Reduced growth velocity from the mid-trimester is associated with placental insufficiency in fetuses born at a normal birthweight

BACKGROUND

Fetal growth restriction (FGR) due to placental insufficiency is a major risk factor for stillbirth. While small-for-gestational-age (SGA; weight < 10th centile) is a commonly used proxy for FGR, detection of FGR among appropriate-for-gestational-age (AGA; weight ≥ 10th centile) fetuses remains an unmet need in clinical care. We aimed to determine whether reduced antenatal growth velocity from the time of routine mid-trimester ultrasound is associated with antenatal, intrapartum and postnatal indicators of placental insufficiency among term AGA infants.

METHODS

Three hundred and five women had biometry measurements recorded from their routine mid-trimester (20-week) ultrasound, at 28 and 36 weeks' gestation, and delivered an AGA infant. Mid-trimester, 28- and 36-week estimated fetal weight (EFW) and abdominal circumference (AC) centiles were calculated. The EFW and AC growth velocities between 20 and 28 weeks, and 20-36 weeks, were examined as predictors of four clinical indicators of placental insufficiency: (i) low 36-week cerebroplacental ratio (CPR; CPR < 5th centile reflects cerebral redistribution-a fetal adaptation to hypoxia), (ii) neonatal acidosis (umbilical artery pH < 7.15) after the hypoxic challenge of labour, (iii) low neonatal body fat percentage (BF%) reflecting reduced nutritional reserve and (iv) placental weight < 10th centile.

RESULTS

Declining 20-36-week fetal growth velocity was associated with all indicators of placental insufficiency. Each one centile reduction in EFW between 20 and 36 weeks increased the odds of cerebral redistribution by 2.5% (odds ratio (OR) = 1.025, P = 0.001), the odds of neonatal acidosis by 2.7% (OR = 1.027, P = 0.002) and the odds of a < 10th centile placenta by 3.0% (OR = 1.030, P < 0.0001). Each one centile reduction in AC between 20 and 36 weeks increased the odds of neonatal acidosis by 3.1% (OR = 1.031, P = 0.0005), the odds of low neonatal BF% by 2.8% (OR = 1.028, P = 0.04) and the odds of placenta < 10th centile by 2.1% (OR = 1.021, P = 0.0004). Falls in EFW or AC of > 30 centiles between 20 and 36 weeks were associated with two-threefold increased relative risks of these indicators of placental insufficiency, while low 20-28-week growth velocities were not.

CONCLUSIONS

Reduced growth velocity between 20 and 36 weeks among AGA fetuses is associated with antenatal, intrapartum and postnatal indicators of placental insufficiency. These fetuses potentially represent an important, under-recognised cohort at increased risk of stillbirth. Encouragingly, this novel fetal assessment would require only one additional ultrasound to current routine care, and adds to the potential benefits of routine 36-week ultrasound.

A survey of current use, dilemma and outlook of antenatal ultrasonography in Taiwan

OBJECTIVE

According to World Health Organization's Jungner and Wilson criteria for competent screening programs, routine antenatal ultrasound screening is legit and effective to improve both maternal and perinatal outcomes. Health Promotion Administration, Ministry of Health and Welfare in Taiwan followed expert recommendations and started reimbursing one antenatal ultrasonography around mid-second trimester since 1995. However, medical disputes pertaining to examination results grew, while confusions challenged doctors and patients alike. The aim of this study is to assess current use of antenatal ultrasonography for low-risk pregnancies in Taiwan. Specifically, the indications, test frequencies, test items, methods of payment, obstetricians' opinions on important scan timing and areas to be improved are surveyed and analyzed. An overview of international antenatal ultrasound practice guidelines are examined and compared to enhance the quality of antenatal ultrasound screening in Taiwan.

MATERIALS AND METHODS

From December 2015 to December 2016, 925 questionnaires were distributed to all licensed obstetricians registered to Taiwan Association of Obstetrics and Gynecology as well as Taiwan Society of Perinatology. A 10-min self-reporting questionnaire was sent by mail, with stamped return envelopes included. Respondents remained entirely anonymous and disclosed no personal information. Data was collected and analyzed for statistical analysis.

RESULTS

Most hospitals are well equipped with ultrasound machines of 3 or more functions. Eighty-eight percent of the obstetricians in Taiwan perform prenatal ultrasonography in every office visit for their patients, mostly free of charge. Scans at gestational age 15-22 weeks, <10 weeks, 11-14 weeks and 28-32 weeks are polled as the most importance in the order of significance. In general, they perceive the one-time antenatal scan offered by the Health Promotion Administration as for general obstetrics scan but not higher-leveled studies. Patient education and doctor-patient communications are opined as the 2 most important aspects to enhance antenatal ultrasound quality.

CONCLUSION

This report is the first of its kind in Taiwan. It could potentially serve as guidance for national health policy innovations in maternal and fetal care, such as increasing frequency of scans, specifications of scan timing, indications and consequences as well as patient education about this screening modality.

Two Cases of Craniospinal Rachischisis Totalis: Role of Magnetic Resonance Imaging in Diagnosis and Review of Neural Tube Defects in the Indian Context with Implications for Folate Fortification

Craniospinal rachischisis is a rare and severe form of neural tube defects (NTDs), which is always fatal. It is characterized by anencephaly accompanied by a bony defect of the spine and exposure of neural tissue. We describe the two patients with ultrasonographic and magnetic resonance imaging appearance of craniospinal rachischisis totalis, detected antenatally at 22 and 25 weeks of gestation, and confirmed after termination of pregnancy. The multifactorial etiology of NTDs, with specific reference to folate deficiency, is discussed with possible role of folate fortification in the Indian context.

Congenital giant hydronephrosis: a rare cause for upper abdominal mass in the newborn

We report a rare case of antenatally detected unilateral pelvi-ureteric junction obstruction leading to congenital giant hydronephrosis presenting as upper abdominal mass at birth.

Large sacrococcygeal teratoma hindering vaginal delivery attempted at home

Sacrococcygeal teratoma in fetus is rare. If it remains antenatally undiagnosed, it may cause sudden arrest of an otherwise uncomplicated vaginal delivery because of the tumor mass. This poses a challenge to obstetricians. In this era of widespread antenatal care, this type of complication is very rare; however, in such cases, if met unexpectedly, an urgent laparotomy followed by a reduction of the tumor mass might help in completion of the delayed delivery.