Prediction of adverse perinatal outcome at midgestation

Impact of Aspirin on Timing of Birth in Pregnancies With Clinical Manifestations of Placental Dysfunction: Evidence From a Multicentre Randomised Clinical Trial

OBJECTIVE

To examine whether aspirin delays gestational age at delivery (GAD) in pregnancies with placental dysfunction (PD) phenotypes (preeclampsia [PE], small-for-gestational-age [SGA], placental abruption and/or stillbirth).

DESIGN

A secondary analysis of a multicentre stepped-wedge cluster randomised trial.

SETTING

18 maternity/diagnostic units in Asia.

POPULATION

Singleton pregnancies examined at 11-13+6 weeks.

METHODS

A model in which the effect of aspirin is to delay the GAD in pregnancies with PD was developed.

MAIN OUTCOME MEASURES

GAD in pregnancies with PD.

RESULTS

Aspirin administration was associated with a significant reduction in PD < 32 weeks (adjusted relative risk 0.543, 95% CI: 0.330-0.864), with a trend for an increase of PD ≥ 32 weeks (test for trend, p-value = 0.0018). Similar findings were observed individually for PE, SGA and/or placental abruption. At 24 weeks, the aspirin-induced prolongation of pregnancies with PD was 2.85 weeks (95% CI: 0.44-5.40), and this effect was decreased by -0.19 weeks (95% CI: -0.33 to -0.05) for each week of gestation; therefore, at 28 and 32 weeks' gestation, the aspirin-induced prolongation was 2.09 and 1.33 weeks, respectively.

CONCLUSIONS

In this secondary analysis of a cluster randomised trial, women at high risk of PE who are destined to develop a clinical spectrum of PD may benefit from longer pregnancy duration through aspirin administration in early pregnancy. Aspirin may delay the GAD due to PD, particularly benefiting those deliveries that would occur at earlier gestations without aspirin administration.

External validation and comparison of Fetal Medicine Foundation competing-risks model for small-for-gestational-age neonate in the first trimester: multicenter cohort study

OBJECTIVES

To examine the predictive performance of the Fetal Medicine Foundation (FMF) competing-risks model for the first-trimester prediction of a small-for-gestational-age (SGA) neonate in a large, independent, unselected European cohort and to compare the competing-risks algorithm with previously published logistic-regression models.

METHODS

This was a retrospective, non-interventional, multicenter cohort study including 35 170 women with a singleton pregnancy who underwent a first-trimester ultrasound assessment between 11 + 0 and 13 + 6 weeks' gestation. We used the default FMF competing-risks model for the prediction of SGA combining maternal factors, uterine artery pulsatility index (UtA-PI), pregnancy-associated plasma protein-A (PAPP-A) and placental growth factor (PlGF) to obtain risks for different cut-offs of birth-weight percentile and gestational age at delivery. We examined the predictive performance in terms of discrimination and calibration and compared it with the published data on the model's development population and with published logistic-regression equations.

RESULTS

At a 10% false-positive rate, maternal factors and UtA-PI predicted 42.2% and 51.5% of SGA < 10th percentile delivered < 37 weeks and < 32 weeks, respectively. The respective values for SGA < 3rd percentile were 44.7% and 51.7%. Also at a 10% false-positive rate, maternal factors, UtA-PI and PAPP-A predicted 42.2% and 51.5% of SGA < 10th percentile delivered < 37 weeks and < 32 weeks, respectively. The respective values for SGA < 3rd percentile were 46.2% and 51.7%. At a 10% false-positive rate, maternal factors, UtA-PI, PAPP-A and PlGF predicted 47.6% and 66.7% of SGA < 10th percentile delivered < 37 weeks and < 32 weeks, respectively. The respective values for SGA < 3rd percentile were 50.0% and 69.0%. These data were similar to those reported in the original model's development study and substantially better than those calculated using pre-existing logistic-regression models (McNemar's test, P < 0.001). The FMF competing-risks model was well calibrated.

CONCLUSIONS

The FMF competing-risks model for the first-trimester prediction of SGA is reproducible in an independent, unselected low-risk cohort and superior to logistic-regression approaches. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

Association of birth weight with neuropsychological functioning in early adolescence: A retrospective cohort study

OBJECTIVE

This study aimed to compare the neuropsychological function in early adolescence between children born small for gestational age (SGA) or large for gestational age (LGA) and those born appropriate for gestational age (AGA).

METHODS

This retrospective cohort study utilized data from the Adolescent Brain Cognitive Development study in 2016-18. Children born of singleton pregnancy with complete information of birth weight and delivery week were enrolled. Their neuropsychological functioning were assessed by the brain structural magnetic resonance imaging (MRI), combined with cognitive and behavioral measurements. Linear mixed-effects models and subgroup analyses were performed.

RESULTS

Among 5,922 children aged 9-11, children born SGA and LGA demonstrated similar cognitive and behavioral performances as children born AGA (P > 0.05). In the MRI measurement, brain area and volume were lower among SGA children compared to AGA children (t=-5.626, Cohen's d = 0.448, P < 0.001; t=-6.071, Cohen's d = 0.427, P < 0.001); brain area and volume were higher among LGA children compared to AGA children (t = 8.562, Cohen's d = 0.470, P < 0.001; t = 8.562, Cohen's d = 0.470, P < 0.001). Cortical thickness was of no statistical difference (P > 0.05). These associations were confirmed by sensitivity analyses and propensity score matching.

CONCLUSION

Children born of SGA and LGA status were associated with altered brain area and volume structure in early adolescence.

Comparison of competing-risks model with angiogenic factors in midgestation screening for preterm growth-related neonatal morbidity

OBJECTIVES

First, to evaluate the predictive performance for preterm growth-related neonatal morbidity of a high soluble fms-like tyrosine kinase-1 (sFlt-1)/placental growth factor (PlGF) ratio or low PlGF at midgestation and, second, to compare the performance of a high sFlt-1/PlGF ratio or low PlGF with that of the competing-risks model for small-for-gestational age (SGA), utilizing a combination of maternal risk factors, sonographic estimated fetal weight and uterine artery pulsatility index.

METHODS

This was a prospective observational study in women attending for a routine hospital visit at 19-24 weeks' gestation in two maternity hospitals in England. The visit included recording of maternal demographic characteristics and medical history, carrying out an ultrasound scan and measuring serum PlGF and sFlt-1. The primary outcome was delivery < 32 and < 37 weeks' gestation of a SGA neonate with birth weight < 10th or < 3rd percentile, combined with neonatal unit (NNU) admission for ≥ 48 h or a composite of major neonatal morbidity. The detection rates in screening by PlGF < 10th percentile, sFlt-1/PlGF ratio > 90th percentile and the competing-risks model for SGA were estimated and then compared using McNemar's test.

RESULTS

In the study population of 40 241 women, prediction of preterm growth-related neonatal morbidity provided by the competing-risks model for SGA was superior to that of screening by low PlGF concentration or high sFlt-1/PlGF ratio. For example, at a screen-positive rate of 10.0%, as defined by the sFlt-1/PlGF ratio > 90th percentile, the competing-risks model predicted 70.1% (95% CI, 61.0-79.2%) of SGA < 10th percentile and 76.9% (95% CI, 67.6-86.3%) of SGA < 3rd percentile with NNU admission for ≥ 48 h delivered < 32 weeks' gestation. The respective values for SGA with major neonatal morbidity were 73.8% (95% CI, 64.4-83.2%) and 77.9% (95% CI, 68.0-87.8%). These were significantly higher than the respective values of 35.1% (95% CI, 25.6-44.6%), 35.9% (95% CI, 25.3-46.5%), 38.1% (95% CI, 27.7-48.5%) and 39.7% (95% CI, 28.1-51.3%) achieved by the application of the sFlt-1/PlGF ratio > 90th percentile (all P < 0.0001).

CONCLUSION

At midgestation, the prediction of growth-related neonatal morbidity by the competing-risks model for SGA is superior to that of a high sFlt-1/PlGF ratio or low PlGF. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Evaluation of angiogenic factors in prediction of growth-related neonatal morbidity at term and comparison with competing-risks model

OBJECTIVES

First, to describe the distribution of biomarkers of impaired placentation in small-for-gestational-age (SGA) pregnancies with neonatal morbidity; second, to examine the predictive performance for growth-related neonatal morbidity of a high soluble fms-like tyrosine kinase-1 (sFlt-1)/placental growth factor (PlGF) ratio or low PlGF; and, third, to compare the performance of a high sFlt-1/PlGF ratio or low PlGF with that of the competing-risks model for SGA in predicting growth-related neonatal morbidity.

METHODS

This was a prospective observational study of women attending for a routine hospital visit at 35 + 0 to 36 + 6 weeks' gestation in two maternity hospitals in England. The visit included recording of maternal demographic characteristics and medical history, an ultrasound scan and measurement of serum PlGF and sFlt-1. The primary outcome was delivery within 4 weeks after assessment and at < 42 weeks' gestation of a SGA neonate with birth weight < 10th or < 3rd percentile, combined with neonatal unit (NNU) admission for ≥ 48 h or a composite of major neonatal morbidity. The detection rates in screening by PlGF < 10th percentile, sFlt-1/PlGF ratio > 90th percentile, sFlt-1/PlGF ratio > 38 and the competing-risks model for SGA, using combinations of maternal risk factors and Z-scores of estimated fetal weight (EFW) with multiples of the median values of uterine artery pulsatility index, PlGF and sFlt-1, were estimated. The detection rates by the different methods of screening were compared using McNemar's test.

RESULTS

In the study population of 29 035 women, prediction of growth-related neonatal morbidity at term provided by the competing-risks model was superior to that of screening by low PlGF concentration or a high sFlt-1/PlGF concentration ratio. For example, at a screen-positive rate (SPR) of 13.1%, as defined by the sFlt-1/PlGF ratio > 38, the competing-risks model using maternal risk factors and EFW predicted 77.5% (95% CI, 71.7-83.3%) of SGA < 10th percentile and 89.3% (95% CI, 83.7-94.8%) of SGA < 3rd percentile with NNU admission for ≥ 48 h delivered within 4 weeks after assessment. The respective values for SGA with major neonatal morbidity were 71.4% (95% CI, 56.5-86.4%) and 90.0% (95% CI, 76.9-100%). These were significantly higher than the respective values of 41.0% (95% CI, 34.2-47.8%) (P < 0.0001), 48.8% (95% CI, 39.9-57.7%) (P < 0.0001), 37.1% (95% CI, 21.1-53.2%) (P = 0.003) and 55.0% (95% CI, 33.2-76.8%) (P = 0.035) achieved by the application of the sFlt-1/PlGF ratio > 38. At a SPR of 10.0%, as defined by PlGF < 10th percentile, the competing-risks model using maternal factors and EFW predicted 71.5% (95% CI, 65.2-77.8%) of SGA < 10th percentile and 84.3% (95% CI, 77.8-90.8%) of SGA < 3rd percentile with NNU admission for ≥ 48 h delivered within 4 weeks after assessment. The respective values for SGA with major neonatal morbidity were 68.6% (95% CI, 53.1-83.9%) and 85.0% (95% CI, 69.4-100%). These were significantly higher than the respective values of 36.5% (95% CI, 29.8-43.2%) (P < 0.0001), 46.3% (95% CI, 37.4-55.2%) (P < 0.0001), 37.1% (95% CI, 21.1-53.2%) (P = 0.003) and 55.0% (95% CI, 33.2-76.8%) (P = 0.021) achieved by the application of PlGF < 10th percentile.

CONCLUSION

At 36 weeks' gestation, the prediction of growth-related neonatal morbidity by the competing-risks model for SGA, using maternal risk factors and EFW, is superior to that of a high sFlt-1/PlGF ratio or low PlGF. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Evaluation of screening performance of first-trimester competing-risks prediction model for small-for-gestational age in Asian population

OBJECTIVE

To examine the external validity of the Fetal Medicine Foundation (FMF) competing-risks model for the prediction of small-for-gestational age (SGA) at 11-14 weeks' gestation in an Asian population.

METHODS

This was a secondary analysis of a multicenter prospective cohort study in 10 120 women with a singleton pregnancy undergoing routine assessment at 11-14 weeks' gestation. We applied the FMF competing-risks model for the first-trimester prediction of SGA, combining maternal characteristics and medical history with measurements of mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI) and serum placental growth factor (PlGF) concentration. We calculated risks for different cut-offs of birth-weight percentile (< 10th , < 5th or < 3rd percentile) and gestational age at delivery (< 37 weeks (preterm SGA) or SGA at any gestational age). Predictive performance was examined in terms of discrimination and calibration.

RESULTS

The predictive performance of the competing-risks model for SGA was similar to that reported in the original FMF study. Specifically, the combination of maternal factors with MAP, UtA-PI and PlGF yielded the best performance for the prediction of preterm SGA with birth weight < 10th percentile (SGA < 10th ) and preterm SGA with birth weight < 5th percentile (SGA < 5th ), with areas under the receiver-operating-characteristics curve (AUCs) of 0.765 (95% CI, 0.720-0.809) and 0.789 (95% CI, 0.736-0.841), respectively. Combining maternal factors with MAP and PlGF yielded the best model for predicting preterm SGA with birth weight < 3rd percentile (SGA < 3rd ) (AUC, 0.797 (95% CI, 0.744-0.850)). After excluding cases with pre-eclampsia, the combination of maternal factors with MAP, UtA-PI and PlGF yielded the best performance for the prediction of preterm SGA < 10th and preterm SGA < 5th , with AUCs of 0.743 (95% CI, 0.691-0.795) and 0.762 (95% CI, 0.700-0.824), respectively. However, the best model for predicting preterm SGA < 3rd without pre-eclampsia was the combination of maternal factors and PlGF (AUC, 0.786 (95% CI, 0.723-0.849)). The FMF competing-risks model including maternal factors, MAP, UtA-PI and PlGF achieved detection rates of 42.2%, 47.3% and 48.1%, at a fixed false-positive rate of 10%, for the prediction of preterm SGA < 10th , preterm SGA < 5th and preterm SGA < 3rd , respectively. The calibration of the model was satisfactory.

CONCLUSION

The screening performance of the FMF first-trimester competing-risks model for SGA in a large, independent cohort of Asian women is comparable with that reported in the original FMF study in a mixed European population. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.