among the 23 studied exposures. Generalized Estimating Equations model was used to evaluate the link between infant mortality and the studied extracted factors.

RESULTS

Marked variation for infant mortality and the characteristics of industrialization was observed among the 66 sub-regions of Poland. Four extracted factors: "poor working environment", "urbanization and employment in the service sector", "industrial pollution", "economic wealth" accounted for 77.3% of cumulative variance between the studied exposures. In the multivariate regression analysis, an increase in factor "poor working environment" of 1 SD was related to an increase in infant mortality of 40 (95% CI: 28-53) per 100,000 live births. Additionally, an increase in factor "industrial pollution" of 1 SD was associated with an increase in infant mortality of 16 (95% CI: 2-30) per 100,000 live births. The factors "urbanization and employment in the service sector" and "economic wealth" were not significantly related to infant mortality.

CONCLUSION

The study findings suggested that, at the population level, infant mortality was associated with an industrial environment. Strategies to improve working conditions and reduce industrial pollution might contribute to a reduction in infant mortality in Poland.

Fetal growth restriction and intra-uterine growth restriction: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians

Small for gestational age (SGA) is defined by weight (in utero estimated fetal weight or birth weight) below the 10th percentile (professional consensus). Severe SGA is SGA below the third percentile (professional consensus). Fetal growth restriction (FGR) or intra-uterine growth restriction (IUGR) usually correspond with SGA associated with evidence indicating abnormal growth (with or without abnormal uterine and/or umbilical Doppler): arrest of growth or a shift in its rate measured longitudinally (at least two measurements, 3 weeks apart) (professional consensus). More rarely, they may correspond with inadequate growth, with weight near the 10th percentile without being SGA (LE2). Birthweight curves are not appropriate for the identification of SGA at early gestational ages because of the disorders associated with preterm delivery. In utero curves represent physiological growth more reliably (LE2). In diagnostic (or reference) ultrasound, the use of growth curves adjusted for maternal height and weight, parity and fetal sex is recommended (professional consensus). In screening, the use of adjusted curves must be assessed in pilot regions to determine the schedule for their subsequent introduction at national level. This choice is based on evidence of feasibility and the absence of any proven benefits for individualized curves for perinatal health in the general population (professional consensus). Children born with FGR or SGA have a higher risk of minor cognitive deficits, school problems and metabolic syndrome in adulthood. The role of preterm delivery in these complications is linked. The measurement of fundal height remains relevant to screening after 22 weeks of gestation (Grade C). The biometric ultrasound indicators recommended are: head circumference (HC), abdominal circumference (AC) and femur length (FL) (professional consensus). They allow calculation of estimated fetal weight (EFW), which, with AC, is the most relevant indicator for screening. Hadlock's EFW formula with three indicators (HC, AC and FL) should ideally be used (Grade B). The ultrasound report must specify the percentile of the EFW (Grade C). Verification of the date of conception is essential. It is based on the crown-rump length between 11 and 14 weeks of gestation (Grade A). The HC, AC and FL measurements must be related to the appropriate reference curves (professional consensus); those modelled from College Francais d'Echographie Fetale data are recommended because they are multicentere French curves (professional consensus). Whether or not a work-up should be performed and its content depend on the context (gestational age, severity of biometric abnormalities, other ultrasound data, parents' wishes, etc.) (professional consensus). Such a work-up only makes sense if it might modify pregnancy management and, in particular, if it has the potential to reduce perinatal and long-term morbidity and mortality (professional consensus). The use of umbilical artery Doppler velocimetry is associated with better newborn health status in populations at risk, especially in those with FGR (Grade A). This Doppler examination must be the first-line tool for surveillance of fetuses with SGA and FGR (professional consensus). A course of corticosteroids is recommended for women with an FGR fetus, and for whom delivery before 34 weeks of gestation is envisaged (Grade C). Magnesium sulphate should be prescribed for preterm deliveries before 32-33 weeks of gestation (Grade A). The same management should apply for preterm FGR deliveries (Grade C). In cases of FGR, fetal growth must be monitored at intervals of no less than 2 weeks, and ideally 3 weeks (professional consensus). Referral to a Level IIb or III maternity ward must be proposed in cases of EFW <1500g, potential birth before 32-34 weeks of gestation (absent or reversed umbilical end-diastolic flow, abnormal venous Doppler) or a fetal disease associated with any of these (professional consensus). Systematic caesarean deliveries for FGR are not recommended (Grade C). In cases of vaginal delivery, fetal heart rate must be monitored continuously during labour, and any delay before intervention must be faster than in low-risk situations (professional consensus). Regional anaesthesia is preferred in trials of vaginal delivery, as in planned caesareans. Morbidity and mortality are higher in SGA newborns than in normal-weight newborns of the same gestational age (LE3). The risk of neonatal mortality is two to four times higher in SGA newborns than in non-SGA preterm and full-term infants (LE2). Initial management of an SGA newborn includes combatting hypothermia by maintaining the heat chain (survival blanket), ventilation with a pressure-controlled insufflator, if necessary, and close monitoring of capillary blood glucose (professional consensus). Testing for antiphospholipids (anticardiolipin, circulating anticoagulant, anti-beta2-GP1) is recommended in women with previous severe FGR (below third percentile) that led to birth before 34 weeks of gestation (professional consensus). It is recommended that aspirin should be prescribed to women with a history of pre-eclampsia before 34 weeks of gestation, and/or FGR below the fifth percentile with a probable vascular origin (professional consensus). Aspirin must be taken in the evening or at least 8h after awakening (Grade B), before 16 weeks of gestation, at a dose of 100-160mg/day (Grade A).

Examination of placental three-dimensional power Doppler indices and perinatal outcome in pregnancies complicated by intrauterine growth restriction

OBJECTIVE

To examine placental vascularization using three-dimensional power Doppler (3DPD) ultrasonography in pregnancies complicated by intrauterine growth restriction (IUGR).

METHODS

The present prospective study was conducted at the University of Szeged (Szeged, Hungary) from February 2012 to March 2013. Women with a singleton pregnancy who attended the maternity outpatient ward in the second or third trimester were enrolled consecutively. Women were divided into two groups: those with a normal pregnancy and those with a pregnancy complicated by IUGR. Three 3DPD indices-vascularization index (VI), flow index (FI), and vascularization flow index (VFI)-were assessed.

RESULTS

A total of 223 women were enrolled: 171 were in the control group and 52 in the IUGR group. Median VI was 3.7% (interquartile range [IQR] 3.2%-4.2%) in the IUGR group and 10.1% (IQR 8.6%-10.9%) in the control group (P=0.001). Median FI was 40.0 (IQR 39.7-42.5) in the IUGR group and 45.1 (IQR 44.1-53.1) in the control group (P=0.012). Median VFI was 2.2 (IQR 2.1-2.4) in the IUGR group and 4.8 (IQR 4.4-5.3) in the control group (P<0.001).

CONCLUSION

Placental vascularization was reduced in pregnancies complicated by IUGR.