FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction

Are there sex differences in fetal growth strategies and in the long-term effects of pregnancy complications on cognitive functioning?

Males and females have been proposed to have different prenatal growth strategies, whereby males invest more in fetal growth and less in placental development, leaving them more susceptible to early-life adversity. We tested predictions of this hypothesis using data from the National Collaborative Perinatal Project. Male newborns were heavier than females, but there was no difference in placental weight, adjusting for birthweight. Among infants born prior to 33 weeks, the difference in birthweight between males and females was greater among those who did not survive than among those who did, potentially reflecting a strategy whereby males maintained growth in the face of prenatal insults, while females adjusted growth. However, there was no significant difference in mortality between the sexes. Being born small-for-gestational age or very preterm (prior to 33 weeks) was associated with significantly reduced performance for most of the cognitive traits examined at 7 years, although maternal preeclampsia was associated with reduced performance in fewer traits. Generally, these effects of early-life adversity (poor fetal growth, prematurity, and preeclampsia) did not differ between the sexes. However, analyzing the sexes separately (rather than testing the interaction between sex and adversity) resulted in numerous spurious sex-specific effects, whereby the effect of early-life adversity appeared to be significant in one sex but not the other. Overall, we found little support for the hypothesis that males prioritize growth more than females, and that this makes them more susceptible to early-life adversity. Furthermore, our results show that analyzing the sexes separately, rather than testing the adversity by sex interaction, can be highly misleading.

Doppler Ultrasound of the Umbilical Artery: Clinical Application

OBJECTIVE

 To provide a survey of relevant literature on umbilical artery Doppler ultrasound use in clinical practice, technical considerations and limitations, and future perspectives.

METHODS

 Literature searches were conducted in PubMed and Medline, restricted to articles written in English. Additionally, the references of all analyzed studies were searched to obtain necessary information.

RESULTS

 The use of this technique as a routine surveillance method is only recommended for high-risk pregnancies with impaired placentation. Meta-analyses of randomized trials have established that obstetric management guided by umbilical artery Doppler findings can improve perinatal mortality and morbidity. The values of the indices of Umbilical artery Doppler decrease with advancing gestational age; however, a lack of consensus on reference ranges prevails.

CONCLUSION

 Important clinical decisions are based on the information obtained with umbilical artery Doppler ultrasound. Future efforts in research are imperative to overcome the current limitations of the technique.

The role of the fetal biophysical profile in the management of fetal growth restriction

Growth-restricted fetuses are at risk of hypoxemia, acidemia, and stillbirth because of progressive placental dysfunction. Current fetal well-being, neonatal risks following delivery, and the anticipated rate of fetal deterioration are the major management considerations in fetal growth restriction. Surveillance has to quantify the fetal risks accurately to determine the delivery threshold and identify the testing frequency most likely to capture future deterioration and prevent stillbirth. From the second trimester onward, the biophysical profile score correlates over 90% with the current fetal pH, and a normal score predicts a pH >7.25 with a 100% positive predictive value; an abnormal score on the other hand predicts current fetal acidemia with similar certainty. Between 30% and 70% of growth-restricted fetuses with a nonreactive heart rate require biophysical profile scoring to verify fetal well-being, and an abnormal score in 8% to 27% identifies the need for delivery, which is not suspected by Doppler findings. Future fetal well-being is not predicted by the biophysical profile score, which emphasizes the importance of umbilical artery Doppler and amniotic fluid volume to determine surveillance frequency. Studies with integrated surveillance strategies that combine frequent heart rate monitoring with biophysical profile scoring and Doppler report better outcomes and stillbirth rates of between 0% and 4%, compared with those between 8% and 11% with empirically determined surveillance frequency. The variations in clinical behavior and management challenges across gestational age are better addressed when biophysical profile scoring is integrated into the surveillance of fetal growth restriction. This review aims to provide guidance on biophysical profile scoring in the in- and outpatient management of fetal growth restriction.

Testing the assumptions of customized intrauterine growth charts using national birth studies

INTRODUCTION

Customized intrauterine growth charts are widely used for growth monitoring and research. They are based on three assumptions: (1) estimated fetal weight (EFW) has a normal distribution with a constant coefficient of variation at all gestational ages; (2) Hadlock's growth curve accurately describes the relation between EFW and gestational ages; (3) associations between EFW and the fetal and maternal characteristics included in the customization model (fetal sex, pre-pregnancy weight, height, parity) are proportional throughout pregnancy. The aim of this study was to test whether these underlying assumptions are verified.

MATERIAL AND METHODS

Data came from (1) the French Longitudinal Study of Children (ELFE) cohort, which recruited births after 32 weeks' gestation in 349 maternity hospitals in France in 2011, and (2) the National Perinatal Survey, which included births from all French maternity hospitals in 2016. The study population included, respectively, 6 920 and 8 969 singleton non-malformed term live births with data on customization characteristics and EFW. We computed the coefficient of variation by gestational age and then modeled the association of gestational age, maternal and fetal characteristics with EFW at the second and third trimester ultrasound and with birthweight using linear regression. To assess the proportionality of the impact of maternal and fetal characteristics, we computed the percent change in weight associated with these characteristics at these three time points.

RESULTS

The coefficient of variation was close to 12% at each gestational age, but EFW was not normally distributed, leading to small but systematic underestimation of fetuses under the 10th percentile. Weights representing the 50th and 10th percentiles based on Hadlock's growth trajectory were lower than observed or predicted weights. Most characteristics more strongly impacted weight at birth than during pregnancy. In the French Longitudinal study of Children (ELFE) cohort, boys were 1.8% (95% confidence interval [CI] 1.3-2.4) heavier than girls in the third trimester, whereas this percentage was 4.6% (95% CI 4.0-5.2) at birth. In the National Perinatal Survey, these percentages were 2.3% (95% CI 1.8-2.8) and 4.3% (95% CI 3.8-4.8).

CONCLUSIONS

These results from two independent sources revealed discrepancies between routine clinical EFW data used for growth monitoring and the customized growth model's assumptions.

Efficacy of Pulsatility Index of Fetal Vessels in Predicting Adverse Perinatal Outcomes in Fetuses with Growth Restriction - Differences in Early- and Late-Onset Fetal Growth Restriction

Background:Doppler ultrasound of fetal vessels plays an important role in diagnosing fetal growth restriction (FGR). It also aids in early detection of fetal compromise and clinical decision making. Aim: To determine the efficacy of the pulsatility index (PI) of the fetal umbilical artery (UA) and middle cerebral artery (MCA) in the third trimester of pregnancy for predicting adverse perinatal outcomes in the growth restricted fetuses. To study the differences in Doppler profiles in early- and late FGR (EFGR and LFGR, respectively) and their association with adverse outcomes. Materials and methods:The study was approved by the Institute's Ethical Committee. Informed consent was taken from study participants. Eighty singleton pregnancies in the third trimester, which had been diagnosed with FGR, were studied. The UA and MCA Doppler PI and cerebroplacental ratio (CPR) (ratios of PI of MCA/UA) as well as perinatal outcomes were recorded. Adverse perinatal outcomes included perinatal death, hypoxia, seizures, respiratory distress, prolonged Neonatal Intensive Care Unit (NICU) stay, and low Apgar scores at one minute and five minutes. Statistical association of PI with adverse outcomes and differences in Doppler profiles of EFGR and LFGR were studied. Results:Abnormal pulsatility in fetal vessels was associated with adverse perinatal outcomes. The UA PI was the most sensitive (66%) and CPR the most specific parameter (80%) for predicting adverse perinatal outcomes. Absent or reversal of diastolic flow in UA was associated with adverse perinatal outcomes in 75% and 40% of cases, respectively. The UA PI was the most sensitive parameter in both EFGR (70%) and LFGR (66%) and specific Doppler parameter in EFGR (75%). However, CPR and MCA PI were the most specific (89%) and diagnostically accurate in LFGR (79%). Conclusion:The UA PI is the most sensitive Doppler parameter for predicting adverse perinatal outcomes. Cerebroplacental ratio has a high specificity and accuracy and is an important parameter in LFGR cases.

Management of fetal Growth Restriction at term by Angiogenic Factors versus feto-maternal Doppler (GRAFD) to avoid adverse perinatal outcomes: multicenter open-label randomized controlled trial study protocol (Preprint)

Background

Fetal smallness affects 10% of pregnancies. Small fetuses are at a higher risk of adverse outcomes. Their management using estimated fetal weight and feto-maternal Doppler has a high sensitivity for adverse outcomes; however, more than 60% of fetuses are electively delivered at 37 to 38 weeks. On the other hand, classification using angiogenic factors seems to have a lower false-positive rate. Here, we present a protocol for the Fetal Growth Restriction at Term Managed by Angiogenic Factors Versus Feto-Maternal Doppler (GRAFD) trial, which compares the use of angiogenic factors and Doppler to manage small fetuses at term.

Objective

The primary objective is to demonstrate that classification based on angiogenic factors is not inferior to estimated fetal weight and Doppler at detecting fetuses at risk of adverse perinatal outcomes.

Methods

This is a multicenter, open-label, randomized controlled trial conducted in 20 hospitals across Spain. A total of 1030 singleton pregnancies with an estimated fetal weight ≤10th percentile at 36+0 to 37+6 weeks+days will be recruited and randomly allocated to either the control or the intervention group. In the control group, standard Doppler-based management will be used. In the intervention group, cases with a soluble fms-like tyrosine kinase to placental growth factor ratio ≥38 will be classified as having fetal growth restriction; otherwise, they will be classified as being small for gestational age. In both arms, the fetal growth restriction group will be delivered at ≥37 weeks and the small for gestational age group at ≥40 weeks. We will assess differences between the groups by calculating the relative risk, the absolute difference between incidences, and their 95% CIs.

Results

Recruitment for this study started on September 28, 2020. The study results are expected to be published in peer-reviewed journals and disseminated at international conferences in early 2023.

Conclusions

The angiogenic factor–based protocol may reduce the number of pregnancies classified as having fetal growth restriction without worsening perinatal outcomes. Moreover, reducing the number of unnecessary labor inductions would reduce costs and the risks derived from possible iatrogenic complications. Additionally, fewer inductions would lower the rate of early-term neonates, thus improving neonatal outcomes and potentially reducing long-term infant morbidities.

Trial Registration

ClinicalTrials.gov NCT04502823; https://clinicaltrials.gov/ct2/show/NCT04502823

International Registered Report Identifier (IRRID)

DERR1-10.2196/37452

The Pivotal Role of the Placenta in Normal and Pathological Pregnancies: A Focus on Preeclampsia, Fetal Growth Restriction, and Maternal Chronic Venous Disease

The placenta is a central structure in pregnancy and has pleiotropic functions. This organ grows incredibly rapidly during this period, acting as a mastermind behind different fetal and maternal processes. The relevance of the placenta extends far beyond the pregnancy, being crucial for fetal programming before birth. Having integrative knowledge of this maternofetal structure helps significantly in understanding the development of pregnancy either in a proper or pathophysiological context. Thus, the aim of this review is to summarize the main features of the placenta, with a special focus on its early development, cytoarchitecture, immunology, and functions in non-pathological conditions. In contraposition, the role of the placenta is examined in preeclampsia, a worrisome hypertensive disorder of pregnancy, in order to describe the pathophysiological implications of the placenta in this disease. Likewise, dysfunction of the placenta in fetal growth restriction, a major consequence of preeclampsia, is also discussed, emphasizing the potential clinical strategies derived. Finally, the emerging role of the placenta in maternal chronic venous disease either as a causative agent or as a consequence of the disease is equally treated.

Should twin-specific growth charts be used to assess fetal growth in twin pregnancies?

One of the hallmarks of twin pregnancies is the slower rate of fetal growth when compared with singleton pregnancies during the third trimester. The mechanisms underlying this phenomenon and whether it represents pathology or benign physiological adaptation are currently unclear. One important implication of these questions relates to the type growth charts that should be used by care providers to monitor growth of twin fetuses. If the slower growth represents pathology (ie, intrauterine growth restriction caused uteroplacental insufficiency), it would be preferable to use a singleton growth chart to identify a small twin fetus that is at risk for perinatal mortality and morbidity. If, however, the relative smallness of twins is the result of benign adaptive mechanisms, it is likely preferable to use a twin-based charts to avoid overdiagnosis of intrauterine growth restriction in twin pregnancies. In the current review, we addressed this question by describing the differences in fetal growth between twin and singleton pregnancies, reviewing the current knowledge regarding the mechanisms responsible for slower fetal growth in twins, summarizing available empirical evidence on the diagnostic accuracy of the 2 types of charts for intrauterine growth restriction in twin pregnancies, and addressing the question of whether uncomplicated dichorionic twins are at an increased risk for fetal death when compared with singleton fetuses. We identified a growing body of evidence that shows that the use of twin charts can reduce the proportion of twin fetuses identified with suspected intrauterine growth restriction by up to 8-fold and can lead to a diagnosis of intrauterine growth restriction that is more strongly associated with adverse perinatal outcomes and hypertensive disorders than a diagnosis of intrauterine growth restriction based on a singleton-based chart without compromising the detection of twin fetuses at risk for adverse outcomes caused by uteroplacental insufficiency. We further found that small for gestational age twins are less likely to experience adverse perinatal outcomes or to have evidence of uteroplacental insufficiency than small for gestational age singletons and that recent data question the longstanding view that uncomplicated dichorionic twins are at an increased risk for fetal death caused by placental insufficiency. Overall, it seems that, based on existing evidence, the of use twin charts is reasonable and may be preferred over the use of singleton charts when monitoring the growth of twin fetuses. Still, it is important to note that the available data have considerable limitations and are primarily derived from observational studies. Therefore, adequately-powered trials are likely needed to confirm the benefit of twin charts before their use is adopted by professional societies.

Which chart and which cut-point: deciding on the INTERGROWTH, World Health Organization, or Hadlock fetal growth chart

OBJECTIVE

To determine how various centile cut points on the INTERGROWTH-21st (INTERGROWTH), World Health Organization (WHO), and Hadlock fetal growth charts predict perinatal morbidity/mortality, and how this relates to choosing a fetal growth chart for clinical use.

METHODS

We linked antenatal ultrasound measurements for fetuses > 28 weeks' gestation from the British Columbia Women's hospital ultrasound unit with the provincial perinatal database. We estimated the risk of perinatal morbidity/mortality (decreased cord pH, neonatal seizures, hypoglycemia, and perinatal death) associated with select centiles on each fetal growth chart (the 3rd, 10th, the centile identifying 10% of the population, and the optimal cut-point by Youden's Index), and determined how well each centile predicted perinatal morbidity/mortality.

RESULTS

Among 10,366 pregnancies, the 10th centile cut-point had a sensitivity of 11% (95% CI 8, 14), 13% (95% CI 10, 16), and 12% (95% CI 10, 16), to detect fetuses with perinatal morbidity/mortality on the INTERGROWTH, WHO, and Hadlock charts, respectively. All charts performed similarly in predicting perinatal morbidity/mortality (area under the curve [AUC] =0.54 for all three charts). The statistically optimal cut-points were the 39th, 31st, and 32nd centiles on the INTERGROWTH, WHO, and Hadlock charts respectively.

CONCLUSION

The INTERGROWTH, WHO, and Hadlock fetal growth charts performed similarly in predicting perinatal morbidity/mortality, even when evaluating multiple cut points. Deciding which cut-point and chart to use may be guided by other considerations such as impact on workflow and how the chart was derived.

Therapeutic advances in overcoming intrauterine growth restriction induced metabolic syndrome

Intrauterine growth restriction (IUGR) remains a great public health challenge as it affects neonatal survival and influences their normal biological development and metabolism. Several clinical researches have revealed the occurrence of metabolic syndrome, such as insulin resistance, obesity, type 2 diabetes mellitus, oxidative stress, dyslipidemia, as direct results of IUGR. Therefore, it is essential to understand its underlying mechanism, impact and develop effective therapies. The purpose of this work is to review the current knowledge on IUGR induced metabolic syndrome and relevant therapies. Here in, we elaborate on the characteristics and causes of IUGR by pointing out recent research findings. Furthermore, we discuss the impact of IUGR on different organs of the body, followed by preclinical studies on IUGR using suitable animal models. Additionally, various metabolic disorders with their genetic implications, such as insulin resistance, type 2 diabetes mellitus, dyslipidemia, obesity are detailed. Finally, the current therapeutic options used in the treatment of IUGR are summarized with some prospective therapies highlighted.

Guidance for Systematic Integration of Undernutrition in Attributing Cause of Death in Children

Minimally invasive tissue sampling (MITS) is increasingly being used to better understand causes of death in low-resource settings. Undernutrition (eg, wasting, stunting) is prevalent among children globally and yet not consistently coded or uniformly included on death certificates in MITS studies when present. Consistent and accurate attribution of undernutrition is fundamental to understanding its contribution to child deaths. In May 2020, members of the MITS Alliance Cause of Death Technical Working Group convened a panel of experts in public health, child health, nutrition, infectious diseases, and MITS to develop guidance for systematic integration of undernutrition, as assessed by anthropometry, in cause of death coding, including as part of the causal chain or as a contributing condition, in children <5 years of age. The guidance presented here will support MITS and other researchers, public health practitioners, and clinicians with a systematic approach to assigning and interpreting undernutrition in death certification.

Maternal HPV Infection: Effects on Pregnancy Outcome

The human papilloma virus (HPV) infection, caused by a ubiquitous virus typically transmitted through the direct contact of infected organs, either through the skin or mucosa, is the most common sexually transmitted infection, placing young women at a high risk of contracting it. Although the vast majority of cases spontaneously clear within 1-2 years, persistent HPV infection remains a serious concern, as it has repeatedly been linked to the development of multiple malignancies, including cervical, anogenital, and oropharyngeal cancers. Additionally, more recent data suggest a harmful effect of HPV infection on pregnancy. As the maternal hormonal environment and immune system undergo significant changes during pregnancy, the persistence of HPV is arguably favored. Various studies have reported an increased risk of adverse pregnancy outcomes among HPV-positive women, with the clinical impact encompassing a range of conditions, including preterm birth, miscarriage, pregnancy-induced hypertensive disorders (PIHD), intrauterine growth restriction (IUGR), low birth weight, the premature rupture of membranes (PROM), and fetal death. Therefore, understanding the mechanisms employed by HPV that negatively impact pregnancy and assessing potential approaches to counteract them would be of interest in the quest to optimize pregnancy outcomes and improve child survival and health.

Bariatric surgery and its impact on fertility, pregnancy and its outcome: A narrative review

Bariatric procedures are on the rise as a surgical treatment for morbid obesity. In reproductive age of women, bariatric surgeries will improve factors related to anovulation and lead to spontaneous fertility. Spontaneous pregnancy can happen within a year after bariatric surgery due to higher level of sex hormone binding globulin and follicular stimulating hormone and reduction in androgens level. Reduction of length of follicular phase of menstrual cycle was reported and contribute to improved ovulatory status.

The major impact to pregnant women is development of small for gestational age babies due to persistent weight loss but this can be minimized by avoiding pregnancies too soon after bariatric surgery and good nutrition supplement. Risk of developing gestational diabetes mellitus and preeclampsia reduced among post bariatric surgery compared to no surgery. Another benefit observed are reduction in the risk of caesarean section and admission to neonatal intensive care unit. There are no significant changes in composition of breast milk in postpartum women without bariatric surgery and with women whom undergone surgery although more study needed to evaluate this effect.

Good prenatal care, micronutrient supplement during antenatal follow up and close supervision from expert managing this pregnancy are essential component to ensure good outcome to mothers and their newborn.

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Bariatric surgery in obese women will lead to improvement in ovulation.

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Bariatric surgery will improve the BMI and reduce risk associated with Gestational Diabetes Mellitus and Preeclampsia.

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Bariatric surgery will improve BMI and reduce miscarriages.

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Bariatric surgery in obese women will improve perinatal outcome.

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Mode of delivery and role of breastfeeding after bariatric surgery in obese women.

How and when to recommend delivery of a growth-restricted fetus: A review

Clinicians consider a range of variables when formulating decisions regarding the diagnosis, monitoring plan, and ultimately the decision to recommend the delivery of a growth-restricted fetus. The differential diagnosis of a pathological fetal growth pattern is initially considered via the history, a physical and laboratory examination of the pregnant person, as well as a comprehensive fetal ultrasound examination. These factors allow a broad distinction between pre-existing disease in the pregnant person, constitutionally small normal growth, placenta-mediated Fetal Growth Restriction (FGR), and intrinsic fetal disease. Most commonly, pathological growth restriction is mediated by underlying placental diseases, of which maternal vascular malperfusion is the most common, and often results in co-existent hypertension. A program of combined monitoring of the pregnant person and fetus, comprising hypertension assessment, and serial fetal ultrasound, including Doppler studies is then instituted, and may be combined with biochemical markers, such as Placental Growth Factor, for greater clinical precision. Recommendations on timing to deliver the growth-restricted fetus worldwide are converging, with similar guidance from clinical practice guidelines informed by high-quality Randomized Controlled Trials (RCTs) and large cohort studies. In most instances, it is reasonable to recommend delivery of all growth-restricted fetuses by approximately 38 weeks. Timing of delivery should take into consideration both short-term neonatal outcomes and long-term outcomes at school age. Mode of delivery is based on many factors, and induction of labor is a safe approach, especially after 34 weeks. Mechanical methods of induction may be preferred to pharmacologic methods, although both have a role and the choice of method is based on individualized assessment. Elective Cesarean birth thereby bypassing fetal stress during labor, is recommended in preterm growth-restricted fetuses with signs of adaptive fetal compromise, especially when ductus venosus flow is abnormal, or a contraction stress test is positive.

Novel side by side Foley catheter balloons for 'extended labour induction': Concept, simulation study and clinical application

OBJECTIVE

To introduce the concept of extended or prolonged mechanical balloon labour induction as opposed to pharmacological methods and amniotomy after single balloon expulsion, by the novel use of side-by-side Foley catheter balloons. This method is of particular relevance when there is prior uterine surgery, fetal reserve is uncertain, the risk of vertical infection is high, or facilities for labour monitoring are limited.

STUDY DESIGN

We conducted simulation studies to compare balloon circumferences and resistance to passage through a simulation cervix between different gauge, fluid distension volume and number of Foley catheters. We describe an illustrative clinical case.

RESULTS

In simulation studies we found modest increases in Foley catheter balloon circumference with increased catheter gauge and with increasing volume of distending fluid. We found that retention of Foley balloon(s) by a flexible simulated cervix was increased with the gauge, distending volume and number of balloons used side-by-side. We describe the case of a mother with pre-eclampsia with severe features and compromised fetal reserve in whom the side-by-side balloon method achieved spontaneous delivery after a single balloon had been expelled without labour commencing.

CONCLUSIONS

Institutional protocols for Balloon labour inductions should take into account the characteristics of locally-available balloon catheters. Further research is justified to determine the usefulness of extended mechanical labour induction with side-by-side balloon catheters, particularly with prior caesarean section, uncertain fetal reserve and settings with limited fetal monitoring capacity.

Perinatal Adverse Effects in Newborns with Estimated Loss of Weight Percentile between the Third Trimester Ultrasound and Delivery. The GROWIN Study

Fetal growth restriction has been associated with an increased risk of adverse perinatal outcomes (APOs). We determined the importance of fetal growth detention (FGD) in late gestation for the occurrence of APOs in small-for-gestational-age (SGA) and appropriate-for-gestational-age (AGA) newborns. For this purpose, we analyzed a retrospective cohort study of 1067 singleton pregnancies. The newborns with higher APOs were SGA non-FGD and SGA FGD in 40.9% and 31.5% of cases, respectively, and we found an association between SGA non-FGD and any APO (OR 2.61; 95% CI: 1.35–4.99; p = 0.004). We did not find an increased APO risk in AGA FGD newborns (OR: 1.13, 95% CI: 0.80, 1.59; p = 0.483), except for cesarean delivery for non-reassuring fetal status (NRFS) with a decrease in percentile cutoff greater than 40 (RR: 2.41, 95% CI: 1.11–5.21) and 50 (RR: 2.93, 95% CI: 1.14–7.54). Conclusions: Newborns with the highest probability of APOs are SGA non-FGDs. AGA FGD newborns do not have a higher incidence of APOs than AGA non-FGDs, although with falls in percentile cutoff over 40, they have an increased risk of cesarean section due to NRFS. Further studies are warranted to detect these newborns who would benefit from close surveillance in late gestation and at delivery.

Competing Risks Model for Prediction of Small for Gestational Age Neonates and the Role of Second Trimester Soluble Fms-like Tyrosine Kinase-1

Small for gestational age (SGA) fetuses/neonates are characterized by the increased risk for adverse outcomes that can be reduced if the condition is identified antenatally. We have recently developed a new approach in SGA prediction that considers SGA a spectrum condition that is reflected in two dimensions: gestational age at delivery and Z score in birth weight for gestational age. The new method has a better predictive ability than the traditionally used risk-scoring systems and logistic regression models. In this prospective study in 40241 singleton pregnancies, at 19–24 weeks’ gestation, we examined the potential value of the antiangiogenic soluble fms-like tyrosine kinase-1 (sFlt-1) and the ratio of sFlt-1 to the angiogenic placental growth factor (PlGF) in the prediction of SGA. We found that first, sFlt-1 did not improve the performance of screening by maternal risk factors, and second, the ratio of sFlt-1/PlGF had a worse performance than PlGF alone in the prediction of SGA. Consequently, second trimester sFlt-1 and sFlt-1/PlGF are not useful in screening for SGA.

Induction of labour in low-resource settings

Due to the disparity in resource availability between low- and high-resource settings, practice recommendations relevant to high-income countries are not always relevant and often need to be adapted to low-resource settings. The adaptation applies to induction of labour (IOL) which is an obstetric procedure that deserves special attention because it involves the initiation of a process that requires regular and frequent monitoring of the mother and foetus by experienced healthcare professionals. Lack of problem recognition and/or substandard care during IOL may result in harm with long-term sequelae. In this article, the authors discuss unique challenges such as insufficient resources (including staff, midwives, doctors, equipment, and medications) that result in occasional inadequate patient monitoring and/or delayed interventions during IOL in low-resource settings. We also discuss modifications in indications and methods for IOL, issues related to human immunodeficiency virus (HIV) infections, the feasibility of outpatient induction, clinical protocols and a minimum dataset for quality improvement projects. Overall, the desire to achieve a vaginal birth with IOL should not cloud the necessity to observe the required safety measures and implement necessary interventions; given that childbirth practices are the major determinants of pregnancy outcomes and patient satisfaction.