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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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Venkatesh KK, Yee LM, Johnson J, Wu J, McNeil B, Mercer B, Simhan H, Reddy UM, Silver RM, Parry S, Saade G, Chung J, Wapner R, Lynch CD, Grobman WA. Neighborhood Socioeconomic Disadvantage and Abnormal Birth Weight. Obstet Gynecol 2023; 142:1199-1207. [PMID: 37769319 PMCID: PMC10972636 DOI: 10.1097/aog.0000000000005384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/29/2023] [Indexed: 09/30/2023]
Abstract
OBJECTIVE To examine whether exposure to community or neighborhood socioeconomic disadvantage as measured by the ADI (Area Deprivation Index) is associated with risk of abnormal birth weight among nulliparous individuals with singleton gestations. METHODS This was a secondary analysis from the prospective cohort NuMoM2b study (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be). Participant addresses at cohort enrollment between 6 and 13 weeks of gestation were geocoded at the Census tract level and linked to the 2015 ADI. The ADI, which incorporates the domains of income, education, employment, and housing quality into a composite national ranking of neighborhood socioeconomic disadvantage, was categorized by quartiles (quartile 1, least disadvantaged, reference; quartile 4, most disadvantaged). Outcomes were large for gestational age (LGA; birth weight at or above the 90th percentile) and small for gestational age (SGA; birth weight below the 10th percentile) compared with appropriate for gestational age (AGA; birth weight 10th-90th percentile) as determined with the 2017 U.S. natality reference data, standardized for fetal sex. Multinomial logistic regression models were adjusted for potential confounding variables. RESULTS Of 8,983 assessed deliveries in the analytic population, 12.7% (n=1,143) were SGA, 8.2% (n=738) were LGA, and 79.1% (n=7,102) were AGA. Pregnant individuals living in the highest ADI quartile (quartile 4, 17.8%) had an increased odds of delivering an SGA neonate compared with those in the lowest referent quartile (quartile 1, 12.4%) (adjusted odds ratio [aOR] 1.32, 95% CI 1.09-1.55). Pregnant individuals living in higher ADI quartiles (quartile 2, 10.3%; quartile 3, 10.7%; quartile 4, 9.2%) had an increased odds of delivering an LGA neonate compared with those in the lowest referent quartile (quartile 1, 8.2%) (aOR: quartile 2, 1.40, 95% CI 1.19-1.61; quartile 3, 1.35, 95% CI 1.09-1.61; quartile 4, 1.47, 95% CI 1.20-1.74). CONCLUSION Neonates of nulliparous pregnant individuals living in U.S. neighborhoods with higher area deprivation were more likely to have abnormal birth weights at both extremes.
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Affiliation(s)
- Kartik K Venkatesh
- Departments of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio, Northwestern University, Chicago, Illinois, Indiana University, Indianapolis, Indiana, Case Western Reserve University, Cleveland, Ohio, University of Pittsburgh, Pittsburgh, Pennsylvania, Columbia University, New York, New York, University of Utah, Salt Lake City, Utah, University of Pennsylvania, Philadelphia, Pennsylvania, University of Texas Medical Branch, Galveston, Texas, and University of California, Irvine, School of Medicine, Orange, California; and RTI International, Durham, North Carolina
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Giouleka S, Tsakiridis I, Mamopoulos A, Kalogiannidis I, Athanasiadis A, Dagklis T. Fetal Growth Restriction: A Comprehensive Review of Major Guidelines. Obstet Gynecol Surv 2023; 78:690-708. [PMID: 38134339 DOI: 10.1097/ogx.0000000000001203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Importance Fetal growth restriction (FGR) is a common pregnancy complication and a significant contributor of fetal and neonatal morbidity and mortality, mainly due to the lack of effective screening, prevention, and management policies. Objective The aim of this study was to review and compare the most recently published influential guidelines on the management of pregnancies complicated by FGR. Evidence Acquisition A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal-Fetal Medicine, the International Federation of Gynecology and Obstetrics, the International Society of Ultrasound in Obstetrics and Gynecology, the Royal College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynecologists of Canada (SOGC), the Perinatal Society of Australia and New Zealand, the Royal College of Physicians of Ireland, the French College of Gynecologists and Obstetricians (FCGO), and the German Society of Gynecology and Obstetrics on FGR was carried out. Results Several discrepancies were identified regarding the definition of FGR and small-for-gestational-age fetuses, the diagnostic criteria, and the need of testing for congenital infections. On the contrary, there is an overall agreement among the reviewed guidelines regarding the importance of early universal risk stratification for FGR to accordingly modify the surveillance protocols. Low-risk pregnancies should unanimously be evaluated by serial symphysis fundal height measurement, whereas the high-risk ones warrant increased sonographic surveillance. Following FGR diagnosis, all medical societies agree that umbilical artery Doppler assessment is required to further guide management, whereas amniotic fluid volume evaluation is also recommended by the ACOG, the SOGC, the Perinatal Society of Australia and New Zealand, the FCGO, and the German Society of Gynecology and Obstetrics. In case of early, severe FGR or FGR accompanied by structural abnormalities, the ACOG, the Society for Maternal-Fetal Medicine, the International Federation of Gynecology and Obstetrics, the Royal College of Obstetricians and Gynecologists, the SOGC, and the FCGO support the performance of prenatal diagnostic testing. Consistent protocols also exist on the optimal timing and mode of delivery, the importance of continuous fetal heart rate monitoring during labor, and the need for histopathological examination of the placenta after delivery. On the other hand, guidelines concerning the frequency of fetal growth and Doppler velocimetry evaluation lack uniformity, although most of the reviewed medical societies recommend an average interval of 2 weeks, reduced to weekly or less when umbilical artery abnormalities are detected. Moreover, there is a discrepancy on the appropriate timing for corticosteroids and magnesium sulfate administration, as well as the administration of aspirin as a preventive measure. Cessation of smoking, alcohol consumption, and illicit drug use are proposed as preventive measures to reduce the incidence of FGR. Conclusions Fetal growth restriction is a clinical entity associated with numerous adverse antenatal and postnatal events, but currently, it has no definitive cure apart from delivery. Thus, the development of uniform international protocols for the early recognition, the adequate surveillance, and the optimal management of growth-restricted fetuses seem of paramount importance to safely guide clinical practice, thereby improving perinatal outcomes of such pregnancies.
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Affiliation(s)
| | | | | | | | | | - Themistoklis Dagklis
- Assistant Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
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Fetal Growth Restriction: Mechanisms, Epidemiology, and Management. MATERNAL-FETAL MEDICINE 2022. [DOI: 10.1097/fm9.0000000000000161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Michel M, Alberti C, Carel JC, Chevreul K. Social inequalities in access to care at birth and neonatal mortality: an observational study. Arch Dis Child Fetal Neonatal Ed 2022; 107:380-385. [PMID: 34656994 DOI: 10.1136/archdischild-2021-321967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 09/27/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To look at the association of socioeconomic status (SES) with the suitability of the maternity where children are born and its association with mortality. DESIGN Retrospective analysis of a prospective cohort constituted using hospital discharge databases. SETTING France POPULATION: Live births in 2012-2014 in maternity hospitals in mainland France followed until discharge from the hospital. MAIN OUTCOME MEASURE Unsuitability of the maternity to newborns' needs based on birth weight and gestational age, early transfers (within 24 hours of birth) and in-hospital mortality. RESULTS 2 149 454 births were included, among which 155 646 (7.2%) were preterm. Preterm newborns with low SES were less frequently born in level III maternities than those with high SES. They had higher odds of being born in an unsuitable maternity (OR=1.174, 95% CI 1.114 to 1.238 in the lowest SES quintile compared with the highest), and no increase in the odds of an early transfer (OR=0.966, 95% CI 0.849 to 1.099 in the lowest SES quintile compared with the highest). Overall, newborns from the lowest SES quintile had a 40% increase in their odds of dying compared with the highest (OR=1.399, 95% CI 1.235 to 1.584). CONCLUSIONS Newborns with the lowest SES were less likely to be born in level III maternity hospitals compared with those with the highest SES, despite having higher prematurity rates. This was associated with a significantly higher mortality in newborns with the lowest SES. Strategies must be developed to increase health equity among mothers and newborns.
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Affiliation(s)
- Morgane Michel
- ECEVE, Université de Paris, Paris, France .,URC Eco, Hôtel Dieu / Unité d'épidémiologie clinique, Hôpital Robert Debré, Assistance Publique - Hôpitaux de Paris, Paris, France.,UMR 1123, Inserm, Paris, France
| | - Corinne Alberti
- ECEVE, Université de Paris, Paris, France.,Unité d'épidémiologie clinique / Unité de recherche clinique, Hôpital Robert Debré, Assistance Publique - Hôpitaux de Paris, Paris, France.,UMR 1123 / CIC-EC 1426, Inserm, Paris, France
| | - Jean-Claude Carel
- Pediatric Endocrinology and Diabetology Department and Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Hôpital Robert Debré, Assistance Publique - Hôpitaux de Paris, Paris, France.,NeuroDiderot, Inserm, Université de Paris, Paris, France
| | - Karine Chevreul
- ECEVE, Université de Paris, Paris, France.,URC Eco, Hôtel Dieu / Unité d'épidémiologie clinique, Hôpital Robert Debré, Assistance Publique - Hôpitaux de Paris, Paris, France.,UMR 1123, Inserm, Paris, France
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Unisex vs sex-specific estimated fetal weight charts for fetal growth monitoring: a population-based study. Am J Obstet Gynecol MFM 2021; 4:100527. [PMID: 34763120 DOI: 10.1016/j.ajogmf.2021.100527] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/22/2021] [Accepted: 11/02/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND In contrast with birthweight or other growth charts, a feature of most intrauterine charts is that they are not differentiated by sex. Differences in weight by sex during pregnancy are considered to be relatively minor; however, small systematic differences may affect the sensitivity and specificity of screening for fetuses with growth restriction. OBJECTIVE To assess differences between unisex and sex-specific estimated fetal weight charts at the third-trimester ultrasound with regard to the sex ratio of fetuses detected with an estimated fetal weight <10th percentile and subsequent detection of small-for-gestational-age newborns with morbidity at birth. STUDY DESIGN The study included 9940 singleton live births from a French population-based study in 2016. Main outcomes were an estimated fetal weight <10th percentile at the routine third-trimester ultrasound between 30 and 35 weeks of gestation, and small for gestational age infants (birthweight <10th percentile) with neonatal morbidity (Apgar score <7 at 5 minutes and/or resuscitation in delivery room and/or admission to a neonatal unit). We used 2 charts with unisex and sex-specific options: the World Health Organization international standard chart and a customized chart for fetal sex based on Gardosi's gestation-related optimal weight model adapted to the French population (Epopé). Hadlock's unisex chart, commonly used in clinical care and research, was also included to provide an external reference. We compared the proportions of female and male fetuses with an estimated fetal weight <10th percentile and the sensitivity and specificity of such estimated fetal weight for predicting small-for-gestational-age newborns with morbidity when using unisex vs sex-specific charts, overall and by sex. RESULTS Among all singleton births, there were 51.6% males and 48.4% females. Males faced higher risks of being small-for-gestational-age with morbidity at birth (2.4% vs 1.8%; P=.031). Using the World Health Organization unisex chart, 6.9% of males and 9.9% of females had an estimated fetal weight <10th percentile vs 9.9% of males and 7.1% of females with the sex-specific chart; these proportions were 3.5% and 4.6% and 4.3% and 2.7%, respectively, for the Epopé. Proportions of estimated fetal weight <10th percentile using Hadlock's chart were slightly higher than those obtained using the unisex World Health Organization chart (7.5% of males and 10.6% of females), but the difference of about 3% was the same. The sensitivity of an estimated fetal weight <10th percentile for identifying small-for-gestational-age newborns with morbidity differed for males and females by type of chart; unisex charts detected more small-for-gestational-age females with morbidity and sex-specific charts detected more small-for-gestational-age males with morbidity, but the overall sensitivity was the same (49.1% for the World Health Organization chart and Hadlock's chart and 34.9% for the Epopé chart). CONCLUSION This study suggests that the use of sex-specific charts instead of unisex charts would reduce sex bias in intrauterine growth screening during the third trimester of pregnancy. Prospective studies are needed to assess the effects of using sex-specific charts rather than unisex charts on obstetrical management and outcomes.
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Inkster AM, Fernández-Boyano I, Robinson WP. Sex Differences Are Here to Stay: Relevance to Prenatal Care. J Clin Med 2021; 10:3000. [PMID: 34279482 PMCID: PMC8268816 DOI: 10.3390/jcm10133000] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 07/02/2021] [Indexed: 12/27/2022] Open
Abstract
Sex differences exist in the incidence and presentation of many pregnancy complications, including but not limited to pregnancy loss, spontaneous preterm birth, and fetal growth restriction. Sex differences arise very early in development due to differential gene expression from the X and Y chromosomes, and later may also be influenced by the action of gonadal steroid hormones. Though offspring sex is not considered in most prenatal diagnostic or therapeutic strategies currently in use, it may be beneficial to consider sex differences and the associated mechanisms underlying pregnancy complications. This review will cover (i) the prevalence and presentation of sex differences that occur in perinatal complications, particularly with a focus on the placenta; (ii) possible mechanisms underlying the development of sex differences in placental function and pregnancy phenotypes; and (iii) knowledge gaps that should be addressed in the development of diagnostic or risk prediction tools for such complications, with an emphasis on those for which it would be important to consider sex.
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Affiliation(s)
- Amy M. Inkster
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada; (A.M.I.); (I.F.-B.)
- Department of Medical Genetics, University of British Columbia, Vancouver, BC V6H 3N1, Canada
| | - Icíar Fernández-Boyano
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada; (A.M.I.); (I.F.-B.)
- Department of Medical Genetics, University of British Columbia, Vancouver, BC V6H 3N1, Canada
| | - Wendy P. Robinson
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada; (A.M.I.); (I.F.-B.)
- Department of Medical Genetics, University of British Columbia, Vancouver, BC V6H 3N1, Canada
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Erdol MA, Tanacan A, Eroglu H, Tonyali NV, Erdogan M, Yucel A, Yazihan N, Sahin D. Pro-BNP Levels and Its Prognostic Role in Chronic Hypertensive Pregnancies: A Prospective Case-Control Study From A Tertiary Care Hospital. Hypertens Pregnancy 2021; 40:202-208. [PMID: 34143704 DOI: 10.1080/10641955.2021.1939712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND This study aimed to investigate the prognostic value of N-terminal B-type natriuretic peptide (NT-proBNP) in pregnancies with isolated chronic hypertension (HT). METHOD 34 pregnant women with chronic HT and 40normotensive controls were enrolled. The association between plasma NT-proBNP levels obtained in the first trimester and perinatal complications were evaluated. RESULTS NT-proBNP levelsstrongly predicted low birth weight (AUC=0.842, p<0.001). NT-proBNP and birth weight were negatively correlated (r= -0.323, p=0.005). NT-proBNP was found to be an individual determinant of low birth weight in univariate analysis (OR:1.03; 95%CI:1.01-1.04). CONCLUSION NT-proBNP levels can be useful to predict low birth weight in pregnancies with chronic HT.
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Affiliation(s)
- Mehmet Akif Erdol
- Department of Cardiology, Turkish Ministry of Health, Ankara City Hospital, Ankara, Turkey
| | - Atakan Tanacan
- Department of Obstetrics and Gynecology, Turkish Ministry of Health, Ankara City Hospital, Ankara, Turkey
| | - Hasan Eroglu
- Department of Obstetrics and Gynecology, Turkish Ministry of Health, Gazi Antep Training and Research Hospital, Gazi Antep, Turkey
| | - Nazan Vanli Tonyali
- Department of Obstetrics and Gynecology, Turkish Ministry of Health, Etlik Zubeyde Hanim Women's Health Training and Research Hospital, Ankara, Turkey
| | - Mehmet Erdogan
- Department of Cardiology, Yildirim Beyazid University, Ankara City Hospital, Ankara, Turkey
| | - Aykan Yucel
- Department of Obstetrics and Gynecology, University of Health Sciences, Turkish Ministry of Health, Ankara City Hospital, Ankara, Turkey
| | - Nuray Yazihan
- Department of Pathophysiology, Ankara University, Faculty of Medicine, Internal Medicine, Pathophysiology Department, Ankara University, Institute of Health Sciences, Interdisciplinary Food, Metabolism and Clinical Nutrition Department, Ankara, Turkey
| | - Dilek Sahin
- Department of Obstetrics and Gynecology, University of Health Sciences, Turkish Ministry of Health, Ankara City Hospital, Ankara, Turkey
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Nohuz E, Rivière O, Coste K, Vendittelli F. Prenatal identification of small-for-gestational age and risk of neonatal morbidity and stillbirth. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:621-628. [PMID: 30950117 DOI: 10.1002/uog.20282] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/17/2019] [Accepted: 03/20/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To assess whether prenatal identification of small-for-gestational age (SGA) was associated with lower rates of the primary composite outcome of stillbirth, death in the delivery room or neonatal complications, and secondary outcomes of the composite outcome according to gestational age at delivery, stillbirth and low 5-min Apgar score. METHODS This historical cohort study included women who had a singleton delivery (≥ 32 weeks) between 1994 and 2011 at one of 247 French maternity units. We excluded pregnancies terminated medically, infants with malformations or with missing data on estimated fetal weight or birth weight, and women with missing delivery data. Among the 24 946 infants born SGA (< 5th percentile), we compared those who had been identified as such prenatally (n = 5093; 20%), with those who had not (n = 19 853; 80%). The main outcome was a composite variable defined as stillbirth or death in the delivery room, or transfer to a neonatal department either immediately or during the neonatal stay in the obstetrics ward. Secondary outcomes were the composite outcome according to gestational age at delivery (32 to < 35 weeks; 35 to < 37 weeks, 37 to < 40 weeks, or ≥ 40 weeks), stillbirth and low 5-min Apgar score (≤ 4 and < 7). RESULTS The mean ± SD birth weight was 2449.1 ± 368.3 g. The rate of the main composite outcome was higher in the group identified prenatally as SGA compared with non-identified SGA fetuses (39.5% vs 13.5%; adjusted relative risk (aRR), 1.29; 95% CI, 1.21-1.38). This association was not observed in the subgroups delivered before 37 weeks. The stillbirth rate was lower in fetuses with prenatal suspicion of SGA (aRR, 0.47; 95% CI, 0.27-0.79), while the 5-min Apgar score did not differ between the two groups. The a-posteriori study power with α = 0.05 was 99%. CONCLUSION Prenatal identification of SGA was not associated with lower fetal or neonatal morbidity overall, although it was associated with a lower rate of stillbirth. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- E Nohuz
- AUDIPOG (Association des Utilisateurs de Dossiers Informatisés en Pédiatrie, Obstétrique et Gynécologie), Faculty of Medicine RTH Laennec, Lyon, France
- Department of Obstetrics and Gynecology, General Hospital of Thiers, Thiers, France
- Université Clermont Auvergne, CHU Clermont-Ferrand, CNRS, SIGMA Clermont, Institut Pascal, Clermont-Ferrand, France
| | - O Rivière
- AUDIPOG (Association des Utilisateurs de Dossiers Informatisés en Pédiatrie, Obstétrique et Gynécologie), Faculty of Medicine RTH Laennec, Lyon, France
| | - K Coste
- AUDIPOG (Association des Utilisateurs de Dossiers Informatisés en Pédiatrie, Obstétrique et Gynécologie), Faculty of Medicine RTH Laennec, Lyon, France
- Université Clermont Auvergne, CHU de Clermont-Ferrand, GRED, CNRS 6293, Inserm U1103, Institut Pascal, Clermont-Ferrand, France
| | - F Vendittelli
- AUDIPOG (Association des Utilisateurs de Dossiers Informatisés en Pédiatrie, Obstétrique et Gynécologie), Faculty of Medicine RTH Laennec, Lyon, France
- Université Clermont Auvergne, CHU Clermont-Ferrand, CNRS, SIGMA Clermont, Institut Pascal, Clermont-Ferrand, France
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Ego A, Monier I, Skaare K, Zeitlin J. Antenatal detection of fetal growth restriction and risk of stillbirth: population-based case-control study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:613-620. [PMID: 31364201 DOI: 10.1002/uog.20414] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/28/2019] [Accepted: 07/18/2019] [Indexed: 05/15/2023]
Abstract
OBJECTIVES Antenatal surveillance of intrauterine growth aims to detect growth-restricted fetuses (FGR), which face increased risk of stillbirth. Improving their detection could be an effective strategy for prevention of stillbirth. The French REPERE study was conducted to estimate the association between antenatal detection of FGR and risk of stillbirth. METHODS REPERE is a case-control study performed in three French districts with a combined total of approximately 30 000 births annually. Cases were singleton small-for-gestational-age (SGA) stillbirths ≥ 24 weeks' gestation and without severe congenital anomaly, between 2012 and 2014, identified using a population-based stillbirth registry; controls were live births fulfilling the same inclusion criteria over a 9-week period from 7 April to 8 June 2014. Data were extracted by trained investigators from medical records and ultrasound reports. SGA was defined as birth weight < 10th percentile of French customized standards. FGR was defined by the presence of at least one of seven predefined parameters (suspected FGR mentioned in medical records or in ultrasound report, suspected faltering growth mentioned in an ultrasound report, documented abdominal circumference or estimated fetal weight < 10th percentile, referral for additional ultrasound examination to monitor growth or abnormal umbilical artery Doppler). We used logistic regression to estimate crude and adjusted odds ratios (ORs) for the association between detection of FGR and risk of stillbirth. Included covariables were parity, maternal medical history, vascular complications during pregnancy and birth-weight percentile, which are known to be associated with risk of detection of FGR and of stillbirth. RESULTS During the study period, there were 92 182 births ≥ 22 weeks' gestation, including 669 stillbirths, of which 79 were singleton SGA stillbirths ≥ 24 weeks and without severe congenital anomaly. Of these cases, 44.3% (35/79) had FGR detected, compared with a detection rate of 36.2% in controls (154/426). The crude OR expressing the association between detection of FGR and risk of stillbirth was 1.4 (95% CI, 0.9-2.3) and the OR adjusted for parity, presence of risk factors for FGR, presence of vascular disorder and birth-weight percentile was 0.6 (95% CI, 0.3-1.0). Among deliveries ≥ 28 weeks, detection rates were 38.3% vs 36.0% for cases and controls, with an adjusted OR of 0.5 (95% CI, 0.2-1.0). CONCLUSION Antenatal detection of FGR was protective against stillbirth, but over 40% of stillbirths among SGA fetuses occurred despite detection of FGR, pointing to the need to improve management following detection. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Ego
- Université Grenoble Alpes, CNRS, Public Health Department CHU Grenoble Alpes, Grenoble INP (Grenoble Institute of Engineering), TIMC-IMAG, Grenoble, France
- INSERM CIC U1406, Grenoble, France
| | - I Monier
- INSERM UMR 1153, Obstetric, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics, Paris-Descartes University, Paris, France
- Antoine Béclère Maternity Unit, Department of Obstetrics and Gynaecology, Université Paris Sud, AP-HP, Paris, France
| | - K Skaare
- INSERM CIC U1406, Grenoble, France
| | - J Zeitlin
- INSERM UMR 1153, Obstetric, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics, Paris-Descartes University, Paris, France
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Profile of severely growth-restricted births undelivered at 40 weeks in Western Australia. Arch Gynecol Obstet 2020; 301:1383-1396. [PMID: 32318796 DOI: 10.1007/s00404-020-05537-y] [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: 10/29/2019] [Accepted: 04/04/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To investigate the proportion of severely growth-restricted singleton births < 3rd percentile (proxy for severe fetal growth restriction; FGR) undelivered at 40 weeks (FGR_40), and compare maternal characteristics and outcomes of FGR_40 births and FGR births at 37-39 weeks' (FGR_37-39) to those not born small-for-gestational-age at term (Not SGA_37+). METHODS The annual rates of singleton FGR_40 births from 2006 to 2015 were calculated using data from linked Western Australian population health datasets. Using 2013-2015 data, maternal factors associated with FGR births were investigated using multinomial logistic regression to estimate odds ratios (OR) with 95% confidence intervals (CI) while relative risks (RR) of birth outcomes between each group were calculated using Poisson regression. Neonatal adverse outcomes were identified using a published composite indicator (diagnoses, procedures and other factors). RESULTS The rate of singleton FGR_40 births decreased by 23.0% between 2006 and 2015. Factors strongly associated with FGR_40 and FGR_37-39 births compared to Not SGA_37+ births included the mother being primiparous (ORs 3.13: 95% CI 2.59-3.79; 1.69, 95% CI 1.47, 1.94, respectively) and ante-natal smoking (ORs 2.55, 95% CI 1.97, 3.32; 4.48, 95% CI 3.74, 5.36, respectively). FGR_40 and FGR_37-39 infants were more likely to have a neonatal adverse outcome (RRs 1.70, 95% CI 1.41, 2.06 and 2.46 95% CI 2.18, 2.46, respectively) compared to Not SGA 37+ infants. CONCLUSIONS Higher levels of poor perinatal outcomes among FGR births highlight the importance of appropriate management including fetal growth monitoring. Regular population-level monitoring of FGR_40 rates may lead to reduced numbers of poor outcomes.
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Selvaratnam RJ, Wallace EM, Flenady V, Davey MA. Risk factor assessment for fetal growth restriction, are we providing best care? Aust N Z J Obstet Gynaecol 2020; 60:470-473. [PMID: 32207159 DOI: 10.1111/ajo.13147] [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: 08/19/2019] [Accepted: 02/02/2020] [Indexed: 12/30/2022]
Abstract
Serial third trimester ultrasound examinations for fetal biometry are recommended for women with risk factors of fetal growth restriction (FGR). We conducted a retrospective cohort study on all singleton births in Victoria from 2009 to 2017 to assess how many women with major risk factors for FGR had serial third trimester biometry. Only 19.5% of women with at least one major risk factor for FGR had evidence of serial third trimester ultrasound assessments. The development and implementation of a state-wide or nationwide guideline for early pregnancy risk factor assessment in FGR may be beneficial.
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Affiliation(s)
- Roshan John Selvaratnam
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Monash University, Melbourne, Victoria, Australia.,Department of Health and Human Services, Safer Care Victoria, Victorian Government, Melbourne, Victoria, Australia
| | - Euan Morrison Wallace
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Monash University, Melbourne, Victoria, Australia.,Department of Health and Human Services, Safer Care Victoria, Victorian Government, Melbourne, Victoria, Australia
| | - Vicki Flenady
- Centre of Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland (MRI-UQ), Brisbane, Queensland, Australia
| | - Mary-Ann Davey
- Department of Obstetrics and Gynaecology, The Ritchie Centre, Monash University, Melbourne, Victoria, Australia.,Department of Health and Human Services, Safer Care Victoria, Victorian Government, Melbourne, Victoria, Australia
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13
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Leite DFB, Morillon AC, Melo Júnior EF, Souza RT, McCarthy FP, Khashan A, Baker P, Kenny LC, Cecatti JG. Examining the predictive accuracy of metabolomics for small-for-gestational-age babies: a systematic review. BMJ Open 2019; 9:e031238. [PMID: 31401613 PMCID: PMC6701563 DOI: 10.1136/bmjopen-2019-031238] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/13/2019] [Accepted: 07/17/2019] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION To date, there is no robust enough test to predict small-for-gestational-age (SGA) infants, who are at increased lifelong risk of morbidity and mortality. OBJECTIVE To determine the accuracy of metabolomics in predicting SGA babies and elucidate which metabolites are predictive of this condition. DATA SOURCES Two independent researchers explored 11 electronic databases and grey literature in February 2018 and November 2018, covering publications from 1998 to 2018. Both researchers performed data extraction and quality assessment independently. A third researcher resolved discrepancies. STUDY ELIGIBILITY CRITERIA Cohort or nested case-control studies were included which investigated pregnant women and performed metabolomics analysis to evaluate SGA infants. The primary outcome was birth weight <10th centile-as a surrogate for fetal growth restriction-by population-based or customised charts. STUDY APPRAISAL AND SYNTHESIS METHODS Two independent researchers extracted data on study design, obstetric variables and sampling, metabolomics technique, chemical class of metabolites, and prediction accuracy measures. Authors were contacted to provide additional data when necessary. RESULTS A total of 9181 references were retrieved. Of these, 273 were duplicate, 8760 were removed by title or abstract, and 133 were excluded by full-text content. Thus, 15 studies were included. Only two studies used the fifth centile as a cut-off, and most reports sampled second-trimester pregnant women. Liquid chromatography coupled to mass spectrometry was the most common metabolomics approach. Untargeted studies in the second trimester provided the largest number of predictive metabolites, using maternal blood or hair. Fatty acids, phosphosphingolipids and amino acids were the most prevalent predictive chemical subclasses. CONCLUSIONS AND IMPLICATIONS Significant heterogeneity of participant characteristics and methods employed among studies precluded a meta-analysis. Compounds related to lipid metabolism should be validated up to the second trimester in different settings. PROSPERO REGISTRATION NUMBER CRD42018089985.
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Affiliation(s)
- Debora Farias Batista Leite
- Department of Tocogynecology, Campinas' State University, Campinas, Brazil
- Department of Maternal and Child Health, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Aude-Claire Morillon
- Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork National University of Ireland, Cork, Ireland
| | | | - Renato T Souza
- Obstetrics and Gynecology, Universidade Estadual de Campinas, Campinas, Brazil
| | - Fergus P McCarthy
- Department of Gynaecology and Obstetrics, St Thomas Hospital, Cork, UK
| | - Ali Khashan
- Department of Epidemiology and Public Health, University College Cork, Cork, Ireland
| | - Philip Baker
- College of Medicine, University of Leicester, Leicester, UK
| | - Louise C Kenny
- Department of Women's and Children's Health, University of Liverpool School of Life Sciences, Liverpool, UK
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Rowley A, Dyer E, Scott JG, Aiken CE. Could masking gestational age estimation during scanning improve detection of small-for-gestational-age fetuses? A controlled pre-post evaluation. Am J Obstet Gynecol MFM 2019; 1:100035. [PMID: 33345799 DOI: 10.1016/j.ajogmf.2019.100035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 07/31/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antenatal detection of small-for-gestational-age fetuses improves outcomes and reduces perinatal mortality rates. However, ultrasonographic estimation of fetal weight is subject to several potential sources of error. One potential source of error is subconscious operator bias towards "normal" measurement values for gestational age (observer-expectancy bias). OBJECTIVE We aimed to determine whether the sensitivity of small-for-gestational-age detection is improved by removing real-time display of estimated gestational age during measurement of the abdominal circumference in the third trimester. STUDY DESIGN This retrospective evaluation (November 2014-May 2018 inclusive) included all singleton infants liveborn at ≥28 weeks gestation in a single United Kingdom obstetrics center. In the preintervention phase, real-time estimated gestational age was displayed to sonographers as they measured fetal abdominal circumference (the key determinant of estimated fetal weight with the use of the INTERGROWTH 21st fetal weight equation) in the third trimester. In the postintervention phase, real-time gestational age information was removed on selected ultrasound machines. Accuracy of birthweight percentile estimation was assessed before and after intervention, both in the full cohort comprising all eligible scans and in a subcohort that was scanned within 4 weeks of delivery. We assessed the accuracy of small-for-gestational-age detection using the sensitivity, positive likelihood ratio, and area under the receiver-operator curve. RESULTS Of the 18,342 eligible pregnancies, 9342 (51%) had a third-trimester growth scan. The sensitivity of ultrasonographic estimation of fetal weight for antenatal detection of small-for-gestational-age babies did not change significantly between the before and after intervention phases (31.5% confidence interval, 27.1-36.2 vs 31.7% confidence interval, 20.2-45.0). Although the sensitivity for small-for-gestational-age detection was higher in the subcohort that was scanned within 4 weeks of delivery than in the full cohort (P<.001), there was no significant difference between the before and after intervention phases (58% confidence interval, 50-66 vs 65% confidence interval, 43-84). With the use of an estimation of the abdominal circumference percentile rather than estimated fetal weight percentile significantly decreased the sensitivity for small-for-gestational-age detection in all groups (P<.01), but there was no difference between the before and after intervention phases. CONCLUSION Blinding operators to the estimated gestation of the fetus during abdominal circumference measurement does not significantly alter the antenatal detection rate of small-for-gestational-age babies. The observer-expectancy effect is therefore unlikely to be a significant contributor to the error that is associated with ultrasonographic estimation of fetal weight.
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Affiliation(s)
- Amanda Rowley
- Department of Obstetrics and Gynaecology, Addenbrookes' Hospital, Cambridge, UK
| | - Ellen Dyer
- Department of Obstetrics and Gynaecology, Addenbrookes' Hospital, Cambridge, UK
| | - James G Scott
- Red McCombs School of Business and Department of Statistics and Data Sciences, University of Texas at Austin, TX
| | - Catherine E Aiken
- Department of Obstetrics and Gynaecology, Addenbrookes' Hospital, Cambridge, UK; University Department of Obstetrics and Gynaecology, University of Cambridge, the NIHR Cambridge Comprehensive Biomedical Research Centre, UK.
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15
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Kapaya H, Dimelow ER, Anumba D. Women's experience of wearing a portable fetal-electrocardiogram device to monitor small-for-gestational age fetus in their home environment. ACTA ACUST UNITED AC 2019; 14:1745506518785620. [PMID: 29968515 PMCID: PMC6048658 DOI: 10.1177/1745506518785620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To determine the acceptability, to women, of wearing a portable fetal
electrocardiogram recording device at different stages of pregnancy and to
gain insight into their experience of its use for long-periods of monitoring
of small-for-gestational fetuses in the home environment. Methods: A qualitative study using both a questionnaire and focus group involving
women with singleton pregnancy >24 weeks gestation, no evidence of fetal
malformation and an estimated fetal weight below 10th gestational centile on
ultrasound scan. Fetal heart rate recordings were collected for up to
20 h. Results: In total, 59 questionnaires were completed; 35 after wearing the monitor for
the first time and an additional 24 from the women who wore the device for a
second time. Six women participated in the focus group; the principal theme
identified related to the practicality of the fetal electrocardiogram
device. Other themes identified were the discomfort that resulted from
wearing the monitor and the reassurance provided in knowing that the baby’s
heart rate was being monitored. Conclusion: Long-term ambulatory fetal electrocardiogram monitoring is an acceptable
method of monitoring small-for-gestational fetuses. Overall, women concluded
that benefits of wearing the device outweighed any discomfort it caused.
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Affiliation(s)
- Habiba Kapaya
- 1 Academic Unit of Reproductive & Developmental Medicine, Department of Oncology & Metabolism, The University of Sheffield, Sheffield, UK
| | | | - Dilly Anumba
- 1 Academic Unit of Reproductive & Developmental Medicine, Department of Oncology & Metabolism, The University of Sheffield, Sheffield, UK
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Beune IM, Bloomfield FH, Ganzevoort W, Embleton ND, Rozance PJ, van Wassenaer-Leemhuis AG, Wynia K, Gordijn SJ. Consensus Based Definition of Growth Restriction in the Newborn. J Pediatr 2018; 196:71-76.e1. [PMID: 29499988 DOI: 10.1016/j.jpeds.2017.12.059] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 11/10/2017] [Accepted: 12/19/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To develop a consensus definition of growth restriction in the newborn that can be used clinically to identify newborn infants at risk and in research to harmonize reporting and definition in the current absence of a gold standard. STUDY DESIGN An international panel of pediatric leaders in the field of neonatal growth were invited to participate in an electronic Delphi procedure using standardized methods and predefined consensus rules. Responses were fed back at group-level and the list of participants was provided. Nonresponders were excluded from subsequent rounds. In the first round, variables were scored on a 5-point Likert scale; in subsequent rounds, inclusion of variables and cut-offs were determined with a 70% level of agreement. In the final round participants selected the ultimate algorithm. RESULTS In total, 57 experts participated in the first round; 79% completed the procedure. Consensus was reached on the following definition: birth weight less than the third percentile, or 3 out of the following: birth weight <10th percentile; head circumference <10th percentile; length <10th percentile; prenatal diagnosis of fetal growth restriction; and maternal pregnancy information. CONCLUSIONS Consensus was reached on a definition for growth restriction in the newborn. This definition recognizes that infants with birth weights <10th percentile may not be growth restricted and that infants with birth weights >10th percentile can be growth restricted. This definition can be adopted in clinical practice and in clinical trials to better focus on newborns at risk, and is complementary to the previously determined definition of fetal growth restriction.
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Affiliation(s)
- Irene M Beune
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | | | - Wessel Ganzevoort
- Department of Obstetrics and Gynecology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicholas D Embleton
- Newcastle Neonatal Service, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Paul J Rozance
- Perinatal Research Center, Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora, CO
| | | | - Klaske Wynia
- Department of Health Sciences, Community and Occupational Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sanne J Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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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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18
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The clinical significance of an estimated fetal weight below the 10th percentile: a comparison of outcomes of <5th vs 5th-9th percentile. Am J Obstet Gynecol 2017; 217:198.e1-198.e11. [PMID: 28433732 DOI: 10.1016/j.ajog.2017.04.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 04/08/2017] [Accepted: 04/11/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND The association between small-for-gestational-age (birthweight <10th percentile for gestational age) and neonatal morbidity is well established. Yet, there is a paucity of data on the relationship between suspected small for gestational age (sonographic-estimated fetal weight <10th percentile) at 2 thresholds and subsequent neonatal morbidity. OBJECTIVE The objective of this study was to determine the relationship between sonographic-estimated fetal weight <5th percentile vs 5-9th percentile and neonatal morbidity. STUDY DESIGN This retrospective study involved 5 centers and included nonanomalous, singletons with sonographic-estimated fetal weight <10th percentile for gestational age who delivered from 2009-2012. Composite neonatal morbidity included respiratory distress syndrome, proven sepsis, intraventricular hemorrhage grade III or IV, necrotizing enterocolitis, thrombocytopenia, seizures, or death. Odd ratios were adjusted for center, maternal age, race, body mass index at first visit, smoking status, use of alcohol, use of drugs, and neonatal gender. RESULTS Of 834 women with suspected small-for-gestational-age fetuses, 513 (62%) had sonographic-estimated fetal weight <5th percentile, and 321 (38%) had sonographic-estimated fetal weight of 5-9th percentile for gestational age. At delivery, 81% of women with a suspected small-for-gestational-age fetus had a confirmed small-for-gestational-age fetus. In the group with a sonographic-estimated fetal weight <5th percentile, 59% of neonates had birthweight <5th percentile; in the group with a sonographic-estimated fetal weight 5-9th percentile, 41% had birthweight <5th percentile, and 36% had birthweight at 5-9th percentile. Neonatal intensive care unit admission differed significantly for those fetuses at <5th percentile (29%) compared with those fetuses at 5-9th percentile (15%; P<.001). The composite neonatal morbidity among the sonographic-estimated fetal weight <5th percentile group was higher than the sonographic-estimated fetal weight of 5-9th percentile group (31% vs 13%; adjusted odds ratio, 2.41; 95% confidence interval, 1.53-3.80). Similar findings were noted when the analysis was limited to sonographic-estimated fetal weight within 28 days of delivery (adjusted odds ratio, 2.22; 95% confidence interval, 1.34-3.67). CONCLUSION Eight of 10 suspected small-for-gestational-age fetuses had birthweight <10th percentile for gestational age; the prediction of actual birthweight was more accurate in the <5th percentile group. Neonates with sonographic-estimated fetal weight of <5th percentile were more likely to be admitted to the neonatal intensive care unit and have complications than were those neonates with sonographic-estimated fetal weight of 5-9th percentile.
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Dupont C, Winer N, Rabilloud M, Touzet S, Branger B, Lansac J, Gaucher L, Duclos A, Huissoud C, Boutitie F, Rudigoz RC, Colin C. Multifaceted intervention to improve obstetric practices: The OPERA cluster-randomized controlled trial. Eur J Obstet Gynecol Reprod Biol 2017. [PMID: 28649035 DOI: 10.1016/j.ejogrb.2017.06.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Suboptimal care contributes to perinatal morbidity and mortality. We investigated the effects of a multifaceted program designed to improve obstetric practices and outcomes. STUDY DESIGN A cluster-randomized trial was conducted from October 2008 to November 2010 in 95 French maternity units randomized either to receive an information intervention about published guidelines or left to apply them freely. The intervention combined an outreach visit with a morbidity/mortality conference (MMC) to review perinatal morbidity/mortality cases. Within the intervention group, the units were randomized to have MMCs with or without clinical psychologists. The primary outcome was the rate of suboptimal care among perinatal morbidity/mortality cases. The secondary outcomes included the rate of suboptimal care among cases of morbidity, the rate of suboptimal care among cases of mortality, the rate of avoidable morbidity and/or mortality cases, and the incidence of, morbidity and/or mortality. A mixed logistic regression model with random intercept was used to quantify the effect of the intervention on the main outcome. RESULTS The study reviewed 2459 cases of morbidity or mortality among 165,353 births. The rate of suboptimal care among morbidity plus mortality cases was not significantly lower in the intervention than in the control group (8.1% vs. 10.6%, OR [95% CI]: 0.75 [0.50-1.12], p=0.15. However, the cases of suboptimal care among morbidity cases were significantly lower in the intervention group (7.6% vs. 11.5%, 0.62 [0.40-0.94], p=0.02); the incidence of perinatal morbidity was also lower (7.0 vs. 8.1‰, p=0.01). No differences were found between psychologist-backed and the other units. CONCLUSIONS The intervention reduced the rate of suboptimal care mainly in morbidity cases and the incidence of morbidity but did not succeed in improving morbidity plus mortality combined. More clear-cut results regarding mortality require a longer study period and the inclusion of structures that intervene before and after the delivery room. (ClinicalTrials.gov ID: NCT02584166).
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Affiliation(s)
- Corinne Dupont
- Hôpital de la Croix-Rousse, Hospices Civils de Lyon, F-69004, Lyon, France; Health Services and Performance Research - HESPER EA 7425, F-69008, Lyon, France.
| | - Norbert Winer
- Service de gynécologie-obstétrique/maternité, Centre Hospitalo-universitaire de Nantes, F-44300, Nantes, France
| | - Muriel Rabilloud
- Service de Biostatistique-Bioinformatique, Hospices Civils de Lyon, F-69003, Lyon, France; Université de Lyon, F-69000, Lyon, France; Université Lyon 1, F-69100, Villeurbanne, France; CNRS UMR 5558 Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, F-69100, Villeurbanne, France
| | - Sandrine Touzet
- Health Services and Performance Research - HESPER EA 7425, F-69008, Lyon, France; Pôle IMER, Hospices Civils de Lyon, F-69003, Lyon, France; Université de Lyon, F-69100, Lyon, France
| | - Bernard Branger
- Réseau Sécurité Naissance, Pays-de-la-Loire, F-44000, Nantes, France
| | - Jacques Lansac
- Réseau périnatal de la Région Centre, F-37000, Tours, France
| | - Laurent Gaucher
- Health Services and Performance Research - HESPER EA 7425, F-69008, Lyon, France; Hospices Civils de Lyon, Hôpital Femme-Mère-Enfant, F-69500 Lyon, France
| | - Antoine Duclos
- Health Services and Performance Research - HESPER EA 7425, F-69008, Lyon, France; Pôle IMER, Hospices Civils de Lyon, F-69003, Lyon, France; Université de Lyon, F-69100, Lyon, France
| | - Cyril Huissoud
- Hôpital de la Croix-Rousse, Hospices Civils de Lyon, F-69004, Lyon, France
| | - Florent Boutitie
- Service de Biostatistique-Bioinformatique, Hospices Civils de Lyon, F-69003, Lyon, France; Université de Lyon, F-69000, Lyon, France; Université Lyon 1, F-69100, Villeurbanne, France; CNRS UMR 5558 Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, F-69100, Villeurbanne, France
| | | | - Cyrille Colin
- Health Services and Performance Research - HESPER EA 7425, F-69008, Lyon, France; Service de Biostatistique-Bioinformatique, Hospices Civils de Lyon, F-69003, Lyon, France; Université de Lyon, F-69000, Lyon, France; Université Lyon 1, F-69100, Villeurbanne, France; CNRS UMR 5558 Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, F-69100, Villeurbanne, France
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Monier I, Ancel PY, Ego A, Jarreau PH, Lebeaux C, Kaminski M, Goffinet F, Zeitlin J. Fetal and neonatal outcomes of preterm infants born before 32 weeks of gestation according to antenatal vs postnatal assessments of restricted growth. Am J Obstet Gynecol 2017; 216:516.e1-516.e10. [PMID: 28188770 DOI: 10.1016/j.ajog.2017.02.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 01/16/2017] [Accepted: 02/01/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Fetal growth restriction is defined using ultrasound parameters during pregnancy or as a low birthweight for gestational age after birth, but these definitions are not always concordant. OBJECTIVE The purpose of this study was to investigate fetal and neonatal outcomes based on antenatal vs postnatal assessments of growth restriction. STUDY DESIGN From the EPIPAGE 2 population-based prospective study of very preterm births in France in 2011, we included 2919 singleton nonanomalous infants 24-31 weeks gestational age. We constituted 4 groups based on whether the infant was suspected with fetal growth restriction during pregnancy and/or was small for gestational age with a birthweight <10th percentile of intrauterine norms by sex: 1) suspected with fetal growth restriction/small for gestational age 2) not suspected with fetal growth restriction/small for gestational age 3) suspected with fetal growth restriction/not small for gestational age and 4) not suspected with fetal growth restriction/not small for gestational age. We estimated relative risks of perinatal mortality and morbidity for these groups adjusting for maternal and neonatal characteristics. RESULTS We found that 22.2% of infants were suspected with fetal growth restriction/small for gestational age, that 11.4% infants were not suspected with fetal growth restriction/small for gestational age, that 3.0% infants were suspected with fetal growth restriction/not small for gestational age, and that 63.4% infants were not suspected with fetal growth restriction/not small for gestational age. Compared with infants who were not suspected with fetal growth restriction/not small-for-gestational-age infants, small-for-gestational-age infants suspected and not suspected with fetal growth restriction had higher risks of stillbirth or termination of pregnancy (adjusted relative risk, 2.0 [95% confidence interval, 1.6-2.5] and adjusted relative risk, 2.8 [95% confidence interval, 2.2-3.4], respectively), in-hospital death (adjusted relative risk, 2.8 [95% confidence interval, 2.0-3.7] and adjusted relative risk, 2.0 [95% confidence interval, 1.5-2.8], respectively), and bronchopulmonary dysplasia (adjusted relative risk, 1.3 [95% confidence interval, 1.2-1.4] and adjusted relative risk, 1.3 [95% confidence interval, 1.1-1.4], respectively), but not severe brain lesions. Risks were not increased for infants suspected with fetal growth restriction but not small-for-gestational-age. CONCLUSION Antenatal and postnatal assessments of fetal growth restriction were not concordant for 14% of very preterm infants. In these cases, birthweight appears to be the more relevant parameter for the identification of infants with higher risks of adverse short-term outcomes.
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