1
|
Moraitis AA, Bainton T, Sovio U, Brocklehurst P, Heazell AE, Thornton JG, Robson SC, Papageorghiou A, Smith GC. Fetal umbilical artery Doppler as a tool for universal third trimester screening: A systematic review and meta-analysis of diagnostic test accuracy. Placenta 2021; 108:47-54. [PMID: 33819861 DOI: 10.1016/j.placenta.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/11/2021] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
The objective of this study was to investigate the accuracy of universal third trimester umbilical artery (UA) Doppler to predict adverse pregnancy outcome at term. We searched Medline, EMBASE, the Cochrane library and ClinicalTrials.gov from inception to October 2020 and we also analyzed previously unpublished data from a prospective cohort study of nulliparous women, the Pregnancy Outcome Prediction (POP) study. We included studies that performed a third-trimester ultrasound scan in unselected, low or mixed risk populations, excluding studies which only included high risk pregnancies. Meta-analysis was performed using the hierarchal summary receiver operating characteristic curve (HSROC) analysis and bivariate logit-normal models. We identified 13 studies (including the POP study) involving 67,764 pregnancies which met our inclusion criteria. The overall quality was variable and only six studies (N = 5777 patients) blinded clinicians to the UA Doppler result. The summary sensitivity and positive likelihood ratio (LR) for small for gestational age (SGA; birthweight <10th centile) were 21.7% (95% CI 13.2-33.6%) and 2.65 (95% CI 1.89-3.72) respectively. The summary positive LR for NICU admission and metabolic acidosis were 1.35 (95% CI 0.93-1.97) and 1.34 (95% CI 0.86-2.08) respectively. The results were similar in the POP study: associations with SGA (positive LR 2.66 [95% CI 2.11-3.36]) and severe SGA (birthweight <3rd centile; positive LR 3.27 [95% CI 2.29-4.68]) but no statistically significant association with neonatal morbidity. We conclude that third trimester UA Doppler has moderate predictive accuracy for small for gestational age but not for indicators of neonatal morbidity in unselected and low risk pregnancies.
Collapse
Affiliation(s)
- Alexandros A Moraitis
- Department of Obstetrics and Gynaecology, University of Cambridge; NIHR Cambridge Comprehensive Biomedical Research Centre, CB2 2SW, United Kingdom
| | - Thomas Bainton
- Department of Obstetrics and Gynaecology, University of Cambridge; NIHR Cambridge Comprehensive Biomedical Research Centre, CB2 2SW, United Kingdom
| | - Ulla Sovio
- Department of Obstetrics and Gynaecology, University of Cambridge; NIHR Cambridge Comprehensive Biomedical Research Centre, CB2 2SW, United Kingdom
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Alexander Ep Heazell
- Maternal and Fetal Health Research Centre, School of Medical Sciences, Faculty of Biological, Medical and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9WL, United Kingdom; St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, United Kingdom
| | - Jim G Thornton
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Stephen C Robson
- Reproductive and Vascular Biology Group, The Medical School, University of Newcastle, Newcastle, United Kingdom
| | - Aris Papageorghiou
- Nuffield Department of Obstetrics and Gynaecology, Oxford, United Kingdom
| | - Gordon Cs Smith
- Department of Obstetrics and Gynaecology, University of Cambridge; NIHR Cambridge Comprehensive Biomedical Research Centre, CB2 2SW, United Kingdom.
| |
Collapse
|
2
|
Wilson ECF, Wastlund D, Moraitis AA, Smith GCS. Late Pregnancy Ultrasound to Screen for and Manage Potential Birth Complications in Nulliparous Women: A Cost-Effectiveness and Value of Information Analysis. Value Health 2021; 24:513-521. [PMID: 33840429 DOI: 10.1016/j.jval.2020.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 11/03/2020] [Accepted: 11/03/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Fetal growth restriction is a major risk factor for stillbirth. A routine late-pregnancy ultrasound scan could help detect this, allowing intervention to reduce the risk of stillbirth. Such a scan could also detect fetal presentation and predict macrosomia. A trial powered to detect stillbirth differences would be extremely large and expensive. OBJECTIVES It is therefore critical to know whether this would be a good investment of public research funds. The aim of this study is to estimate the cost-effectiveness of various late-pregnancy screening and management strategies based on current information and predict the return on investment from further research. METHODS Synthesis of current evidence structured into a decision model reporting expected costs, quality-adjusted life-years, and net benefit over 20 years and value-of-information analysis reporting predicted return on investment from future clinical trials. RESULTS Given a willingness to pay of £20 000 per quality-adjusted life-year gained, the most cost-effective strategy is a routine presentation-only scan for all women. Universal ultrasound screening for fetal size is unlikely to be cost-effective. Research exploring the cost implications of induction of labor has the greatest predicted return on investment. A randomized, controlled trial with an endpoint of stillbirth is extremely unlikely to be a value for money investment. CONCLUSION Given current value-for-money thresholds in the United Kingdom, the most cost-effective strategy is to offer all pregnant women a presentation-only scan in late pregnancy. A randomized, controlled trial of screening and intervention to reduce the risk of stillbirth following universal ultrasound to detect macrosomia or fetal growth restriction is unlikely to represent a value for money investment.
Collapse
Affiliation(s)
- Edward C F Wilson
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK; The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
| | - David Wastlund
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK; Parexel Access Consulting, Parexel International, Stockholm, Sweden
| | - Alexandros A Moraitis
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Gordon C S Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| |
Collapse
|
3
|
Smith GC, Moraitis AA, Wastlund D, Thornton JG, Papageorghiou A, Sanders J, Heazell AE, Robson SC, Sovio U, Brocklehurst P, Wilson EC. Universal late pregnancy ultrasound screening to predict adverse outcomes in nulliparous women: a systematic review and cost-effectiveness analysis. Health Technol Assess 2021; 25:1-190. [PMID: 33656977 PMCID: PMC7958245 DOI: 10.3310/hta25150] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Currently, pregnant women are screened using ultrasound to perform gestational aging, typically at around 12 weeks' gestation, and around the middle of pregnancy. Ultrasound scans thereafter are performed for clinical indications only. OBJECTIVES We sought to assess the case for offering universal late pregnancy ultrasound to all nulliparous women in the UK. The main questions addressed were the diagnostic effectiveness of universal late pregnancy ultrasound to predict adverse outcomes and the cost-effectiveness of either implementing universal ultrasound or conducting further research in this area. DESIGN We performed diagnostic test accuracy reviews of five ultrasonic measurements in late pregnancy. We conducted cost-effectiveness and value-of-information analyses of screening for fetal presentation, screening for small for gestational age fetuses and screening for large for gestational age fetuses. Finally, we conducted a survey and a focus group to determine the willingness of women to participate in a future randomised controlled trial. DATA SOURCES We searched MEDLINE, EMBASE and the Cochrane Library from inception to June 2019. REVIEW METHODS The protocol for the review was designed a priori and registered. Eligible studies were identified using keywords, with no restrictions for language or location. The risk of bias in studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Health economic modelling employed a decision tree analysed via Monte Carlo simulation. Health outcomes were from the fetal perspective and presented as quality-adjusted life-years. Costs were from the perspective of the public sector, defined as NHS England, and the costs of special educational needs. All costs and quality-adjusted life-years were discounted by 3.5% per annum and the reference case time horizon was 20 years. RESULTS Umbilical artery Doppler flow velocimetry, cerebroplacental ratio, severe oligohydramnios and borderline oligohydramnios were all either non-predictive or weakly predictive of the risk of neonatal morbidity (summary positive likelihood ratios between 1 and 2) and were all weakly predictive of the risk of delivering a small for gestational age infant (summary positive likelihood ratios between 2 and 4). Suspicion of fetal macrosomia is strongly predictive of the risk of delivering a large infant, but it is only weakly, albeit statistically significantly, predictive of the risk of shoulder dystocia. Very few studies blinded the result of the ultrasound scan and most studies were rated as being at a high risk of bias as a result of treatment paradox, ascertainment bias or iatrogenic harm. Health economic analysis indicated that universal ultrasound for fetal presentation only may be both clinically and economically justified on the basis of existing evidence. Universal ultrasound including fetal biometry was of borderline cost-effectiveness and was sensitive to assumptions. Value-of-information analysis indicated that the parameter that had the largest impact on decision uncertainty was the net difference in cost between an induced delivery and expectant management. LIMITATIONS The primary literature on the diagnostic effectiveness of ultrasound in late pregnancy is weak. Value-of-information analysis may have underestimated the uncertainty in the literature as it was focused on the internal validity of parameters, which is quantified, whereas the greatest uncertainty may be in the external validity to the research question, which is unquantified. CONCLUSIONS Universal screening for presentation at term may be justified on the basis of current knowledge. The current literature does not support universal ultrasonic screening for fetal growth disorders. FUTURE WORK We describe proof-of-principle randomised controlled trials that could better inform the case for screening using ultrasound in late pregnancy. STUDY REGISTRATION This study is registered as PROSPERO CRD42017064093. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 15. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Gordon Cs Smith
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Alexandros A Moraitis
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - David Wastlund
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jim G Thornton
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Aris Papageorghiou
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK
| | - Julia Sanders
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Alexander Ep Heazell
- Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Stephen C Robson
- Reproductive and Vascular Biology Group, The Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Ulla Sovio
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Edward Cf Wilson
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK
| |
Collapse
|
4
|
Moraitis AA, Shreeve N, Sovio U, Brocklehurst P, Heazell AEP, Thornton JG, Robson SC, Papageorghiou A, Smith GC. Universal third-trimester ultrasonic screening using fetal macrosomia in the prediction of adverse perinatal outcome: A systematic review and meta-analysis of diagnostic test accuracy. PLoS Med 2020; 17:e1003190. [PMID: 33048935 PMCID: PMC7553291 DOI: 10.1371/journal.pmed.1003190] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 09/09/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The effectiveness of screening for macrosomia is not well established. One of the critical elements of an effective screening program is the diagnostic accuracy of a test at predicting the condition. The objective of this study is to investigate the diagnostic effectiveness of universal ultrasonic fetal biometry in predicting the delivery of a macrosomic infant, shoulder dystocia, and associated neonatal morbidity in low- and mixed-risk populations. METHODS AND FINDINGS We conducted a predefined literature search in Medline, Excerpta Medica database (EMBASE), the Cochrane library and ClinicalTrials.gov from inception to May 2020. No language restrictions were applied. We included studies where the ultrasound was performed as part of universal screening and those that included low- and mixed-risk pregnancies and excluded studies confined to high risk pregnancies. We used the estimated fetal weight (EFW) (multiple formulas and thresholds) and the abdominal circumference (AC) to define suspected large for gestational age (LGA). Adverse perinatal outcomes included macrosomia (multiple thresholds), shoulder dystocia, and other markers of neonatal morbidity. The risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Meta-analysis was carried out using the hierarchical summary receiver operating characteristic (ROC) and the bivariate logit-normal (Reitsma) models. We identified 41 studies that met our inclusion criteria involving 112,034 patients in total. These included 11 prospective cohort studies (N = 9986), one randomized controlled trial (RCT) (N = 367), and 29 retrospective cohort studies (N = 101,681). The quality of the studies was variable, and only three studies blinded the ultrasound findings to the clinicians. Both EFW >4,000 g (or 90th centile for the gestational age) and AC >36 cm (or 90th centile) had >50% sensitivity for predicting macrosomia (birthweight above 4,000 g or 90th centile) at birth with positive likelihood ratios (LRs) of 8.74 (95% confidence interval [CI] 6.84-11.17) and 7.56 (95% CI 5.85-9.77), respectively. There was significant heterogeneity at predicting macrosomia, which could reflect the different study designs, the characteristics of the included populations, and differences in the formulas used. An EFW >4,000 g (or 90th centile) had 22% sensitivity at predicting shoulder dystocia with a positive likelihood ratio of 2.12 (95% CI 1.34-3.35). There was insufficient data to analyze other markers of neonatal morbidity. CONCLUSIONS In this study, we found that suspected LGA is strongly predictive of the risk of delivering a large infant in low- and mixed-risk populations. However, it is only weakly (albeit statistically significantly) predictive of the risk of shoulder dystocia. There was insufficient data to analyze other markers of neonatal morbidity.
Collapse
Affiliation(s)
- Alexandros A. Moraitis
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom
| | - Norman Shreeve
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom
| | - Ulla Sovio
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Alexander E. P. Heazell
- Maternal and Fetal Health Research Centre, School of Medical Sciences, Faculty of Biological, Medical and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Jim G. Thornton
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Stephen C. Robson
- Reproductive and Vascular Biology Group, The Medical School, University of Newcastle, Newcastle, United Kingdom
| | - Aris Papageorghiou
- Nuffield Department of Obstetrics and Gynaecology, Oxford, United Kingdom
| | - Gordon C. Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom
| |
Collapse
|
5
|
Verger C, Moraitis AA, Barnfield L, Sovio U, Bamfo JEAK. Performance of different fetal growth charts in prediction of large-for-gestational age and associated neonatal morbidity in multiethnic obese population. Ultrasound Obstet Gynecol 2020; 56:73-77. [PMID: 31364195 DOI: 10.1002/uog.20413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 07/08/2019] [Accepted: 07/19/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To examine the performance of different fetal growth charts in the prediction of large-for-gestational age (LGA) and associated neonatal morbidity at term in a multiethnic, obese population. METHODS This was a retrospective cohort study of 253 non-anomalous, singleton, term pregnancies that underwent serial third-trimester ultrasound scans due to maternal body mass index ≥ 35 kg/m2 . We compared the performance of the Hadlock, Gestation Related Optimal Weight (GROW), INTERGROWTH-21st (IG-21), World Health Organization (WHO) and Fetal Medicine Foundation (FMF) fetal growth reference charts in the prediction of LGA at birth, defined as birth weight > 90th percentile, and neonatal morbidity, defined as a composite of neonatal intensive care unit admission or 5-min Apgar score < 7. RESULTS In the study population, 53 (20.9%) infants were born LGA, 27 (10.7%) experienced neonatal morbidity and nine (3.6%) were LGA with associated neonatal morbidity. The Hadlock and GROW charts showed similar performance in predicting LGA, with sensitivity of 66.0% for both and specificity of 82.5% and 83.5%, respectively. The positive likelihood ratios (LR+) were 3.77 (95% CI, 2.64-5.40) and 4.00 (95% CI, 2.77-5.78), respectively. The IG-21, WHO and FMF charts performed similarly and had higher sensitivity of about 85%, with specificity between 66% and 72%. LR+ was 2.74 (95% CI, 2.16-3.47), 2.50 (95% CI, 2.00-3.12) and 3.03 (95% CI, 2.36-3.89), respectively. All charts had high sensitivity for predicting neonatal morbidity associated with LGA, with LR+ ranging between 2.35 and 3.61. CONCLUSIONS In our multiethnic, obese population, all fetal growth charts performed well in predicting LGA and associated neonatal morbidity. However, the choice of fetal reference chart is likely to affect intervention rates. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- C Verger
- The Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - L Barnfield
- Luton and Dunstable University Hospital, Bedfordshire Hospitals NHS Foundation Trust, Luton, UK
| | - U Sovio
- University of Cambridge, Cambridge, UK
| | - J E A K Bamfo
- Luton and Dunstable University Hospital, Bedfordshire Hospitals NHS Foundation Trust, Luton, UK
| |
Collapse
|
6
|
Wastlund D, Moraitis AA, Thornton JG, Sanders J, White IR, Brocklehurst P, Smith G, Wilson E. The cost-effectiveness of universal late-pregnancy screening for macrosomia in nulliparous women: a decision analysis. BJOG 2019; 126:1243-1250. [PMID: 31066982 PMCID: PMC6771727 DOI: 10.1111/1471-0528.15809] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2019] [Indexed: 12/16/2022]
Abstract
Objective To identify the most cost‐effective policy for detection and management of fetal macrosomia in late‐stage pregnancy. Design Health economic simulation model. Setting All English NHS antenatal services. Population Nulliparous women in the third trimester treated within the UK NHS. Methods A health economic simulation model was used to compare long‐term maternal–fetal health and cost outcomes for two detection strategies (universal ultrasound scanning at approximately 36 weeks of gestation versus selective ultrasound scanning), combined with three management strategies (planned caesarean section versus induction of labour versus expectant management) of suspected fetal macrosomia. Probabilities, costs and health outcomes were taken from literature. Main outcome measures Expected costs to the NHS and quality‐adjusted life‐years (QALYs) gained from each strategy, calculation of net benefit and hence identification of most cost‐effective strategy. Results Compared with selective ultrasound, universal ultrasound increased QALYs by 0.0038 (95% CI 0.0012–0.0076), but also costs by £123.50 (95% CI 99.6–149.9). Overall, the health gains were too small to justify the cost increase given current UK thresholds cost‐effective policy was selective ultrasound coupled with induction of labour where macrosomia was suspected. Conclusions The most cost‐effective policy for detection and management of fetal macrosomia is selective ultrasound scanning coupled with induction of labour for all suspected cases of macrosomia. Universal ultrasound scanning for macrosomia in late‐stage pregnancy is not cost‐effective. Tweetable abstract Universal late‐pregnancy ultrasound screening for fetal macrosomia is not warranted. Universal late‐pregnancy ultrasound screening for fetal macrosomia is not warranted.
Collapse
Affiliation(s)
- D Wastlund
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.,Cambridge Centre for Health Services Research, Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK
| | - A A Moraitis
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - J G Thornton
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - J Sanders
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - I R White
- MRC Clinical Trials Unit, University College London, London, UK
| | - P Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Gcs Smith
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Ecf Wilson
- Cambridge Centre for Health Services Research, Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK.,Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK
| |
Collapse
|
7
|
Wastlund D, Moraitis AA, Dacey A, Sovio U, Wilson ECF, Smith GCS. Screening for breech presentation using universal late-pregnancy ultrasonography: A prospective cohort study and cost effectiveness analysis. PLoS Med 2019; 16:e1002778. [PMID: 30990808 PMCID: PMC6467368 DOI: 10.1371/journal.pmed.1002778] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 03/11/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Despite the relative ease with which breech presentation can be identified through ultrasound screening, the assessment of foetal presentation at term is often based on clinical examination only. Due to limitations in this approach, many women present in labour with an undiagnosed breech presentation, with increased risk of foetal morbidity and mortality. This study sought to determine the cost effectiveness of universal ultrasound scanning for breech presentation near term (36 weeks of gestational age [wkGA]) in nulliparous women. METHODS AND FINDINGS The Pregnancy Outcome Prediction (POP) study was a prospective cohort study between January 14, 2008 and July 31, 2012, including 3,879 nulliparous women who attended for a research screening ultrasound examination at 36 wkGA. Foetal presentation was assessed and compared for the groups with and without a clinically indicated ultrasound. Where breech presentation was detected, an external cephalic version (ECV) was routinely offered. If the ECV was unsuccessful or not performed, the women were offered either planned cesarean section at 39 weeks or attempted vaginal breech delivery. To compare the likelihood of different mode of deliveries and associated long-term health outcomes for universal ultrasound to current practice, a probabilistic economic simulation model was constructed. Parameter values were obtained from the POP study, and costs were mainly obtained from the English National Health Service (NHS). One hundred seventy-nine out of 3,879 women (4.6%) were diagnosed with breech presentation at 36 weeks. For most women (96), there had been no prior suspicion of noncephalic presentation. ECV was attempted for 84 (46.9%) women and was successful in 12 (success rate: 14.3%). Overall, 19 of the 179 women delivered vaginally (10.6%), 110 delivered by elective cesarean section (ELCS) (61.5%) and 50 delivered by emergency cesarean section (EMCS) (27.9%). There were no women with undiagnosed breech presentation in labour in the entire cohort. On average, 40 scans were needed per detection of a previously undiagnosed breech presentation. The economic analysis indicated that, compared to current practice, universal late-pregnancy ultrasound would identify around 14,826 otherwise undiagnosed breech presentations across England annually. It would also reduce EMCS and vaginal breech deliveries by 0.7 and 1.0 percentage points, respectively: around 4,196 and 6,061 deliveries across England annually. Universal ultrasound would also prevent 7.89 neonatal mortalities annually. The strategy would be cost effective if foetal presentation could be assessed for £19.80 or less per woman. Limitations to this study included that foetal presentation was revealed to all women and that the health economic analysis may be altered by parity. CONCLUSIONS According to our estimates, universal late pregnancy ultrasound in nulliparous women (1) would virtually eliminate undiagnosed breech presentation, (2) would be expected to reduce foetal mortality in breech presentation, and (3) would be cost effective if foetal presentation could be assessed for less than £19.80 per woman.
Collapse
Affiliation(s)
- David Wastlund
- Cambridge Centre for Health Services Research, Cambridge Institute of Public Health, Cambridge, United Kingdom
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Alexandros A. Moraitis
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom
| | - Alison Dacey
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom
| | - Ulla Sovio
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom
| | - Edward C. F. Wilson
- Cambridge Centre for Health Services Research, Cambridge Institute of Public Health, Cambridge, United Kingdom
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Gordon C. S. Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom
| |
Collapse
|
8
|
Sovio U, Moraitis AA, Wong HS, Smith GCS. Universal vs selective ultrasonography to screen for large-for-gestational-age infants and associated morbidity. Ultrasound Obstet Gynecol 2018; 51:783-791. [PMID: 28425156 DOI: 10.1002/uog.17491] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/06/2017] [Accepted: 04/14/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To compare the diagnostic effectiveness of selective vs universal ultrasonography as a screening test for large-for-gestational-age (LGA) infants, and to determine whether previously described ultrasound markers of excessive fetal growth could identify suspected LGA fetuses that are at increased risk of adverse neonatal outcome. METHODS Data from the Pregnancy Outcome Prediction study, a prospective cohort study of nulliparous women with a viable singleton pregnancy at the time of the dating ultrasound scan, were analyzed. Women were selected for clinically indicated ultrasound assessment in the third trimester as per routine clinical care, and the results of these scans were reported ('selective ultrasonography'). In addition, all participants underwent research ultrasound scans, including estimated fetal weight (EFW) assessment, at around 36 weeks' gestation, in which both the women and their clinicians were blinded to the results ('universal ultrasonography'). Participants who attended the 36-week research scan and had a live birth at the Rosie Hospital were included in the study. Screen positive for LGA was defined as EFW > 90th percentile at ≥ 34 weeks. RESULTS The current analysis included 3866 eligible women, of whom 1354 (35%) had a clinically indicated ultrasound scan at or after 34 weeks' gestation. A total of 177 (4.6%) infants had a birth weight > 90th percentile. The sensitivity for detection of LGA infants was 27% for selective ultrasonography and 38% for universal ultrasonography. The specificity of both approaches was high (99% and 97%, respectively). Using universal ultrasonography, neonatal outcome differed (P for interaction) by abdominal circumference growth velocity (ACGV) for both any neonatal morbidity (P = 0.08) and severe adverse neonatal outcome (P = 0.03). LGA fetuses with increased ACGV had a relative risk of any neonatal morbidity of 2.0 (95% CI, 1.1-3.6; P = 0.04) and of severe adverse neonatal outcome of 6.5 (95% CI, 2.0-21.1; P = 0.01), whereas LGA fetuses with normal ACGV were not at increased risk. CONCLUSIONS Third-trimester screening of nulliparous women by universal ultrasound fetal biometry increases the detection rate of LGA infants and, combined with ACGV, identifies those at increased risk of adverse neonatal outcome. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- U Sovio
- Department of Obstetrics and Gynaecology, University of Cambridge; NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, UK
| | - A A Moraitis
- Department of Obstetrics and Gynaecology, University of Cambridge; NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, UK
| | - H S Wong
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - G C S Smith
- Department of Obstetrics and Gynaecology, University of Cambridge; NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, UK
| |
Collapse
|
9
|
Aye ILMH, Moraitis AA, Stanislaus D, Charnock-Jones DS, Smith GCS. Retosiban Prevents Stretch-Induced Human Myometrial Contractility and Delays Labor in Cynomolgus Monkeys. J Clin Endocrinol Metab 2018; 103:1056-1067. [PMID: 29293998 PMCID: PMC5868409 DOI: 10.1210/jc.2017-02195] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 12/20/2017] [Indexed: 12/13/2022]
Abstract
Context Stretch of the myometrium promotes its contractility and is believed to contribute to the control of parturition at term and to the increased risk of preterm birth in multiple pregnancies. Objective To determine the effects of the putative oxytocin receptor (OTR) inverse agonist retosiban on (1) the contractility of human myometrial explants and (2) labor in nonhuman primates. Design Human myometrial biopsies were obtained at planned term cesarean, and explants were exposed to stretch in the presence and absence of a range of drugs, including retosiban. The in vivo effects of retosiban were determined in cynomolgus monkeys. Results Prolonged mechanical stretch promoted myometrial extracellular signal-regulated kinase (ERK)1/2 phosphorylation. Moreover, stretch-induced stimulation of myometrial contractility was prevented by ERK1/2 inhibitors. Retosiban (10 nM) prevented stretch-induced stimulation of myometrial contractility and phosphorylation of ERK1/2. Moreover, the inhibitory effect of retosiban on stretch-induced ERK1/2 phosphorylation was prevented by coincubation with a 100-fold excess of a peptide OTR antagonist, atosiban. Compared with vehicle-treated cynomolgus monkeys, treatment with oral retosiban (100 to 150 days of gestational age) reduced the risk of spontaneous delivery (hazard ratio = 0.07, 95% confidence interval 0.01 to 0.60, P = 0.015). Conclusions The OTR acts as a uterine mechanosensor, whereby stretch increases myometrial contractility through agonist-free activation of the OTR. Retosiban prevents this through inverse agonism of the OTR and, in vivo, reduced the likelihood of spontaneous labor in nonhuman primates. We hypothesize that retosiban may be an effective preventative treatment of preterm birth in high-risk multiple pregnancies, an area of unmet clinical need.
Collapse
Affiliation(s)
- Irving L M H Aye
- Department of Obstetrics and Gynaecology, University of Cambridge, National Institute for Health Research, Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom
| | - Alexandros A Moraitis
- Department of Obstetrics and Gynaecology, University of Cambridge, National Institute for Health Research, Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom
| | - Dinesh Stanislaus
- Department of Reproductive Toxicology, GlaxoSmithKline, Philadelphia Navy Yard, Philadelphia, Pennsylvania
| | - D Stephen Charnock-Jones
- Department of Obstetrics and Gynaecology, University of Cambridge, National Institute for Health Research, Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom
| | - Gordon C S Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, National Institute for Health Research, Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom
| |
Collapse
|
10
|
Moraitis AA, Cordeaux Y, Charnock-Jones DS, Smith GCS. The Effect of an Oxytocin Receptor Antagonist (Retosiban, GSK221149A) on the Response of Human Myometrial Explants to Prolonged Mechanical Stretch. Endocrinology 2015. [PMID: 26207346 DOI: 10.1210/en.2015-1378] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Multiple pregnancy is a major cause of spontaneous preterm birth, which is related to uterine overdistention. The objective of this study was to determine whether an oxytocin receptor antagonist, retosiban (GSK221149A), inhibited the procontractile effect of stretch on human myometrium. Myometrial biopsies were obtained at term planned cesarean delivery (n = 12). Each biopsy specimen was dissected into 8 strips that were exposed in pairs to low or high stretch (0.6 or 2.4 g) in the presence of retosiban (1 μM) or vehicle (dimethylsulfoxide) for 24 hours. Subsequently, we analyzed the contractile responses to KCl and oxytocin in the absence of retosiban. We found that incubation under high stretch in vehicle alone increased the response of myometrial explants to both KCl (P = .007) and oxytocin (P = .01). However, there was no statistically significant effect of stretch when explants were incubated with retosiban (P = .3 and .2, respectively). Incubation with retosiban in low stretch had no statistically significant effect on the response to either KCl or oxytocin (P = .8 and >.9, respectively). Incubation with retosiban in high stretch resulted in a statistically significant reduction (median fold change, interquartile range, P) in the response to both KCl (0.74, 0.60-1.03, P = .046) and oxytocin (0.71, 0.53-0.91, P = .008). The greater the effect of stretch on explants from a given patient, the greater was the inhibitory effect of retosiban (r = -0.65, P = .02 for KCl and r= -0.73, P = .007 for oxytocin). These results suggest that retosiban prevented stretch-induced stimulation of human myometrial contractility. Retosiban treatment is a potential approach for preventing preterm birth in multiple pregnancy.
Collapse
Affiliation(s)
- Alexandros A Moraitis
- Department of Obstetrics and Gynaecology, University of Cambridge, National Institute for Health Research Cambridge Comprehensive Biomedical Research Centre, CB2 2SW, United Kingdom
| | - Yolande Cordeaux
- Department of Obstetrics and Gynaecology, University of Cambridge, National Institute for Health Research Cambridge Comprehensive Biomedical Research Centre, CB2 2SW, United Kingdom
| | - D Stephen Charnock-Jones
- Department of Obstetrics and Gynaecology, University of Cambridge, National Institute for Health Research Cambridge Comprehensive Biomedical Research Centre, CB2 2SW, United Kingdom
| | - Gordon C S Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, National Institute for Health Research Cambridge Comprehensive Biomedical Research Centre, CB2 2SW, United Kingdom
| |
Collapse
|
11
|
Moraitis AA, Oliver-Williams C, Wood AM, Fleming M, Pell JP, Smith G. Previous caesarean delivery and the risk of unexplained stillbirth: retrospective cohort study and meta-analysis. BJOG 2015; 122:1467-74. [PMID: 26033155 DOI: 10.1111/1471-0528.13461] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2015] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To determine whether caesarean delivery in the first pregnancy is a risk factor for unexplained antepartum stillbirth in a second pregnancy. DESIGN A population-based retrospective cohort study and meta-analysis. SETTING All maternity units in Scotland. PARTICIPANTS A cohort of 128 585 second births, 1999-2008. METHODS Time-to-event analysis and random-effects meta-analysis. MAIN OUTCOME MEASURE Risk of unexplained antepartum stillbirth in a second pregnancy. RESULTS There were 88 stillbirths among 23 688 women with a previous caesarean delivery (2.34 per 10 000 women per week) and 288 stillbirths in 104 897 women who had previously delivered vaginally (1.67 per 10 000 women per week, P = 0.002). When analysed by cause, women with a previous caesarean delivery had an increased risk of unexplained stillbirth (hazard ratio, HR 1.47; 95% confidence interval, 95% CI 1.12-1.94; P = 0.006) and, as previously observed, the excess risk was apparent from 34 weeks of gestation onwards. The risk did not differ in relation to the indication of the caesarean delivery, and was independent of maternal characteristics and previous obstetric complications. We identified three other comparable studies (two in North America and one in Europe), and meta-analysis of these studies showed a statistically significant association between previous caesarean delivery and the risk of antepartum stillbirth in the second pregnancy (pooled HR 1.40; 95% CI 1.10-1.77; P = 0.006). CONCLUSIONS Women who have had a previous caesarean delivery are at increased risk of unexplained stillbirth in the second pregnancy. TWEETABLE ABSTRACT Caesarean first delivery is associated with an increased risk of unexplained stillbirth in the next pregnancy.
Collapse
Affiliation(s)
- A A Moraitis
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, UK.,National Institute for Health Research (NIHR), Cambridge Comprehensive Biomedical Research Centre, Cambridge, UK
| | - C Oliver-Williams
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - A M Wood
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - M Fleming
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - J P Pell
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Gcs Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, UK.,National Institute for Health Research (NIHR), Cambridge Comprehensive Biomedical Research Centre, Cambridge, UK
| |
Collapse
|
12
|
Abstract
OBJECTIVE To estimate the association between birth weight percentile and the risk of perinatal death at term in relation to the cause of death. METHODS We performed a retrospective cohort study of all term singleton births in delivery units in Scotland between 1992 and 2008 (n=784,576), excluding perinatal deaths ascribed to congenital anomaly. RESULTS There were 1,700 perinatal deaths in the cohort, which were not the result of congenital anomaly (21.7/10,000 women at term). We observed a reversed J-shaped association between birth weight percentile and the risk of antepartum stillbirth in all women, but the associations significantly differed (P<.001) according to smoking status. The highest risk (adjusted odds ratio referent to 21st-80th percentile, 95% confidence interval) among nonsmokers was for birth weight third or less percentile (10.5, 8.2-13.3), but there were also positive associations for birth weight percentiles 4th-10th (3.8, 3.0-4.8), 11th-20th (1.9, 1.5-2.4), and 98th-100th (1.8, 1.3-2.4). Among smokers, the associations with being small were weaker and the associations with being large were stronger. We also observed a reversed J-shaped association between birth weight percentile and the risk of delivery-related perinatal death (ie, intrapartum stillbirth or neonatal death), but there was no interaction with smoking. The highest risk was for birth weight greater than the 97th percentile (2.3, 1.6-3.3), but there were also associations with third or less percentile (2.1, 1.4-3.1), 4th-10th (1.8, 1.4-2.4), and 11th-20th (1.5, 1.2-2.0). Analysis of the attributable fraction indicated that approximately one in three antepartum stillbirths and one in six delivery-related deaths at term could be related to birth weight percentile outside the range 21st-97th percentile. CONCLUSION Effective detection of variation in fetal size at term has potential as a screening test for the risk of perinatal death. LEVEL OF EVIDENCE II.
Collapse
Affiliation(s)
- Alexandros A Moraitis
- Departments of Obstetrics and Gynaecology and Public Health and Primary Care, University of Cambridge, and the National Institute for Health Research Cambridge Comprehensive Biomedical Research Centre, Cambridge, and the Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | | | | | | |
Collapse
|