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Additional single third trimester ultrasound scan in detection of large for gestational age fetuses. Curr Opin Obstet Gynecol 2022; 34:275-278. [PMID: 36036474 DOI: 10.1097/gco.0000000000000813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To evaluate the accuracy of growth scans in the third trimester. To evaluate the accuracy of universal third trimester ultrasound scans in the detection of large for gestational age (LGA) fetuses. To investigate how universal ultrasound scans affect the delivery and outcomes. RECENT FINDINGS Universal third trimester screening for LGA recorded a 22% positive predictive value (PPV), and 96% negative predicted value (NPV). The sensitivity in most studies reaches around 70% or more, of all the LGA fetuses delivered, there are different studies for and against universal ultrasonic screening of LGA. Estimated fetal weight (>4 kg/90th centile) and abdominal circumference are the best predictors of LGA with nearly 70% sensitivity. One study reported that an antenatal ultrasonic diagnosis of LGA in a low risk population has a weak association with the incidence of shoulder dystocia or poor neonatal outcomes. Universal screening in the third trimester for LGAs is not cost effective. SUMMARY Low risk pregnancies constitute the majority of the pregnancy population. All low risk pregnancy women will only receive two routine scans throughout the whole pregnancy. There is no evidence at present that conclusively demonstrates that an additional scan at 36 weeks improves maternal and neonatal outcomes and is cost effective.
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Westerneng M, de Jonge A, van Baar AL, Witteveen AB, Jellema P, Paarlberg KM, Rijnders M, van der Horst HE. The effect of offering a third-trimester routine ultrasound on pregnancy-specific anxiety and mother-to-infant bonding in low-risk women: A pragmatic cluster-randomized controlled trial. Birth 2022; 49:61-70. [PMID: 34288070 PMCID: PMC9290476 DOI: 10.1111/birt.12573] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 06/28/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Third-trimester routine ultrasounds are increasingly offered to monitor fetal growth. In addition to limited evidence for its clinical effectiveness, little is known about its importance for pregnancy-specific anxiety and mother-to-infant bonding. METHODS 1275 low-risk women participated in a Dutch nationwide pragmatic cluster-randomized trial and answered questionnaires on pregnancy-specific anxiety (PRAQ-R) and prenatal mother-to-infant bonding (MAAS) before and after a third-trimester routine ultrasound was offered to the intervention group. Linear mixed model regression analyses were performed to examine the effect of offering a third-trimester routine ultrasound on pregnancy-specific anxiety and mother-to-infant bonding. In addition, we examined whether the effect depended on maternal background characteristics and level of satisfaction with the ultrasound procedure. RESULTS We found no effect of offering a third-trimester routine ultrasound on pregnancy-specific anxiety and mother-to-infant bonding. However, interaction analyses showed that women with high levels of depressive symptoms at baseline and women who were very satisfied with the ultrasound procedure benefited somewhat more from offering a third-trimester routine ultrasound in terms of mother-to-infant bonding compared with women with low or no depressive symptoms, or less satisfied women. CONCLUSIONS The relationship between offering a third-trimester routine ultrasound with pregnancy-specific anxiety and mother-to-infant bonding is limited. A beneficial effect only applies to some subgroups of women. This implies that, in terms of psychological outcomes, there are no counterarguments to implementing a third-trimester routine ultrasound. Strong evidence for offering all pregnant women a third-trimester routine ultrasound for psychological reasons, however, is lacking.
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Affiliation(s)
- Myrte Westerneng
- Midwifery ScienceAVAGAmsterdam Public Health Research InstituteAmsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Ank de Jonge
- Midwifery ScienceAVAGAmsterdam Public Health Research InstituteAmsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | | | - Anke B. Witteveen
- Midwifery ScienceAVAGAmsterdam Public Health Research InstituteAmsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Petra Jellema
- Midwifery ScienceAVAGAmsterdam Public Health Research InstituteAmsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | | | | | - Henriëtte E. van der Horst
- Department of General Practice and Elderly Care MedicineAmsterdam Public Health Research InstituteAmsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
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Tong S, Joy Kaitu'u-Lino T, Walker SP, MacDonald TM. Blood-based biomarkers in the maternal circulation associated with fetal growth restriction. Prenat Diagn 2019; 39:947-957. [PMID: 31299098 DOI: 10.1002/pd.5525] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/28/2019] [Accepted: 07/03/2019] [Indexed: 11/11/2022]
Abstract
Fetal growth restriction (FGR) is associated with threefold to fourfold increased risk of stillbirth. Identifying FGR, through its commonly used surrogate-the small-for-gestational-age (SGA, estimated fetal weight and/or abdominal circumference <10th centile) fetus-and instituting fetal surveillance and timely delivery decrease stillbirth risk. Methods available to clinicians for antenatal identification of SGA fetuses have surprisingly poor sensitivity. About 80% of cases remain undetected. Measuring the symphysis-fundal height detects only 20% of SGA fetuses, and even universal third trimester ultrasound detects, at best, 57% of those born SGA. There is an urgent need to find better ways to identify this at-risk cohort. This review summarises efforts to identify molecular biomarkers (proteins, metabolites, or ribonucleic acids) that could be used to better predict FGR. Most studies examining potential biomarkers to date have utilised case-control study designs without proceeding to validation in independent cohorts. To develop a robust test for FGR, large prospective studies are required with a priori validation plans and cohorts. Given that current clinical care detects 20% of SGA fetuses, even a screening test with ≥60% sensitivity at 90% specificity could be clinically useful, if developed. This may be an achievable aspiration. If discovered, such a test may decrease stillbirth.
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Affiliation(s)
- Stephen Tong
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, Victoria, Australia.,Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Tu'uhevaha Joy Kaitu'u-Lino
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, Victoria, Australia.,Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Susan Philippa Walker
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, Victoria, Australia.,Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Teresa Mary MacDonald
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, Victoria, Australia.,Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
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Heazell AEP, Hayes DJL, Whitworth M, Takwoingi Y, Bayliss SE, Davenport C. Biochemical tests of placental function versus ultrasound assessment of fetal size for stillbirth and small-for-gestational-age infants. Cochrane Database Syst Rev 2019; 5:CD012245. [PMID: 31087568 PMCID: PMC6515632 DOI: 10.1002/14651858.cd012245.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Stillbirth affects 2.6 million pregnancies worldwide each year. Whilst the majority of cases occur in low- and middle-income countries, stillbirth remains an important clinical issue for high-income countries (HICs) - with both the UK and the USA reporting rates above the mean for HICs. In HICs, the most frequently reported association with stillbirth is placental dysfunction. Placental dysfunction may be evident clinically as fetal growth restriction (FGR) and small-for-dates infants. It can be caused by placental abruption or hypertensive disorders of pregnancy and many other disorders and factorsPlacental abnormalities are noted in 11% to 65% of stillbirths. Identification of FGA is difficult in utero. Small-for-gestational age (SGA), as assessed after birth, is the most commonly used surrogate measure for this outcome. The degree of SGA is associated with the likelihood of FGR; 30% of infants with a birthweight < 10th centile are thought to be FGR, while 70% of infants with a birthweight < 3rd centile are thought to be FGR. Critically, SGA is the most significant antenatal risk factor for a stillborn infant. Correct identification of SGA infants is associated with a reduction in the perinatal mortality rate. However, currently used tests, such as measurement of symphysis-fundal height, have a low reported sensitivity and specificity for the identification of SGA infants. OBJECTIVES The primary objective was to assess and compare the diagnostic accuracy of ultrasound assessment of fetal growth by estimated fetal weight (EFW) and placental biomarkers alone and in any combination used after 24 weeks of pregnancy in the identification of placental dysfunction as evidenced by either stillbirth, or birth of a SGA infant. Secondary objectives were to investigate the effect of clinical and methodological factors on test performance. SEARCH METHODS We developed full search strategies with no language or date restrictions. The following sources were searched: MEDLINE, MEDLINE In Process and Embase via Ovid, Cochrane (Wiley) CENTRAL, Science Citation Index (Web of Science), CINAHL (EBSCO) with search strategies adapted for each database as required; ISRCTN Registry, UK Clinical Trials Gateway, WHO International Clinical Trials Portal and ClinicalTrials.gov for ongoing studies; specialist abstract and conference proceeding resources (British Library's ZETOC and Web of Science Conference Proceedings Citation Index). Search last conducted in Ocober 2016. SELECTION CRITERIA We included studies of pregnant women of any age with a gestation of at least 24 weeks if relevant outcomes of pregnancy (live birth/stillbirth; SGA infant) were assessed. Studies were included irrespective of whether pregnant women were deemed to be low or high risk for complications or were of mixed populations (low and high risk). Pregnancies complicated by fetal abnormalities and multi-fetal pregnancies were excluded as they have a higher risk of stillbirth from non-placental causes. With regard to biochemical tests, we included assays performed using any technique and at any threshold used to determine test positivity. DATA COLLECTION AND ANALYSIS We extracted the numbers of true positive, false positive, false negative, and true negative test results from each study. We assessed risk of bias and applicability using the QUADAS-2 tool. Meta-analyses were performed using the hierarchical summary ROC model to estimate and compare test accuracy. MAIN RESULTS We included 91 studies that evaluated seven tests - blood tests for human placental lactogen (hPL), oestriol, placental growth factor (PlGF) and uric acid, ultrasound EFW and placental grading and urinary oestriol - in a total of 175,426 pregnant women, in which 15,471 pregnancies ended in the birth of a small baby and 740 pregnancies which ended in stillbirth. The quality of included studies was variable with most domains at low risk of bias although 59% of studies were deemed to be of unclear risk of bias for the reference standard domain. Fifty-three per cent of studies were of high concern for applicability due to inclusion of only high- or low-risk women.Using all available data for SGA (86 studies; 159,490 pregnancies involving 15,471 SGA infants), there was evidence of a difference in accuracy (P < 0.0001) between the seven tests for detecting pregnancies that are SGA at birth. Ultrasound EFW was the most accurate test for detecting SGA at birth with a diagnostic odds ratio (DOR) of 21.3 (95% CI 13.1 to 34.6); hPL was the most accurate biochemical test with a DOR of 4.78 (95% CI 3.21 to 7.13). In a hypothetical cohort of 1000 pregnant women, at the median specificity of 0.88 and median prevalence of 19%, EFW, hPL, oestriol, urinary oestriol, uric acid, PlGF and placental grading will miss 50 (95% CI 32 to 68), 116 (97 to 133), 124 (108 to 137), 127 (95 to 152), 139 (118 to 154), 144 (118 to 161), and 144 (122 to 161) SGA infants, respectively. For the detection of pregnancies ending in stillbirth (21 studies; 100,687 pregnancies involving 740 stillbirths), in an indirect comparison of the four biochemical tests, PlGF was the most accurate test with a DOR of 49.2 (95% CI 12.7 to 191). In a hypothetical cohort of 1000 pregnant women, at the median specificity of 0.78 and median prevalence of 1.7%, PlGF, hPL, urinary oestriol and uric acid will miss 2 (95% CI 0 to 4), 4 (2 to 8), 6 (6 to 7) and 8 (3 to 13) stillbirths, respectively. No studies assessed the accuracy of ultrasound EFW for detection of pregnancy ending in stillbirth. AUTHORS' CONCLUSIONS Biochemical markers of placental dysfunction used alone have insufficient accuracy to identify pregnancies ending in SGA or stillbirth. Studies combining U and placental biomarkers are needed to determine whether this approach improves diagnostic accuracy over the use of ultrasound estimation of fetal size or biochemical markers of placental dysfunction used alone. Many of the studies included in this review were carried out between 1974 and 2016. Studies of placental substances were mostly carried out before 1991 and after 2013; earlier studies may not reflect developments in test technology.
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Affiliation(s)
- Alexander EP Heazell
- University of ManchesterMaternal and Fetal Health Research Centre5th floor (Research), St Mary's Hospital, Oxford RoadManchesterUKM13 9WL
| | - Dexter JL Hayes
- University of ManchesterMaternal and Fetal Health Research Centre5th floor (Research), St Mary's Hospital, Oxford RoadManchesterUKM13 9WL
| | - Melissa Whitworth
- University of ManchesterMaternal and Fetal Health Research Centre5th floor (Research), St Mary's Hospital, Oxford RoadManchesterUKM13 9WL
| | - Yemisi Takwoingi
- University of BirminghamInstitute of Applied Health ResearchEdgbastonBirminghamUKB15 2TT
| | - Susan E Bayliss
- University of BirminghamInstitute of Applied Health ResearchEdgbastonBirminghamUKB15 2TT
| | - Clare Davenport
- University of BirminghamInstitute of Applied Health ResearchEdgbastonBirminghamUKB15 2TT
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Drouin O, Boutin A, Paquette K, Gasse C, Guerby P, Demers S, Bujold E. First-Trimester Uterine Artery Doppler for the Prediction of SGA at Birth: The Great Obstetrical Syndromes Study. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:1592-1599. [PMID: 30314872 DOI: 10.1016/j.jogc.2018.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/30/2018] [Accepted: 02/02/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To estimate the role of first-trimester uterine artery pulsatility index (UtA-PI) for the prediction of small-for-gestational age (SGA). METHODS We conducted a prospective cohort study of nulliparous women with singleton pregnancy (Great Obstetrical Syndromes study). UtA-PI was performed at 11 + 0 to 13 + 6 weeks and was reported in multiple of median (MoM). SGA was defined as birth weight below the 10th percentile and stratified as term or preterm SGA. Receiver operating characteristic curves analyses with their area under the curve (AUC) were used to estimate the predictive values of UtA-PI, alone and UtA-PI combined with maternal characteristics. We computed the detection rate and false-positive rate (FPR) of the SOGC SGA screening guidelines in our population. RESULTS Of 4610 participants, SGA was identified in 486 pregnancies (10.3%), including 15 (0.3%) associated with preterm delivery. Compared with unaffected pregnancies, the mean log UtA-PI was significantly higher in term SGA and preterm SGA. The difference between preterm SGA and unaffected pregnancies remains significant after exclusion of SGA without preeclampsia. First-trimester UtA-PI was more predictive of preterm (AUC: 0.89) than term (AUC: 0.60) SGA (P < 0.01). Combined with maternal characteristics, UtA-PI could have predicted 64% of preterm and 20% of term SGA (10% FPR). The SOGC guidelines criteria for early screening of SGA had a detection rate of 21% for a FPR of 21%. CONCLUSIONS First-trimester UtA-PI can be used to predict SGA, but mainly preterm SGA. The current SOGC guidelines criteria for SGA screening are not efficient in nulliparous women.
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Affiliation(s)
- Olivier Drouin
- Department of Gynecology, Obstetrics and Reproduction, Faculty of Medicine, Université Laval, Québec City, QC; Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, AB
| | - Amélie Boutin
- Reproduction, Mother and Child Health Unit, CHU de Québec - Université Laval Research Centre, Université Laval, Québec City, QC
| | - Kim Paquette
- Reproduction, Mother and Child Health Unit, CHU de Québec - Université Laval Research Centre, Université Laval, Québec City, QC
| | - Cédric Gasse
- Reproduction, Mother and Child Health Unit, CHU de Québec - Université Laval Research Centre, Université Laval, Québec City, QC
| | - Paul Guerby
- Department of Obstetrics and Gynecology, Hôpital Paule de Viguier (CHU Toulouse), Toulouse, France
| | - Suzanne Demers
- Department of Gynecology, Obstetrics and Reproduction, Faculty of Medicine, Université Laval, Québec City, QC; Reproduction, Mother and Child Health Unit, CHU de Québec - Université Laval Research Centre, Université Laval, Québec City, QC
| | - Emmanuel Bujold
- Department of Gynecology, Obstetrics and Reproduction, Faculty of Medicine, Université Laval, Québec City, QC; Reproduction, Mother and Child Health Unit, CHU de Québec - Université Laval Research Centre, Université Laval, Québec City, QC.
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6
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MacDonald TM, Tran C, Kaitu'u-Lino TJ, Brennecke SP, Hiscock RJ, Hui L, Dane KM, Middleton AL, Cannon P, Walker SP, Tong S. Assessing the sensitivity of placental growth factor and soluble fms-like tyrosine kinase 1 at 36 weeks' gestation to predict small-for-gestational-age infants or late-onset preeclampsia: a prospective nested case-control study. BMC Pregnancy Childbirth 2018; 18:354. [PMID: 30170567 PMCID: PMC6119271 DOI: 10.1186/s12884-018-1992-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 08/23/2018] [Indexed: 11/10/2022] Open
Abstract
Background Fetal growth restriction is a disorder of placental dysfunction with three to four-fold increased risk of stillbirth. Fetal growth restriction has pathophysiological features in common with preeclampsia. We hypothesised that angiogenesis-related factors in maternal plasma, known to predict preeclampsia, may also detect fetal growth restriction at 36 weeks’ gestation. We therefore set out to determine the diagnostic performance of soluble fms-like tyrosine kinase 1 (sFlt-1), placental growth factor (PlGF), and the sFlt-1:PlGF ratio, measured at 36 weeks’ gestation, in identifying women who subsequently give birth to small-for-gestational-age (SGA; birthweight <10th centile) infants. We also aimed to validate the predictive performance of the analytes for late-onset preeclampsia in a large independent, prospective cohort. Methods A nested 1:2 case-control study was performed including 102 cases of SGA infants and a matched group of 207 controls; and 39 cases of preeclampsia. We determined the diagnostic performance of each angiogenesis-related factor, and of their ratio, to detect SGA infants or preeclampsia, for a predetermined 10% false positive rate. Results Median plasma levels of PlGF at 36 weeks’ gestation were significantly lower in women who subsequently had SGA newborns (178.5 pg/ml) compared to normal birthweight controls (326.7 pg/ml, p < 0.0001). sFlt-1 was also higher among SGA cases, but this was not significant after women with concurrent preeclampsia were excluded. The sensitivity of PlGF to predict SGA infants was 28.8% for a 10% false positive rate. The sFlt-1:PlGF ratio demonstrated better sensitivity for preeclampsia than either analyte alone, detecting 69.2% of cases for a 10% false positive rate. Conclusions Plasma PlGF at 36 weeks’ gestation is significantly lower in women who subsequently deliver a SGA infant. While the sensitivity and specificity of PlGF currently limit clinical translation, our findings support a blood-based biomarker approach to detect late-onset fetal growth restriction. Thirty-six week sFlt-1:PlGF ratio predicts 69.2% of preeclampsia cases, and could be a useful screening test to triage antenatal surveillance. Electronic supplementary material The online version of this article (10.1186/s12884-018-1992-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Teresa M MacDonald
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia. .,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia. .,Translational Obstetrics Group, University of Melbourne, Melbourne, VIC, Australia.
| | - Chuong Tran
- Department of Laboratory Services, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Tu'uhevaha J Kaitu'u-Lino
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia.,Translational Obstetrics Group, University of Melbourne, Melbourne, VIC, Australia
| | - Shaun P Brennecke
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia.,Department of Maternal-Fetal Medicine, Royal Women's Hospital, Melbourne, VIC, Australia
| | - Richard J Hiscock
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia
| | - Lisa Hui
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia.,Translational Obstetrics Group, University of Melbourne, Melbourne, VIC, Australia
| | - Kirsten M Dane
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Anna L Middleton
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia
| | - Ping Cannon
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia.,Translational Obstetrics Group, University of Melbourne, Melbourne, VIC, Australia
| | - Susan P Walker
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia.,Translational Obstetrics Group, University of Melbourne, Melbourne, VIC, Australia
| | - Stephen Tong
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia.,Translational Obstetrics Group, University of Melbourne, Melbourne, VIC, Australia
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7
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Henrichs J, Verfaille V, Viester L, Westerneng M, Molewijk B, Franx A, van der Horst H, Bosmans JE, de Jonge A, Jellema P. Effectiveness and cost-effectiveness of routine third trimester ultrasound screening for intrauterine growth restriction: study protocol of a nationwide stepped wedge cluster-randomized trial in The Netherlands (The IRIS Study). BMC Pregnancy Childbirth 2016; 16:310. [PMID: 27737654 PMCID: PMC5064939 DOI: 10.1186/s12884-016-1104-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 10/08/2016] [Indexed: 11/10/2022] Open
Abstract
Background Intrauterine growth retardation (IUGR) is a major risk factor for perinatal mortality and morbidity. Thus, there is a compelling need to introduce sensitive measures to detect IUGR fetuses. Routine third trimester ultrasonography is increasingly used to detect IUGR. However, we lack evidence for its clinical effectiveness and cost-effectiveness and information on ethical considerations of additional third trimester ultrasonography. This nationwide stepped wedge cluster-randomized trial examines the (cost-)effectiveness of routine third trimester ultrasonography in reducing severe adverse perinatal outcome through subsequent protocolized management. Methods For this trial, 15,000 women with a singleton pregnancy receiving care in 60 participating primary care midwifery practices will be included at 22 weeks of gestation. In the intervention (n = 7,500) and control group (n = 7,500) fetal growth will be monitored by serial fundal height assessments. All practices will start offering the control condition (ultrasonography based on medical indication). Every three months, 20 practices will be randomized to the intervention condition, i.e. apart from ultrasonography if indicated, two routine ultrasound examinations will be performed (at 28–30 weeks and 34–36 weeks). If IUGR is suspected, both groups will receive subsequent clinical management as described in the IRIS study protocol that will be developed before the start of the trial. The primary dichotomous clinical composite outcome is ‘severe adverse perinatal outcome’ up to 7 days after birth, including: perinatal death; Apgar score <4 at 5 minutes after birth; impaired consciousness; need for assisted ventilation for more than 24 h; asphyxia; septicemia; meningitis; bronchopulmonary dysplasia; intraventricular hemorrhage; cystic periventricular leukomalacia; neonatal seizures or necrotizing enterocolitis. For the economic evaluation, costs will be measured from a societal perspective. Quality of life will be measured using the EQ-5D-5 L to enable calculation of QALYs. Cost-effectiveness and cost-utility analyses will be performed. In a qualitative sub-study (using diary notes from 32 women for 9 months, at least 10 individual interviews and 2 focus group studies) we will explore ethical considerations of additional ultrasonography and how to deal with them. Discussion The results of this trial will assist healthcare providers and policymakers in making an evidence-based decision about whether or not introducing routine third trimester ultrasonography. Trial registration NTR4367, 21 March 2014.
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Affiliation(s)
- Jens Henrichs
- Department of Midwifery Science, AVAG and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, A-511, 1081 BT, Amsterdam, The Netherlands. .,Department of Pediatrics, Emma Children's Hospital, Amsterdam Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Viki Verfaille
- Department of Midwifery Science, AVAG and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, A-511, 1081 BT, Amsterdam, The Netherlands
| | - Laura Viester
- Department of Midwifery Science, AVAG and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, A-511, 1081 BT, Amsterdam, The Netherlands
| | - Myrte Westerneng
- Department of Midwifery Science, AVAG and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, A-511, 1081 BT, Amsterdam, The Netherlands
| | - Bert Molewijk
- Department of Medical Humanities, EMGO+ Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
| | - Arie Franx
- Department of Gynecology, Utrecht University Medical Center, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Henriette van der Horst
- Department of General Practice, EMGO+ Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
| | - Judith E Bosmans
- Department of Health Sciences and the EMGO+ Institute for Health and Care Research, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands
| | - Ank de Jonge
- Department of Midwifery Science, AVAG and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, A-511, 1081 BT, Amsterdam, The Netherlands
| | - Petra Jellema
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Heazell AEP, Worton SA, Higgins LE, Ingram E, Johnstone ED, Jones RL, Sibley CP. IFPA Gábor Than Award Lecture: Recognition of placental failure is key to saving babies' lives. Placenta 2015; 36 Suppl 1:S20-8. [PMID: 25582276 DOI: 10.1016/j.placenta.2014.12.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 12/04/2014] [Accepted: 12/17/2014] [Indexed: 11/21/2022]
Abstract
In high-income countries, placental failure is implicated in up to 65% of cases of stillbirth. Placental failure describes the situation where the placenta cannot meet the fetus' needs and may be the end-result of a variety of underlying pathological processes evident in the placental disc, membranes and umbilical cord. These include lesions with genetic, environmental, infectious, inflammatory, mechanical, metabolic, traumatic or vascular origin. Investigation of placental tissue from stillbirths and from pregnancies at an increased risk of stillbirth has demonstrated changes in macroscopic and microscopic structure which are themselves related to abnormal placental function. A better understanding and identification of placental failure may improve the management of pregnancy complications and of pregnancies after stillbirth (which have a 5-fold increased risk of stillbirth). The majority of current antenatal tests focus on the fetus and its response to the intrauterine environment; few of these investigations reduce stillbirths in low-risk pregnancies. However, some currently used investigations reflect placental development, structure and vascular function, while other investigations employed in clinical research settings such as the evaluation of placental structure and shape have a good predictive value for adverse fetal outcome. In addition, recent studies suggest that biomarkers of placental inflammation and deteriorating placental function can be detected in maternal blood suggesting that holistic evaluation of placental structure and function is possible. We anticipate that development of reliable tests of placental structure and function, coupled to assessment of fetal wellbeing offer a new opportunity to identify pregnancies at risk of stillbirth and to direct novel therapeutic strategies to prevent it.
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Affiliation(s)
- A E P Heazell
- Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, UK; St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL, UK.
| | - S A Worton
- Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, UK; St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL, UK
| | - L E Higgins
- Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, UK; St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL, UK
| | - E Ingram
- Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, UK; St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL, UK
| | - E D Johnstone
- Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, UK; St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL, UK
| | - R L Jones
- Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, UK; St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL, UK
| | - C P Sibley
- Maternal and Fetal Health Research Centre, Institute of Human Development, University of Manchester, UK; St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL, UK
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Al-Amin A, Hingston T, Mayall P, Araujo Júnior E, Fabrício Da Silva C, Friedman D. The utility of ultrasound in late pregnancy compared with clinical evaluation in detecting small and large for gestational age fetuses in low-risk pregnancies. J Matern Fetal Neonatal Med 2014; 28:1495-9. [DOI: 10.3109/14767058.2014.961007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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A predictor of small-for-gestational-age infant: oral glucose challenge test. Ir J Med Sci 2014; 184:285-9. [PMID: 24643741 DOI: 10.1007/s11845-014-1101-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 02/26/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study was performed to investigate the role of first-hour 50-g oral glucose challenge test (GCT) parameters in predicting the risk of delivering a small-for-gestational-age infant and to determine the accuracy of estimated fetal weight. METHODS We screened 2,643 pregnant women >20 years of age and excluded 552 patients according to exclusion criteria. Newborns were assigned to three groups as SGA(n:100), AGA(n:100), and LGA(n:100) according to birth weight. All mothers received 50-g GCT in their 24-28th weeks of gestation. We examined the relationship between birthweight and test results. RESULTS First-hour serum glucose level after the test significantly predicted babies with small for gestational age. Optimal cutoff value was obtained at a level of 74.5 mg/dl with 67% sensitivity and 55% specificity. The estimated fetal weight of Hadlock 5 formula was strongly correlated with the birth weight (Pearson r = 0.89). CONCLUSION Our study revealed that 50-g oral glucose challenge test may predict small-for-gestational-age cases with 67% sensitivity, and our data revealed that there is a significant correlation between estimated fetal weight of Hadlock 5 formula and the birth weight.
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Abstract
Reduced fetal movement (RFM) is commonly defined as any reduction in maternal perception of fetal activity. Perceived fetal activity may be movement of limbs, trunk or head movement, but excludes fetal hiccoughs (as this is involuntary movement). The perception of fetal movement by an expectant mother is the first, and ongoing, non-sonographic indicator of fetal viability. The “normal” pattern of fetal movements varies from pregnancy to pregnancy, and often does not become established until 28 weeks’ gestation. Many babies have particularly active periods of the day, usually corresponding to periods of maternal rest and inactivity (which may in itself reflect increased maternal awareness of fetal movement). A variable percentage of sonographically observed fetal movements are perceived by prospective mothers (commonly 30–40%, although some studies report rates as high as 80%).
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12
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Goetzinger KR, Tuuli MG, Odibo AO, Roehl KA, Macones GA, Cahill AG. Screening for fetal growth disorders by clinical exam in the era of obesity. J Perinatol 2013; 33:352-7. [PMID: 23079776 PMCID: PMC3640749 DOI: 10.1038/jp.2012.130] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 09/14/2012] [Accepted: 09/18/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the performance of clinical estimation of fetal weight as a screening test for fetal growth disorders and then to estimate the effect of maternal body mass index (BMI) on its screening efficiency. STUDY DESIGN This was a retrospective cohort study of patients referred for third trimester ultrasound for the indication of 'size unequal to dates'. Patients with medical co-morbidities that may alter their a priori risk for fetal growth disorders were excluded. The incidence of fetal growth disorders as well as amniotic fluid disturbances was determined for each group and then compared across maternal BMI categories of <25 kg m(-2), 25-30 kg m(-2), ≥ 30 kg m(-2) and ≥ 40 kg m(-2). To evaluate the accuracy of clinical estimation of fetal weight in predicting fetal growth disorders, the sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios, as well as number needed to scan (NNS) was calculated and compared across BMI categories. RESULT Of 51366 patients, 1623 were referred for the indication of size>dates and 1543 for the indication of size90th percentile and 13.5 and 96.7% for predicting BW<10th percentile. The NNS to detect one neonate with a BW<10th percentile ranged from 5 to 19, whereas the NNS to detect one neonate with a BW>90th percentile ranged from 6 to 13 across BMI categories. CONCLUSION Overall, clinical estimation of fetal weight yields a low detection rate of fetal growth abnormalities; however, its screening efficiency is not adversely impacted by maternal BMI.
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Affiliation(s)
- K R Goetzinger
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St Louis, St Louis, MO 63110, USA.
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O’Connor C, Stuart B, Fitzpatrick C, Turner MJ, Kennelly MM. A review of contemporary modalities for identifying abnormal fetal growth. J OBSTET GYNAECOL 2013; 33:239-45. [DOI: 10.3109/01443615.2012.753423] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Cohain JS. Suspected macrosomia: will induction of labour modify the risk of caesarean delivery? BJOG 2012; 119:1016-7; author reply 1017. [PMID: 22703425 DOI: 10.1111/j.1471-0528.2012.03326.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The objective of this review was to assess the evidence that supports cesarean delivery for fetal indications. The main fetal reasons for abdominal delivery include abnormal fetal heart rate patterns in labor, malpresentation, fetal macrosomia, multiple gestation, and both functional and structural fetal abnormalities. Although the level of evidence is not as strong as anticipated, there is sufficient support for cesarean delivery when these fetal conditions complicate pregnancy. Efforts to decrease cesarean delivery for fetal indications in the current medicolegal environment will not be easy; however, the development of more sensitive tools to assess fetal well-being in labor and practices to deliver or reduce fetuses in breech presentation at term have the potential for greatest impact on the overall primary cesarean delivery rate.
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Affiliation(s)
- Lynn L Simpson
- Department of Obstetrics and Gynecology, Columbia University Medical Center, NY 10032, USA.
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