A practical approach to fetal growth restriction

Late-onset fetal growth restriction management: a national survey

BACKGROUND

Fetal growth restriction (FGR) is an obstetric condition that increases the risk of adverse neonatal outcomes. FGR antenatal care aims to decrease fetal morbidity and mortality through optimal fetal monitoring. However, no univocal strategies for late-onset FGR outpatient management are available, and this survey investigated gynaecologists' attitudes concerning outpatient frequency tests.

METHODS

We mailed a survey to 429 Italian gynaecologists. The primary purpose was the ambulatory care of late-onset FGR without doppler alterations evaluation. The queries estimated the self-reported medical practice regarding cardiotocography (CTG) and obstetric ultrasound exams before hospitalization. Statistical analysis was performed with Stata 14.1 (Stata corp., College Station, TX, USA) for symmetrically distributed continuous variables, and the mean differences were analyzed using the t-test. Where appropriate, the proportions between the groups were evaluated using Fisher's exact or χ2 test. All P value <0.05 were considered statistically significant.

RESULTS

128 responses (29.8%) from the 429 SCCAL members were available for the survey. 39.9% of respondents had a late FGR standardized protocol. Regarding non-severe FGR with normal fetal doppler, 70.8% suggested a fetal doppler study after one week (92/128), 13.8% (18/128) and 6.9% (9/128) proposed the exam, respectively, two and three times for a week. 0.8% (1/128) of respondents had a daily doppler exam, 7.7% (10/128) did not answer, and 3.1% (4/128) repeated the ultrasound exam to time for a week. The antenatal CTG was offered: 70.8% (92/128) of gynaecologists recommended one weekly CTG, whereas 13.8% (18/128) suggested two. 6.9% (9/128) recommended three weekly tests and 0.8% a daily test. 7.7% (10/128) of gynaecologists did not respond. At least, we investigated the gynaecologist's recommendations for outpatient EFW evaluation: 59.4% (76/128) repeated EFW after two weeks, 31.3% (40/128) after one week. 3.9% (4/128) and 3.1 (4/128) recommended EFW after three weeks and twice a week.

CONCLUSIONS

Gynaecologists recommend unnecessary cardiotocography and ultrasound Doppler exams for non-severe late-onset FGR with normal doppler. However, additional studies and comprehensive surveys are needed to support a standardized protocol and assess the feto-maternal outcomes impact.

Antiphospholipid syndrome in cardiovascular disease and cancer

Antiphospholipid syndrome is an autoimmune disorder which is characterized by the presence of heterogeneous antiphospholipid antibodies. There is an evidence on antiphospholipid (aPL) antibodies related to thromboembolic events in cancer patients. In fact, the thrombotic complications in patients with malignancy occur at a rather high frequency, compared to other risk factors. In parallel with standard therapies available, there is need of case-by-case monitoring of each patient and the introduction of new therapies and need for more clinical trials which will address many questions for the optimal management of patients. This paper presents a basic review of the literature on the aPL antibodies associated with cardiovascular disease and cancer, as well as its complications, which are reported so far in the bibliography.

Choice of standards for sonographic fetal abdominal circumference percentile

BACKGROUND

The diagnosis of abnormal fetal abdominal circumference is based on values >90th or <10th percentile. There are dozens of established norms that can be used to determine the percentile of a given abdominal circumference measurement, but there is no established method to determine which norms should be used.

OBJECTIVE

This study aimed to evaluate the applicability of 5 established abdominal circumference norms to our measurements and to determine which, if any, should be used for the diagnosis of abnormal fetal abdominal circumference.

STUDY DESIGN

Data were pooled from 6 maternal-fetal medicine practices to conduct a cross-sectional study. The inclusion criteria were a singleton fetus at 22.0 to 39.9 weeks of gestation with cardiac activity present, complete fetal biometry measured, and examination from 2019 or 2020. For patients with >1 eligible examination during the study period, a single examination was chosen at random for inclusion. Five norms of abdominal circumference were studied: the Hadlock formula, the World Health Organization Fetal Growth Curves, the International Fetal and Newborn Growth Consortium for the 21st-Century Project; and the National Institutes of Child Health and Human Development Fetal Growth Studies (fetuses of White patients and unified standard). Using formulas relating abdominal circumference to gestational age, we calculated the z scores of abdominal circumference (standard deviations from the mean), standard deviation of the z score, Kolmogorov-Smirnov D statistic, and relative mean squared error. The 5 norms were assessed for fit to our data based on 6 criteria: mean z score close to 0, standard deviation of the z score close to 1, low D statistic, low mean squared error, fraction of values >90th percentile close to 10%, and fraction of values <10th percentile close to 10%.

RESULTS

The inclusion criteria were met in 40,684 ultrasound examinations in 15,042 patients. Considering the 6 evaluation criteria, observed abdominal circumferences had the best fit to the World Health Organization standard (mean z score of 0.11±1.05, D statistic of 0.041, mean squared error of 0.84±1.46, 13% of examinations >90th percentile, and 7% of examinations <10th percentile). The Hadlock reference had an anomaly in its assumption of a constant standard deviation, resulting in the underdiagnosis of abnormal values at early gestational ages and overdiagnosis at late gestational ages. The International Fetal and Newborn Growth Consortium for the 21st-Century Project standard had a mean circumference smaller than all the other norms, resulting in the underdiagnosis of small circumferences and the overdiagnosis of large circumferences. Similar results were observed when restricting the analyses to a low-risk subgroup of 5487 examinations without identified risk factors for large for gestational age or small for gestational age.

CONCLUSION

The diagnosis of abnormal abdominal circumference depends on the norms used to define abdominal circumference percentiles. The World Health Organization standard had the best fit for our data.

Lower fetal fraction in clinical cell-free DNA screening results is associated with increased risk of hypertensive disorders of pregnancy

OBJECTIVE

To evaluate if fetal fraction (FF) reported on cell-free DNA (cfDNA) screening is a marker for adverse obstetric outcomes.

METHODS

We retrospectively reviewed medical records from a cohort of women with singleton pregnancies who had cfDNA screening. We evaluated if reported FF could predict the following pregnancy complications: hypertensive disorders of pregnancy (HDP), fetal growth restriction, preterm delivery, gestational diabetes mellitus, or a composite maternal morbidity, defined as the presence of at least one of these outcomes.

RESULTS

Receiver operating curve analysis was performed on FF from 534 women to define the FF that differentiated a low FF group (<10%; N = 259) and a high FF group (≥10%; N = 275). Hypertensive disorders of pregnancy were more common for women in the low FF group (32.0% vs. 11.6% and p < 0.001), who had a two-fold odds of developing HDP (p = 0.006). Composite maternal morbidity was also more common for women in the low FF group (51.4% vs. 30.2% and p < 0.001), who had a 1.7-fold odds of developing any of the adverse obstetrical outcomes (p = 0.014).

CONCLUSION

We found that low FF on cfDNA screening is associated with an increased risk of HDP. Fetal fraction reported that cfDNA screening reports have potential as a predictive marker for the development of HDP and adverse outcomes.

Maternal Serum and Cord Blood Leptin Concentrations at Delivery in Normal Pregnancies and in Pregnancies Complicated by Intrauterine Growth Restriction

INTRODUCTION

Leptin is a polypeptide hormone, and in pregnancy, it is secreted by the placenta and maternal and fetal adipose tissues. Normal leptin production is a factor responsible for uncomplicated gestation, embryo development, and fetal growth. The study compared maternal serum and cord blood leptin concentrations at delivery in normal pregnancies and in pregnancies complicated by intrauterine growth restriction (IUGR).

METHODS

The study was performed in 25 pregnant women with isolated IUGR and in 194 pregnant women without any complications. Leptin concentrations in maternal serum and in cord blood samples collected at delivery were measured by ELISA and subsequently analyzed by maternal body mass index (BMI), mode of delivery, and infant gender and birth weight. For comparative analyses of normally distributed variables, parametric tests were used, that is, the Student t test and a one-way ANOVA. The nonparametric Mann-Whitney test was used when the distribution was not normal. The Pearson correlation coefficient was calculated to assess the correlation between normally distributed variables (p < 0.05).

RESULTS

In pregnancies complicated by IUGR, the mean maternal serum leptin concentration at delivery was significantly higher (52.73 ± 30.49 ng/mL) than in normal pregnancies (37.17 ± 28.07 ng/mL) (p = 0.01). The mean cord blood leptin concentration in pregnancies complicated by IUGR was 7.97 ± 4.46 ng/mL and significantly lower than in normal pregnancies (14.78 ± 15.97 ng/mL) (p = 0.04). In normal pregnancies, but not in pregnancies complicated by IUGR, a statistically significant correlation was established between maternal serum leptin concentrations and maternal BMI at delivery (r = 0.22; p = 0.00). No statistically significant correlation was found between cord blood leptin concentrations and maternal BMI in either study subjects or controls. In normal pregnancies, but not in pregnancies complicated by IUGR, a strong correlation was observed between cord blood leptin concentrations and birth weight (r = 0.23; p = 0.00).

CONCLUSIONS

Elevated maternal blood leptin concentrations in pregnancies complicated by IUGR may indicate a significant adverse effect of elevated leptin on fetal growth. The differences in leptin concentrations, measured in maternal serum and in cord blood, between the study subjects and controls suggest that deregulated leptin levels may increase the risk of obstetric complications associated with placental insufficiency.

Antiphospholipid Antibodies Increase the Risk of Fetal Growth Restriction: A Systematic Meta-Analysis

OBJECTIVE

Antiphospholipid syndrome (APS) is a chronic autoimmune disease with a high prevalence in females. Published data have identified pregnant women with APS may suffer from recurrent miscarriage, fetal death. However, the association between antiphospholipid antibody (aPL) and fetal growth restriction (FGR) remains controversial. This study aims to systematically review the literature on population-based studies investigating an association between aPL and FGR.

METHODS

The literature was searched on 1 November, 2021, using Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL), following the MOOSE checklist. Study inclusion criteria focused on peer-reviewed published articles that reported an association between aPL and FGR. Quality assessment was performed based on the Newcastle-Ottawa scale. The between-study heterogeneity was assessed by the Q test. Publication bias was assessed by funnel plots.

RESULTS

Twenty-two studies (with 11745 pregnant women) were included in the final analysis. Pooled odds ratio for association of aPL, anticardiolipin antibodies (ACA), anti-beta2 glycoprotein 1 antibodies (β2GP1), and FGR was 1.26 (95%CI 1.12, 1.40), 2.25 (95%CI 1.55, 2.94), and 1.31 (95% CI 1.12, 1.49), respectively. Lupus anticoagulant (LA) did not increase the chance of FGR (OR 0.82, 95%CI 0.54, 1.10).

CONCLUSIONS

Our meta-analysis showed that aPL increased the risk of FGR. The risk of FGR varies with the aPL types. ACA and β2GP1 are strongly associated with FGR. There are currently insufficient data to support a significant relationship between LA and FGR.

Impact of adding abdominal circumference to the definition of fetal growth restriction

BACKGROUND

Fetal growth restriction has traditionally been defined as fetuses with an estimated fetal weight <10th percentile for gestational age. In 2020, the Society for Maternal-Fetal Medicine recommended that the definition be expanded to include either an estimated fetal weight<10th percentile or a fetal abdominal circumference<10th percentile.

OBJECTIVE

We sought to determine the impact of adding the criterion abdominal circumference<10th percentile on the rate of diagnosis of fetal growth restriction vs using the criterion estimated fetal weight<10th percentile alone. In addition, we evaluated the definition proposed by Copel and Bahtiyar, estimated fetal weight<10th percentile or abdominal circumference<5th percentile.

STUDY DESIGN

This was a retrospective, descriptive study from 3 consultative maternal-fetal medicine practices. Biometry was compiled from ultrasound examinations from January 2019 to July 2020. The inclusion criteria were singleton pregnancy, gestational age of ≥24 weeks, presence of fetal cardiac activity, and presence of 4 standard fetal biometry parameters (biparietal diameter, head circumference, abdominal circumference, and femur length). We tabulated the indications for the examinations and the number of examinations meeting several criteria for the diagnosis of fetal growth restriction: Traditional criterion (estimated fetal weight<10th percentile), Copel-Bahtiyar criteria (estimated fetal weight<10th percentile or abdominal circumference<5th percentile), and Society for Maternal-Fetal Medicine criteria (estimated fetal weight<10th percentile or abdominal circumference<10th percentile).

RESULTS

During the study period, 20,633 ultrasound examinations met the inclusion criteria. In 62% of examinations, there was ≥1 factor for fetal growth restriction, and in 51% of examinations, there was ≥1 factor for large for gestational age. The rate of estimated fetal weight<10th percentile was 9.7%. The rate of abdominal circumference<5th percentile was 5.7%, and the rate of abdominal circumference<10th percentile was 9.2%. The rate of fetal growth restriction was 9.7% using the traditional definition (estimated fetal weight<10th percentile only). The rate of fetal growth restriction was 10.2% using the Copel-Bahtiyar definition (estimated fetal weight<10th percentile or abdominal circumference<5th percentile), significantly higher than using the traditional definition (P<.001). The rate of fetal growth restriction was 11.6% using the Society for Maternal-Fetal Medicine definition (estimated fetal weight<10th percentile or abdominal circumference<10th percentile), significantly higher than using either the traditional or Copel-Bahtiyar definition (P<.001 for both). Among examinations with an abdominal circumference<10th percentile, 79% also had an estimated fetal weight<10th percentile and was considered fetal growth restriction even without considering abdominal circumference.

CONCLUSION

Adding the criterion abdominal circumference<5th percentile or abdominal circumference<10th percentile to the definition of fetal growth restriction resulted in a statistically significant increase in the rate of diagnosis of fetal growth restriction. However, the absolute increase in the rate was small and was not expected to place a large burden on practice resources.

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).

ACR Appropriateness Criteria® Growth Disturbances-Risk of Fetal Growth Restriction

Fetal growth restriction, or an estimated fetal weight of less than the 10th percentile, is associated with adverse perinatal outcome. Optimizing management for obtaining the most favorable outcome for mother and fetus is largely based on detailed ultrasound findings. Identifying and performing those ultrasound procedures that are most associated with adverse outcome is necessary for proper patient management. Transabdominal ultrasound is the mainstay of initial management and assessment of fetal growth. For those fetuses that are identified as small for gestational age, assessment of fetal well-being with biophysical profile and Doppler velocimetry provide vital information for differentiating those fetuses that may be compromised and may require delivery and those that are well compensated. Delivery of the pregnancy is primarily based upon the gestational age of the pregnancy and the ultrasound findings. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Fetal adrenal gland: Total gland volume and fetal zone to total gland ratio as markers of small for gestational age

PURPOSE

Fetal adrenal gland changes have previously been investigated as novel markers of preterm labor and small for gestational age (SGA) fetuses. We aimed to compare the fetal adrenal gland parameters in SGA and appropriate for gestational age (AGA) fetuses.

METHODS

A prospective cohort study was conducted on SGA fetuses with estimated fetal weight (EFW) ≤10th centile and AGA (EFW >10th centile) at 17 to 34 weeks gestation. Fetal adrenal total gland volume (TGV), TGV corrected for EFW (cTGV), fetal zone volume (FZV), FZV corrected for EFW (cFZV), and FZV:TGV ratio were compared and correlated with gestational age and EFW. Receiver operator curves assessed FZV:TGV ratio, cTGV, and cFZV in detecting SGA.

RESULTS

Ultrasound examinations from 103 AGA and 50 SGA fetuses showed that (a) SGA fetuses had higher TGV (P = .002), FZV (P = .001), and FZV:TGV (P = .036) compared to AGA fetuses; (b) fetal adrenal TGV, FZV, cFZV, and FZV:TGV increase with advancing gestational age and EFW while cTGV does not; (c) Fetal adrenal changes in cTGV, cFZV, and FZV:TGV have ability to differentiate SGA; (d) FZV:TGV ratio 10 and 25 may be used to identify or exclude SGA in antenatally suspected SGA.

CONCLUSIONS

We investigated the concept that SGA fetuses have measurable changes to the adrenal gland. We have shown that fetal TGV, TGV, and FZV:TGV ratio show differences between AGA and SGA with TGV remaining significant after accounting for GA at scan. These findings may be useful as potential biomarkers for diagnosing or excluding SGA.

Different morphological and gene expression profile in placentas of the same sickle cell anemia patient in pregnancies of opposite outcomes

IMPACT STATEMENT

Environmentally induced changes in placental morphological and molecular phenotypes may provide relevant insight towards pathophysiology of diseases. The rare opportunity to evaluate the same patient, with sickle cell anemia (SCA), in two different pregnancies, of opposite outcomes (one early onset severe preeclampsia (PE) and the other mostly non-complicated) can prove such concept. In addition, the comparison to other conditions of known placental and vascular/inflammatory involvement strengthens such findings. Our results suggest that the clinical association between SCA and PE can be supported by common pathophysiological mechanisms, but that pathways involving response to copper and triglyceride metabolism may be important drivers of the pathophysiology of PE. Future studies using in a larger number of samples should confirm these findings and explore pathways involved in the pathophysiology of PE and its relationship with SCA.

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.

Beyond endothelial cells: Vascular endothelial growth factors in heart, vascular anomalies and placenta

Vascular endothelial growth factors regulate vascular and lymphatic growth. Dysregulation of VEGF signaling is connected to many pathological states, including hemangiomas, arteriovenous malformations and placental abnormalities. In heart, VEGF gene transfer induces myocardial angiogenesis. Besides vascular and lymphatic endothelial cells, VEGFs affect multiple other cell types. Understanding VEGF biology and its paracrine signaling properties will offer new targets for novel treatments of several diseases.

Antenatal interventions based upon fetal surveillance of the daily opioid-exposed fetus: a descriptive analysis

Objective: Daily opioid dependence for maternal pain management, methadone maintenance, or buprenorphine/naloxone therapy is an increasing trend in modern obstetrics. Opioids may produce depressive effects on fetal neurobehavioral status and thus on fetal heart rate patterns. Our primary objective was to describe the current methods utilized in antenatal monitoring of the daily opioid exposed fetus; and to describe interventions based upon monitoring which precipitated a recommendation for delivery. Our ultimate goal was to determine an optimal, evidence-based recommendation for fetal assessment of the daily opioid exposed pregnancy.Study design: A retrospective review of patients undergoing antenatal assessment from January 2016 through April 2017 at two maternal-fetal medicine testing centers identified singleton, fetuses without a known major genetic abnormality with daily opioid exposure. Nonstress tests, amniotic fluid indexes, biophysical profiles, umbilical artery Doppler measurements, and serial biometry were analyzed. Test characteristics and frequency of interventions for abnormal monitoring were quantified.Results: Criteria for daily opioid exposure was identified in 27 patients (77.8% on methadone (n = 21), 14.8% on prescription opioid for chronic pain (n = 4), and 7.4% on buprenorphine/naloxone (n = 2)). Mean maternal age was 30.3 years ±5.5 (range 21-42 years). Parity zero was 6/27 (22.2%). Identified race was 52% Caucasian, 26% African American, 19% Hispanic, and 4% Pacific Islander. There were 112 growth scans, 102 biophysical profiles, 10 isolated nonstress tests, and 81 umbilical artery Doppler studies reviewed. Delivery precipitated by abnormal testing occurred in 6/27 patients (22.2%). Gestational ages of delivery were all between 36 and 38 weeks. Indications for delivery were isolated oligohydramnios 2/6 (one at 37 weeks, one at 38 weeks), oligohydramnios with associated intrauterine growth restriction 2/6 (both at 36 weeks), isolated nonreactive nonstress test 1/6 (occurring at 38 weeks), and low biophysical profile score 1/6 (occurring at 36 weeks). The average nonstress test baseline was 131 (±11) beats per minute (range of 120-150), with no episodes of significant fetal bradycardia or tachycardia. Overall, 94.6% (106/112) of the nonstress tests were reactive, all nonstress tests had variability, 96.4% (108/112) had moderate variability, and 99.1% (111/112) had no decelerations. Time to nonstress test reactivity was <20 min in 93% (104/112), with a mean time to first acceleration of 5.3 (±7.7) min (range of 1-44). Umbilical artery Doppler measurements had an elevated systolic to diastolic ratio >95% for gestational age in 9/83 cases, with no measurements demonstrating absent or reversed end diastolic flow. Umbilical artery Doppler studies did not initiate changes in management.Conclusion: In our population, antepartum assessment with a biophysical profile at no later than 36-week gestation identified all fetuses with testing abnormalities necessitating delivery in the daily opioid exposed fetus (6/27, 22.2%). Oligohydramnios was the most frequent indication for delivery. Serial growth ultrasounds by 32 weeks were necessary to identify the 11.1% of growth restricted, opioid exposed fetuses. A depressive effect of daily opioids on nonstress test reactivity or variability was not evident in our cohort. Future studies should attempt to define optimal monitoring based upon category of opioid dependence, type and dose of opioid consumed, and timing of opioid administration.

The relationship between intrapartum cerebroplacental ratio and adverse perinatal outcomes in term fetuses

OBJECTIVES

The cerebroplacental ratio (CPR) Doppler has been proposed as an instrument for predicting adverse perinatal outcomes particularly during antepartum period. Abnormal CPR is associated with non-reassuring fetal status requiring operative delivery, low Apgar score and neonatal complications. The aim of this study was to assess the role of CPR Doppler in the labor triage suite, so as to identify fetuses at risk for non-reassuring status as well as other adverse perinatal outcomes.

METHODS

This was a prospective cohort study of term pregnancies who attended the labor room during the latent phase of labor. Both fetal Middle Cerebral Artery Pulsatility Index (MCA-PI) and Umbilical Artery Pulsatility Index (UA-PI) were measured and these values were converted to CPR values. Non-reassuring fetal status requiring operative delivery and other adverse perinatal outcomes were compared between women with normal and abnormal CPR values. Accuracy of CPR for predicting non-reassuring fetal status and abnormal fetal heart rate patterns were calculated.

RESULTS

A total of 384 women were recruited. Lower CPR values were observed in women who underwent operative delivery for non-reassuring fetal status. However, when dividing women into normal and abnormal CPR groups, using 3 different cut-off values, the rate of non-reassuring fetal status was not significantly different between the groups. There was a significantly higher rate of abnormal fetal heart rate monitoring in fetuses with CPR < 5^th percentile and CPR < 1. CPR appeared to have a low positive predictive value (PPV) for predicting non-reassuring fetal heart rate patterns, however, the negative predictive value (NPV) was high.

CONCLUSIONS

In term fetuses, lower CPR is associated with non-reassuring fetal status. CPR measurement during the intrapartum period with currently available CPR cut-off values is not a good predictor for adverse perinatal outcomes, with the exception of abnormal fetal heart rate patterns. However, the high NPV may be used to stratify pregnant women who may benefit from continuous fetal heart rate monitoring.

Examining the link between placental pathology, growth restriction, and stillbirth

Stillbirth, often defined as death of a fetus ≥20 weeks of gestation, is emotionally devastating for families and caregivers. It is often associated with fetal growth restriction (FGR). Indeed, FGR or small-for-gestational age fetus (SGA) is a major risk factor for stillbirth. In rare cases, this is due to genetic abnormalities or infections. However, in most cases, it is linked to placental insufficiency. This may be due to abnormal placental development or placental damage, thereby resulting in decreased blood flow, oxygen, and nutrients to the fetus. Several placental histological abnormalities are associated with stillbirth, FGR, or both. Most involve vascular abnormalities but some are inflammatory lesions. This paper reviews evidence regarding the relationships between placental function and pathology, FGR, and stillbirth. Issues with clinical relevance, knowledge gaps, and areas for further research are highlighted.

Relationship between second-trimester amniotic fluid levels of Prokineticin-1 and Matrix Metalloproteinase-2 with adverse pregnancy outcome

To investigate the levels of Prokineticin-1 (PROK1) and matrix metalloproteinase-2 (MMP-2) in second-trimester amniotic fluid (AF). AF samples were investigated in 81 patients. AF-PROK1 and AF-MMP-2 were not significantly associated with adverse pregnancy outcomes (preeclampsia, intrauterine growth retardation, spontaneous preterm birth, gestational diabetes, gestational hypertension). AF-PROK1 levels in patients with abnormal first-trimester screening were significantly higher than those who underwent amniocentesis due to abnormal second-trimester screening tests (p = .04). AF-PROK1 or AF-MMP-2 do not have a role in the prediction of adverse pregnancy outcomes.

Defining fetal growth restriction: abdominal circumference as an alternative criterion

PURPOSE

The purpose of this study is to determine if using abdominal circumference percentile (AC) to define fetal growth restriction (FGR) improves ultrasound at ≥36 weeks as a screening test for small for gestational age (SGA).

MATERIALS AND METHODS

All non-anomalous singletons undergoing ultrasound at a single center at ≥36 weeks during 12/2008-5/2014 were included. FGR was defined as (estimated fetal weight) estimated fetal weight (EFW) and/or abdominal circumference (AC) < 10 for gestational age (GA). The primary outcome was SGA (birthweight ≤10th percentile for GA). Data were stratified by maternal race/ethnicity and BMI. Sensitivity, specificity, false-positive rate (FPR), positive- and negative-predictive values (positive-predictive value (PPV), negative-predictive value (NPV)), and areas under the receiver-operating characteristic (ROC) curve (AUC were calculated.

RESULTS

There were 1594 ultrasounds. Median (IQR) ultrasound GA was 37.3 (36.6-38.0), days to delivery 10.6 (5.0-18.4), and delivery GA 39.29 (38.6-39.9). EFW <10 had the following characteristics: sensitivity 50.6%, FPR 2.0%, PPV 83.8%, and AUC 0.743. Using AC <10, these were 64.0, 2.9, 81.3, and 0.806, respectively. Using AC or EFW <10, these were 67.5, 3.3, 80.3, and 0.821, respectively; this criterion has the largest AUC (p < .008). This finding persisted when stratified by maternal race/ethnicity and BMI.

CONCLUSIONS

AC <10 is more sensitive and has a similar PPV compared with EFW <10 for SGA. Using AC <10 or EFW <10 has the best balance of sensitivity and specificity as a screening test and has a low FPR. AC may be a reasonable alternative criterion to EFW for FGR diagnosis.

Fetal and neonatal outcomes of preterm infants born before 32 weeks of gestation according to antenatal vs postnatal assessments of restricted growth

BACKGROUND

Fetal growth restriction is defined using ultrasound parameters during pregnancy or as a low birthweight for gestational age after birth, but these definitions are not always concordant.

OBJECTIVE

The purpose of this study was to investigate fetal and neonatal outcomes based on antenatal vs postnatal assessments of growth restriction.

STUDY DESIGN

From the EPIPAGE 2 population-based prospective study of very preterm births in France in 2011, we included 2919 singleton nonanomalous infants 24-31 weeks gestational age. We constituted 4 groups based on whether the infant was suspected with fetal growth restriction during pregnancy and/or was small for gestational age with a birthweight <10th percentile of intrauterine norms by sex: 1) suspected with fetal growth restriction/small for gestational age 2) not suspected with fetal growth restriction/small for gestational age 3) suspected with fetal growth restriction/not small for gestational age and 4) not suspected with fetal growth restriction/not small for gestational age. We estimated relative risks of perinatal mortality and morbidity for these groups adjusting for maternal and neonatal characteristics.

RESULTS

We found that 22.2% of infants were suspected with fetal growth restriction/small for gestational age, that 11.4% infants were not suspected with fetal growth restriction/small for gestational age, that 3.0% infants were suspected with fetal growth restriction/not small for gestational age, and that 63.4% infants were not suspected with fetal growth restriction/not small for gestational age. Compared with infants who were not suspected with fetal growth restriction/not small-for-gestational-age infants, small-for-gestational-age infants suspected and not suspected with fetal growth restriction had higher risks of stillbirth or termination of pregnancy (adjusted relative risk, 2.0 [95% confidence interval, 1.6-2.5] and adjusted relative risk, 2.8 [95% confidence interval, 2.2-3.4], respectively), in-hospital death (adjusted relative risk, 2.8 [95% confidence interval, 2.0-3.7] and adjusted relative risk, 2.0 [95% confidence interval, 1.5-2.8], respectively), and bronchopulmonary dysplasia (adjusted relative risk, 1.3 [95% confidence interval, 1.2-1.4] and adjusted relative risk, 1.3 [95% confidence interval, 1.1-1.4], respectively), but not severe brain lesions. Risks were not increased for infants suspected with fetal growth restriction but not small-for-gestational-age.

CONCLUSION

Antenatal and postnatal assessments of fetal growth restriction were not concordant for 14% of very preterm infants. In these cases, birthweight appears to be the more relevant parameter for the identification of infants with higher risks of adverse short-term outcomes.

Late preterm and early term: when to induce a growth restricted fetus? A population-based study

PURPOSE

(1) Compare fetal and neonatal morbidity and mortality associated with induction of labor (IOL) versus expectant management (EM) in women with isolated fetal growth restriction (FGR) between 34^0/7 and 38^6/7 weeks; (2) Determine optimal gestational age for delivery of such fetuses.

MATERIALS AND METHODS

A retrospective population based cohort study of 2232 parturients with isolated FGR, including two groups: (1) IOL (n = 1428); 2) EM (n = 804).

RESULTS

IOL group had a lower stillbirth and neonatal death rates (p = .042, p < .001), higher 1 and 5 min Apgar scores and a higher vaginal delivery rate compared to the EM group. In the late preterm period, EM was associated with increased rate of low 1 and 5 min Apgar scores, nonreassuring fetal heart rate tracing (NRFHR), stillbirth and neonatal death rate (p = .001, p = .039). In the early term cohort, EM was associated with a higher rate of NRFHR and low 1 min Apgar scores (p = .003, p = .002). IOL at 37 weeks protected from stillbirth but not from adverse composite neonatal outcomes.

CONCLUSIONS

IOL of FGR fetuses at 37 weeks had a protective effect against stillbirth. In addition, at late preterm, it is associated with lower rates of stillbirth, neonatal death, and NRFHR.

Evaluation of the INTERGROWTH-21st project newborn standard for use in Canada

Objective

To evaluate the performance of the INTERGROWTH-21^st Project newborn standard vis-a-vis the current Canadian birth weight-for-gestational age reference.

Methods

All hospital-based singleton live births in Canada (excluding Quebec) between 2002 and 2012 with a gestational age between 33 and 42 weeks were included using information obtained from the Canadian Institute for Health Information. Small- and large-for gestational age centile categories of the INTERGROWTH standard and Canadian reference were contrasted in terms of frequency distributions and rates of composite neonatal morbidity/mortality.

Results

Among 2,753,817 singleton live births, 0.87% and 9.63% were <3^rd centile and >97^th centile, respectively, of the INTERGROWTH standard, while 2.27% and 3.55% were <3^rd centile and >97^th centile, respectively, of the Canadian reference. Infants <3^rd centile and >97^th centile had a composite neonatal morbidity/mortality rate of 46.4 and 12.9 per 1,000 live births, respectively, under the INTERGROWTH standard and 30.9 and 16.6 per 1,000 live births, respectively, under the Canadian reference. The INTERGROWTH standard <3^rd centile and >97^th centile categories had detection rates of 3.14% and 9.74%, respectively, for composite neonatal morbidity/ mortality compared with 5.48% and 4.60%, respectively for the Canadian reference. Similar patterns were evident in high- and low-risk subpopulations.

Conclusions

The centile distribution of the INTERGROWTH newborn standard is left shifted compared with the Canadian reference, and this shift alters the frequencies and neonatal morbidity/mortality rates associated with specific centile categories. Further outcome-based research is required for defining abnormal growth categories before the INTERGROWTH newborn standard can be used.

The Effects of Fetal Movement Counting on Pregnancy Outcomes

INTRODUCTION

Counting fetal movements may lead to timely assess fetal health and prevent the adverse effects of pregnancy.

AIM

The aim of this study was to determine the effect of fetal movement counting on pregnancy outcomes.

MATERIALS AND METHODS

In a randomized controlled trial, 208 women with singleton pregnancy were randomly divided into two groups of fetal movement counting and control. Pregnancy outcomes were compared between the two groups. Data were analysed with SPSS and p<0.05 was considered significant.

RESULTS

There was no significant difference in the mean maternal concern (p=0.36), admission to hospital due to the decreased fetal movements (p=0.99), birth weight (p=0.21), Apgar score (p=0.51), the mean of gestational age at the time of decreased fetal movements (p=0.49) and mode of delivery (p=0.69) between the two groups. There were no cases of premature labour, intrauterine growth retardation and fetal death in the two groups.

CONCLUSION

Pregnancy outcome was similar in the two groups of fetal movement counting and control. Further studies are needed to evaluate the effect of fetal movement counting on the major outcomes of pregnancy such as intrauterine fetal death.

Does the Presence of Risk Factors for Fetal Growth Restriction Increase the Probability of Antenatal Detection? A French National Study

BACKGROUND

Screening for fetal growth restriction (FGR) is a major component of prenatal care. We investigated whether the presence of maternal and pregnancy risk factors for FGR improves the antenatal suspicion of FGR for infants born small-for-gestational age (SGA) as well as their impact on screening specificity.

METHODS

Data are from a representative sample of births from the 2010 French National Perinatal Survey (n = 14 100). Detection of FGR was determined by a suspicion of FGR noted in medical charts. Analyses were performed for singleton infants with birthweight under the 10th percentile (SGA), under the 3rd percentile (severely SGA), and above the 10th percentile (false positives) of French references. We studied risk factors for FGR (medical and obstetric conditions, advanced maternal age, nulliparity, body mass index and smoking) using multivariable Poisson regression to derive adjusted risk ratios (aRR).

RESULTS

Of SGA infants, 21.7% were suspected of FGR. The presence of obstetric and medical risk factors for FGR was associated with higher suspicion among SGA infants [RR 2.1, 95% confidence interval (CI) 1.7, 2.7]. However, despite the presence of these factors, 60% and 40% of SGA and severely SGA infants, respectively, were not suspected of FGR. Two per cent of normal birthweight infants were suspected of FGR, increasing to 5% when obstetric and medical risk factors were present. Smoking and older maternal age were unrelated to suspicion while females were more likely to be suspected of FGR.

CONCLUSION

Our results suggest that better risk assessment could improve antenatal identification of FGR. Sex-specific fetal growth references should be used to avoid systematic bias linked to sex.

Predisposing Factors to Abnormal First Trimester Placentation and the Impact on Fetal Outcomes

Normal placentation during the first trimester sets the stage for the rest of pregnancy and involves a finely orchestrated cellular and molecular interplay of maternal and fetal tissues. The resulting intrauterine environment plays an important role in fetal programming and the future health of the fetus, and is impacted by multiple genetic and epigenetic factors. Abnormalities in placentation and spiral artery invasion can lead to ischemia, placental disease, and adverse obstetrical outcomes including preeclampsia, intrauterine growth restriction, and placental abruption. Although first trimester placentation is affected by multiple factors, preconception environmental influences such as mode of conception, including assisted reproductive technologies which result in fertilization in vitro and intrauterine influences due to sex differences, are emerging as potential significant factors impacting first trimester placentation.

Ischemic placental syndrome--prediction and new disease monitoring

The last decade has seen an improved understanding of the cause of the development of pathologies such as gestational hypertension, preeclampsia, intrauterine growth restriction, intrauterine fetal death or placental abruption. Nowadays, we know that most conditions within this group share the same pathogenesis, the cause of which is placental ischemia. The following review is an attempt to propose a new method for prediction, diagnosis and--above all--appropriate monitoring of pregnant women and fetuses developing the ischemic placental syndrome with the use of tests that are new but yet widely available in clinical diagnosis. They are closely related to the condition's pathogenesis, therefore their elevated levels may predate clinical symptoms, and--most importantly--they correlate with syndrome aggravation and the occurrence of complications. Perhaps, the new look will allow us to improve perinatal results by reducing mortality and severe complications in pregnant women and fetal deaths resulting from sudden intrauterine fetal death or placental abruption.