Accuracy of immediate antepartum ultrasound estimated fetal weight and its impact on mode of delivery and outcome - a cohort analysis

How to enhance the applicability of a risk prediction model for term small-for-gestational-age neonates in clinical settings?

OBJECTIVE

To construct a simple term small-for-gestational-age (SGA) neonate prediction model that is clinically practical.

METHODS

This analysis was based on the Born in Guangzhou Cohort Study (BIGCS). Mothers who had a singleton pregnancy, delivered a term neonate, and had an ultrasonography within 30 + 0 to 32 + 6 weeks of gestation were included. Term SGA was defined with customized population percentiles. Prediction models were constructed with backward selection logistic regression in a four-step approach, where model 1 contained fetal biometrics only, models 2 and 3 included maternal features and a time factor (weeks between ultrasonography and delivery), respectively; and model 4 contained all features mentioned. The prediction performance of individual models was evaluated based on area under the curve (AUC) and a calibration test was performed.

RESULTS

The prevalence of SGA in the study population of 21 346 women was 11.5%. With a complete-case analysis approach, data of 19 954 women were used for model construction and validation. The AUC of the four models were 0.781, 0.793, 0.823, and 0.834, respectively, and all were well-calibrated. Model 3 consisted of fetal biometrics and corrected for time to delivery was chosen as the final model to build risk prediction graphs for clinical use.

CONCLUSION

A prediction model derived from fetal biometrics in early third trimester is satisfactory to predict SGA.

The Impact on Birth Outcomes of Sonographic Fetal Weight Estimation in Neonatal Macrosomia

OBJECTIVE

 Our objective was to examine the association between sonographic estimated fetal weight (EFW) and obstetrical and neonatal outcomes in women with neonatal macrosomia.

STUDY DESIGN

 This study, conducted at a tertiary university-affiliated hospital from 2017 to 2021, compared obstetrical and neonatal outcomes between two groups of women who delivered macrosomic newborns (actual birthweight ≥ 4,000 g): (1) those with EFW ≥ 3,800 g (suspected impending macrosomia) and (2) those with EFW < 3,800 g (unsuspected impending macrosomia).

RESULTS

 During the study period, 854 women with neonatal macrosomia attempted vaginal delivery. Only 9.2% had a sonographic EFW ≥ 4,000 g. Among women with EFW ≥ 3,800 g (n = 317) compared with EFW < 3,800 g (n = 537), the cesarean delivery (CD) rate was higher (17.0 vs. 10.5%, p = 0.004) and the operative delivery rate was lower (3.2 vs. 0.6%, p = 0.015). Among primiparous women, the CD rate was higher among those with EFW ≥ 3,800 versus <3,800 g (37.3 vs. 23.2%, p = 0.033). EFW ≥3,800 g was associated with CD, regardless of predelivery body mass index, parity, diabetes mellitus, maximal fetal weight at previous deliveries, actual birthweight, and labor induction (p = 0.014). EFW ≥ 3,800 g and diabetes mellitus were independent predictors of CD. Among women with EFW ≥3,800 g and diabetes mellitus, the risk of CD was double that of those without diabetes and with EFW ≥ 3,800 g (31.4% vs. 15.2%, p = 0.02), although their actual birthweights were similar. Obstetrical and neonatal outcomes were similar between those with sonographic EFW ≥ 3,800 and < 3,800 g.

CONCLUSION

 Larger EFW increased CD risk among pregnancies with actual neonatal macrosomia. Antenatally suspected macrosomia might alter labor management due to concerns for potential complications, especially when associated with primiparity, diabetes mellitus, or maternal obesity. The increase in the CD rate did not show an association with improved maternal and neonatal outcomes.

KEY POINTS

· Antenatally suspected macrosomia might alter labor management due to concerns about complications.. · Larger EFW increased cesarean delivery risk among pregnancies with actual neonatal macrosomia.. · The increase in the cesarean delivery rate was not associated with improved outcomes..

Does fetal size affect maternal perception of fetal movements? Evidence from an individual participant data meta-analysis

INTRODUCTION

Maternal perception of fetal movements during pregnancy are reassuring; however, the perception of a reduction in movements are concerning to women and known to be associated with increased odds of late stillbirth. Prior to full term, little evidence exists to provide guidelines on how to proceed unless there is an immediate risk to the fetus. Increased strength of movement is the most commonly reported perception of women through to full term, but perception of movement is also hypothesized to be influenced by fetal size. The study aimed to assess the pattern of maternal perception of strength and frequency of fetal movement by gestation and customized birthweight quartile in ongoing pregnancies. A further aim was to assess the association of stillbirth to perception of fetal movements stratified by customized birthweight quartile.

MATERIAL AND METHODS

This analysis was an individual participant data meta-analyses of five case-control studies investigating factors associated with stillbirth. The dataset included 851 cases of women with late stillbirth (>28 weeks' gestation) and 2257 women with ongoing pregnancies who then had a liveborn infant.

RESULTS

The frequency of prioritized fetal movement from 28 weeks' gestation showed a similar pattern for each quartile of birthweight with increased strength being the predominant perception of fetal movement through to full term. The odds of stillbirth associated with reduced fetal movements was increased in all quartiles of customized birthweight centiles but was notably greater in babies in the lowest two quartiles (Q1: adjusted OR: 9.34, 95% CI: 5.43, 16.06 and Q2: adjusted OR: 6.11, 95% CI: 3.11, 11.99). The decreased odds associated with increased strength of movement was present for all customized birthweight quartiles (adjusted OR range: 0.25-0.56).

CONCLUSIONS

Increased strength of fetal movements in late pregnancy is a positive finding irrespective of fetal size. However, reduced fetal movements are associated with stillbirth, and more so when the fetus is small.

"I felt like I had no options": Navigating an ultrasound prediction of a large baby in pregnancy

BACKGROUND

Pregnancy ultrasound is deeply embedded in maternity care worldwide, undertaken routinely and in response to clinical indicators. Though ultrasound fetal size predictions can be inaccurate, they heavily influence clinical decision-making. As a result, women with a scan prediction of a 'large' baby may be more likely to have unnecessary interventions.

AIM

This study aimed to explore the implications of an ultrasound prediction of a 'large' baby on birthing women's experiences of their pregnancies and births.

METHODS

The study was underpinned by feminist poststructural theory. Semi-structured interviews were undertaken with women who had an ultrasound prediction of a 'large' baby. Transcripts were analysed using reflexive thematic analysis, with particular attention to discourse.

FINDINGS

Dominant medicalising discourses prioritised surveillance and risk-centric care, and problematised large babies. Engagement with these produced oppressive effects on women including loss of control as they were directed towards high intervention care, and the experience of fear and guilt.

DISCUSSION

A 'large' baby prediction has a negative impact on women's experiences. Women take up dominant discourses that frame predicted large babies as a medical problem to be managed, with little tangible improvement in outcomes. They struggle with fear and guilt as they experience their pregnancies as sites of risk and are constituted as failed mothers who are responsible for their large babies.

CONCLUSION

The prediction of a 'large' baby in pregnancy has undeniably negative impacts on women. We encourage midwives to scrutinise the dominant discourses of authoritative scans and problematic large babies, becoming vectors for critical thinking and resistance.

Characteristics associated with antenatally unidentified small-for-gestational-age fetuses: prospective cohort study nested within DESiGN randomized controlled trial

OBJECTIVE

To identify the clinical characteristics and patterns of ultrasound use amongst pregnancies with an antenatally unidentified small-for-gestational-age (SGA) fetus, compared with those in which SGA is identified, to understand how to design interventions that improve antenatal SGA identification.

METHODS

This was a prospective cohort study of singleton, non-anomalous SGA (birth weight < 10th centile) neonates born after 24 + 0 gestational weeks at 13 UK sites, recruited for the baseline period and control arm of the DESiGN trial. Pregnancy with antenatally unidentified SGA was defined if there was no scan or if the final scan showed estimated fetal weight (EFW) at the 10th centile or above. Identified SGA was defined if EFW was below the 10th centile at the last scan. Maternal and fetal sociodemographic and clinical characteristics were studied for associations with unidentified SGA using unadjusted and adjusted logistic regression models. Ultrasound parameters (gestational age at first growth scan, number and frequency of ultrasound scans) were described, stratified by presence of indication for serial ultrasound. Associations of unidentified SGA with absolute centile and percentage weight difference between the last scan and birth were also studied on unadjusted and adjusted logistic regression, according to time between the last scan and birth.

RESULTS

Of the 15 784 SGA babies included, SGA was not identified antenatally in 78.7% of cases. Of pregnancies with unidentified SGA, 47.1% had no recorded growth scan. Amongst 9410 pregnancies with complete data on key maternal comorbidities and antenatal complications, the risk of unidentified SGA was lower for women with any indication for serial scans (adjusted odds ratio (aOR), 0.56 (95% CI, 0.49-0.64)), for Asian compared with white women (aOR, 0.80 (95% CI, 0.69-0.93)) and for those with non-cephalic presentation at birth (aOR, 0.58 (95% CI, 0.46-0.73)). The risk of unidentified SGA was highest among women with a body mass index (BMI) of 25.0-29.9 kg/m2 (aOR, 1.15 (95% CI, 1.01-1.32)) and lowest in those with underweight BMI (aOR, 0.61 (95% CI, 0.48-0.76)) compared to women with BMI of 18.5-24.9 kg/m2 . Compared to women with identified SGA, those with unidentified SGA had fetuses of higher SGA birth-weight centile (adjusted odds for unidentified SGA increased by 1.21 (95% CI, 1.18-1.23) per one-centile increase between the 0th and 10th centiles). Duration between the last scan and birth increased with advancing gestation in pregnancies with unidentified SGA. SGA babies born within a week of the last growth scan had a mean difference between EFW and birth-weight centiles of 19.5 (SD, 13.8) centiles for the unidentified-SGA group and 0.2 (SD, 3.3) centiles for the identified-SGA group (adjusted mean difference between groups, 19.0 (95% CI, 17.8-20.1) centiles).

CONCLUSIONS

Unidentified SGA was more common amongst women without an indication for serial ultrasound, and in those with cephalic presentation at birth, BMI of 25.0-29.9 kg/m2 and less severe SGA. Ultrasound EFW was overestimated in women with unidentified SGA. This demonstrates the importance of improving the accuracy of SGA screening strategies in low-risk populations and continuing performance of ultrasound scans for term pregnancies. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

How to Reach the Best Ultrasound Performance in the Delivery Room

Ultrasonography is an instrument that is present in the maternal-fetal assessment throughout pregnancy and with widely documented benefits, but its use in intrapartum is becoming increasingly relevant. From the assessment of labor progression to the assessment of placental disorders, ultrasound can be used to correlate with physiological findings and physical examination, as its benefit in the delivery room cannot yet be proven. There are still few professionals with adequate training for its use in the delivery room and for the correct interpretation of data. Thus, this article aims to present a review of the entire applicability of ultrasound in the delivery room, considering the main stages of labor. There is still limited research in evidence-based medicine of its various possible uses in intrapartum, but it is expected that further studies can bring improvements in the quality of maternal and neonatal health during labor.

Perinatal factors associated with admission to neonatal intensive care unit following cesarean delivery in Kano, northern Nigeria

OBJECTIVES

Cesarean section is the most common obstetric surgical procedure, with associated risks for adverse neonatal outcomes. The interplay of perinatal factors associated with neonatal admissions following cesarean delivery remains poorly understood in developing countries. We examined how perinatal and facility-based factors affect Neonatal Intensive Care Unit (NICU) admission after cesarean delivery in northern Nigeria.

METHODS

A prospective cohort study involving 200 women undergoing cesarean section were consecutively enrolled with subsequent follow-up of their infants in the post-natal period. Data were abstracted from the medical record using an interviewer-administered questionnaire. The primary outcomes were NICU admission and intrauterine or early neonatal deaths. Binary logistic regression modelling was used to identify variables independently associated with the outcomes.

RESULTS

Over the study period (six months), there were 200 cesarean sections. A total of 30 (15.0%) neonates were admitted into the NICU following the procedure. No stillbirths or early neonatal deaths were recorded. NICU admission was associated with gestational age (preterm vs. term [adjusted odds ratio, aOR: 18.9, 95% confidence interval (CI): 4.0-90.4]), birth weight (small vs. appropriate [aOR: 6.7, 95% CI 1.9-22.7] and large vs. appropriate birth weight [aOR: 20.3, 95% CI 2.9-143.7]) and the number of indications for cesarean section (≥2 vs. one [aOR: 0.2, 95% 0.1-0.8]).

CONCLUSIONS

Prematurity, small and large for gestational age neonates; and indications for cesarean section were associated with increased likelihood of neonatal admission following cesarean delivery. These findings could inform ongoing quality enhancement initiatives to improve NICU admission outcomes at the study site, and other similar settings.

Percent error of ultrasound examination to estimate fetal weight at term in different categories of birth weight with focus on maternal diabetes and obesity

BACKGROUND

Sonography based estimate of fetal weight is a considerable issue for delivery planning. The study evaluated the influence of diabetes, obesity, excess weight gain, fetal and neonatal anthropometrics on accuracy of estimated fetal weight with respect to the extent of the percent error of estimated fetal weight to birth weight for different categories.

METHODS

Multicenter retrospective analysis from 11,049 term deliveries and fetal ultrasound biometry performed within 14 days to delivery. Estimated fetal weight was calculated by Hadlock IV. Percent error from birth weight was determined for categories in 250 g increments between 2500 g and 4500 g. Estimated fetal weight accuracy was categorized as accurate ≤ 10% of birth weight, under- and overestimated by >  ± 10% - ± 20% and > 20%.

RESULTS

Diabetes was diagnosed in 12.5%, obesity in 12.6% and weight gain exceeding IOM recommendation in 49.1% of the women. The percentage of accurate estimated fetal weight was not significantly different in the presence of maternal diabetes (70.0% vs. 71.8%, p = 0.17), obesity (69.6% vs. 71.9%, p = 0.08) or excess weight gain (71.2% vs. 72%, p = 0.352) but of preexisting diabetes (61.1% vs. 71.7%; p = 0.007) that was associated with the highest macrosomia rate (26.9%). Mean percent error of estimated fetal weight from birth weight was 2.39% ± 9.13%. The extent of percent error varied with birth weight with the lowest numbers for 3000 g-3249 g and increasing with the extent of birth weight variation: 5% ± 11% overestimation in the lowest and 12% ± 8% underestimation in the highest ranges.

CONCLUSION

Diabetes, obesity and excess weight gain are not necessarily confounders of estimated fetal weight accuracy. Percent error of estimated fetal weight is closely related to birth weight with clinically relevant over- and underestimation at both extremes. This work provides detailed data regarding the extent of percent error for different birth weight categories and may therefore improve delivery planning.

Application of Prospect Theory in Obstetrics by Evaluating Mode of Delivery and Outcomes in Neonates Born Small or Appropriate for Gestational Age

IMPORTANCE

Antenatal diagnosis of fetal weight is challenging, and the detection rate of fetal growth restriction (FGR) is low. Neonates with FGR are known to have an increased rate of obstetric intervention during labor, but the association of antenatal fetal weight estimation with mode of delivery and neonatal outcomes among neonates who are small and appropriate for gestational age (SGA and AGA) has not been reported.

OBJECTIVE

To evaluate the association of antenatal fetal weight estimation with mode of delivery and neonatal outcomes among neonates who are SGA and AGA, applying psychological concepts of cognitive bias and prospect theory to a model of clinical behavior.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted between 2019 and 2020 using data from 2006 to 2018 at a tertiary care center in Jerusalem, Israel. Participants were 100 198 term singleton neonates without anomalies who were categorized into 4 groups according to the presence of an antenatal suspicion of FGR and final birth weight. Neonates with false positives (FPs; ie, group 1-FP: those with suspected FGR who were AGA) and neonates with true positives (TPs; ie, group 2-TP: those with suspected FGR who were SGA) were compared with neonates with AGA antenatal fetal weight estimation, including neonates with false negatives (FNs; ie, group 3-FN: those not suspected to have FGR who were SGA) and neonates with true negatives (TNs; ie, group 4-TN: those not suspected to have FGR who were AGA). Data were analyzed from July 2019 to July 2020.

EXPOSURES

Fetal weight estimation was performed according to sonographic and clinical evaluation at admission to labor, with FGR defined as a birth weight less than the 10th percentile for gestational age. Sonographic fetal weight estimation was performed according to Hadlock formula. Clinical weight estimation was performed by trained obstetricians.

MAIN OUTCOMES AND MEASURES

The primary outcomes were obstetric intervention and mode of delivery; the secondary outcomes were neonatal Apgar score (with low Apgar score defined as <7) and neonatal intensive care unit (NICU) admission rates.

RESULTS

Among 100 198 neonates eligible for the study (50941 [50.8%] male neonates), there were 5671 neonates in group 1-FP, 3040 neonates in group 2-TP, 8508 neonates in group 3-FN, and 82 979 neonates in group 4-TN. Mean (SD) maternal age was 28.6 (5.7) years. Among 8711 neonates with suspected FGR, 34.9% were below the 10th percentile at birth, while 65.1% were AGA. Neonates with suspected FGR had a significantly increased rate of induction of labor (group 1-FP: 649 neonates [11.4%] and group 2-TP: 969 neonates [31.9%]) compared with neonates in group 3-FN (1055 neonates [12.4%]) and group 4-TN (7136 neonates [8.6%]) (P < .001) and a significantly increased rate of cesarean delivery (group 1-FP: 915 neonates [16.1%] and group 2-TP: 556 neonates [18.3%] vs group 3-FN: 1106 neonates [13.0%] and group 4-TN: 6588 neonates [7.9%]; P < .001). Increased NICU admission was found for neonates who were SGA compared with neonates who were AGA (group 2-TP: 182 neonates [6.0%] and group 3-FN: 328 neonates [3.9%] vs group 1-FP: 51 neonates [0.9%] and group 4-TN: 704 neonates [0.8%]; P <.001), as was increased rate of low Apgar score (eg, at 1 minute: group 2-TP: 149 neonates [4.9%] and group 3-FN: 384 neonates [4.5%] vs group 1-FP: 124 neonates [2.2%] and group 4-TN: 1595 neonates [1.9%]; P < .001). In a multivariable model comparing group 1-FP, group 2-TP, and group 3-FN with group 4-TN, suspicion of FGR was independently associated with increased risk of caesarean delivery among neonates in group 1-FP (odds ratio, 1.72; 95% CI, 1.56-1.88; P < .001).

CONCLUSIONS AND RELEVANCE

This study found that antenatal diagnosis of FGR was independently associated with an increase in risk of caesarean delivery by 70% in neonates who were AGA without improvement in neonatal outcomes. These findings suggest that such outcomes may be explained by application of prospect theory and may be associated with cognitive bias in clinical decision-making.

Comparison of diagnostic value of two-dimensional ultrasound and clinical examination in fetal weight estimation

Background:

Estimation of fetal weight during pregnancy plays an important role in prenatal and intrapartum care and is more important in pregnancies after 37 weeks to determine the type of delivery. The aim of this study was to compare and evaluate the accuracy and diagnostic value of two-dimensional ultrasound and clinical examination in estimating fetal weight and pregnancy outcomes.

Materials and Methods:

This cross-sectional study was conducted on 300 pregnant women without abnormal fetuses and pregnancies after 37 weeks; mothers who had a normal delivery or cesarean section were evaluated by the available method. The weight of the fetus was estimated before and after delivery, using ultrasound and clinical examination. Newborns were classified into five groups based on their fetal weight. Analysis of collected data was performed with SPSS software.

Results:

The mean age of the patients was 31 years and the mean weight of the neonates was 3450 g. At a weight of less than 3000 g, ultrasound and clinical evaluation were strongly correlated with the actual weight of the infant, but at weights of more than 3500 and 4000 g, weight estimation with ultrasound was highly accurate, and clinical examination had poor accuracy. In lower weights, square errors were fewer in both ultrasound and clinical examination, in comparison with higher weights. In higher weights, ultrasound is more reliable, and the diagnostic accuracy of clinical examination is reduced.

Conclusion:

Estimation of fetal weight with prenatal ultrasound is highly accurate. Clinical examination is more accurate in determining the weight of small fetuses and does not pay much attention to the diagnosis of macrosomic fetuses and even leads to overestimation, while ultrasound is much more accurate in diagnosing fetal macrosomia.

The association between sonographic fetal head circumference, obstetric anal sphincter injury and mode of delivery: A retrospective cohort study

BACKGROUND

There is no consensus to the implications of an increased sonographic fetal head circumference (HC) and its impact on delivery.

AIM

To examine if there is any association between sonographic fetal HC, obstetric anal sphincter injury (OASIS) and mode of delivery.

MATERIALS AND METHODS

A retrospective cohort study of term, singleton births between April 2017 and March 2019 at a large regional hospital in Australia with a third trimester ultrasound. Logistic regressions were performed investigating sonographic fetal HC and additional risk factors for OASIS. Further multinomial logistic regressions assessed the relationship between the sonographic HC and mode of delivery. Odds ratios and their 95% CIs were reported.

RESULTS

Of 667 eligible women, 487 (73%) had vaginal births, with 32 (6.6%) sustaining an OASIS and 180 (27%) had caesarean sections (CS). The sonographic fetal HC did not show an association with OASIS (odds ratio 1.005; CI 0.99-1.01, P = 0.447). A statistically significant association (P < 0.05) with OASIS was found with Asian ethnicity (4.38; 1.5-11.32), prolonged second stage (≥2 h) (4.26; 1.57-10.49) and occiput posterior position (4.01; 1.08-11.92). For women with a sonographic fetal HC ≥ 90th percentile, the odds of having CS compared to a spontaneous vaginal birth are 2.77 (95% CI: 1.36, 5.62; P = 0.005) times higher than those who have a HC < 90th percentile.

CONCLUSION

This study does not support the use of sonographic fetal HC in assessing a woman's risk of sustaining an OASIS. Sonographic fetal HC is associated with mode of delivery.

Ultrasound for the Pregnant Person With Diabesity

Diabetes and obesity increase the risk of congenital anomalies, but the putative mechanisms of this increased risk are not fully elucidated. In this chapter, we delve into sonographic characteristics associated with diabetes and obesity, including fetal structural anomalies, functional cardiac alterations, and growth abnormalities. We will also discuss the technical challenges of imaging in the patient with diabesity and propose methodologies for optimizing imaging. Lastly, we will address the prevention of workplace-associated musculoskeletal disorders injury for sonographers.

[Sulfadoxine-pyrimethamine-based intermittent preventive treatment in pregnant women and its effect on birth weight: application of 3-dosing regimen in the urban area of South Benin in 2017]

Introduction

Le paludisme est un problème de santé publique majeur, responsable de nombreuses complications durant la grossesse parmi lesquelles le retard de croissance intra utérin et les hypotrophies. L'objectif de ce travail était de déterminer l'effet du respect des 3 doses du traitement préventif intermittent (TPI) à la sulfadoxine-pyrimétamine (SP) sur le poids de naissance des nouveau-nés de la zone sanitaire Cotonou II et III.

Méthodes

Il s'agit d'une étude transversale qui a porté sur 630 femmes en période post partum résidant dans la zone sanitaire Cotonou II-III et sélectionnées par une technique de sondage à deux degrés. Les données ont été recueillies par un questionnaire et une fiche de dépouillement. Pour l'analyse, les données ont été pondérées et nous avons utilisé l'analyse de variance pour la comparaison des moyennes et une comparaison de proportions avec le test de chi² assorti d'une estimation de la force de l'association par l'odds ratio (OR) et son intervalle de confiance à 95%.

Résultats

Le respect des 3 doses du TPI à la SP était de 34,08% (IC95%: [24,84% - 43,30%]). On note un gain significatif de poids de naissance de 264,5g (p < 0,001) chez les mères qui avaient reçu plus de 3 doses de SP et la probabilité d'avoir un bébé ayant un faible poids de naissance était plus faible (OR = 0,45; p = 0,001) chez ces mères comparativement à celles qui avaient reçu moins de 3 doses de sulfadoxine-pyriméthamine.

Conclusion

Cette étude révèle une faible observance de la nouvelle politique à 3 doses du traitement préventif intermittent à la sulfadoxine-pyriméthamine dans la zone sanitaire de Cotonou II et III, mais elle témoigne de son potentiel de contribution à la réduction du risque de faible poids de naissance. Des stratégies doivent donc être mises en œuvre pour renforcer son application en vue de la prévention du paludisme et de ses conséquences pour les cibles vulnérables.