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Bligard KH, Kelly JC, Frolova AI, Odibo AO, Raghuraman N. Peripartum Prediction of Fetal Weight in Gravidas With Obesity. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024. [PMID: 38994809 DOI: 10.1002/jum.16523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/24/2024] [Accepted: 06/29/2024] [Indexed: 07/13/2024]
Abstract
OBJECTIVES Estimated fetal weight (EFW) is an important metric at delivery as neonates with abnormal birthweight and their mothers are at higher risk of birth complications. Data regarding optimal EFW assessment in gravidas with obesity is inconsistent, and with the increasing incidence of obesity, clarification of this question is crucial. We aimed to compare accuracy of ultrasound (US)-derived EFW and clinical assessments of EFW in predicting neonatal birthweight among gravidas with obesity. METHODS This prospective cohort study enrolled gravidas with obesity and a singleton pregnancy admitted for delivery at term. EFW was determined using either US biometry or clinical assessment (Leopold's maneuvers, Johnson's formula, and Insler's formula) at time of admission. Our primary outcome was accurate EFW, defined as EFW within 500 g of birthweight. Secondary outcomes included ability to predict small-for-gestational age (SGA) and large-for-gestational age (LGA) birthweights. These outcomes were compared between all EFW methods. RESULTS A total of 250 gravidas with a median body mass index of 36.4 kg/m2 were enrolled. Admission US outperformed Leopold's maneuvers in obtaining accurate EFW (81.6% versus 74.5%, P = .03). When comparing all methods, Johnson's and Insler's formulae performed the worst, accurately predicting EFW in only 27.4% and 14.3% of cases, respectively. Likewise, US-derived EFW outperformed Leopold's maneuvers and fundal height in the prediction of SGA and LGA neonates. CONCLUSIONS US is more accurate than clinical assessment of EFW in gravidas with obesity both for estimation of actual birthweight and prediction of abnormal birthweight. Universal late third-trimester or peripartum US for EFW should be considered in gravidas with obesity.
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Affiliation(s)
- Katherine H Bligard
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Ultrasound, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Jeannie C Kelly
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Ultrasound, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Antonina I Frolova
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Ultrasound, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Anthony O Odibo
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Ultrasound, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Nandini Raghuraman
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Ultrasound, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
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Roberts AW, Hotra J, Soto E, Pedroza C, Sibai BM, Blackwell SC, Chauhan SP. Indicated vs universal third-trimester ultrasound examination in low-risk pregnancies: a pre-post-intervention study. Am J Obstet Gynecol MFM 2024; 6:101373. [PMID: 38583714 DOI: 10.1016/j.ajogmf.2024.101373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/13/2024] [Accepted: 04/01/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND In low-risk pregnancies, a third-trimester ultrasound examination is indicated if fundal height measurement and gestational age discrepancy are observed. Despite potential improvement in the detection of ultrasound abnormality, prior trials to date on universal third-trimester ultrasound examination in low-risk pregnancies, compared with indicated ultrasound examination, have not demonstrated improvement in neonatal or maternal adverse outcomes. OBJECTIVE The primary objective was to determine if universal third-trimester ultrasound examination in low-risk pregnancies could attenuate composite neonatal adverse outcomes. The secondary objectives were to compare changes in composite maternal adverse outcomes and detection of abnormalities of fetal growth (fetal growth restriction or large for gestational age) or amniotic fluid (oligohydramnios or polyhydramnios). STUDY DESIGN Our pre-post intervention study at 9 locations included low-risk pregnancies, those without indication for ultrasound examination in the third trimester. Compared with indicated ultrasound in the preimplementation period, in the postimplementation period, all patients were scheduled for ultrasound examination at 36.0-37.6 weeks. In both periods, clinicians intervened on the basis of abnormalities identified. Composite neonatal adverse outcomes included any of: Apgar score ≤5 at 5 minutes, cord pH <7.00, birth trauma (bone fracture or brachial plexus palsy), intubation for >24 hours, hypoxic-ischemic encephalopathy, seizure, sepsis (bacteremia proven with blood culture), meconium aspiration syndrome, intraventricular hemorrhage grade III or IV, periventricular leukomalacia, necrotizing enterocolitis, stillbirth after 36 weeks, or neonatal death within 28 days of birth. Composite maternal adverse outcomes included any of the following: chorioamnionitis, wound infection, estimated blood loss >1000 mL, blood transfusion, deep venous thrombus or pulmonary embolism, admission to intensive care unit, or death. Using Bayesian statistics, we calculated a sample size of 600 individuals in each arm to detect >75% probability of any reduction in primary outcome (80% power; 50% hypothesized risk reduction). RESULTS During the preintervention phase, 747 individuals were identified during the initial ultrasound examination, and among them, 568 (76.0%) met the inclusion criteria at 36.0-37.6 weeks; during the postintervention period, the corresponding numbers were 770 and 661 (85.8%). The rate of identified abnormalities of fetal growth or amniotic fluid increased from between the pre-post intervention period (7.1% vs 22.2%; P<.0001; number needed to diagnose, 7; 95% confidence interval, 5-9). The primary outcome occurred in 15 of 568 (2.6%) individuals in the preintervention and 12 of 661 (1.8%) in the postintervention group (83% probability of risk reduction; posterior relative risk, 0.69 [95% credible interval, 0.34-1.42]). The composite maternal adverse outcomes occurred in 8.6% in the preintervention and 6.5% in the postintervention group (90% probability of risk; posterior relative risk, 0.74 [95% credible interval, 0.49-1.15]). The number needed to treat to reduce composite neonatal adverse outcomes was 121 (95% confidence interval, 40-200). In addition, the number to reduce composite maternal adverse outcomes was 46 (95% confidence interval, 19-74), whereas the number to prevent cesarean delivery was 18 (95% confidence interval, 9-31). CONCLUSION Among low-risk pregnancies, compared with routine care with indicated ultrasound examination, implementation of a universal third-trimester ultrasound examination at 36.0-37.6 weeks attenuated composite neonatal and maternal adverse outcomes.
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Affiliation(s)
- Aaron W Roberts
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center, Houston, TX (Dr Roberts, Mr Hotra, Drs Soto, Sibai, Blackwell, and Chauhan).
| | - John Hotra
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center, Houston, TX (Dr Roberts, Mr Hotra, Drs Soto, Sibai, Blackwell, and Chauhan)
| | - Eleazar Soto
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center, Houston, TX (Dr Roberts, Mr Hotra, Drs Soto, Sibai, Blackwell, and Chauhan)
| | - Claudia Pedroza
- Center for Clinical Research and Evidence-Based Medicine, Department of Pediatrics, The University of Texas Health Science Center at Houston, Houston, TX (Dr Pedroza)
| | - Baha M Sibai
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center, Houston, TX (Dr Roberts, Mr Hotra, Drs Soto, Sibai, Blackwell, and Chauhan)
| | - Sean C Blackwell
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center, Houston, TX (Dr Roberts, Mr Hotra, Drs Soto, Sibai, Blackwell, and Chauhan)
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center, Houston, TX (Dr Roberts, Mr Hotra, Drs Soto, Sibai, Blackwell, and Chauhan)
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Caradeux J, Martínez-Portilla RJ, Martínez-Egea J, Ávila F, Figueras F. Routine third-trimester ultrasound assessment for intrauterine growth restriction. Am J Obstet Gynecol MFM 2024; 6:101294. [PMID: 38281581 DOI: 10.1016/j.ajogmf.2024.101294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 01/30/2024]
Abstract
Intrauterine growth restriction significantly impacts perinatal outcomes. Undetected IUGR escalates the risk of adverse outcomes. Serial symphysis-fundal height measurement, a recommended strategy, is insufficient in detecting abnormal fetal growth. Routine third-trimester ultrasounds significantly improve detection rates compared with this approach, but direct high-quality evidence supporting enhanced perinatal outcomes from routine scanning is lacking. In assessing fetal growth, abdominal circumference alone performs comparably to estimated fetal weight. Hadlock formulas demonstrate accurate fetal weight estimation across diverse gestational ages and settings. When choosing growth charts, prescriptive standards (encompassing healthy pregnancies) should be prioritized over descriptive ones. Customized fetal standards may enhance antenatal IUGR detection, but conclusive high-quality evidence is elusive. Emerging observational data suggest that longitudinal fetal growth assessment could predict adverse outcomes better. However, direct randomized trial evidence supporting this remains insufficient.
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Affiliation(s)
- Javier Caradeux
- Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Clínica Santa María, Santiago, Chile (Drs Caradeux and Ávila)
| | - Raigam J Martínez-Portilla
- Clinical Research Branch, Evidence-Based Medicine Department, National Institute of Perinatology, Mexico City, Mexico (Dr Martínez-Portilla)
| | - Judit Martínez-Egea
- BCNatal Fetal Medicine Research Center, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Instituto Clínic de Ginecología, Obstetricia i Neonatología, Universitat de Barcelona, Barcelona, Spain (Drs Martínez-Egea and Figueras)
| | - Francisco Ávila
- Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Clínica Santa María, Santiago, Chile (Drs Caradeux and Ávila)
| | - Francesc Figueras
- BCNatal Fetal Medicine Research Center, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Instituto Clínic de Ginecología, Obstetricia i Neonatología, Universitat de Barcelona, Barcelona, Spain (Drs Martínez-Egea and Figueras).
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Mustafa HJ, Javinani A, Muralidharan V, Khalil A. Diagnostic performance of 32 vs 36 weeks ultrasound in predicting late-onset fetal growth restriction and small-for-gestational-age neonates: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2024; 6:101246. [PMID: 38072237 DOI: 10.1016/j.ajogmf.2023.101246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 11/21/2023] [Accepted: 11/30/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVE Fetal growth restriction is an independent risk factor for fetal death and adverse neonatal outcomes. The main aim of this study was to investigate the diagnostic performance of 32 vs 36 weeks ultrasound of fetal biometry in detecting late-onset fetal growth restriction and predicting small-for-gestational-age neonates. DATA SOURCES A systematic search was performed to identify relevant studies published until June 2022, using the databases PubMed, Web of Science, and Scopus. STUDY ELIGIBILITY CRITERIA Cohort studies in low-risk or unselected singleton pregnancies with screening ultrasound performed at ≥32 weeks of gestation were used. METHODS The estimated fetal weight and abdominal circumference were assessed as index tests for the prediction of small for gestational age (birthweight of <10th percentile) and detecting fetal growth restriction (estimated fetal weight of <10th percentile and/or abdominal circumference of <10th percentile). The quality of the included studies was independently assessed by 2 reviewers using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. For the meta-analysis, hierarchical summary area under the receiver operating characteristic curves were constructed, and quantitative data synthesis was performed using random-effects models. RESULTS The analysis included 25 studies encompassing 73,981 low-risk pregnancies undergoing third-trimester ultrasound assessment for growth, of which 5380 neonates (7.3%) were small for gestational age at birth. The pooled sensitivities for estimated fetal weight of <10th percentile and abdominal circumference of <10th percentile in predicting small for gestational age were 36% (95% confidence interval, 27%-46%) and 37% (95% confidence interval, 19%-60%), respectively, at 32 weeks ultrasound and 48% (95% confidence interval, 41%-56%) and 50% (95% confidence interval, 25%-74%), respectively, at 36 weeks ultrasound. The pooled specificities for estimated fetal weight of <10th percentile and abdominal circumference of <10th percentile in detecting small for gestational age were 93% (95% confidence interval, 91%-95%) and 95% (95% confidence interval, 85%-98%), respectively, at 32 weeks ultrasound and 93% (95% confidence interval, 91%-95%) and 97% (95% confidence interval, 85%-98%), respectively, at 36 weeks ultrasound. The observed diagnostic odds ratios for an estimated fetal weight of <10th percentile and an abdominal circumference of <10th percentile in detecting small for gestational age were 8.8 (95% confidence interval, 5.4-14.4) and 11.6 (95% confidence interval, 6.2-21.6), respectively, at 32 weeks ultrasound and 13.3 (95% confidence interval, 10.4-16.9) and 36.0 (95% confidence interval, 4.9-260.0), respectively, at 36 weeks ultrasound. The pooled sensitivity, specificity, and diagnostic odds ratio in predicting fetal growth restriction were 71% (95% confidence interval, 52%-85%), 90% (95% confidence interval, 79%-95%), and 25.8 (95% confidence interval, 14.5-45.8), respectively, at 32 weeks ultrasound and 48% (95% confidence interval, 41%-55%), 94% (95% confidence interval, 93%-96%), and 16.9 (95% confidence interval, 10.8-26.6), respectively, at 36 weeks ultrasound. Abdominal circumference of <10th percentile seemed to have comparable sensitivity to estimated fetal weight of <10th percentile in predicting small-for-gestational-age neonates. CONCLUSION An ultrasound assessment of the fetal biometry at 36 weeks of gestation seemed to have better predictive accuracy for small-for-gestational-age neonates than an ultrasound assessment at 32 weeks of gestation. However, an opposite trend was noted when the outcome was fetal growth restriction. Fetal abdominal circumference had a similar predictive accuracy to that of estimated fetal weight in detecting small-for-gestational-age neonates.
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Affiliation(s)
- Hiba J Mustafa
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN (Dr Mustafa); Riley Children and Indiana University Health Fetal Center, Indianapolis, IN (Dr Mustafa).
| | - Ali Javinani
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr Javinani)
| | | | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, United Kingdom (Dr Khalil); Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom (Dr Khalil)
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Kingdom J, Ashwal E, Lausman A, Liauw J, Soliman N, Figueiro-Filho E, Nash C, Bujold E, Melamed N. Directive clinique n o 442 : Retard de croissance intra-utérin : Dépistage, diagnostic et prise en charge en contexte de grossesse monofœtale. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102155. [PMID: 37730301 DOI: 10.1016/j.jogc.2023.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
OBJECTIF Le retard de croissance intra-utérin est une complication obstétricale fréquente qui touche jusqu'à 10 % des grossesses dans la population générale et qui est le plus souvent due à une pathologie placentaire sous-jacente. L'objectif de la présente directive clinique est de fournir des déclarations sommaires et des recommandations pour appuyer un protocole clinique de dépistage, diagnostic et prise en charge du retard de croissance intra-utérin pour les grossesses à risque ou atteintes. POPULATION CIBLE Toutes les patientes enceintes menant une grossesse monofœtale. BéNéFICES, RISQUES ET COûTS: La mise en application des recommandations de la présente directive devrait améliorer la compétence des cliniciens quant à la détection du retard de croissance intra-utérin et à la réalisation des interventions indiquées. DONNéES PROBANTES: La littérature publiée a été colligée par des recherches effectuées jusqu'en septembre 2022 dans les bases de données PubMed, Medline, CINAHL et Cochrane Library en utilisant un vocabulaire contrôlé au moyen de termes MeSH pertinents (fetal growth retardation and small for gestational age) et de mots-clés (fetal growth, restriction, growth retardation, IUGR, FGR, low birth weight, small for gestational age, Doppler, placenta, pathology). Seuls les résultats de revues systématiques, d'essais cliniques randomisés ou comparatifs et d'études observationnelles ont été retenus. La littérature grise a été obtenue par des recherches menées dans des sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, des registres d'essais cliniques et des sites Web de sociétés de spécialité médicale nationales et internationales. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Obstétriciens, médecins de famille, infirmières, sages-femmes, spécialistes en médecine fœto-maternelle, radiologistes et autres professionnels de la santé qui prodiguent des soins aux patientes enceintes. RéSUMé POUR TWITTER: Mise à jour de la directive sur le dépistage, le diagnostic et la prise en charge du retard de croissance intra-utérin pour les grossesses à risque ou atteintes. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS: Prédiction du retard de croissance intra-utérin Prévention du retard de croissance intra-utérin Détection du retard de croissance intra-utérin Examens en cas de retard de croissance intra-utérin soupçonné Prise en charge du retard de croissance intra-utérin précoce Prise en charge du retard de croissance intra-utérin tardif Prise en charge du post-partum et consultations préconception.
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Kingdom J, Ashwal E, Lausman A, Liauw J, Soliman N, Figueiro-Filho E, Nash C, Bujold E, Melamed N. Guideline No. 442: Fetal Growth Restriction: Screening, Diagnosis, and Management in Singleton Pregnancies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102154. [PMID: 37730302 DOI: 10.1016/j.jogc.2023.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
OBJECTIVE Fetal growth restriction is a common obstetrical complication that affects up to 10% of pregnancies in the general population and is most commonly due to underlying placental diseases. The purpose of this guideline is to provide summary statements and recommendations to support a clinical framework for effective screening, diagnosis, and management of pregnancies that are either at risk of or affected by fetal growth restriction. TARGET POPULATION All pregnant patients with a singleton pregnancy. BENEFITS, HARMS, AND COSTS Implementation of the recommendations in this guideline should increase clinician competency to detect fetal growth restriction and provide appropriate interventions. EVIDENCE Published literature in English was retrieved through searches of PubMed or MEDLINE, CINAHL, and The Cochrane Library through to September 2022 using appropriate controlled vocabulary via MeSH terms (fetal growth retardation and small for gestational age) and key words (fetal growth, restriction, growth retardation, IUGR, FGR, low birth weight, small for gestational age, Doppler, placenta, pathology). Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. Grey literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Table A1 for definitions and Table A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE Obstetricians, family physicians, nurses, midwives, maternal-fetal medicine specialists, radiologists, and other health care providers who care for pregnant patients. TWEETABLE ABSTRACT Updated guidelines on screening, diagnosis, and management of pregnancies at risk of or affected by FGR. SUMMARY STATEMENTS RECOMMENDATIONS: Prediction of FGR Prevention of FGR Detection of FGR Investigations in Pregnancies with Suspected Fetal Growth Restriction Management of Early-Onset Fetal Growth Restriction Management of Late-Onset FGR Postpartum management and preconception counselling.
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Sande R, Jenderka KV, Moran CM, Marques S, Jimenez Diaz JF, Ter Haar G, Marsal K, Lees C, Abramowicz JS, Salvesen KÅ, Miloro P, Dall'Asta A, Brezinka C, Kollmann C. Safety Aspects of Perinatal Ultrasound. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2021; 42:580-598. [PMID: 34352910 DOI: 10.1055/a-1538-6295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Ultrasound safety is of particular importance in fetal and neonatal scanning. Fetal tissues are vulnerable and often still developing, the scanning depth may be low, and potential biological effects have been insufficiently investigated. On the other hand, the clinical benefit may be considerable. The perinatal period is probably less vulnerable than the first and second trimesters of pregnancy, and ultrasound is often a safer alternative to other diagnostic imaging modalities. Here we present step-by-step procedures for obtaining clinically relevant images while maintaining ultrasound safety. We briefly discuss the current status of the field of ultrasound safety, with special attention to the safety of novel modalities, safety considerations when ultrasound is employed for research and education, and ultrasound of particularly vulnerable tissues, such as the neonatal lung. This CME is prepared by ECMUS, the safety committee of EFSUMB, with contributions from OB/GYN clinicians with a special interest in ultrasound safety.
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Affiliation(s)
- Ragnar Sande
- Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Science, University of Bergen, Norway
| | | | - Carmel M Moran
- Centre for Cardiovascular Science, Edinburgh University, Edinburgh, United Kingdom of Great Britain and Northern Ireland
| | - Susana Marques
- Department of Gastroenterology and Digestive Endoscopy, Champalimaud Foundation, Lisboa, Portugal
| | - J F Jimenez Diaz
- Sport Sciences Faculty, Castilla La Mancha University Education Faculty of Toledo, Spain
- Sport Medicine Department, UCAM, Murcia, Spain
| | - Gail Ter Haar
- Physics, Institute of Cancer Research, Sutton, United Kingdom of Great Britain and Northern Ireland
| | - Karel Marsal
- Department of Obstetrics and Gynecology, Lund University, Lund, Sweden
| | - Christoph Lees
- Center for Fetal Care, Queen Charlotte's and Chelsea Hospital, London, United Kingdom of Great Britain and Northern Ireland
| | - Jacques S Abramowicz
- Department of Obstetrics and Gynecology, University of Chicago Medical Center, CHICAGO, United States
- Safety Committee, World Federation for Ultrasound in Medicine and Biology, Chicago, United States
| | - Kjell Åsmund Salvesen
- Department of Obstetrics and Gynecology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Piero Miloro
- Ultrasound and Underwater Acoustics, National Physical Laboratory, Teddington, United Kingdom of Great Britain and Northern Ireland
| | - Andrea Dall'Asta
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, Universita degli Studi di Parma, Italy
| | - Christoph Brezinka
- Department of Obstetrics and Gynecology, Medical University Innsbruck Department of Gynecology, Innsbruck, Austria
| | - Christian Kollmann
- Center for Medical Physics & Biomedical Engineering, Medical University Vienna, Austria
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Bonnevier A, Maršál K, Källén K. Detection and clinical outcome of small-for-gestational-age fetuses in the third trimester-A comparison between routine ultrasound examination and examination on indication. Acta Obstet Gynecol Scand 2021; 101:102-110. [PMID: 34726265 DOI: 10.1111/aogs.14278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 09/29/2021] [Accepted: 10/02/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Fetal growth restriction is a major risk factor for adverse perinatal outcome. As most of the growth-restricted fetuses are small for gestational age (SGA), an efficient antenatal screening method for SGA fetuses would have a major impact on perinatal health. The aim of this study was to compare the SGA prediction rate achieved with third-trimester routine ultrasound estimation of fetal weight (EFW) with that obtained using ultrasound examination on indication. The secondary aim was to evaluate the clinical outcome in relation to the SGA screening method. MATERIAL AND METHODS During 1995-2009, two perinatal centers in southern Sweden offered routine ultrasound examination at 32-34 gestational weeks to 99 265 women with singleton pregnancies. Of these, 59 452 (60%) underwent the ultrasound examination. The other population, comprising 24 868 pregnancies, was cared for in another three centers that used a risk-based method with ultrasound examinations on indication only. Of them, 5792 (23%) underwent ultrasound examination at 32-36 gestational weeks. The deviation in the EFW from the expected one was expressed as the EFW z-score, SGA EFW being defined as the EFW z-score less than -2. SGA prediction ability was assessed by receiver operating characteristic (ROC) curves. Crude and adjusted risk ratios were calculated for selected variables of perinatal outcome when comparing the populations. RESULTS The SGA prediction ability for routine ultrasound was high, area under the ROC curve was 0.90 (95% CI 0.89-0.91). For an EFW z-score of -1, the sensitivity was 67.3% and specificity was 90.5% among routinely screened pregnancies; corresponding numbers in the ultrasound on indication population were 34.3% and 96.6%. The screened population had a lower risk of preterm birth, birthweight z-score less than -3, and Apgar score less than 7 at 5 min with adjusted risk ratios 0.87 (95% CI 0.82-0.92), 0.75 (95% CI 0.61-0.92), and 0.77 (95% CI 0.68-0.87), respectively. No difference in perinatal mortality was detected. There were no differences in perinatal outcome between the two subcohorts of infants born SGA. CONCLUSIONS Third-trimester routine ultrasound improves the detection of SGA antenatally compared with ultrasound performed on indication, but no convincing improvement in perinatal outcome was identified.
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Affiliation(s)
- Anna Bonnevier
- Obstetrics and Gynecology, Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Obstetrics and Gynecology, Ystad Hospital, Ystad, Sweden
| | - Karel Maršál
- Obstetrics and Gynecology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Karin Källén
- Obstetrics and Gynecology, Department of Clinical Sciences, Lund University, Lund, Sweden.,Centre of Reproduction Epidemiology, Tornblad Institute, Department of Clinical Sciences, Lund University, Lund, Sweden
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Wanyonyi SZ, Orwa J, Ozelle H, Martinez J, Atsali E, Vinayak S, Temmerman M, Figueras F. Routine third-trimester ultrasound for the detection of small-for-gestational age in low-risk pregnancies (ROTTUS study): randomized controlled trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:910-916. [PMID: 33619823 DOI: 10.1002/uog.23618] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/30/2021] [Accepted: 02/08/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To compare the proportion of small-for-gestational-age (SGA) infants detected by routine third-trimester ultrasound vs those detected by selective ultrasound based on serial symphysis-fundus height (SFH) measurements (standard care) in low-risk pregnancy. METHODS This was an open-label randomized controlled trial conducted at a hospital in Kenya between May 2018 and February 2020. Low-risk pregnant women were randomly allocated (ratio of 1:1) to routine ultrasound for fetal growth assessment between 36 + 0 and 37 + 6 weeks' gestation (intervention group) or to standard care, which involved a selective growth scan on clinical suspicion of fetal growth abnormality based on serial SFH measurements (control group). During ultrasound examination, fetal growth was assessed by measurement of the abdominal circumference (AC), and AC < 10th centile was used to diagnose a SGA fetus. The main prespecified outcomes were the detection of neonatal SGA, defined as birth weight < 10th centile, and of severe neonatal SGA, defined as birth weight < 3rd centile. The predictive performance of routine third-trimester ultrasound and selective ultrasound based on serial SFH measurements was determined using receiver-operating-characteristics (ROC)-curve analysis. RESULTS Of 566 women assessed for eligibility, 508 (89.8%) were randomized, of whom 253 were allocated to the intervention group and 255 to the control group. Thirty-six babies in the intervention group and 26 in the control group had a birth weight < 10th centile. The detection rate of SGA infants by routine third-trimester ultrasound vs that by standard care was 52.8% (19/36) vs 7.7% (2/26) (P < 0.001) and the specificity was 95.5% (191/200) and 97.9% (191/195), respectively (P = 0.08). The detection rate of severe SGA was 66.7% (12/18) by routine ultrasound vs 8.3% (1/12) by selective ultrasound based on SFH measurements (P < 0.001), with specificities of 91.7% (200/218) and 98.1% (205/209), respectively (P = 0.006). The area under the ROC curve of routine third-trimester ultrasound in prediction of SGA was significantly greater than that of selective ultrasound based on SFH measurements (0.92 (95% CI, 0.87-0.96) vs 0.68 (95% CI, 0.58-0.77); P < 0.001). CONCLUSIONS In low-risk pregnancy, routine ultrasound performed between 36 + 0 and 37 + 6 weeks is superior to selective ultrasound based on serial SFH measurements for the detection of true SGA, with high specificity. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S Z Wanyonyi
- Department of Obstetrics and Gynaecology, Aga Khan University, Nairobi, Kenya
| | - J Orwa
- Department of Population Health Sciences, Aga Khan University, Nairobi, Kenya
| | - H Ozelle
- Department of Obstetrics and Gynaecology, Aga Khan University, Nairobi, Kenya
| | - J Martinez
- Fetal Medicine Research Center, BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, Institut Clínic de Ginecologia, Obstetrícia i Neonatologia, University of Barcelona, Barcelona, Spain
| | - E Atsali
- School of Nursing and Midwifery, Aga Khan University, Nairobi, Kenya
| | - S Vinayak
- Department of Radiology and Imaging, Aga Khan University, Nairobi, Kenya
| | - M Temmerman
- Department of Obstetrics and Gynaecology, Aga Khan University, Nairobi, Kenya
| | - F Figueras
- Fetal Medicine Research Center, BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, Institut Clínic de Ginecologia, Obstetrícia i Neonatologia, University of Barcelona, Barcelona, Spain
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10
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Åmark H, Pilo C, Hulthén Varli I. Stillbirth in term and late term gestations in Stockholm during a 20-year period, incidence and causes. PLoS One 2021; 16:e0251965. [PMID: 34033674 PMCID: PMC8148351 DOI: 10.1371/journal.pone.0251965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 05/06/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction The incidence of stillbirth has decreased marginally or remained stable during the past decades in high income countries. A recent report has shown Stockholm to have a lower incidence of stillbirth at term than other parts of Sweden. The risk of antepartum stillbirth increases in late term and postterm pregnancies which is one of the factors contributing to the current discussion regarding the optimal time of induction of labor due to postterm pregnancy. Material and methods This is a cohort study based on the Stockholm Stillbirth Database which contains all cases of stillbirth from 1998-2018 in Stockholm County. All cases were reviewed systematically and the cause of death was evaluated according to the Stockholm Stillbirth Classification. Stillbirths diagnosed between gestational week (GW) 37+0 and 40+6 n = 605 were compared to stillbirths diagnosed from GW 41+0 and onwards n = 157, according to the cause of stillbirth and pregnancy and maternal characteristics. The aim was to evaluate the incidence of stillbirth over time and the incidence of stillbirth diagnosed from GW 41+0. Results In Stockholm County the overall incidence of stillbirth has decreased from 4.6/1000 births during the period 1998-2004 to 3.4/1000 births during the period 2014-2018, p-value <0.001. When comparing the same time periods, the incidence of stillbirth diagnosed from GW 41+0 and onwards has decreased from 0.5/1000 births to 0.15/1000 births, p-value <0.001. Among women still pregnant at GW 41+0 the incidence of stillbirth has decreased from 1.8/ 1000 to 0.5/ 1000. When comparing stillbirths diagnosed at GW 37+0-40+6 with stillbirths diagnosed from GW 41+0 and onwards infection was a more common cause of stillbirth in the latter group. Conclusion In Stockholm County there was a decreasing incidence of stillbirth overall and in stillbirths diagnosed from 41+0 weeks of gestation and onwards during the period 1998-2018. In stillbirths diagnosed from GW 41+0 and onwards infection was a more common cause of death compared to stillbirths diagnosed between GW 37+0 and 40+6.
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Affiliation(s)
- Hanna Åmark
- Department of Clinical Science and Education, Unit of Obstetrics and Gynecology, Karolinska Institute, Södersjukhuset, Stockholm, Sweden
- * E-mail:
| | - Christina Pilo
- Department of Obstetrics and Gynecology, Södertälje Hospital, Stockholm, Sweden
| | - Ingela Hulthén Varli
- Department of Women´s and Children´s Health, Karolinska Institutet, Stockholm, Sweden
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11
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Melamed N, Baschat A, Yinon Y, Athanasiadis A, Mecacci F, Figueras F, Berghella V, Nazareth A, Tahlak M, McIntyre HD, Da Silva Costa F, Kihara AB, Hadar E, McAuliffe F, Hanson M, Ma RC, Gooden R, Sheiner E, Kapur A, Divakar H, Ayres‐de‐Campos D, Hiersch L, Poon LC, Kingdom J, Romero R, Hod M. FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction. Int J Gynaecol Obstet 2021; 152 Suppl 1:3-57. [PMID: 33740264 PMCID: PMC8252743 DOI: 10.1002/ijgo.13522] [Citation(s) in RCA: 195] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Fetal growth restriction (FGR) is defined as the failure of the fetus to meet its growth potential due to a pathological factor, most commonly placental dysfunction. Worldwide, FGR is a leading cause of stillbirth, neonatal mortality, and short- and long-term morbidity. Ongoing advances in clinical care, especially in definitions, diagnosis, and management of FGR, require efforts to effectively translate these changes to the wide range of obstetric care providers. This article highlights agreements based on current research in the diagnosis and management of FGR, and the areas that need more research to provide further clarification of recommendations. The purpose of this article is to provide a comprehensive summary of available evidence along with practical recommendations concerning the care of pregnancies at risk of or complicated by FGR, with the overall goal to decrease the risk of stillbirth and neonatal mortality and morbidity associated with this condition. To achieve these goals, FIGO (the International Federation of Gynecology and Obstetrics) brought together international experts to review and summarize current knowledge of FGR. This summary is directed at multiple stakeholders, including healthcare providers, healthcare delivery organizations and providers, FIGO member societies, and professional organizations. Recognizing the variation in the resources and expertise available for the management of FGR in different countries or regions, this article attempts to take into consideration the unique aspects of antenatal care in low-resource settings (labelled “LRS” in the recommendations). This was achieved by collaboration with authors and FIGO member societies from low-resource settings such as India, Sub-Saharan Africa, the Middle East, and Latin America.
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Affiliation(s)
- Nir Melamed
- Division of Maternal Fetal MedicineDepartment of Obstetrics and GynecologySunnybrook Health Sciences CentreUniversity of TorontoTorontoONCanada
| | - Ahmet Baschat
- Center for Fetal TherapyDepartment of Gynecology and ObstetricsJohns Hopkins UniversityBaltimoreMDUSA
| | - Yoav Yinon
- Fetal Medicine UnitDepartment of Obstetrics and GynecologySheba Medical CenterTel‐HashomerSackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
| | - Apostolos Athanasiadis
- Third Department of Obstetrics and GynecologyAristotle University of ThessalonikiThessalonikiGreece
| | - Federico Mecacci
- Maternal Fetal Medicine UnitDivision of Obstetrics and GynecologyDepartment of Biomedical, Experimental and Clinical SciencesUniversity of FlorenceFlorenceItaly
| | - Francesc Figueras
- Maternal‐Fetal Medicine DepartmentBarcelona Clinic HospitalUniversity of BarcelonaBarcelonaSpain
| | - Vincenzo Berghella
- Division of Maternal‐Fetal MedicineDepartment of Obstetrics and GynecologyThomas Jefferson UniversityPhiladelphiaPAUSA
| | - Amala Nazareth
- Jumeira Prime Healthcare GroupEmirates Medical AssociationDubaiUnited Arab Emirates
| | - Muna Tahlak
- Latifa Hospital for Women and ChildrenDubai Health AuthorityEmirates Medical AssociationMohammad Bin Rashid University for Medical Sciences, Dubai, United Arab Emirates
| | | | - Fabrício Da Silva Costa
- Department of Gynecology and ObstetricsRibeirão Preto Medical SchoolUniversity of São PauloRibeirão PretoSão PauloBrazil
| | - Anne B. Kihara
- African Federation of Obstetricians and GynaecologistsKhartoumSudan
| | - Eran Hadar
- Helen Schneider Hospital for WomenRabin Medical CenterPetach TikvaIsrael
- Sackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
| | - Fionnuala McAuliffe
- UCD Perinatal Research CentreSchool of MedicineNational Maternity HospitalUniversity College DublinDublinIreland
| | - Mark Hanson
- Institute of Developmental SciencesUniversity Hospital SouthamptonSouthamptonUK
- NIHR Southampton Biomedical Research CentreUniversity of SouthamptonSouthamptonUK
| | - Ronald C. Ma
- Department of Medicine and TherapeuticsThe Chinese University of Hong KongHong Kong SARChina
- Hong Kong Institute of Diabetes and ObesityThe Chinese University of Hong KongHong Kong SARChina
| | - Rachel Gooden
- FIGO (International Federation of Gynecology and Obstetrics)LondonUK
| | - Eyal Sheiner
- Soroka University Medical CenterBen‐Gurion University of the NegevBe’er‐ShevaIsrael
| | - Anil Kapur
- World Diabetes FoundationBagsværdDenmark
| | | | | | - Liran Hiersch
- Sourasky Medical Center and Sackler Faculty of MedicineLis Maternity HospitalTel Aviv UniversityTel AvivIsrael
| | - Liona C. Poon
- Department of Obstetrics and GynecologyPrince of Wales HospitalThe Chinese University of Hong KongShatinHong Kong SAR, China
| | - John Kingdom
- Division of Maternal Fetal MedicineDepartment of Obstetrics and GynecologyMount Sinai HospitalUniversity of TorontoTorontoONCanada
| | - Roberto Romero
- Perinatology Research BranchEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentNational Institutes of HealthU.S. Department of Health and Human ServicesBethesdaMDUSA
| | - Moshe Hod
- Helen Schneider Hospital for WomenRabin Medical CenterPetach TikvaIsrael
- Sackler Faculty of MedicineTel‐Aviv UniversityTel AvivIsrael
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12
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Anderson KB, Andersen AS, Hansen DN, Sinding M, Peters DA, Frøkjaer JB, Sørensen A. Placental transverse relaxation time (T2) estimated by MRI: Normal values and the correlation with birthweight. Acta Obstet Gynecol Scand 2020; 100:934-940. [PMID: 33258106 DOI: 10.1111/aogs.14057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Placental transverse relaxation time (T2) assessed by MRI may have the potential to improve the antenatal identification of small for gestational age. The aims of this study were to provide normal values of placental T2 in relation to gestational age at the time of MRI and to explore the correlation between placental T2 and birthweight. MATERIAL AND METHODS A mixed cohort of 112 singleton pregnancies was retrieved from our placental MRI research database. MRI was performed at 23.6-41.3 weeks of gestation in a 1.5T system (TE (8): 50-440 ms, TR: 4000 ms). Normal pregnancies were defined by uncomplicated pregnancies with normal obstetric outcome and birthweight deviation within ±1 SD of the expected for gestational age. The correlation between placental T2 and birthweight was investigated using the following outcomes; small for gestational age (birthweight ≤-2 SD of the expected for gestational age) and birthweight deviation (birthweight Z-scores). RESULTS In normal pregnancies (n = 27), placenta T2 showed a significant negative linear correlation with gestational age (r = -.91, P = .0001) being 184 ms ± 15.94 ms (mean ± SD) at 20 weeks of gestation and 89 ms ± 15.94 ms at 40 weeks of gestation. Placental T2 was significantly reduced among small-for-gestational-age pregnancies (mean Z-score -1.95, P < .001). Moreover, we found a significant positive correlation between placenta T2 deviation (Z-score) and birthweight deviation (Z-score) (R2 = .26, P = .0001). CONCLUSIONS This study provides normal values of placental T2 to be used in future studies on placental MRI. Placental T2 is closely related to birthweight and may improve the antenatal identification of small-for-gestational-age pregnancies.
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Affiliation(s)
- Kristi B Anderson
- Department of Pathology, Aalborg University Hospital, Aalborg, Denmark
| | - Anna S Andersen
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark
| | - Ditte N Hansen
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marianne Sinding
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - David A Peters
- Department of Clinical Engineering, Central Denmark Region, Aarhus, Denmark
| | - Jens B Frøkjaer
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Anne Sørensen
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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13
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Ginsberg Y, Ganor-Ariav O, Hussein H, Adam D, Khatib N, Weiner Z, Beloosesky R, Goldstein I. Quantification of Fetal Gyrogenesis in the Third Trimester. A Novel Algorithm for Evaluating Fetal Sulci Development. J Neuroimaging 2020; 31:372-378. [PMID: 33270956 DOI: 10.1111/jon.12817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/11/2020] [Accepted: 11/14/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE The fetal brain changes significantly throughout gestation. From a smooth (lissencephalic) cortex, it transforms into its convolved (gyrencephalic) state. Despite its importance, the diagnosis of delay in brain gyrogenesis is a challenge for many sonographers. This study presents a novel semiautomatic image processing algorithm for simple quantification of sagittal sulci maturation in the third trimester. METHODS Mid-sagittal fetal brain ultrasound images were obtained during routine third trimester scans. Fetal brain sulci length measurements were performed using a novel semiautomatic image processing algorithm followed by manual measurements. Correlations between the total length of the sulci, gestational age, and fetal biometry were examined. RESULTS The study included 64 patients. A significant positive linear correlation was found between total sulci length and gestational age (r = .658 for automated measurement, r = .7 for manual measurement, P < .0001). A similar relationship was found comparing total sulci length and fetal head circumference (r = .694 for automated measurement, r = .74 for manual measurement; P < .0001). A significant correlation was observed between automated and manual measurements (r = .947). CONCLUSIONS We found that fetal gyrogenesis is linear throughout the third trimester of pregnancy. The use of a computer algorithm to measure fetal sulci can be used as a simple prenatal screening test for delayed gyral maturation of the fetal brain.
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Affiliation(s)
- Yuval Ginsberg
- Department of Obstetrics and Gynecology, Rambam Medical Center, Haifa, Israel
| | - Oryan Ganor-Ariav
- Department of Obstetrics and Gynecology, Rambam Medical Center, Haifa, Israel
| | - Hadeel Hussein
- Department of Biomedical Engineering, Technion-Israel Institute of Technology, Haifa, Israel
| | - Dan Adam
- Department of Biomedical Engineering, Technion-Israel Institute of Technology, Haifa, Israel
| | - Nizar Khatib
- Department of Obstetrics and Gynecology, Rambam Medical Center, Haifa, Israel
| | - Zeev Weiner
- Department of Obstetrics and Gynecology, Rambam Medical Center, Haifa, Israel
| | - Ron Beloosesky
- Department of Obstetrics and Gynecology, Rambam Medical Center, Haifa, Israel
| | - Israel Goldstein
- Department of Obstetrics and Gynecology, Rambam Medical Center, Haifa, Israel
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14
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Dodd M, Lindqvist PG. Antenatal awareness and obstetric outcomes in large fetuses: A retrospective evaluation. Eur J Obstet Gynecol Reprod Biol 2020; 256:314-319. [PMID: 33264690 DOI: 10.1016/j.ejogrb.2020.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/29/2020] [Accepted: 11/05/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION There is currently no consensus on the management of large fetuses in order to minimize fetal complications. The aim of this study was to assess whether antenatal recognition of large-for-gestational age (LGA) reduced poor obstetric newborn outcomes in a hospital where expectant management was used. MATERIAL AND METHODS A retrospective cohort study was made of two delivery units at Karolinska University Hospital, Stockholm, Sweden, using expectant management of LGA. All deliveries > 37+0 weeks of gestation during an 8-year period (2002-2009) were included. The main outcome was severe adverse outcome, a composite variable including neonatal trauma (brachial plexus birth palsy [BPBP] and fractures) and asphyxic sequelae (severe asphyxia, cerebral damage, and fetal/infant death). RESULTS The study population consisted of 63,542 appropriate-for-gestational age (AGA) and 3,343 LGA pregnancies (of which 21 % were identified before delivery). Compared to AGA, LGA pregnancies showed a five-fold increased risk of neonatal trauma (OR 5.1, 95 % CI 4.0 - 6.4), but no differences were seen regarding asphyxic sequelae. LGA fetuses identified antenatally had adverse outcomes in 3.7 % of all cases, compared to 3.5 % where LGA was not identified (OR 1.07 95 % CI 0.7 - 1.7). When adjusted for newborn weight deviation, the OR was 0.96, 95 % CI 0.6 - 1.5. There was a three-fold higher risk (OR 3.0, 95 % CI 1.2 - 7.4) of neonatal trauma among non-identified LGA cases > 41+0 gestational weeks. A total of 81 % of those with LGA were identified after a week 41 routine ultrasound. Out of 68 cases with planned vaginal delivery and expected birth weight > 5000 g, 7.4 % suffered BPBP, representing a 31-fold increase in risk, compared to 0% BPBP among those delivered by elective caesarean section. CONCLUSION Antenatal awareness of LGA did not lower the risk of severe adverse outcomes in a unit using expectant management, but those identified postdate were at a lower risk of neonatal trauma. For every 14 fetuses with an expected birth weight > 5000 g delivered by cesarean section, one case of BPBP could be avoided.
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Affiliation(s)
- Maja Dodd
- Karolinska Institutet, Stockholm, Sweden
| | - Pelle G Lindqvist
- Clinical Sciences and Education, Karolinska Institutet, Sodersjukhuset, Stockholm, Sweden; Department of Obstetrics and Gynecology, Sodersjukhuset, Stockholm, Sweden.
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15
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Bonnevier A, Maršál K, Brodszki J, Thuring A, Källén K. Cerebroplacental ratio as predictor of adverse perinatal outcome in the third trimester. Acta Obstet Gynecol Scand 2020; 100:497-503. [PMID: 33078387 PMCID: PMC8049045 DOI: 10.1111/aogs.14031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 02/05/2023]
Abstract
Introduction Fetal growth restriction is associated with adverse perinatal outcome and the clinical management of these pregnancies is a challenge. The aim of this study was to investigate the potential of cerebroplacental ratio (CPR) to predict adverse perinatal outcome in high‐risk pregnancies in the third trimester. Another aim was to study whether the CPR has better predictive value than its components, middle cerebral artery (MCA) pulsatility index (PI) and umbilical artery (UA) PI. Material and methods The study was a retrospective cohort study including 1573 singleton high‐risk pregnancies with Doppler examinations performed at 32+0 to 40+6 gestational weeks at Lund University Hospital and the University Hospital of Malmö between 29 December 1994 and 31 December 2017. Receiver operating characteristics (ROC) curves were used to investigate the predictive value of the gestational age‐specific z‐scores for CPR, UA PI and MCA PI, respectively, for the primary outcome “perinatal asphyxia/mortality” and the secondary outcomes “birthweight small for gestational age (SGA)” and two composite outcomes: “appropriate for gestational age/large for gestational age liveborn infants with neonatal morbidity” and “SGA liveborn infants with neonatal morbidity.” Results The performance in predicting perinatal asphyxia/mortality was poor for all three variables and did not differ significantly. The ROC area under curve (AUC) was 0.56, 0.55 and 0.53 for CPR, UA PI and MCA PI z‐scores, respectively. The ROC AUC for CPR z‐scores to predict SGA was 0.73, significantly higher than that for either UA PI or MCA PI (P < .001). The ability of CPR and the MCA PI to predict appropriate for gestational age/large for gestational age infant morbidity and SGA infant morbidity was similar and significantly better than UA PI (P < .001). Conclusions In the present study, none of the three Doppler measures proved to be useful in predicting perinatal asphyxia and mortality. CPR and MCA PI were equally good in predicting neonatal morbidity, especially in SGA pregnancies, and both were significantly better predictors than the UA PI. CPR had a high predictive value for SGA at birth, better than that of its two components, UA PI and MCA PI.
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Affiliation(s)
- Anna Bonnevier
- Obstetrics and Gynecology, Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Obstetrics and Gynecology, Ystad Hospital, Ystad, Sweden
| | - Karel Maršál
- Obstetrics and Gynecology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Jana Brodszki
- Obstetrics and Gynecology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Ann Thuring
- Obstetrics and Gynecology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Karin Källén
- Obstetrics and Gynecology, Department of Clinical Sciences, Lund University, Lund, Sweden
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16
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Al-Hafez L, Chauhan SP, Riegel M, Balogun OA, Hammad IA, Berghella V. Routine third-trimester ultrasound in low-risk pregnancies and perinatal death: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2020; 2:100242. [PMID: 33345941 DOI: 10.1016/j.ajogmf.2020.100242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 09/16/2020] [Accepted: 09/21/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE This study aimed to determine whether routine third-trimester ultrasounds in low-risk pregnancies decrease the rate of perinatal death compared with regular antenatal care with serial fundal height measurements. DATA SOURCES This was a systematic review and meta-analysis of randomized control trials to identify relevant studies published from inception to October 2019. The databases used were Ovid, PubMed, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials using a combination of key words related to "third trimester ultrasound" and "low-risk." STUDY ELIGIBILITY CRITERIA We included all randomized control trials of singleton, nonanomalous low-risk pregnancies that were randomized to either one or more third-trimester ultrasounds (ultrasound group) or serial fundal height (fundal height group). Exclusion criteria were patients with multiple gestations, maternal medical complications, or fetal abnormalities requiring a third-trimester ultrasound. STUDY APPRAISAL AND SYNTHESIS METHODS The primary outcome was the rate of perinatal death. The secondary outcomes were rates of fetal growth restriction, suspected large for gestational age, polyhydramnios, oligohydramnios, fetal anomalies, antenatal interventions, stillbirth, neonatal death, cesarean delivery, induction of labor, and other neonatal outcomes. This meta-analysis was performed with the use of the random effects model of DerSimonian and Laird to produce relative risk or mean difference with a corresponding 95% confidence interval. RESULTS A total of 7 randomized control trials with 23,643 participants (12,343 in the ultrasound group vs 11,300 in the fundal height group) were included. The total rate of perinatal death was similar among the groups (41 of 11,322 [0.4%] vs 34 of 10,285 [0.3%]; relative risk, 1.14; 95% confidence interval, 0.68-1.89). The rate of fetal growth restriction was higher in the ultrasound group (763 of 10,388 [7%] vs 337 of 9021 [4%]; relative risk, 2.11; 95% confidence interval, 1.86-2.39) and the rate of suspected large for gestational age (1060 of 3513 [30%] vs 375 of 3558 [11%]; relative risk, 2.84; 95% confidence interval, 2.6-3.2). Polyhydramnios was also significantly higher in the ultrasound group than the fundal height group (18 of 323 [6%] vs 4 of 322 [1%] relative risk, 3.93; 95% confidence interval, 1.4-11). The rates of the remainder of the secondary outcomes were similar among the groups. CONCLUSION Routine third-trimester ultrasounds do not decrease the rate of perinatal death compared with serial fundal height in low-risk pregnancies. Ideally, an adequately powered trial is warranted to determine whether perinatal mortality in the fundal height group can be reduced by one-third with third-trimester ultrasound.
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Affiliation(s)
- Leen Al-Hafez
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Melissa Riegel
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Olaide Ashimi Balogun
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Ibrahim A Hammad
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health and Intermountain Healthcare, Salt Lake City, UT
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA.
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17
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Drukker L, Bradburn E, Rodriguez GB, Roberts NW, Impey L, Papageorghiou AT. How often do we identify fetal abnormalities during routine third-trimester ultrasound? A systematic review and meta-analysis. BJOG 2020; 128:259-269. [PMID: 32790134 DOI: 10.1111/1471-0528.16468] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Routine third-trimester ultrasound is frequently offered to pregnant women to identify fetuses with abnormal growth. Infrequently, a congenital anomaly is incidentally detected. OBJECTIVE To establish the prevalence and type of fetal anomalies detected during routine third-trimester scans using a systematic review and meta-analysis. SEARCH STRATEGY Electronic databases (MEDLINE, Embase and the Cochrane library) from inception until August 2019. SELECTION CRITERIA Population-based studies (randomised control trials, prospective and retrospective cohorts) reporting abnormalities detected at the routine third-trimester ultrasound performed in unselected populations with prior screening. Case reports, case series, case-control studies and reviews without original data were excluded. DATA COLLECTION AND ANALYSIS Prevalence and type of anomalies detected in the third trimester. We calculated pooled prevalence as the number of anomalies per 1000 scans with 95% confidence intervals. Publication bias was assessed. MAIN RESULTS The literature search identified 9594 citations: 13 studies were eligible representing 141 717 women; 643 were diagnosed with an unexpected abnormality. The pooled prevalence of a new abnormality diagnosed was 3.68 per 1000 women scanned (95% CI 2.72-4.78). The largest groups of abnormalities were urogenital (55%), central nervous system abnormalities (18%) and cardiac abnormalities (14%). CONCLUSION Combining data from 13 studies and over 140 000 women, we show that during routine third-trimester ultrasound, an incidental fetal anomaly will be found in about 1 in 300 scanned women. This information should be taken into account when taking consent from women for third-trimester ultrasound and when designing and assessing cost of third-trimester ultrasound screening programmes. TWEETABLE ABSTRACT One in 300 women attending a third-trimester scan will have a finding of a fetal abnormality.
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Affiliation(s)
- L Drukker
- Nuffield Department of Women's & Reproductive Health, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Fetal Medicine Unit, Department of Maternal and Fetal Medicine, Women's Center, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - E Bradburn
- Nuffield Department of Women's & Reproductive Health, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - G B Rodriguez
- Nuffield Department of Women's & Reproductive Health, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | - N W Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - L Impey
- Fetal Medicine Unit, Department of Maternal and Fetal Medicine, Women's Center, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A T Papageorghiou
- Nuffield Department of Women's & Reproductive Health, John Radcliffe Hospital, University of Oxford, Oxford, UK
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18
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Smith G. A critical review of the Cochrane meta-analysis of routine late-pregnancy ultrasound. BJOG 2020; 128:207-213. [PMID: 32598533 DOI: 10.1111/1471-0528.16386] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2020] [Indexed: 11/29/2022]
Abstract
A Cochrane review of universal late-pregnancy ultrasound has been highly influential in guiding UK practice, concluding that it does not improve outcome. However, the meta-analysis combines trials that used diverse definitions of screen positive, were designed in the absence of high-quality data on diagnostic effectiveness and did not couple screening to an effective intervention. Moreover, even if the trials had combined a highly effective screening test with a highly effective intervention, the sample size was 15% of that required to study perinatal death. It is not known whether universal late-pregnancy ultrasound confers benefit on the mother or baby. TWEETABLE ABSTRACT: Despite >50 years of research, we do not know whether universal late-pregnancy ultrasound confers benefit on the mother or baby.
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Affiliation(s)
- Gcs Smith
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
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20
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Hansen DN, Odgaard HS, Uldbjerg N, Sinding M, Sørensen A. Screening for small-for-gestational-age fetuses. Acta Obstet Gynecol Scand 2019; 99:503-509. [PMID: 31670396 DOI: 10.1111/aogs.13764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 10/24/2019] [Accepted: 10/29/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION It is well established that correct antenatal identification of small-for-gestational-age (SGA) fetuses reduces their risk of adverse perinatal outcome with long-term consequences. Ultrasound estimates of fetal weight (EFWus ) are the ultimate tool for this identification. It can be conducted as a "universal screening", that is, all pregnant women at a specific gestational age. However, in Denmark it is conducted as "selective screening", that is, only on clinical indication. The aim of this study was to assess the performance of the Danish national SGA screening program and the consequences of false-positive and false-negative SGA cases. MATERIAL AND METHODS In this retrospective cohort study, we included 2928 women with singleton pregnancies with due dates in 2015. We defined "risk of SGA" by an EFWus ≤ -15% of expected for the gestational age and "SGA" as birthweight ≤-22% of expected for gestational age. RESULTS At birth, the prevalence of SGA was 3.3%. The overall sensitivity of the Danish screening program was 62% at a false-positive rate of 5.6%. Within the entire cohort, 63% had an EFWus compared with 79% of the SGA cases. The sensitivity was 79% for those born before 37 weeks of gestation but only 40% for those born after 40 weeks of gestation. The sensitivity was also associated with birthweight deviation; 73% among extreme SGA cases (birthweight deviation ≤-33%) and 55% among mild SGA (birthweight deviation between -22% and -27%). False diagnosis of SGA was associated with an increased rate of induction of labor (ORadj = 2.51, 95% CI 1.70-3.71) and cesarean section (ORadj = 1.44, 95% CI 0.96-2.18). CONCLUSIONS The performance of the Danish national screening program for SGA based on selective EFWus on clinical indication has improved considerably over the last 20 years. Limitations of the program are the large proportion of women referred to ultrasound scan and the low performance post-term.
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Affiliation(s)
- Ditte N Hansen
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Helle S Odgaard
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark
| | - Niels Uldbjerg
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Marianne Sinding
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne Sørensen
- Department of Obstetrics and Gynecology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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21
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Karaaslan O, Islamova G, Soylemez F, Kalafat E. Ultrasound in labor admission to predict need for emergency cesarean section: a prospective, blinded cohort study. J Matern Fetal Neonatal Med 2019; 34:1991-1998. [PMID: 31718351 DOI: 10.1080/14767058.2019.1687682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To assess whether assessment with ultrasound could improve the detection of emergency cesarean section (ECS) in laboring women. METHODS Women who presented with symptoms of active labor or women in need of labor induction were invited to participate in the study. Women included in the study were evaluated with ultrasonography for fetal biometry and vaginal examinations for Bishop score assessment. The main aim in this study was determining factors associated with ECS due to fetal distress and obstructed labor. RESULTS No fetal biometry variable was associated with ECS due to any indication (fetal distress and obstructed labor combined) in the univariate analysis. In multivariate analyses, biometry variables were adjusted for Bishop score at admission and only abdominal circumference percentile showed a significant association with the odds of ECS due to any indication (OR:1.02, 95% CI: 1.01-1.03). Biparietal diameter and abdominal circumference variables were associated with the odds of ECS due to obstructed labor in both univariate and multivariate analyses (p < .05 for all). However, the predictive accuracy of biparietal diameter percentile (area under the curve (AUC): 0.55, 95% CI: 0.46-0.63) and abdominal circumference percentile (AUC: 0.56, 95% CI: 0.48-0.64) without adjunct variables were poor. Moreover, the addition of fetal biometry parameters to Bishop score did not improve the predictive accuracy of Bishop score. CONCLUSION Ultrasound assessment at admission, in addition to Bishop score assessment, did not significantly improve the prediction of ECS. Also, the fetal biometry alone had poor predictive capability for ECS. Routine ultrasound assessment at labor admission appears to be ineffective for predicting ECS.PrecisFetal biparietal diameter and abdominal circumference showed an association with emergency cesarean due to obstructed labor but the predictive accuracy of fetal biometry was low. Routine ultrasound examination at admission, in addition to Bishop score assessment, may not useful for assessing the risk of emergency section in unselected populations.
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Affiliation(s)
- Onur Karaaslan
- Obstetrics and Gynecology Clinic, Hakkari State Hospital, Hakkari, Turkey
| | - Gunel Islamova
- Department of Obstetrics and Gynecology, Ankara University, Ankara, Turkey
| | - Feride Soylemez
- Department of Obstetrics and Gynecology, Ankara University, Ankara, Turkey
| | - Erkan Kalafat
- Obstetrics and Gynecology Clinic, Hakkari State Hospital, Hakkari, Turkey.,Department of Obstetrics and Gynecology, Ankara University, Ankara, Turkey.,Department of Statistics, Middle East Technical University, Ankara, Turkey
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22
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Sex differences in fetal growth and immediate birth outcomes in a low-risk Caucasian population. Biol Sex Differ 2019; 10:48. [PMID: 31500671 PMCID: PMC6734449 DOI: 10.1186/s13293-019-0261-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 08/26/2019] [Indexed: 11/28/2022] Open
Abstract
Background According to the WHO Multicentre Growth Reference Study Group recommendations, boys and girls have different growth trajectories after birth. Our aim was to develop gender-specific fetal growth curves in a low-risk population and to compare immediate birth outcomes. Methods First, second, and third trimester fetal ultrasound examinations were conducted between 2002 and 2012. The data was selected using the following criteria: routine examinations in uncomplicated singleton pregnancies, Caucasian ethnicity, and confirmation of gestational age by a crown-rump length (CRL) measurement in the first trimester. Generalized Additive Model for Location, Scale and Shape (GAMLSS) was used to align the time frames of the longitudinal fetal measurements, corresponding with the methods of the postnatal growth curves of the WHO MGRS Group. Results A total of 27,680 complete scans were selected from the astraia© ultrasound database representing 12,368 pregnancies. Gender-specific fetal growth curves for biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL) were derived. The HC and BPD were significantly larger in boys compared to girls from 20 weeks of gestation onwards (p < 0.001) equating to a 3-day difference at 20–24 weeks. Boys were significantly heavier, longer, and had greater head circumference than girls (p < 0.001) at birth. The Apgar score at 1 min (p = 0.01) and arterial cord pH (p < 0.001) were lower in boys. Conclusions These longitudinal fetal growth curves for the first time allow integration with neonatal and pediatric WHO gender-specific growth curves. Boys exceed head growth halfway of the pregnancy, and immediate birth outcomes are worse in boys than girls. Gender difference in intrauterine growth is sufficiently distinct to have a clinically important effect on fetal weight estimation but also on the second trimester dating. Therefore, these differences might already play a role in early fetal or immediate neonatal management. Electronic supplementary material The online version of this article (10.1186/s13293-019-0261-7) contains supplementary material, which is available to authorized users.
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23
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Dulgheroff FF, Peixoto AB, Petrini CG, Caldas TMRDC, Ramos DR, Magalhães FO, Araujo E. Fetal structural anomalies diagnosed during the first, second and third trimesters of pregnancy using ultrasonography: a retrospective cohort study. SAO PAULO MED J 2019; 137:391-400. [PMID: 31939566 PMCID: PMC9745821 DOI: 10.1590/1516-3180.2019.026906082019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 08/06/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The prevalence of congenital abnormalities in general populations is approximately 3-5%. One of the most important applications of obstetric ultrasound is in detection of fetal structural defects. OBJECTIVE To assess fetal structural anomalies diagnosed using ultrasound in the three trimesters of pregnancy. DESIGN AND SETTING Retrospective cohort study at the Mário Palmério University Hospital of the University of Uberaba (Universidade de Uberaba, UNIUBE), from March 2014 to December 2016. METHODS Ultrasound data at gestational weeks 11-13 + 6, 20-24 and 32-36 were recorded to identify fetal anomalies in each trimester and in the postnatal period. The primary outcome measurements were sensitivity, specificity, positive predictive value and negative predictive value for detection of fetal anomalies and their prevalence. RESULTS The prevalence of anomalies detected using ultrasound was 2.95% in the prenatal period and 7.24% in the postnatal period. The fetal anomalies most frequently diagnosed using ultrasound in the three trimesters were genitourinary tract anomalies, with a prevalence of 27.8%. Cardiac anomalies were diagnosed more often in the postnatal period, accounting for 51.0% of all cases. High specificity, negative predictive value and accuracy of ultrasound were observed in all three trimesters of pregnancy. CONCLUSION Ultrasound is safe and has utility for detecting fetal anomalies that are associated with high rates of morbidity and mortality. However, the low sensitivity of ultrasound for detecting fetal anomalies in unselected populations limits its utility for providing reassurance to examiners and to pregnant women with normal results.
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Affiliation(s)
- Fernando Felix Dulgheroff
- MD. Physician, Department of Obstetrics and Gynecology, Mário Palmério Hospital Universitário (MPHU), School of Medicine, Universidade de Uberaba (UNIUBE), Uberaba (MG), Brazil.
| | - Alberto Borges Peixoto
- MD, PhD. Adjunct Professor, Department of Obstetrics and Gynecology, Mário Palmério Hospital Universitário (MPHU), School of Medicine, Universidade de Uberaba (UNIUBE), Uberaba (MG); and Adjunct Professor, Department of Obstetrics and Gynecology, Universidade Federal do Triângulo Mineiro (UFTM), Uberaba (MG), Brazil.
| | - Caetano Galvão Petrini
- MD. Physician, Department of Obstetrics and Gynecology Mário Palmério Hospital Universitário (MPHU), School of Medicine, Universidade de Uberaba (UNIUBE), Uberaba (MG), Brazil.
| | - Taciana Mara Rodrigues da Cunha Caldas
- MD. Physician, Department of Obstetrics and Gynecology, Mário Palmério Hospital Universitário (MPHU), School of Medicine, Universidade de Uberaba (UNIUBE), Uberaba (MG), Brazil.
| | - Daniela Rocha Ramos
- MD. Medical Resident, Department of Obstetrics and Gynecology, Mário Palmério Hospital Universitário (MPHU), School of Medicine, Universidade de Uberaba (UNIUBE), Uberaba (MG), Brazil.
| | - Fernanda Oliveira Magalhães
- MD, PhD. Adjunct Professor, Department of Internal Medicine, Mário Palmério Hospital Universitário (MPHU), School of Medicine, Universidade de Uberaba (UNIUBE), Uberaba (MG), Brazil.
| | - Edward Araujo
- MD, PhD. Associate Professor, Department of Obstetrics, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.
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Carlin A, Kadji C, Cannie MM, Resta S, Kang X, Jani JC. The use of magnetic resonance imaging in the prediction of birthweight. Prenat Diagn 2019; 40:125-135. [PMID: 31319434 DOI: 10.1002/pd.5530] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/05/2019] [Accepted: 07/08/2019] [Indexed: 01/11/2023]
Abstract
Extremes of fetal growth can increase adverse pregnancy outcomes, and this is equally applicable to single and multiple gestations. Traditionally, these cases have been identified using simple two-dimensional ultrasound which is quite limited by its low precision. Magnetic resonance imaging (MRI) has now been used for many years in obstetrics, mainly as an adjunct to ultrasound for congenital abnormalities and increasingly as part of the post-mortem examination. However, MRI can also be used to accurately assess fetal weight as first demonstrated by Baker et al in 1994, using body volumes rather than standard biometric measurements. This publication was followed by several others, all of which confirmed the superiority of MRI; however, despite this initial promise, the technique has never been successfully integrated into clinical practice. In this review, we provide an overview of the literature, detail the various techniques and formulas currently available, discuss the applicability to specific high-risk groups and present our vision for the future of MRI within clinical obstetrics.
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Affiliation(s)
- Andrew Carlin
- Department of Obstetrics and Gynaecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Caroline Kadji
- Department of Obstetrics and Gynaecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Mieke M Cannie
- Department of Radiology, University Hospital Brugmann, Brussels, Belgium.,Department of Radiology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Serena Resta
- Department of Obstetrics and Gynaecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Xin Kang
- Department of Obstetrics and Gynaecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques C Jani
- Department of Obstetrics and Gynaecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
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Caradeux J, Martinez-Portilla RJ, Peguero A, Sotiriadis A, Figueras F. Diagnostic performance of third-trimester ultrasound for the prediction of late-onset fetal growth restriction: a systematic review and meta-analysis. Am J Obstet Gynecol 2019; 220:449-459.e19. [PMID: 30633918 DOI: 10.1016/j.ajog.2018.09.043] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/25/2018] [Accepted: 09/04/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The objective of the study was to establish the diagnostic performance of ultrasound screening for predicting late smallness for gestational age and/or fetal growth restriction. DATA SOURCES A systematic search was performed to identify relevant studies published since 2007 in English, Spanish, French, Italian, or German, using the databases PubMed, ISI Web of Science, and SCOPUS. STUDY ELIGIBILITY CRITERIA We used rrospective and retrospective cohort studies in low-risk or nonselected singleton pregnancies with screening ultrasound performed at ≥32 weeks of gestation. STUDY APPRAISAL AND SYNTHESIS METHODS The estimated fetal weight and fetal abdominal circumference were assessed as index tests for the prediction of birthweight <10th (i.e. smallness for gestational age), less than the fifth, and less than the third centile and fetal growth restriction (estimated fetal weight less than the third or estimated fetal weight <10th plus Doppler signs). Quality of the included studies was independently assessed by 2 reviewers, using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. For the meta-analysis, hierarchical summary receiver-operating characteristic curves were constructed, and quantitative data synthesis was performed using random-effects models. The sensitivity of the abdominal circumference <10th centile and estimated fetal weight <10th centile for a fixed 10% false-positive rate was derived from the corresponding hierarchical summary receiver-operating characteristic curves. Heterogeneity between studies was visually assessed using Galbraith plots, and publication bias was assessed by funnel plots and quantified by Deeks' method. RESULTS A total of 21 studies were included. Observed pooled sensitivities of abdominal circumference and estimated fetal weight <10th centile for birthweight <10th centile were 35% (95% confidence interval, 20-52%) and 38% (95% confidence interval, 31-46%), respectively. Observed pooled specificities were 97% (95% confidence interval, 95-98%) and 95% (95% confidence interval, 93-97%), respectively. Modeled sensitivities of abdominal circumference and estimated fetal weight <10th centile for 10% false-positive rate were 78% (95% confidence interval, 61-95%) and 54% (95% confidence interval, 46-52%), respectively. The sensitivity of estimated fetal weight <10th centile was better when aimed to fetal growth restriction than to smallness for gestational age. Meta-regression analysis showed a significant increase in sensitivity when ultrasound evaluation was performed later in pregnancy (P = .001). CONCLUSION Third-trimester abdominal circumference and estimated fetal weight perform similar in predicting smallness for gestational age. However, for a fixed 10% false-positive rate extrapolated sensitivity is higher for abdominal circumference. There is evidence of better performance when the scan is performed near term and when fetal growth restriction is the targeted condition.
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Figueras F, Caradeux J, Crispi F, Eixarch E, Peguero A, Gratacos E. Diagnosis and surveillance of late-onset fetal growth restriction. Am J Obstet Gynecol 2018; 218:S790-S802.e1. [PMID: 29422212 DOI: 10.1016/j.ajog.2017.12.003] [Citation(s) in RCA: 166] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/16/2017] [Accepted: 12/01/2017] [Indexed: 11/18/2022]
Abstract
By consensus, late fetal growth restriction is that diagnosed >32 weeks. This condition is mildly associated with a higher risk of perinatal hypoxic events and suboptimal neurodevelopment. Histologically, it is characterized by the presence of uteroplacental vascular lesions (especially infarcts), although the incidence of such lesions is lower than in preterm fetal growth restriction. Screening procedures for fetal growth restriction need to identify small babies and then differentiate between those who are healthy and those who are pathologically small. First- or second-trimester screening strategies provide detection rates for late smallness for gestational age <50% for 10% of false positives. Compared to clinically indicated ultrasonography in the third trimester, universal screening triples the detection rate of late smallness for gestational age. As opposed to early third-trimester ultrasound, scanning late in pregnancy (around 37 weeks) increases the detection rate for birthweight <3rd centile. Contrary to early fetal growth restriction, umbilical artery Doppler velocimetry alone does not provide good differentiation between late smallness for gestational age and fetal growth restriction. A combination of biometric parameters (with severe smallness usually defined as estimated fetal weight or abdominal circumference <3rd centile) with Doppler criteria of placental insufficiency (either in the maternal [uterine Doppler] or fetal [cerebroplacental ratio] compartments) offers a classification tool that correlates with the risk for adverse perinatal outcome. There is no evidence that induction of late fetal growth restriction at term improves perinatal outcomes nor is it a cost-effective strategy, and it may increase neonatal admission when performed <38 weeks.
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Affiliation(s)
- Francesc Figueras
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona; and Center for Biomedical Research on Rare Diseases, Madrid, Spain.
| | - Javier Caradeux
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona; and Center for Biomedical Research on Rare Diseases, Madrid, Spain
| | - Fatima Crispi
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona; and Center for Biomedical Research on Rare Diseases, Madrid, Spain
| | - Elisenda Eixarch
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona; and Center for Biomedical Research on Rare Diseases, Madrid, Spain
| | - Anna Peguero
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona; and Center for Biomedical Research on Rare Diseases, Madrid, Spain
| | - Eduard Gratacos
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona; and Center for Biomedical Research on Rare Diseases, Madrid, Spain
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Volpe G, Ioannou C, Cavallaro A, Vannuccini S, Ruiz-Martinez S, Impey L. The influence of fetal sex on the antenatal diagnosis of small for gestational age. J Matern Fetal Neonatal Med 2018; 32:1832-1837. [PMID: 29295639 DOI: 10.1080/14767058.2017.1419180] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE We evaluated the influence of fetal sex on the antenatal diagnosis and detection of small for gestational age (SGA). METHODS The cohort consisted of unselected singleton pregnancies, undergoing routine biometry and cerebroplacental ratio (CPR) assessment at 36 weeks. Locally fitted equations for centiles and Z scores were used. "Ultrasound SGA" was defined as estimated fetal weight (EFW) < 10th centile, "SGA at birth" as birthweight (BW) < 10th centile adjusted for sex. RESULTS Among 4112 pregnancies, there were 235 female "ultrasound SGA" fetuses and 177 male; (odds ratios (OR) 1.502 (1.223 - 1.845)); the detection rate of SGA at birth was 50.6% and 40.9%, respectively (OR 1.479 (0.980 - 2.228)). In "ultrasound SGA" girls the abdominal circumference growth velocity (ACGV) between 20 and 36 weeks was less frequently in the lowest decile (OR 0.490 (0.320 - 0.750)), with no differences in CPR. CONCLUSIONS Females are more commonly diagnosed as SGA; those diagnosed may be at less risk than males.
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Affiliation(s)
- Grazia Volpe
- a Nuffield Department of Obstetrics and Gynaecology , University of Oxford, John Radcliffe Hospital , Oxford , UK.,b Department of Maternal and Fetal Medicine, Women's Center, Fetal Medicine Unit , John Radcliffe Hospital, Oxford University Hospitals National Institute for Health Research Foundation Trust , Oxford , UK
| | - Christos Ioannou
- a Nuffield Department of Obstetrics and Gynaecology , University of Oxford, John Radcliffe Hospital , Oxford , UK.,b Department of Maternal and Fetal Medicine, Women's Center, Fetal Medicine Unit , John Radcliffe Hospital, Oxford University Hospitals National Institute for Health Research Foundation Trust , Oxford , UK
| | - Angelo Cavallaro
- a Nuffield Department of Obstetrics and Gynaecology , University of Oxford, John Radcliffe Hospital , Oxford , UK.,b Department of Maternal and Fetal Medicine, Women's Center, Fetal Medicine Unit , John Radcliffe Hospital, Oxford University Hospitals National Institute for Health Research Foundation Trust , Oxford , UK
| | - Silvia Vannuccini
- a Nuffield Department of Obstetrics and Gynaecology , University of Oxford, John Radcliffe Hospital , Oxford , UK.,b Department of Maternal and Fetal Medicine, Women's Center, Fetal Medicine Unit , John Radcliffe Hospital, Oxford University Hospitals National Institute for Health Research Foundation Trust , Oxford , UK
| | - Sara Ruiz-Martinez
- a Nuffield Department of Obstetrics and Gynaecology , University of Oxford, John Radcliffe Hospital , Oxford , UK.,b Department of Maternal and Fetal Medicine, Women's Center, Fetal Medicine Unit , John Radcliffe Hospital, Oxford University Hospitals National Institute for Health Research Foundation Trust , Oxford , UK
| | - Lawrence Impey
- b Department of Maternal and Fetal Medicine, Women's Center, Fetal Medicine Unit , John Radcliffe Hospital, Oxford University Hospitals National Institute for Health Research Foundation Trust , Oxford , UK
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Maršál K. Preeclampsia and intrauterine growth restriction: placental disorders still not fully understood. J Perinat Med 2017; 45:775-777. [PMID: 28985185 DOI: 10.1515/jpm-2017-0272] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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29
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Evidence of lower oxygen reserves during labour in the growth restricted human foetus: a retrospective study. BMC Pregnancy Childbirth 2017; 17:209. [PMID: 28668074 PMCID: PMC5494130 DOI: 10.1186/s12884-017-1392-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/22/2017] [Indexed: 11/16/2022] Open
Abstract
Background The aim of the present study is to test the hypothesis that Growth Restricted foetuses (FGR) have the tendency to develop more pathological cardiotocograpic tracings during labour than do appropriate for gestational age foetuses and that there is a shorter time lapse from the beginning of labour and the advent of a pathological cardiotocograpic tracing. Methods The study was carried out at the Maternal-Foetal Medicine Unit of the Sant’Anna University Hospital, Turin, Italy. A total of 930 foetuses born at term between January and December 2012 were analysed: 355 small for gestational age (SGA) comprising both constitutional small for gestational age and growth restricted foetuses (cases group) and 575 Appropriate for Gestational Age (AGA) foetuses (control group). Tracings were evaluated independently by two obstetric consultants, according to the International Federation of Gynaecology and Obstetrics (FIGO) classification. The main outcomes considered were the incidence of pathological cardiotocograpic tracings and the time interval between the beginning of labour and the advent of pathological cardiotocograpic tracing. The Student’s t-test, chi-square test and ANOVA were used for comparisons between cases and controls and amongst groups. Significance was set at <0.05. Univariate and multivariate odds-ratios were calculated. Results Foetuses with birthweight <3rd centile (growth restricted foetuses) more frequently presented pathological cardiotocograpic tracings in labour than did controls (43.8% vs. 21.6%; p < 0.001). Pathological cardiotocograpic tracing developed faster in the foetuses with birthweight <3rd centile group (53′, 0′-277′) than it did in the control group (170.5′, 0′-550′; p < 0.05). A higher induction rate was observed in the cases (29.6%) than in the control group (17%), with statistical significance p < 0.001. To correct for this possible confounding factor a multivariate logistic regression analysis was performed. It confirmed a statistically significant increased risk of pathological cardiotocographic tracings in the FGR group (OR 1.63; CI 1.30–2.05). Conclusion The results confirm the hypothesis that Growth Restricted foetuses (FGR) have fewer oxygen reserves to deal with labour. Our results underscore the importance of the prenatal detection of these foetuses and of their continuous cardiotocographic monitoring during labour. Electronic supplementary material The online version of this article (doi:10.1186/s12884-017-1392-7) contains supplementary material, which is available to authorized users.
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Abstract
Suspected fetal macrosomia is encountered commonly in obstetric practice. As birth weight increases, the likelihood of labor abnormalities, shoulder dystocia, birth trauma, and permanent injury to the neonate increases. The purpose of this document is to quantify those risks, address the accuracy and limitations of methods for estimating fetal weight, and suggest clinical management for a pregnancy with suspected fetal macrosomia.
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Peixoto AB, da Cunha Caldas TMR, Dulgheroff FF, Martins WP, Araujo Júnior E. Fetal biometric parameters: Reference charts for a non-selected risk population from Uberaba, Brazil. J Ultrason 2017; 17:23-29. [PMID: 28439425 PMCID: PMC5392550 DOI: 10.15557/jou.2017.0003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 07/22/2016] [Accepted: 07/26/2016] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To establish reference charts for fetal biometric parameters in a non-selected risk population from Uberaba, Southeast of Brazil. METHODS A retrospective cross-sectional study was performed among 5656 non-selected risk singleton pregnant women between 14 and 41 weeks of gestation. The ultrasound exams were performed during routine visits of second and third trimesters. Biparietal diameter (BPD) was measured at the level of the thalami and cavum septi pellucidi. Head circumference (HC) was calculated by the following formula: HC = 1.62*(BPD + occipital frontal diameter, OFD). Abdominal circumference (AC) was measured using the following formula: AC = (anteroposterior diameter + transverse abdominal diameter) × 1.57. Femur diaphysis length (FDL) was obtained in the longest axis of femur without including the distal femoral epiphysis. The estimated fetal weight (EFW) was obtained by the Hadlock formula. Polynomial regressions were performed to obtain the best-fit model for each fetal biometric parameter as the function of gestational age (GA). RESULTS The mean, standard deviations (SD), minimum and maximum of BPD (cm), HC (cm), AC (cm), FDL (cm) and EFW (g) were 6.9 ± 1.9 (2.3 - 10.5), 24.51 ± 6.61 (9.1 - 36.4), 22.8 ± 7.3 (7.5 - 41.1), 4.9 ± 1.6 (1.2 - 8.1) and 1365 ± 1019 (103 - 4777), respectively. Second-degree polynomial regressions between the evaluated parameters and GA resulted in the following formulas: BPD = -4.044 + 0.540 × GA - 0.0049 × GA2 (R2 = 0.97); HC= -15.420 + 2.024 GA - 0.0199 × GA2 (R2 = 0.98); AC = -9.579 + 1.329 × GA - 0.0055 × GA2 (R2 = 0.97); FDL = -3.778 + 0.416 × GA - 0.0035 × GA2 (R2 = 0.98) and EFW = 916 - 123 × GA + 4.70 × GA2 (R2 = 0.96); respectively. CONCLUSION Reference charts for the fetal biometric parameters in a non-selected risk population from Uberaba, Southeast of Brazil, were established.
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Affiliation(s)
- Alberto Borges Peixoto
- Mario Palmério University Hospital - University of Uberaba (Uniube), Uberaba-MG, Brazil.,Radiologic Clinic of Uberaba (CRU), Uberaba-MG, Brazil
| | | | | | - Wellington P Martins
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo (DGO-FMRP-USP), Ribeirão Preto-SP, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP), São Paulo-SP, Brazil
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ICNIRP Statement on Diagnostic Devices Using Non-ionizing Radiation: Existing Regulations and Potential Health Risks. HEALTH PHYSICS 2017; 112:305-321. [PMID: 28121732 PMCID: PMC5515634 DOI: 10.1097/hp.0000000000000654] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Use of non-ionizing radiation (NIR) for diagnostic purposes allows non-invasive assessment of the structure and function of the human body and is widely employed in medical care. ICNIRP has published previous statements about the protection of patients during medical magnetic resonance imaging (MRI), but diagnostic methods using other forms of NIR have not been considered. This statement reviews the range of diagnostic NIR devices currently used in clinical settings; documents the relevant regulations and policies covering patients and health care workers; reviews the evidence around potential health risks to patients and health care workers exposed to diagnostic NIR; and identifies situations of high NIR exposure from diagnostic devices in which patients or health care workers might not be adequately protected by current regulations. Diagnostic technologies were classified by the types of NIR that they employ. The aim was to describe the techniques in terms of general device categories which may encompass more specific devices or techniques with similar scientific principles. Relevant legally-binding regulations for protection of patients and workers and organizations responsible for those regulations were summarized. Review of the epidemiological evidence concerning health risks associated with exposure to diagnostic NIR highlighted a lack of data on potential risks to the fetus exposed to MRI during the first trimester, and on long-term health risks in workers exposed to MRI. Most of the relevant epidemiological evidence that is currently available relates to MRI or ultrasound. Exposure limits are needed for exposures from diagnostic technologies using optical radiation within the body. There is a lack of data regarding risk of congenital malformations following exposure to ultrasound in utero in the first trimester and also about the possible health effects of interactions between ultrasound and contrast media.
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Figueras F, Gratacos E. An integrated approach to fetal growth restriction. Best Pract Res Clin Obstet Gynaecol 2016; 38:48-58. [PMID: 27940123 DOI: 10.1016/j.bpobgyn.2016.10.006] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 10/04/2016] [Accepted: 10/10/2016] [Indexed: 01/08/2023]
Abstract
Fetal growth restriction (FGR) is among the most common complications of pregnancy. FGR is associated with placental insufficiency and poor perinatal outcomes. Clinical management is challenging because of variability in clinical presentation. Fetal smallness (estimated fetal weight <10th centile for gestational age) remains the best clinical surrogate for FGR. However, it is commonly accepted that not all forms of fetal smallness represent true FGR. In a significant subset of small fetuses, there is no evidence of placental involvement, perinatal outcomes are nearly normal, and they are clinically referred to as "only" small for gestational age (SGA). Doppler may improve the clinical management of FGR; however, the need to use several parameters sometimes results in a number of combinations that may render interpretation challenging when translating into clinical decisions. We propose that the management of FGR can be simplified using a sequential approach based on three steps: (1) identification of the "small fetus," (2) differentiation between FGR and SGA, and (3) timing of delivery according to a protocol based on stages of fetal deterioration.
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Affiliation(s)
- Francesc Figueras
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, Spain; Centre for Biomedical Research on Rare Diseases (CIBER-ER), Spain
| | - Eduard Gratacos
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, Spain; Centre for Biomedical Research on Rare Diseases (CIBER-ER), Spain.
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Razavi AS, Chasen ST. Low PAPP-A: the impact of ultrasound to evaluate fetal growth. Prenat Diagn 2015; 36:112-6. [PMID: 26552045 DOI: 10.1002/pd.4723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 10/22/2015] [Accepted: 11/03/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Our objective was to describe utilization and impact of sonographic growth assessment in pregnancies with low pregnancy-associated plasma protein-A (PAPP-A). METHODS Singleton pregnancies with PAPP-A ≤5th percentile and no other risk factors for fetal growth restriction from January 2011-June 2013 were included. Antepartum and delivery data were obtained by reviewing medical records. Outcomes of pregnancies referred for sonographic growth assessment were compared with those not referred for ultrasound. Fisher's exact test, chi-square analysis, and Mann-Whitney U were used for statistical comparison. RESULTS Two hundred ninety-five patients were included. Of 285 pregnancies reaching the third trimester, 77.5% were referred for ultrasound, with the initial scan at a median gestational age of 28 weeks [26-29]. Referral for growth scans was associated with earlier gestational age at delivery and higher rates of delivery for fetal indications. Those who did not undergo growth scans were more likely to deliver a small for gestational age infant at term, 20.7% versus 35.0% (p = 0.04). There was one third-trimester fetal demise, occurring in a patient who had been undergoing growth scans. CONCLUSION Growth scans in those with low PAPP-A were associated with delivery at earlier gestational age, with higher rates of delivery for fetal indications and lower rates of small for gestational age newborns at term. No significant differences in neonatal outcomes were observed.
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Affiliation(s)
- Armin S Razavi
- Department of Obstetrics and Gynecology, Weill Cornell Medical Center, New York, NY, USA
| | - Stephen T Chasen
- Department of Obstetrics and Gynecology, Weill Cornell Medical Center, New York, NY, USA
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Callec R, Lamy C, Perdriolle-Galet E, Patte C, Heude B, Morel O. Impact on obstetric outcome of third-trimester screening for small-for-gestational-age fetuses. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:216-220. [PMID: 25487165 DOI: 10.1002/uog.14755] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 11/26/2014] [Accepted: 12/04/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To evaluate the performance of screening for small-for-gestational-age (SGA) fetuses by ultrasound biometry at 30-35 weeks' gestation, and to determine the impact of screening on obstetric and neonatal outcomes. METHODS For this prospective cohort study, pregnant women were recruited from two French university maternity centers between 2003 and 2006. Performance measures of third-trimester biometry for the prediction of SGA, defined as estimated fetal weight < 10(th) centile, were analyzed. Obstetric outcomes and neonatal health status were compared, first, between SGA neonates diagnosed correctly at ultrasound examination (true positive (TP); n = 45) and SGA neonates that went undiagnosed (false negative (FN); n = 110) and, second, between non-SGA neonates identified as normal at ultrasound examination (true negative (TN); n = 1641) and non-SGA neonates diagnosed incorrectly as SGA (false positive (FP); n = 101). RESULTS In the prediction of SGA, third-trimester ultrasound had a sensitivity of 29.0% (95% CI, 22.5-36.6%) and specificity of 94.2% (95% CI, 93.0-95.2%). Positive and negative predictive values were 30.8% (95% CI, 23.9-38.7%) and 93.7% (95% CI, 92.5-94.8%), respectively. One hundred and ten SGA neonates went undiagnosed at ultrasound. Compared to the TN neonates considered as of normal weight at ultrasound, planned preterm delivery (before 37 weeks) and elective Cesarean section for a fetal growth indication were 2.4 (P = 0.01) and 2.85 (P = 0.003) times more likely to occur, respectively, in the FP group of non-SGA neonates, diagnosed incorrectly as SGA during the antenatal period. There was no statistically significant difference in 5-min Apgar score < 7, cord blood pH at birth < 7.15 and need for neonatal resuscitation between the two subgroups (TN vs FP and TP vs FN). CONCLUSIONS The performance of third-trimester ultrasound screening for SGA seems poor, as it misses the diagnosis of a large number of SGA neonates. The consequences of routine screening for SGA in a low-risk population may lead to unnecessary planned preterm deliveries and elective Cesarean sections in FP pregnancies, without improved neonatal outcome in the FN pregnancies.
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Affiliation(s)
- R Callec
- Obstetrics and Fetal Medicine Unit, Centre Hospitalier Universitaire, Nancy, France
- Université de Lorraine, Nancy, France
- INSERM, U947, Nancy, France
| | - C Lamy
- Obstetrics and Fetal Medicine Unit, Centre Hospitalier Universitaire, Nancy, France
| | - E Perdriolle-Galet
- Obstetrics and Fetal Medicine Unit, Centre Hospitalier Universitaire, Nancy, France
- Université de Lorraine, Nancy, France
- INSERM, U947, Nancy, France
| | - C Patte
- Obstetrics and Fetal Medicine Unit, Centre Hospitalier Universitaire, Nancy, France
| | - B Heude
- Centre for Research in Epidemiology and Population Health (CESP), INSERM, Villejuif, France
- Université Paris Sud, Villejuif, France
| | - O Morel
- Obstetrics and Fetal Medicine Unit, Centre Hospitalier Universitaire, Nancy, France
- Université de Lorraine, Nancy, France
- INSERM, U947, Nancy, France
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Abstract
BACKGROUND Diagnostic ultrasound is used selectively in late pregnancy where there are specific clinical indications. However, the value of routine late pregnancy ultrasound screening in unselected populations is controversial. The rationale for such screening would be the detection of clinical conditions which place the fetus or mother at high risk, which would not necessarily have been detected by other means such as clinical examination, and for which subsequent management would improve perinatal outcome. OBJECTIVES To assess the effects on obstetric practice and pregnancy outcome of routine late pregnancy ultrasound, defined as greater than 24 weeks' gestation, in women with either unselected or low-risk pregnancies. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies. SELECTION CRITERIA All acceptably controlled trials of routine ultrasound in late pregnancy (defined as after 24 weeks). DATA COLLECTION AND ANALYSIS Three review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS Thirteen trials recruiting 34,980 women were included in the systematic review. Risk of bias was low for allocation concealment and selective reporting, unclear for random sequence generation and incomplete outcome data and high for blinding of both outcome assessment and participants and personnel. There was no difference in antenatal, obstetric and neonatal outcome or morbidity in screened versus control groups. Routine late pregnancy ultrasound was not associated with improvements in overall perinatal mortality. There is little information on long-term substantive outcomes such as neurodevelopment. There is a lack of data on maternal psychological effects.Overall, the evidence for the primary outcomes of perinatal mortality, preterm birth less than 37 weeks, induction of labour and caesarean section were assessed to be of moderate or high quality with GRADE software. There was no association between ultrasound in late pregnancy and perinatal mortality (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.67 to 1.54; participants = 30,675; studies = eight; I² = 29%), preterm birth less than 37 weeks (RR 0.96, 95% CI 0.85 to 1.08; participants = 17,151; studies = two; I² = 0%), induction of labour (RR 0.93, 95% CI 0.81 to 1.07; participants = 22,663; studies = six; I² = 78%), or caesarean section (RR 1.03, 95% CI 0.92 to 1.15; participants = 27,461; studies = six; I² = 54%). Three additional primary outcomes chosen for the 'Summary of findings' table were preterm birth less than 34 weeks, maternal psychological effects and neurodevelopment at age two. Because none of the included studies reported these outcomes, they were not assessed for quality with GRADE software. AUTHORS' CONCLUSIONS Based on existing evidence, routine late pregnancy ultrasound in low-risk or unselected populations does not confer benefit on mother or baby. There was no difference in the primary outcomes of perinatal mortality, preterm birth less than 37 weeks, caesarean section rates, and induction of labour rates if ultrasound in late pregnancy was performed routinely versus not performed routinely. Meanwhile, data were lacking for the other primary outcomes: preterm birth less than 34 weeks, maternal psychological effects, and neurodevelopment at age two, reflecting a paucity of research covering these outcomes. These outcomes may warrant future research.
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Affiliation(s)
| | - Nancy Medley
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Jeremy J Pratt
- Bunbury Regional HospitalRobertson DriveBunburyAustraliaWA 6230
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Haragan AF, Hulsey TC, Hawk AF, Newman RB, Chang EY. Diagnostic accuracy of fundal height and handheld ultrasound-measured abdominal circumference to screen for fetal growth abnormalities. Am J Obstet Gynecol 2015; 212:820.e1-8. [PMID: 25818672 PMCID: PMC4465094 DOI: 10.1016/j.ajog.2015.03.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 02/14/2015] [Accepted: 03/20/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVE We sought to compare fundal height and handheld ultrasound-measured fetal abdominal circumference (HHAC) for the prediction of fetal growth restriction (FGR) or large for gestational age. STUDY DESIGN This was a diagnostic accuracy study in nonanomalous singleton pregnancies between 24 and 40 weeks' gestation. Patients underwent HHAC and fundal height measurement prior to formal growth ultrasound. FGR was defined as estimated fetal weight less than 10%, whereas large for gestational age was defined as estimated fetal weight greater than 90%. Sensitivity and specificity were calculated and compared using methods described elsewhere. RESULTS There were 251 patients included in this study. HHAC had superior sensitivity and specificity for the detection of FGR (sensitivity, 100% vs 42.86%) and (specificity, 92.62% vs 85.24%). HHAC had higher specificity but lower sensitivity when screening for LGA (specificity, 85.66% vs 66.39%) and (sensitivity, 57.14% vs 71.43%). CONCLUSION HHAC could prove to be a valuable screening tool in the detection of FGR. Further studies are needed in a larger population.
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Affiliation(s)
- Adriane F Haragan
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC.
| | - Thomas C Hulsey
- West Virginia University School of Public Health, Morgantown, WV
| | - Angela F Hawk
- Maternal-Fetal Medicine, Regional Obstetrical Consultants, Chattanooga, TN
| | - Roger B Newman
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC
| | - Eugene Y Chang
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC
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Freud LR, Moon-Grady A, Escobar-Diaz MC, Gotteiner NL, Young LT, McElhinney DB, Tworetzky W. Low rate of prenatal diagnosis among neonates with critical aortic stenosis: insight into the natural history in utero. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:326-332. [PMID: 25251721 PMCID: PMC4351121 DOI: 10.1002/uog.14667] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 08/03/2014] [Accepted: 09/12/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To better understand the natural history and spectrum of fetal aortic stenosis (AS), we aimed to (1) determine the prenatal diagnosis rate of neonates with critical AS and a biventricular (BV) outcome, and (2) describe the findings at fetal echocardiography in patients diagnosed prenatally. METHODS A multicenter, retrospective study was performed on neonates who presented with critical AS and who were discharged with a BV outcome from 2000 to 2013. The prenatal diagnosis rate was compared with that reported for hypoplastic left heart syndrome (HLHS). We reviewed fetal echocardiographic findings in patients who were diagnosed prenatally. RESULTS In only 10 (8.5%) of 117 neonates with critical AS and a BV outcome was the diagnosis made prenatally, a rate significantly lower than that for HLHS in the contemporary era (82%; P < 0.0001). Of the 10 patients diagnosed prenatally, all had developed left ventricular dysfunction by a median gestational age of 33 (range, 28-35) weeks. When present, Doppler abnormalities such as retrograde flow in the aortic arch (n = 2), monophasic mitral inflow (n = 3) and left-to-right flow across the foramen ovale (n = 8) developed late in gestation (median 33 weeks). CONCLUSION The prenatal diagnosis rate of critical AS and a BV outcome among neonates is very low, probably owing to a relatively normal four-chamber view in mid-gestation with development of significant obstruction in the third trimester. The natural history contrasts with that of severe mid-gestation AS with evolving HLHS and suggests that the gestational timing of development of significant AS has an important impact on subsequent left-heart growth in utero.
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Affiliation(s)
- Lindsay R. Freud
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School
| | - Anita Moon-Grady
- Department of Pediatrics, Division of Cardiology, Benioff Children’s Hospital, University of California-San Francisco School of Medicine
| | | | - Nina L. Gotteiner
- Department of Pediatrics, Division of Cardiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine
| | - Luciana T. Young
- Department of Pediatrics, Division of Cardiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine
| | - Doff B. McElhinney
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School
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Pay ASD, Wiik J, Backe B, Jacobsson B, Strandell A, Klovning A. Symphysis-fundus height measurement to predict small-for-gestational-age status at birth: a systematic review. BMC Pregnancy Childbirth 2015; 15:22. [PMID: 25884884 PMCID: PMC4328041 DOI: 10.1186/s12884-015-0461-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 01/30/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Fetal growth restriction is among the most common and complex problems in modern obstetrics. Symphysis-fundus (SF) height measurement is a non-invasive test that may help determine which women are at risk. This study is a systematic review of the literature on the accuracy of SF height measurement for the prediction of small-for-gestational-age (SGA) status at birth in unselected and low-risk pregnancies. METHODS The Medline, Embase, Cinahl, SweMed, and Cochrane Library databases were searched with no limitation on publication date (through September 2014), which returned 722 citations. Two reviewers then developed a short list of 51 publications of possible relevance and assessed them using the following inclusion criteria: cohort study of test accuracy performed in a routine prenatal care setting; SF height measurement for all participants; classification of SGA, defined as birth weight (BW) < 10th, 5th, or 3rd percentile or ≥ one or two standard deviations below the mean; study conducted in Northern, Western, or Central Europe; USA; Canada; Australia; or New Zealand; and sufficient data for 2 × 2 table construction. Quality of the included studies was assessed in duplicate using criteria suggested by the Cochrane Collaboration. Review Manager 5.3 software was used to analyze the data, including plotting of summary receiver operating curve spaces. RESULTS Eight studies were included in the final dataset and seven were included in summary analyses. The sensitivity of SF height measurement for SGA (BW < 10(th) percentile) prediction ranged from 0.27 to 0.76 and specificity ranged from 0.79 to 0.92. Positive and negative likelihood ratios ranged from 1.91 to 9.09 and from 0.29 to 0.83, respectively. CONCLUSIONS SF height can serve as a clinical indicator along with other clinical findings, information about medical conditions, and previous obstetric history. However, SF height has high false-negative rates for SGA. Clinicians must understand the limitations of this test. The protocol has been registered in the international prospective register of systematic reviews, PROSPERO (Registration No. CRD42014008928, http://www.crd.york.ac.uk/prospero/display_record.asp?ID=CRD42014008928 ).
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Affiliation(s)
- Aase Serine D Pay
- Department of Obstetrics and Department of Gynecology, Women's and Children's Division, Oslo University Hospital, Oslo, Norway. .,Department of International Public Health, Norwegian Institute of Public Health, Oslo, Norway.
| | - Johanna Wiik
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden.
| | - Bjørn Backe
- Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Technology and Science, Trondheim University Hospital, Trondheim, Norway.
| | - Bo Jacobsson
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden. .,Department of Genes and Environment, Norwegian Institute of Public Health, Oslo, Norway.
| | - Annika Strandell
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden.
| | - Atle Klovning
- Department of General Practice, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.
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Papastefanou I, Pilalis A, Chrelias C, Kassanos D, Souka AP. Screening for birth weight deviations by second and third trimester ultrasound scan. Prenat Diagn 2014; 34:759-64. [DOI: 10.1002/pd.4361] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 03/18/2014] [Accepted: 03/18/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Ioannis Papastefanou
- Fetal Medicine Unit, 3rd Department of Obstetrics and Gynaecology; University of Athens, ‘Attikon’ University Hospital; Athens Greece
| | - Athanasios Pilalis
- Fetal Medicine Unit, 3rd Department of Obstetrics and Gynaecology; University of Athens, ‘Attikon’ University Hospital; Athens Greece
| | - Charalampos Chrelias
- Fetal Medicine Unit, 3rd Department of Obstetrics and Gynaecology; University of Athens, ‘Attikon’ University Hospital; Athens Greece
| | - Dimitrios Kassanos
- Fetal Medicine Unit, 3rd Department of Obstetrics and Gynaecology; University of Athens, ‘Attikon’ University Hospital; Athens Greece
| | - Athena P. Souka
- Fetal Medicine Unit, 3rd Department of Obstetrics and Gynaecology; University of Athens, ‘Attikon’ University Hospital; Athens Greece
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