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Alda MG, Holberton J, MacDonald TM, Charlton JK. Small for gestational age at preterm birth identifies adverse neonatal outcomes more reliably than antenatal suspicion of fetal growth restriction. J Matern Fetal Neonatal Med 2023; 36:2279017. [PMID: 37981759 DOI: 10.1080/14767058.2023.2279017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 10/30/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Fetal growth restriction (FGR) is an important reason for premature delivery and a leading cause of perinatal morbidity and mortality. We aimed to evaluate whether classification as small for gestational age (SGA; <10th centile) at birth or antenatal suspicion of FGR was more strongly associated with neonatal morbidity and mortality in preterm infants. METHODS A retrospective audit of infants born between 24 + 0 and 32 + 6 weeks of gestation from 2012-2019 and admitted to the Neonatal Unit at Mercy Hospital for Women (MHW). Infants were categorized according to whether FGR was listed as an antenatal complication in the medical records and whether they were SGA (<10th centile on Fenton chart) or appropriate for gestational age (AGA) at birth, and comparisons for neonatal outcomes were made. RESULTS 371/2126 preterm infants (17.5%) had antenatal suspicion of FGR, and 166 (7.8%) were SGA at birth. No differences in any neonatal outcomes were found between infants with or without suspected FGR, except decreased intraventricular hemorrhage (IVH) in the FGR group. SGA classification was associated with increased rates of all morbidities other than IVH, including bronchopulmonary dysplasia, retinopathy of prematurity, and necrotizing enterocolitis, compared with the AGA group. Death was significantly higher in the SGA group (7.2%) compared with the AGA group (3.5%). CONCLUSION SGA by Fenton chart more reliably identified neonates at risk of adverse neonatal outcomes than antenatal suspicion of FGR, suggesting it is a reasonable clinical proxy. This most likely reflects the much lower tenth centile weight cutoffs on the Fenton charts compared to in-utero charts used antenatally to diagnose FGR based on ultrasound estimated fetal weight. SGA classification by Fenton approximately equates to <3rd centile on in-utero charts at our institution, therefore identifying the most severe FGR cases.
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Affiliation(s)
- Maria G Alda
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Department of Paediatrics, Mercy Hospital for Women, Melbourne, Australia
| | - James Holberton
- Department of Paediatrics, Mercy Hospital for Women, Melbourne, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| | - Teresa M MacDonald
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia
| | - Julia K Charlton
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Division of Neonatology, BC Women's Hospital, Vancouver, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
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Gardosi J, Hugh O. Stillbirth risk and smallness for gestational age according to Hadlock, INTERGROWTH-21st, WHO, and GROW fetal weight standards: analysis by maternal ethnicity and body mass index. Am J Obstet Gynecol 2023; 229:547.e1-547.e13. [PMID: 37247647 DOI: 10.1016/j.ajog.2023.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Appropriate growth charts are essential for fetal surveillance, to confirm that growth is proceeding normally and to identify pregnancies that are at risk. Many stillbirths are avoidable through antenatal detection of the small-for-gestational-age fetus. In the absence of an international consensus on which growth chart to use, it is essential that clinical practice reflects outcome-based evidence. OBJECTIVE This study investigated the performance of 4 internationally used fetal weight standards and their ability to identify stillbirth risk in different ethnic and maternal size groups of a heterogeneous population. STUDY DESIGN We analyzed routinely collected maternity data from more than 2.2 million pregnancies. Three population-based fetal weight standards (Hadlock, Intergrowth-21st, and World Health Organization) were compared with the customized GROW standard that was adjusted for maternal height, weight, parity, and ethnic origin. Small-for-gestational-age birthweight and stillbirth risk were determined for the 2 largest ethnic groups in our population (British European and South Asian), in 5 body mass index categories, and in 4 maternal size groups with normal body mass index (18.5-25.0 kg/m2). The differences in trend between stillbirth and small-for-gestational-age rates were assessed using the Clogg z test, and differences between stillbirths and body mass index groups were assessed using the chi-square trend test. RESULTS Stillbirth rates (per 1000) were higher in South Asian pregnancies (5.51) than British-European pregnancies (3.89) (P<.01) and increased in both groups with increasing body mass index (P<.01). Small-for-gestational-age rates were 2 to 3-fold higher for South Asian babies than British European babies according to the population-average standards (Hadlock: 26.2% vs 12.2%; Intergrowth-21st: 12.1% vs 4.9%; World Health Organization: 32.2% vs 16.0%) but were similar by the customized GROW standard (14.0% vs 13.6%). Despite the wide variation, each standard's small-for-gestation-age cases had increased stillbirth risk compared with non-small-for-gestation-age cases, with the magnitude of risk inversely proportional to the rate of cases defined as small for gestational age. All standards had similar stillbirth risk when the small-for-gestation-age rate was fixed at 10% by varying their respective thresholds for defining small for gestational age. When analyzed across body mass index subgroups, the small-for-gestation-age rate according to the GROW standard increased with increasing stillbirth rate, whereas small-for-gestation-age rates according to Hadlock, Intergrowth-21st, and World Health Organization fetal weight standards declined with increasing body mass index, showing a difference in trend (P<.01) to stillbirth rates across body mass index groups. In the normal body mass index subgroup, stillbirth rates showed little variation across maternal size groups; this trend was followed by GROW-based small-for-gestation-age rates, whereas small-for-gestation-age rates defined by each population-average standard declined with increasing maternal size. CONCLUSION Comparisons between population-average and customized fetal growth charts require examination of how well each standard identifies pregnancies at risk of adverse outcomes within subgroups of any heterogeneous population. In both ethnic groups studied, increasing maternal body mass index was accompanied by increasing stillbirth risk, and this trend was reflected in more pregnancies being identified as small for gestational age only by the customized standard. In contrast, small-for-gestation-age rates fell according to each population-average standard, thereby hiding the increased stillbirth risk associated with high maternal body mass index.
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Affiliation(s)
| | - Oliver Hugh
- Perinatal Institute, Birmingham, United Kingdom
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Pritchard NL, Hiscock R, Walker SP, Tong S, Lindquist AC. Defining poor growth and stillbirth risk in pregnancy for infants of mothers with overweight and obesity. Am J Obstet Gynecol 2023; 229:59.e1-59.e12. [PMID: 36623632 DOI: 10.1016/j.ajog.2022.12.322] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 12/17/2022] [Accepted: 12/19/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Mothers who are obese carry heavier fetuses and have lower rates of small for gestational age (<10th birthweight centile) infants. However, their infants may be growth-restricted (with an increased risk of stillbirth) at a higher birthweight centile compared with infants from healthy-weight women. OBJECTIVE This study aimed to quantify the birthweight centile at which the risk of stillbirth in infants born to obese women equaled that of <10th-centile infants born to healthy-weight women, and clarify the relationship between maternal body mass index, infant size, and stillbirth. STUDY DESIGN We conducted a retrospective cohort study on all infants born in Victoria, Australia, from 2009 to 2019 (754,946 cases for analysis). We applied uncustomized birthweight centiles to all infants, and stratified the maternal cohort by body mass index (<20 kg/m2, 20-25 kg/m2, 25-30 kg/m2, 30-35 kg/m2, 35-40 kg/m2, ≥40 kg/m2). For each body mass index category, we assessed proportions of infants born <10th centile and <3rd centile, stillbirth rates among infants of all sizes, and small for gestational age infants. We calculated the stillbirth rate (per 1000) and relative risk (risk of stillbirth if born <10th centile vs >10th centile) for healthy-weight women (body mass index, 20-25 kg/m2). We then determined the birthweight centile for infants born to mothers within other body mass index categories that equaled that rate or risk. RESULTS Stillbirth rates increased with increasing maternal body mass index. Infants classified as small for gestational age (<10th centile) from mothers with high body mass index had a higher risk of stillbirth (relative risk, 3.15; 95% confidence interval, 2.22-4.47; for mothers with body mass index ≥40 kg/m2 vs healthy-weight mothers [body mass index, 20-25 kg/m2]). The stillbirth rate (stillborn infants per 1000 births) among <10th-centile infants born to healthy-weight mothers was 7.5 per 1000. The same stillbirth rate was observed at higher birthweight centiles for infants of women with higher body mass index (<18th centile for those with a body mass index of 25-30 kg/m2, <25th centile for body mass index of 30-35 kg/m2, <31st centile for body mass index of 35-40 kg/m2, <41st centile for body mass index of ≥40 kg/m2). The relative risk of stillbirth among small for gestational age infants of healthy-weight mothers was 5.46 (95% confidence interval, 4.65-6.40). The birthweight centile with a comparable relative risk of stillbirth increased with increasing body mass index (<16th centile for women with body mass index of 25-30 kg/m2, <19th centile for body mass index of 30-35 kg/m2, <28th centile for body mass index of 35-40 kg/m2, <30th centile for body mass index ≥40 kg/m2). CONCLUSION Obesity affects the relationship between infant size and perinatal mortality. The stillbirth risk observed in <10th-centile infants from healthy-weight mothers occurs at higher birthweight centiles with overweight or obese mothers. Clinicians should be aware that the same infant risk exists at a higher birthweight centile for women with higher body mass index.
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Affiliation(s)
- Natasha L Pritchard
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Australia.
| | - Richard Hiscock
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Australia
| | - Susan P Walker
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Australia
| | - Stephen Tong
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Australia
| | - Anthea C Lindquist
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Australia
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Leal CRV, Rezende KP, Macedo EDCPD, Rezende GDC, Corrêa Júnior MD. Comparison between Protocols for Management of Fetal Growth Restriction. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:96-103. [PMID: 36977407 PMCID: PMC10078887 DOI: 10.1055/s-0043-1764493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/17/2022] [Indexed: 03/30/2023] Open
Abstract
This comprehensive review compares clinical protocols of important entities regarding the management of fetal growth restriction (FGR), published since 2015. Five protocols were chosen for data extraction. There were no relevant differences regarding the diagnosis and classification of FGR between the protocols. In general, all protocols suggest that the assessment of fetal vitality must be performed in a multimodally, associating biophysical parameters (such as cardiotocography and fetal biophysical profile) with the Doppler velocimetry parameters of the umbilical artery, middle cerebral artery, and ductus venosus. All protocols reinforce that the more severe the fetal condition, the more frequent this assessment should be made. The timely gestational age and mode of delivery to terminate the pregnancy in these cases can vary much between the protocols. Therefore, this paper presents, in a didactic way, the particularities of different protocols for monitoring FGR, in order to help obstetricians to better manage the cases.
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Butler E, Hugh O, Gardosi J. Evaluating the Growth Assessment Protocol for stillbirth prevention: progress and challenges. J Perinat Med 2022; 50:737-747. [PMID: 35618671 DOI: 10.1515/jpm-2022-0209] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2022] [Indexed: 11/15/2022]
Abstract
Many stillbirths are associated with fetal growth restriction, and are hence potentially avoidable. The Growth Assessment Protocol (GAP) is a multidisciplinary program with an evidence based care pathway, training in risk assessment, fetal growth surveillance with customised charts and rolling audit. Antenatal detection of small for gestational age (SGA) has become an indicator of quality of care. Evaluation is essential to understand the impact of such a prevention program. Randomised trials will not be effective if they cannot ensure proper implementation before assessment. Observational studies have allowed realistic evaluation in practice, with other factors excluded that may have influenced the outcome. An award winning 10 year study of stillbirth data in England has been able to assess the effect of GAP in isolation, and found a strong, causal association with improved antenatal detection of SGA babies, and the sustained decline in national stillbirth rates. The challenge now is to apply this program more widely in low and middle income settings where the main global burden of stillbirth is, and to adapt it to local needs and resources.
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Kofman R, Farkash R, Rottenstreich M, Samueloff A, Wasserteil N, Kasirer Y, Grisaru Granovsky S. Parity-Adjusted Term Neonatal Growth Chart Modifies Neonatal Morbidity and Mortality Risk Stratification. J Clin Med 2022; 11:jcm11113097. [PMID: 35683486 PMCID: PMC9181536 DOI: 10.3390/jcm11113097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/08/2022] [Accepted: 05/26/2022] [Indexed: 12/10/2022] Open
Abstract
Objective: To investigate the impact of parity-customized versus population-based birth weight charts on the identification of neonatal risk for adverse outcomes in small (SGA) or large for gestational age (LGA) infants compared to appropriate for gestational age (AGA) infants. Study design: Observational, retrospective, cohort study based on electronic medical birth records at a single center between 2006 and 2017. Neonates were categorized by birth weight (BW) as SGA, LGA, or AGA, with the 10th and 90th centiles as boundaries for AGA in a standard population-based model adjusted for gestational age and gender only (POP) and a customized model adjusted for gestational age, gender, and parity (CUST). Neonates defined as SGA or LGA by one standard and not overlapping the other, are SGA/LGA CUST/POP ONLY. Analyses used a reference group of BW between the 25th and 75th centile for the population. Results: Overall 132,815 singleton, live, term neonates born to mothers with uncomplicated pregnancies were included. The customized model identified 53% more neonates as SGA-CUST ONLY who had significantly higher rates of morbidity and mortality compared to the reference group (OR = 1.33 95% CI [1.16−1.53]; p < 0.0001). Neonates defined as LGA by the customized model (LGA-CUST) and AGA by the population-based model LGA-CUST ONLY had a significantly higher risk for morbidity compared to the reference (OR = 1.36 95% CI [1.09−1.71]; p = 0.007) or the LGA POP group. Neonatal mortality only occurred in the SGA and AGA groups. Conclusions: The application of a parity-customized only birth weight chart in a population of singleton, term neonates is a simple platform to better identify birth weight related neonatal risk for morbidity and mortality.
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Affiliation(s)
- Roie Kofman
- Department of Internal Medicine, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, POB 12000, Jerusalem 91120, Israel;
| | - Rivka Farkash
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel; (R.F.); (A.S.); (S.G.G.)
| | - Misgav Rottenstreich
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel; (R.F.); (A.S.); (S.G.G.)
- Correspondence: ; Tel.: +972-2-655-5562; Fax: +972-2-666-6053
| | - Arnon Samueloff
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel; (R.F.); (A.S.); (S.G.G.)
| | - Netanel Wasserteil
- Department of Pediatrics, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel; (N.W.); (Y.K.)
| | - Yair Kasirer
- Department of Pediatrics, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel; (N.W.); (Y.K.)
| | - Sorina Grisaru Granovsky
- Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel; (R.F.); (A.S.); (S.G.G.)
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Dheresa M, Daraje G, Fekadu G, Ayana GM, Balis B, Negash B, Raru TB, Dessie Y, Alemu A, Merga BT. Perinatal mortality and its predictors in Kersa Health and Demographic Surveillance System, Eastern Ethiopia: population-based prospective study from 2015 to 2020. BMJ Open 2022; 12:e054975. [PMID: 35584868 PMCID: PMC9119174 DOI: 10.1136/bmjopen-2021-054975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Perinatal mortality is an important outcome indicator for newborn care and directly mirrors the quality of prenatal, intra partum and newborn care. Therefore, this study was aimed at estimating perinatal mortality and its predictors in Eastern Ethiopia using data from Kersa Health and Demographic Surveillance System (KHDSS). DESIGN, SETTINGS AND PARTICIPANTS An open dynamic cohort design was employed among pregnant women from 2015 to 2020 at KHDSS. A total of 19 687 women were observed over the period of 6 years, and 29 719 birth outcomes were registered. OUTCOME MEASURES Perinatal mortality rate was estimated for each year of cohort and the cumulative of 6 years. Predictors of perinatal mortality are identified. RESULTS From a total of 29 306 births 783 (26.72 deaths per 1000 births; 95% CI 24.88 to 28.66) deaths were occurred during perinatal period. Rural residence (adjusted OR (AOR)=3.43; 95% CI 2.04 to 5.76), birth weight (low birth weight, AOR=3.98; 95% CI 3.04 to 5.20; big birth weight, AOR=2.51; 95% CI 1.76 to 3.57), not having antenatal care (ANC) (AOR=1.67; 95% CI 1.29 to 2.17) were associated with higher odds of perinatal mortality whereas the parity (multipara, AOR=0.46; 95% CI 0.34 to 0.62; grand multipara, AOR=0.31; 95% CI 0.21 to 0.47) was associated with lower odds of perinatal mortality. CONCLUSIONS The study revealed relatively high perinatal mortality rate. Place of residence, ANC, parity and birth weight were identified as predictors of perinatal mortality. Devising strategies that enhance access to and utilisations of ANC services with due emphasis for rural residents, primipara mothers and newborn with low and big birth weights may be crucial for reducing perinatal mortality.
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Affiliation(s)
- Merga Dheresa
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Gamachis Daraje
- Department of Statistics, Haramaya University, Haramaya, Ethiopia
| | - Gelana Fekadu
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Galana Mamo Ayana
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Bikila Balis
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Belay Negash
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Temam Beshir Raru
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Yadeta Dessie
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Addisu Alemu
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Bedasa Taye Merga
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
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Aulinas A, Stantonyonge N, García-Patterson A, Adelantado JM, Medina C, Espinós JJ, López E, Webb SM, Corcoy R. Hypopituitarism and pregnancy: clinical characteristics, management and pregnancy outcome. Pituitary 2022; 25:275-284. [PMID: 34846622 PMCID: PMC8894301 DOI: 10.1007/s11102-021-01196-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE To describe the clinical characteristics, management and pregnancy outcome of women with prepregnancy hypopituitarism (HYPO) that received care at our center. METHODS Retrospective study describing 12 pregnancies in women with prepregnancy HYPO (two or more pituitary hormonal deficiencies under replacement treatment) that received care during pregnancy at Hospital Santa Creu i Sant Pau. Clinical characteristics, management and pregnancy outcome were systematically collected. RESULTS Average patients' age was 35 years and HYPO duration at the beginning of pregnancy was 19 years. The most frequent cause of HYPO was surgical treatment of a sellar mass (8 pregnancies). Eight pregnancies were in primigravid women and 10 required assisted reproductive techniques. The hormonal deficits before pregnancy were as follows: GH in 12 women, TSH in 10, gonadotropin in 9, ACTH in 5 and ADH in 2. All deficits were under hormonal substitution except for GH deficit in 4 pregnancies. During pregnancy, 4 new deficits were diagnosed. The dosage of replacement treatment for TSH, ACTH and ADH deficits was increased and GH was stopped. Average gestational age at birth was 40 weeks, gestational weight gain was excessive in 9 women, 8 patients required induction/elective delivery and cesarean section was performed in 6. Average birthweight was 3227 g. No major complications were observed. Five women were breastfeeding at discharge. CONCLUSIONS In this group of women with long-standing HYPO, with careful clinical management (including treatment of new-onset hormonal deficits) pregnancy outcome was satisfactory but with a high rate of excessive gestational weight gain and cesarean section.
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Affiliation(s)
- Anna Aulinas
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER Unidad 747), ISCIII, Barcelona, Spain
- Department of Medicine, University of Vic - Central University of Catalonia, Vic, Barcelona, Spain
- Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Nicole Stantonyonge
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Juan M Adelantado
- Department of Gynecology and Obstetrics, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Carmen Medina
- Department of Gynecology and Obstetrics, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Juan José Espinós
- Department of Gynecology and Obstetrics, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Esther López
- Department of Pediatrics, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Susan M Webb
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER Unidad 747), ISCIII, Barcelona, Spain
- Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rosa Corcoy
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
- Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBERBBN), ISCIII, Madrid, Spain.
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Parity status and the relationship between antenatal rubella serology with obstetric outcome. Sci Rep 2022; 12:1278. [PMID: 35075197 PMCID: PMC8786935 DOI: 10.1038/s41598-022-05376-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 01/05/2022] [Indexed: 11/08/2022] Open
Abstract
Routine antenatal rubella serological testing is adopted in many countries. In a population covered by universal childhood rubella immunization for four decades, we have observed an association between pre-eclampsia with maternal rubella seronegativity among multiparous gravidae. This retrospective cohort study was further performed to elucidate the interaction between parity status and rubella seronegativity on obstetric outcome in singleton pregnancies carried to ≥ 24 weeks gestation managed from 1997 to 2019, with the data retrieved from a computerized database used for annual statistics and auditing. Of the 133,926 singleton pregnancies eligible for the study, the 13,320 (9.9%) rubella seronegative gravidae had higher mean booking weight and body mass index (BMI), but shorter height, and higher incidence of advanced age (≥ 35 years), high BMI, short stature, and lower incidence of nulliparas. Univariate analysis showed that adverse obstetric outcomes were more frequently found among the multiparas. On multivariate analysis, there was increased postdated (> 41 weeks) pregnancy irrespective of parity status, while nulliparas had reduced gestational hypertension (aRR 0.714, 95% CI 0.567-0.899) and gestational diabetes (aRR 0.850, 95% CI 0.762-0.950), and multiparas had increased pre-eclampsia (aRR 1.261, 95% CI 1.005-1.582), neonatal death (aRR 2.796, 95% CI 1.243-6.291), and perinatal death (aRR 2.123, 95% CI 1.257-3.587). In conclusion, in a population covered by universal childhood rubella immunization, antenatal rubella seronegativity is associated with increased pre-eclampsia and perinatal loss only in multiparas, suggesting that the rubella seronegativity in these women served as proxy for some form of altered immune response which increases adverse pregnancy outcome.
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Fay E, Hugh O, Francis A, Katz R, Sitcov K, Souter V, Gardosi J. Customized GROW vs INTERGROWTH-21 st birthweight standards to identify small for gestational age associated perinatal outcomes at term. Am J Obstet Gynecol MFM 2021; 4:100545. [PMID: 34875415 DOI: 10.1016/j.ajogmf.2021.100545] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/17/2021] [Accepted: 11/30/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fetal growth restriction is associated with stillbirth and other adverse pregnancy outcomes, and use of the correct weight standard is an essential proxy indicator of growth status and perinatal risk. OBJECTIVE We sought to assess the performance of two international birthweight standards for their ability to identify perinatal morbidity and mortality indicators associated with small for gestational age (SGA) infants at term. STUDY DESIGN This retrospective cohort study used data from a multi-center perinatal quality initiative including a multi-ethnic dataset of 125,826 births from 2012-2017. Of the singleton term births, 92,622 had complete outcome data including stillbirth, neonatal death, 5-minute Apgar <7, neonatal glucose instability and need for newborn transfer to a higher level of care or NICU admission. The customized (GROW) and INTERGROWTH-21st (IG21) birthweight standards were applied to determine SGA (<10th centile) according to their respective methods and formulae. Associations with adverse outcomes were expressed as relative risk (RR) with 95% confidence interval (CI) and population attributable fraction (PAF). RESULTS GROW classified 9,578 (10.3%) and IG21 classified 4,079 (4.4%) pregnancies as SGA, respectively. For all of the outcomes assessed, GROW identified more SGA infants with adverse outcomes than IG21, including more stillbirths, perinatal deaths, low Apgar scores, glucose instability, newborn seizure and transfers to a higher level of care. Thirteen of the 27 stillbirths (48%) that were SGA by either method were identified as SGA by GROW but not by IG21. Similarly, additional cases of all other adverse outcome indicators were identified by GROW as SGA, while only in one category (glucose instability) did IG21 identify 9 of 295 cases (3.1%) which were not identified as SGA by GROW. CONCLUSION Customized assessment using GROW results in increased identification of small for gestational age term babies that are at significantly increased risk of an array of adverse pregnancy outcomes.
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Affiliation(s)
- Emily Fay
- OB COAP, Foundation for Health Care Quality, Seattle WA 98104, USA; Department of Obstetrics & Gynecology, University of Washington, Seattle WA 98195, USA
| | - Oliver Hugh
- Perinatal Institute, Birmingham B15 3BU, United Kingdom
| | - Andre Francis
- Perinatal Institute, Birmingham B15 3BU, United Kingdom
| | - Ronit Katz
- Department of Obstetrics & Gynecology, University of Washington, Seattle WA 98195, USA
| | - Kristin Sitcov
- OB COAP, Foundation for Health Care Quality, Seattle WA 98104, USA
| | - Vivienne Souter
- OB COAP, Foundation for Health Care Quality, Seattle WA 98104, USA
| | - Jason Gardosi
- Perinatal Institute, Birmingham B15 3BU, United Kingdom.
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11
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Perinatal Adverse Effects in Newborns with Estimated Loss of Weight Percentile between the Third Trimester Ultrasound and Delivery. The GROWIN Study. J Clin Med 2021; 10:jcm10204643. [PMID: 34682766 PMCID: PMC8537032 DOI: 10.3390/jcm10204643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 11/24/2022] Open
Abstract
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.
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12
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Yuill S, Velentzis LS, Smith M, Egger S, Wrede CD, Bateson D, Arbyn M, Canfell K. The impact of HPV vaccination beyond cancer prevention: effect on pregnancy outcomes. Hum Vaccin Immunother 2021; 17:3562-3576. [PMID: 34506257 PMCID: PMC8437490 DOI: 10.1080/21645515.2021.1936860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 05/22/2021] [Indexed: 10/20/2022] Open
Abstract
While the benefits of human papillomavirus (HPV) vaccination relating to cervical cancer prevention have been widely documented, recent published evidence is suggestive of an impact on adverse pregnancy outcomes (APOs) in vaccinated mothers and their infants, including a reduction in rates of preterm births and small for gestational age infants. In this review, we examine this evidence and the possible mechanisms by which HPV vaccination may prevent these APOs. Large-scale studies linking HPV vaccination status with birth registries are needed to confirm these results. Potential confounding factors to consider in future analyses include other risk factors for APOs, and historical changes in both the management of cervical precancerous lesions and prevention of APOs. If confirmed, these additional benefits of HPV vaccination in reducing APO rates will be of global significance, due to the substantial health, social and economic costs associated with APOs, strengthening the case for worldwide HPV immunization.
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Affiliation(s)
- Susan Yuill
- Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, Australia
- School of Public Health, University of Sydney, Sydney, Australia
| | - Louiza S. Velentzis
- Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, Australia
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Megan Smith
- Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, Australia
| | - Sam Egger
- Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, Australia
| | - C. David Wrede
- Department of Oncology & Dysplasia, Royal Women’s Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Deborah Bateson
- Family Planning NSW, Australia
- Discipline of Obstetrics, Gynaecology & Neonatology, Faculty of Medicine and Health, The University of Sydney School of Medicine, Sydney, Australia
| | - Marc Arbyn
- Unit Cancer Epidemiology, Belgian Cancer Centre, Sciensano, Brussels, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Karen Canfell
- Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, Australia
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13
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Allotey J, Snell KI, Smuk M, Hooper R, Chan CL, Ahmed A, Chappell LC, von Dadelszen P, Dodds J, Green M, Kenny L, Khalil A, Khan KS, Mol BW, Myers J, Poston L, Thilaganathan B, Staff AC, Smith GC, Ganzevoort W, Laivuori H, Odibo AO, Ramírez JA, Kingdom J, Daskalakis G, Farrar D, Baschat AA, Seed PT, Prefumo F, da Silva Costa F, Groen H, Audibert F, Masse J, Skråstad RB, Salvesen KÅ, Haavaldsen C, Nagata C, Rumbold AR, Heinonen S, Askie LM, Smits LJ, Vinter CA, Magnus PM, Eero K, Villa PM, Jenum AK, Andersen LB, Norman JE, Ohkuchi A, Eskild A, Bhattacharya S, McAuliffe FM, Galindo A, Herraiz I, Carbillon L, Klipstein-Grobusch K, Yeo S, Teede HJ, Browne JL, Moons KG, Riley RD, Thangaratinam S. Validation and development of models using clinical, biochemical and ultrasound markers for predicting pre-eclampsia: an individual participant data meta-analysis. Health Technol Assess 2021; 24:1-252. [PMID: 33336645 DOI: 10.3310/hta24720] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity. Early identification of women at risk is needed to plan management. OBJECTIVES To assess the performance of existing pre-eclampsia prediction models and to develop and validate models for pre-eclampsia using individual participant data meta-analysis. We also estimated the prognostic value of individual markers. DESIGN This was an individual participant data meta-analysis of cohort studies. SETTING Source data from secondary and tertiary care. PREDICTORS We identified predictors from systematic reviews, and prioritised for importance in an international survey. PRIMARY OUTCOMES Early-onset (delivery at < 34 weeks' gestation), late-onset (delivery at ≥ 34 weeks' gestation) and any-onset pre-eclampsia. ANALYSIS We externally validated existing prediction models in UK cohorts and reported their performance in terms of discrimination and calibration. We developed and validated 12 new models based on clinical characteristics, clinical characteristics and biochemical markers, and clinical characteristics and ultrasound markers in the first and second trimesters. We summarised the data set-specific performance of each model using a random-effects meta-analysis. Discrimination was considered promising for C-statistics of ≥ 0.7, and calibration was considered good if the slope was near 1 and calibration-in-the-large was near 0. Heterogeneity was quantified using I 2 and τ2. A decision curve analysis was undertaken to determine the clinical utility (net benefit) of the models. We reported the unadjusted prognostic value of individual predictors for pre-eclampsia as odds ratios with 95% confidence and prediction intervals. RESULTS The International Prediction of Pregnancy Complications network comprised 78 studies (3,570,993 singleton pregnancies) identified from systematic reviews of tests to predict pre-eclampsia. Twenty-four of the 131 published prediction models could be validated in 11 UK cohorts. Summary C-statistics were between 0.6 and 0.7 for most models, and calibration was generally poor owing to large between-study heterogeneity, suggesting model overfitting. The clinical utility of the models varied between showing net harm to showing minimal or no net benefit. The average discrimination for IPPIC models ranged between 0.68 and 0.83. This was highest for the second-trimester clinical characteristics and biochemical markers model to predict early-onset pre-eclampsia, and lowest for the first-trimester clinical characteristics models to predict any pre-eclampsia. Calibration performance was heterogeneous across studies. Net benefit was observed for International Prediction of Pregnancy Complications first and second-trimester clinical characteristics and clinical characteristics and biochemical markers models predicting any pre-eclampsia, when validated in singleton nulliparous women managed in the UK NHS. History of hypertension, parity, smoking, mode of conception, placental growth factor and uterine artery pulsatility index had the strongest unadjusted associations with pre-eclampsia. LIMITATIONS Variations in study population characteristics, type of predictors reported, too few events in some validation cohorts and the type of measurements contributed to heterogeneity in performance of the International Prediction of Pregnancy Complications models. Some published models were not validated because model predictors were unavailable in the individual participant data. CONCLUSION For models that could be validated, predictive performance was generally poor across data sets. Although the International Prediction of Pregnancy Complications models show good predictive performance on average, and in the singleton nulliparous population, heterogeneity in calibration performance is likely across settings. FUTURE WORK Recalibration of model parameters within populations may improve calibration performance. Additional strong predictors need to be identified to improve model performance and consistency. Validation, including examination of calibration heterogeneity, is required for the models we could not validate. STUDY REGISTRATION This study is registered as PROSPERO CRD42015029349. 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. 24, No. 72. See the NIHR Journals Library website for further project information.
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14
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González González NL, González Dávila E, González Martín A, Padrón E, García Hernández JÁ. Maternal Thinness and Obesity and Customized Fetal Weight Charts. Fetal Diagn Ther 2021; 48:551-559. [PMID: 34407539 DOI: 10.1159/000515251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 02/15/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of the study was to determine if customized fetal growth charts developed excluding obese and underweight mothers (CC(18.5-25)) are better than customized curves (CC) at identifying pregnancies at risk of perinatal morbidity. MATERIAL AND METHODS Data from 20,331 infants were used to construct CC and from 11,604 for CC(18.5-25), after excluding the cases with abnormal maternal BMI. The 2 models were applied to 27,507 newborns and the perinatal outcomes were compared between large for gestational age (LGA) or small for gestational age (SGA) according to each model. Logistic regression was used to calculate the OR of outcomes by the group, with gestational age (GA) as covariable. The confidence intervals of pH were calculated by analysis of covariance. RESULTS The rate of cesarean and cephalopelvic disproportion (CPD) were higher in LGAonly by CC(18.5-25) than in LGAonly by CC. In SGAonly by CC(18.5-25), neonatal intensive care unit (NICU) and perinatal mortality rates were higher than in SGAonly by CC. Adverse outcomes rate was higher in LGAonly by CC(18.5-25) than in LGAonly by CC (21.6%; OR = 1.61, [1.34-193]) vs. (13.5%; OR = 0.84, [0.66-1.07]), and in SGA only by CC(18.5-25) than in SGAonly by CC (9.6%; OR = 1.62, [1.25-2.10] vs. 6.3%; OR = 1.18, [0.85-1.66]). CONCLUSION The use of CC(18.5-25) allows a more accurate identification of LGA and SGA infants at risk of perinatal morbidity than conventional CC. This benefit increase and decrease, respectively, with GA.
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Affiliation(s)
- Nieves L González González
- Obstetrics and Gynecology Department, University of La Laguna, Canary Islands, University Hospital of Canary Islands., La Laguna, Spain
| | - Enrique González Dávila
- Mathematics, Statistics and Operations Research Department, University of La Laguna, La Laguna, Spain
| | - Agustina González Martín
- Obstetrics and Gynecology Department, University of La Laguna, Canary Islands, University Hospital of Canary Islands., La Laguna, Spain
| | - Erika Padrón
- Obstetrics and Gynecology Department, University of La Laguna, Canary Islands, University Hospital of Canary Islands., La Laguna, Spain
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15
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Customized versus Population Growth Standards for Morbidity and Mortality Risk Stratification Using Ultrasonographic Fetal Growth Assessment at 22 to 29 Weeks' Gestation. Am J Perinatol 2021; 38:e46-e56. [PMID: 32198743 PMCID: PMC7537732 DOI: 10.1055/s-0040-1705114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The aim of study is to compare the performance of ultrasonographic customized and population fetal growth standards for prediction adverse perinatal outcomes. STUDY DESIGN This was a secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be, in which l data were collected at visits throughout pregnancy and after delivery. Percentiles were assigned to estimated fetal weights (EFWs) measured at 22 to 29 weeks using the Hadlock population standard and a customized standard (www.gestation.net). Areas under the curve were compared for the prediction of composite and severe composite perinatal morbidity using EFW percentile. RESULTS Among 8,701 eligible study participants, the population standard diagnosed more fetuses with fetal growth restriction (FGR) than the customized standard (5.5 vs. 3.5%, p < 0.001). Neither standard performed better than chance to predict composite perinatal morbidity. Although the customized performed better than the population standard to predict severe perinatal morbidity (areas under the curve: 0.56 vs. 0.54, p = 0.003), both were poor. Fetuses considered FGR by the population standard but normal by the customized standard had morbidity rates similar to fetuses considered normally grown by both standards.The population standard diagnosed FGR among black women and Hispanic women at nearly double the rate it did among white women (p < 0.001 for both comparisons), even though morbidity was not different across racial/ethnic groups. The customized standard diagnosed FGR at similar rates across groups. Using the population standard, 77% of FGR cases were diagnosed among female fetuses even though morbidity among females was lower (p < 0.001). The customized model diagnosed FGR at similar rates in male and female fetuses. CONCLUSION At 22 to 29 weeks' gestation, EFW percentile alone poorly predicts perinatal morbidity whether using customized or population fetal growth standards. The population standard diagnoses FGR at increased rates in subgroups not at increased risk of morbidity and at lower rates in subgroups at increased risk of morbidity, whereas the customized standard does not.
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16
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Bacon S, Burger D, Tailor M, Sanchez JJ, Tomlinson G, Murphy HR, Feig DS. Can placental growth factors explain birthweight variation in offspring of women with type 1 diabetes? Diabetologia 2021; 64:1527-1537. [PMID: 33839801 DOI: 10.1007/s00125-021-05438-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/11/2020] [Indexed: 11/26/2022]
Abstract
AIMS/HYPOTHESIS Maternal hyperglycaemia alone does not explain the incidence of large offspring amongst women with type 1 diabetes. The objective of the study was to determine if there is an association between placental function, as measured by angiogenic factors, and offspring birthweight z score in women with type 1 diabetes. METHODS This cohort study included samples from 157 Continuous Glucose Monitoring in Pregnant Women with Type 1 Diabetes (CONCEPTT) trial participants. Correlations were estimated between birthweight z score and placental growth factor (PlGF) and soluble fms-like tyrosine kinase (sFlt-1) levels measured at baseline and at 24 and 34 weeks of gestation. Linear regression was used to assess the relationship between birthweight z score and placental health, as measured by PlGF and sFlt-1/PlGF ratio, stratified by glycaemic status (continuous glucose monitoring and HbA1c measures) and adjusted for potential confounders of maternal BMI, smoking and weight gain. Higher PlGF levels and lower sFlt-1/PlGF ratios represent healthy placentas, while lower PlGF levels and higher sFlt-1/PlGF ratios represent unhealthy placentas. RESULTS Among CONCEPTT participants, the slopes relating PlGF levels to birthweight z scores differed according to maternal glycaemia at 34 weeks of gestation (p = 0.003). With optimal maternal glycaemia (HbA1c < 48 mmol/mol [6.5%]/ or continuous glucose monitoring time above range ≤ 30%), birthweight z scores were reduced towards zero (normal weight) with increasing PlGF values (representing a healthy placenta), and increased with decreasing PlGF values. With suboptimal glycaemic status (HbA1c ≥ 48 mmol/mol [6.5%] or time above range > 30%), increasing PlGF values were associated with heavier infants. Those with a healthy placenta (PlGF > 100) and suboptimal glycaemic control had a higher mean z score (2.45) than those with an unhealthy placenta (mean z score = 1.86). Similar relationships were seen when using sFlt-1/PlGF ratio as a marker for a healthy vs unhealthy placenta. CONCLUSIONS/INTERPRETATION In women with type 1 diabetes, infant birthweight is influenced by both glycaemic status and placental function. In women with suboptimal glycaemia, infant birthweight was heavier when placentas were healthy. Suboptimal placental function should be considered in the setting of suboptimal glycaemia and apparently 'normal' birthweight.
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Affiliation(s)
- Siobhan Bacon
- Mount Sinai Hospital, Sinai Health System, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dylan Burger
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Mayur Tailor
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - George Tomlinson
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | - Helen R Murphy
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
- Women's Health Academic Centre, Division of Women and Children's Health, Kings College London, London, UK
| | - Denice S Feig
- Mount Sinai Hospital, Sinai Health System, Toronto, ON, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
- Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada.
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17
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Side-Population Trophoblasts Exhibit the Differentiation Potential of a Trophoblast Stem Cell Population, Persist to Term, and are Reduced in Fetal Growth Restriction. Stem Cell Rev Rep 2021; 16:764-775. [PMID: 32548656 DOI: 10.1007/s12015-020-09991-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Fetal growth restriction often results from poor placental function and is a major cause of stillbirth. Clinically, fetal growth restriction is difficult to diagnose and currently has no effective treatment. Trophoblasts are unique placental cells that form the feto-maternal interface and facilitate nutrient and gas exchange. Fetal growth restriction is linked to inadequate trophoblast function. However, our understanding of the mechanisms underlying this dysfunction are poor, in part because of our inability to isolate and study the trophoblast stem cells from which mature trophoblasts arise in pathologic pregnancies. METHODS Cells isolated from first-trimester placentae using the Hoechst side-population technique were propagated or differentiated into mature trophoblasts. Side-population trophoblasts were isolated from normal third-trimester and growth restricted placentae using the same technique. First and third-trimester side-population trophoblasts were compared by microarray analysis. RESULTS First-trimester side-population trophoblasts could be propagated in an undifferentiated state or differentiated, via intermediate cytotrophoblasts, into syncytiotrophoblast or extravillous trophoblasts. Using the same technique, side-population trophoblasts could be isolated from term placentae for the first time, demonstrating that while they were present at consistent levels throughout gestation (~3·5%), side-population trophoblasts were significantly depleted in growth restricted pregnancies (0·32%). CONCLUSIONS Our novel method of isolating a population of human trophoblast stem cell-like cells directly from human placental tissue throughout gestation provides the first insights into trophoblast dysfunction in pregnancy pathologies. The depletion of side-population trophoblasts in growth restricted placentae may contribute to poor placental function.
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18
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Pacora P, Romero R, Jung E, Gudicha DW, Hernandez-Andrade E, Musilova I, Kacerovsky M, Jaiman S, Erez O, Hsu CD, Tarca AL. Reduced fetal growth velocity precedes antepartum fetal death. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:942-952. [PMID: 32936481 PMCID: PMC9651138 DOI: 10.1002/uog.23111] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/24/2020] [Accepted: 08/26/2020] [Indexed: 05/25/2023]
Abstract
OBJECTIVES To determine whether decreased fetal growth velocity precedes antepartum fetal death and to evaluate whether fetal growth velocity is a better predictor of antepartum fetal death compared to a single fetal biometric measurement at the last available ultrasound scan prior to diagnosis of demise. METHODS This was a retrospective, longitudinal study of 4285 singleton pregnancies in African-American women who underwent at least two fetal ultrasound examinations between 14 and 32 weeks of gestation and delivered a liveborn neonate (controls; n = 4262) or experienced antepartum fetal death (cases; n = 23). Fetal death was defined as death diagnosed at ≥ 20 weeks of gestation and confirmed by ultrasound examination. Exclusion criteria included congenital anomaly, birth at < 20 weeks of gestation, multiple gestation and intrapartum fetal death. The ultrasound examination performed at the time of fetal demise was not included in the analysis. Percentiles for estimated fetal weight (EFW) and individual biometric parameters were determined according to the Hadlock and Perinatology Research Branch/Eunice Kennedy Shriver National Institute of Child Health and Human Development (PRB/NICHD) fetal growth standards. Fetal growth velocity was defined as the slope of the regression line of the measurement percentiles as a function of gestational age based on two or more measurements in each pregnancy. RESULTS Cases had significantly lower growth velocities of EFW (P < 0.001) and of fetal head circumference, biparietal diameter, abdominal circumference and femur length (all P < 0.05) compared to controls, according to the PRB/NICHD and Hadlock growth standards. Fetuses with EFW growth velocity < 10th percentile of the controls had a 9.4-fold and an 11.2-fold increased risk of antepartum death, based on the Hadlock and customized PRB/NICHD standards, respectively. At a 10% false-positive rate, the sensitivity of EFW growth velocity for predicting antepartum fetal death was 56.5%, compared to 26.1% for a single EFW percentile evaluation at the last available ultrasound examination, according to the customized PRB/NICHD standard. CONCLUSIONS Given that 74% of antepartum fetal death cases were not diagnosed as small-for-gestational age (EFW < 10th percentile) at the last ultrasound examination when the fetuses were alive, alternative approaches are needed to improve detection of fetuses at risk of fetal death. Longitudinal sonographic evaluation to determine growth velocity doubles the sensitivity for prediction of antepartum fetal death compared to a single EFW measurement at the last available ultrasound examination, yet the performance is still suboptimal. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- Percy Pacora
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, USA
- Detroit Medical Center, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Florida International University, Miami, Florida, USA
| | - Eunjung Jung
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Dereje W. Gudicha
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Edgar Hernandez-Andrade
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Ivana Musilova
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Marian Kacerovsky
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Sunil Jaiman
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Offer Erez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Chaur-Dong Hsu
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Physiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Adi L. Tarca
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS), Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Computer Science, Wayne State University College of Engineering, Detroit, Michigan, USA
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19
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Hugh O, Williams M, Turner S, Gardosi J. Reduction of stillbirths in England from 2008 to 2017 according to uptake of the Growth Assessment Protocol: 10-year population-based cohort study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:401-408. [PMID: 32851727 DOI: 10.1002/uog.22187] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/13/2020] [Accepted: 08/18/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Antenatal detection of small-for-gestational age (SGA) can reduce significantly the risk of stillbirth. The Growth Assessment Protocol (GAP) was developed to address the problem that most SGA fetuses are missed antenatally. We set out to analyze the effect that the GAP program has had on stillbirth rates in England. METHODS We analyzed data from 2008 (the year before roll-out of the GAP program) to 2017 (latest available Office for National Statistics (ONS) unit-based data). The program consists of five elements: training, evidence-based guidelines for risk assessment and surveillance of fetal growth, customized charts, recording of process and outcome indicators, and audit of missed SGA cases. All maternity units in England were categorized into one of three groups according to their GAP status in 2017: (1) not in the GAP program; (2) GAP implemented partially (incomplete adoption of protocol, no monitoring and audit); and (3) GAP implemented completely. A subset of the complete-implementation group comprised the 20 units with the highest SGA detection rates. Unit-level live-birth and stillbirth data were obtained from the ONS for each of these groups. RESULTS Stillbirth rates declined across all groups from 2008 to 2017, and significantly more in units in which GAP was implemented completely than in the non-GAP units (P < 0.05). The steepest decline in stillbirth rate was observed in the 20 units with the highest SGA detection rates, which had a 24% lower stillbirth rate compared with the units not using GAP (P < 0.01) in 2017. This difference remained significant after mixed-effects logistic regression analysis of potential confounding, including social deprivation (odds ratio, 0.76 (95% CI, 0.64-0.90)). Assessment of the nine Bradford Hill causality criteria and associated characteristics suggested that the association between implementation of the GAP program and reduction in stillbirth rate was causal. CONCLUSIONS There has been an overall reduction in stillbirth rates in England that is likely to be a result of increased awareness of the importance of antenatal detection of SGA as a key risk factor for stillbirth. The decline in stillbirth rates was significantly greater in maternity units that had fully implemented the GAP program, and was most pronounced in the units with the highest antenatal SGA detection rates. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- O Hugh
- Perinatal Institute, Birmingham, UK
| | | | - S Turner
- Perinatal Institute, Birmingham, UK
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20
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Melamed N, Hiersch L, Aviram A, Keating S, Kingdom JC. Customized birth-weight centiles and placenta-related fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:409-416. [PMID: 33073889 DOI: 10.1002/uog.23516] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 08/20/2020] [Accepted: 09/30/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE The value of using customized birth-weight centiles to improve the diagnostic accuracy for fetal growth restriction (FGR), in comparison with using population-based charts, remains a matter of debate. One potential explanation for the conflicting data is that most studies used measures of perinatal mortality and morbidity as proxies for placenta-mediated FGR, many of which are not specific and may be confounded by other factors such as prematurity. The aim of this study was to compare the diagnostic accuracy of small-for-gestational age (SGA) at birth, defined according to customized vs population-based charts, for associated abnormal placental pathology. METHODS This was a secondary analysis of data from a prospective cohort study on risk factors for placenta-mediated complications and abnormal placental pathology in low-risk nulliparous women. All placentae were sent for detailed histopathological examination by two perinatal pathologists. The primary exposure was SGA, defined as birth weight < 10th centile for gestational age using either a customized (SGAcust ) or a population-based (SGApop ) birth-weight reference. The outcomes of interest were one of three types of abnormal placental pathology associated with FGR: maternal vascular malperfusion (MVM), chronic villitis and fetal vascular malperfusion (FVM). Adjusted relative risks (aRR) with 95% CIs were estimated using modified Poisson regression analysis, with adjustment for smoking, body mass index and aspirin treatment. RESULTS A total of 857 nulliparous women met the study criteria. The proportions of infants identified as SGA based on the customized and population-based charts were 12.6% (108/857) and 11.4% (98/857), respectively. A diagnosis of SGA using either customized or population-based charts was associated with an increased risk of any placental pathology (aRR, 3.04 (95% CI, 2.29-4.04) and 1.60 (95% CI, 1.10-2.31), respectively) and MVM pathology (aRR, 12.33 (95% CI, 6.60-23.03) and 5.29 (95% CI, 2.87-9.76), respectively). SGAcust , but not SGApop , was also associated with an increased risk for chronic villitis (aRR, 1.85 (95% CI, 1.07-3.18)) and FVM pathology (aRR, 2.48 (95% CI, 1.25-4.93)). SGAcust had a higher detection rate for any placental pathology (30.3% vs 17.1%; P < 0.001), MVM pathology (63.2% vs 39.5%; P = 0.003) and chronic villitis (20.8% vs 8.3%; P = 0.007) than did SGApop , for a similar false-positive rate. This was mainly the result of a higher detection rate for abnormal pathology in the white and East-Asian subgroups and a lower false-positive rate for abnormal pathology in the South-Asian subgroup by SGAcust than by SGApop . In addition, pregnancies in the SGAcust group, but not those in the SGApop group, were more likely to be complicated by preterm birth and a low 5-min Apgar score than were the corresponding non-SGA group. CONCLUSION These findings suggest that customized birth-weight centiles may be superior to population-based birth-weight centiles in detecting FGR that is due to underlying placental disease. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- N Melamed
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - L Hiersch
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - A Aviram
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - S Keating
- Department of Laboratory Medicine and Pathobiology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - J C Kingdom
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada
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21
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Meek CL, Corcoy R, Asztalos E, Kusinski LC, López E, Feig DS, Murphy HR. Which growth standards should be used to identify large- and small-for-gestational age infants of mothers with type 1 diabetes? A pre-specified analysis of the CONCEPTT trial. BMC Pregnancy Childbirth 2021; 21:96. [PMID: 33514342 PMCID: PMC7845036 DOI: 10.1186/s12884-021-03554-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 01/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background Offspring of women with type 1 diabetes are at increased risk of fetal growth patterns which are associated with perinatal morbidity. Our aim was to compare rates of large- and small-for-gestational age (LGA; SGA) defined according to different criteria, using data from the Continuous Glucose Monitoring in Type 1 Diabetes Pregnancy Trial (CONCEPTT). Methods This was a pre-specified analysis of CONCEPTT involving 225 pregnant women and liveborn infants from 31 international centres (ClinicalTrials.gov NCT01788527; registered 11/2/2013). Infants were weighed immediately at birth and GROW, INTERGROWTH and WHO centiles were calculated. Relative risk ratios, sensitivity and specificity were used to assess the different growth standards with respect to perinatal outcomes, including neonatal hypoglycaemia, hyperbilirubinaemia, respiratory distress, neonatal intensive care unit (NICU) admission and a composite neonatal outcome. Results Accelerated fetal growth was common, with mean birthweight percentiles of 82.1, 85.7 and 63.9 and LGA rates of 62, 67 and 30% using GROW, INTERGROWTH and WHO standards respectively. Corresponding rates of SGA were 2.2, 1.3 and 8.9% respectively. LGA defined according to GROW centiles showed stronger associations with preterm delivery, neonatal hypoglycaemia, hyperbilirubinaemia and NICU admission. Infants born > 97.7th centile were at highest risk of complications. SGA defined according to INTERGROWTH centiles showed slightly stronger associations with perinatal outcomes. Conclusions GROW and INTERGROWTH standards performed similarly and identified similar numbers of neonates with LGA and SGA. GROW-defined LGA and INTERGROWTH-defined SGA had slightly stronger associations with neonatal complications. WHO standards underestimated size in preterm infants and are less applicable for use in type 1 diabetes. Trial registration This trial is registered with ClinicalTrials.gov. number NCT01788527. Trial registered 11/2/2013. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03554-6.
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Affiliation(s)
- Claire L Meek
- Institute of Metabolic Science, University of Cambridge, Addenbrooke's Hospital, Box 289, Cambridge, CB2 0QQ, UK. .,Cambridge Universities NHS Foundation Trust, Cambridge, UK.
| | - Rosa Corcoy
- Servei d'Endocrinologia i Nutrició, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Institut de Recerca, Hospital de la Santa Creu i Sant Pau, CIBER-BBN, Barcelona, Spain.,Department de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Elizabeth Asztalos
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Laura C Kusinski
- Institute of Metabolic Science, University of Cambridge, Addenbrooke's Hospital, Box 289, Cambridge, CB2 0QQ, UK.,Cambridge Universities NHS Foundation Trust, Cambridge, UK
| | - Esther López
- Institut de Recerca, Hospital de la Santa Creu i Sant Pau, CIBER-BBN, Barcelona, Spain.,Servei de Pediatria, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Denice S Feig
- Mount Sinai Hospital, Department of Medicine, University of Toronto, Toronto, Canada.,Lunenfeld-Tanenbaum Research Institute, Toronto, Canada
| | - Helen R Murphy
- Cambridge Universities NHS Foundation Trust, Cambridge, UK.,Norwich Medical School, University of East Anglia, Norwich, UK.,Department of Women and Children's Health, King's College London, London, UK
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22
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Gibbons KS, McIntyre HD, Mamun A, Chang AMZ. Development of the Birthweight Appropriateness Quotient: A New Measure of Infant's Size. Matern Child Health J 2020; 24:1202-1211. [PMID: 32794153 DOI: 10.1007/s10995-020-02994-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The customised birthweight model can be used to improve detection of babies that may be at risk of adverse outcomes associated with abnormal growth, however it is currently used in conjunction with either an intrauterine growth standard or the individualised birthweight ratio (IBR), both of which have significant methodological flaws. Our aim was to investigate the statistical validity of the IBR and attempt to develop a new measurement to represent the appropriateness of an infant's size at birth that will support clinicians in identifying infants requiring further attention. METHODS Routinely collected hospital maternity and neonatal data on singleton, term births from a tertiary Australian hospital were extracted for the time period 1998-2009. The relationships between birthweight, customised birthweight and IBR are investigated using correlation, regression analysis and division of births into groups of < 2500 g, 2500-4000 g and > 4000 g. A new measure, the Birthweight Appropriateness Quotient (BAQ), is developed. The utility of the BAQ is compared with IBR and birthweight to identify infants with a composite neonatal morbidity outcome. RESULTS Statistical flaws with the IBR due to significant correlation between birthweight and customised birthweight and a heterogenous relationship between these two measurements across the range of birthweight are present. BAQ is uncorrelated with birthweight. Comparison of BAQ and IBR as indicators of adverse neonatal outcome demonstrates that BAQ identifies babies at risk due to their small size and those babies at risk due to inappropriate size. CONCLUSIONS FOR PRACTICE BAQ is a customised measurement of an infant's size free of the statistical flaws experienced by the IBR with the ability to identify at-risk infants.
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Affiliation(s)
- Kristen S Gibbons
- Mothers and Babies Research, Mater Research Institute - The University of Queensland, South Brisbane, Australia. .,Level 4, Centre for Children's Health Research, 62 Graham St, South Brisbane, QLD, 4101, Australia.
| | - H David McIntyre
- Mothers and Babies Research, Mater Research Institute - The University of Queensland, South Brisbane, Australia.,UQ/Mater Clinical School, The University of Queensland, Brisbane, Australia
| | - Abdullah Mamun
- Institute for Social Science Research, The University of Queensland, Brisbane, Australia
| | - Allan M Z Chang
- Department of Obstetrics and Gynaecology, Chinese University of Hong Kong, Shatin, Hong Kong
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23
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Tesfa D, Tadege M, Digssie A, Abebaw S. Intrauterine growth restriction and its associated factors in South Gondar zone hospitals, Northwest Ethiopia, 2019. ACTA ACUST UNITED AC 2020; 78:89. [PMID: 33005403 PMCID: PMC7526174 DOI: 10.1186/s13690-020-00475-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 09/22/2020] [Indexed: 11/23/2022]
Abstract
Background After prematurity, intrauterine growth restriction (IUGR) is the second leading cause of perinatal mortality. IUGR has significant consequences in fetal, neonatal, and adult life. Currently, Ethiopia lacks information on IUGR’s prevalence and its determinants. This study aimed to assess the proportion of IUGR at birth and its associated factors. Methods A cross-sectional study was carried out among women who give birth in four hospitals of south Gonder zone from November 2018 to February 2019. Multi-stage sampling was applied to select the required samples. IUGR was assessed using a standardized cutoff percentile/mean for each measurement. Data were collected by trained MSc clinical midwives. Bi-variable and multivariable logistic analyses were deployed to identify the association. Results A total of 803 maternity women were participating in this study with a response rate of 95%. The proportion of IUGR 23.5% (95% CI: 20.7–26.6), low birth weight 13.3%, small-for- gestational-age 19.7%,and preterm birth 23.16%. Women who was unable to read and write, (AOR; 2.46, 95% CI: 1.02–5.92), total family size ≥7 (AOR; 1.67, 95% CI: 1.04–2.66), maternal mid-upper arm circumference (MUAC) < 23 cm (AOR; 2.10, 95% CI: 1.39–3.01), body mass index (BMI) < 18.5 kg/m2 (AOR; 2.57, 95% CI: 1.72–3.83), altitude > 3000 m (AOR; 1.89 95% CI: 1.19–3.01), small placental size (< 350 g) (AOR; 2.42, 95% CI: 1.67–3.54) and small-for-gestational-age (AOR; 1.94, 95% CI:1.86–4.52) were the most predictors of IUGR. Conclusions IUGR was a major public health concern in this study. Women who were unable to read and write, small-for-gestational-age, maternal BMI < 18.5 kg/m2, family size ≥7, maternal MUAC < 23 cm, small placental size, and altitude > 3000 m were found the most predictor variables. Strengthen female education, nutritional intervention before and during pregnancy, and routine maternity care is critical. Further clinical follow-up research is essential which includes maternal, fetal, and placental gens.
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Affiliation(s)
- Desalegn Tesfa
- Department of Public Health, College of Health Sciences, Debre Tabor University, Debretabor, Ethiopia
| | - Melaku Tadege
- Department of Public Health, College of Health Sciences, Debre Tabor University, Debretabor, Ethiopia
| | - Alemayehu Digssie
- Department of Public Health, College of Health Sciences, Debre Tabor University, Debretabor, Ethiopia
| | - Sofonyas Abebaw
- Department of Public Health, College of Health Sciences, Debre Tabor University, Debretabor, Ethiopia
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24
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van der Vlugt ER, Verburg PE, Leemaqz SY, McCowan LME, Poston L, Kenny LC, Myers J, Walker JJ, Dekker GA, Roberts CT. Sex- and growth-specific characteristics of small for gestational age infants: a prospective cohort study. Biol Sex Differ 2020; 11:25. [PMID: 32370773 PMCID: PMC7201715 DOI: 10.1186/s13293-020-00300-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 04/14/2020] [Indexed: 11/16/2022] Open
Abstract
Background Asymmetric fetal growth and male sex are both associated with adverse neonatal outcome. However, less is known about the influence of asymmetric growth and fetal sex within SGA neonates, a group of infants already at increased risk for adverse neonatal outcomes. The aim of the present study was to provide insight into variance in risk factors for SGA in a fetal sex- and growth symmetry-specific way. Methods For this prospective, multicenter cohort study, data from the Screening for Pregnancy Endpoints (SCOPE) study were used with 5628 nulliparous participants, of which 633 (11.3%) pregnancies were complicated with SGA and 3376 (60.0%) women had uncomplicated pregnancies. Association between risk factors for SGA, SGA subgroups, and uncomplicated pregnancies were assessed with multivariable analyses. Results Prevalence of asymmetric growth varied from 45.8% of SGA infants to 5.5% of infants with a customized birthweight > 90th percentile (p < 0.001). Significantly more SGA males had asymmetric growth compared to SGA female infants (51.2% vs 40.4%, p = 0.009). Maternal pre-pregnancy diet and BMI < 20 and ≥ 30 were significantly associated with symmetric SGA but not with asymmetric SGA. Asymmetric SGA infants had not only lower customized birthweight percentile (4.4 (SD 2.8) vs 5.0 (SD 3.0), p < 0.001), but also lower rates of stillbirth (p = 0.041) and less often Apgar scores < 7 (p = 0.060). Conclusions Among SGA infants, low customized birthweight percentiles and male sex are associated with asymmetric growth. Only symmetric SGA is significantly associated with maternal risk factors in early pregnancy. There is a substantial variance in risk factors and neonatal outcomes for SGA based on growth symmetry, implying a different pathogenesis. Trial registration ACTRN12607000551493
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Affiliation(s)
- Eva R van der Vlugt
- The Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, Australia.,The VU University Amsterdam, Amsterdam, the Netherlands
| | - Petra E Verburg
- The Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, Australia.,The University of Groningen, Groningen, the Netherlands
| | - Shalem Y Leemaqz
- The Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Lesley M E McCowan
- The Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Lucilla Poston
- The Division of Woman's Health, Women's Health Academic Centre, King's College London and King's Health Partners, London, UK
| | - Louise C Kenny
- Department of Women's and Children's Health, Institute of Translational Research, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Jenny Myers
- Maternal and Fetal Health Research Centre, University of Manchester, Manchester, UK
| | - James J Walker
- Section of Obstetrics and Gynaecology, Institute of Biochemical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Gustaaf A Dekker
- The Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, Australia.,The Women and Children's Division, Lyell McEwin Hospital, University of Adelaide, Adelaide, Australia
| | - Claire T Roberts
- The Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, Australia. .,Adelaide Medical School, University of Adelaide, Adelaide, Australia. .,Flinders Institute of Health and Medical Research, Flinders University, Bedford Park, Australia.
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25
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Cartwright RD, Anderson NH, Sadler LC, Harding JE, McCowan LME, McKinlay CJD. Neonatal morbidity and small and large size for gestation: a comparison of birthweight centiles. J Perinatol 2020; 40:732-742. [PMID: 32080336 DOI: 10.1038/s41372-020-0631-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 01/20/2020] [Accepted: 02/11/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To compare rates of small- and large-for-gestational age (SGA and LGA) neonates using four different weight centiles, and to relate these classifications to neonatal morbidity. STUDY DESIGN Neonates born at 33-40 weeks' gestation in a multiethnic population were classified as SGA or LGA by population reference (Fenton), population standard (INTERGROWTH), fetal growth curves (WHO), and customized (GROW) centiles. Likelihood of composite morbidity was determined compared with a common appropriate-for-gestational age referent group. RESULT Among 45,505 neonates, SGA and LGA rates varied up to threefold by different centiles. Those most likely to develop neonatal morbidity were SGA or LGA on both the population reference and an alternative centile. Customized centiles identified over twice as many at-risk SGA neonates. CONCLUSIONS Customized centiles were most useful in identifying neonates at increased risk of morbidity, and those that were small on both customized and population reference centiles were at the highest risk.
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Affiliation(s)
| | - Ngaire H Anderson
- Waitemata District Health Board, Auckland, New Zealand.,Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Lynn C Sadler
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand.,National Women's Health, Auckland City Hospital, Auckland, New Zealand.,Department of Epidemiology and Biostatistics, University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Lesley M E McCowan
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand.,National Women's Health, Auckland City Hospital, Auckland, New Zealand
| | - Christopher J D McKinlay
- Liggins Institute, University of Auckland, Auckland, New Zealand. .,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand. .,Kidz First Neonatal Care, Counties Manukau Health, Auckland, New Zealand.
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Kabiri D, Romero R, Gudicha DW, Hernandez-Andrade E, Pacora P, Benshalom-Tirosh N, Tirosh D, Yeo L, Erez O, Hassan SS, Tarca AL. Prediction of adverse perinatal outcome by fetal biometry: comparison of customized and population-based standards. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:177-188. [PMID: 31006913 PMCID: PMC6810752 DOI: 10.1002/uog.20299] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 04/09/2019] [Accepted: 04/12/2019] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To compare the predictive performance of estimated fetal weight (EFW) percentiles, according to eight growth standards, to detect fetuses at risk for adverse perinatal outcome. METHODS This was a retrospective cohort study of 3437 African-American women. Population-based (Hadlock, INTERGROWTH-21st , World Health Organization (WHO), Fetal Medicine Foundation (FMF)), ethnicity-specific (Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)), customized (Gestation-Related Optimal Weight (GROW)) and African-American customized (Perinatology Research Branch (PRB)/NICHD) growth standards were used to calculate EFW percentiles from the last available scan prior to delivery. Prediction performance indices and relative risk (RR) were calculated for EFW < 10th and > 90th percentiles, according to each standard, for individual and composite adverse perinatal outcomes. Sensitivity at a fixed (10%) false-positive rate (FPR) and partial (FPR < 10%) and full areas under the receiver-operating-characteristics curves (AUC) were compared between the standards. RESULTS Ten percent (341/3437) of neonates were classified as small-for-gestational age (SGA) at birth, and of these 16.4% (56/341) had at least one adverse perinatal outcome. SGA neonates had a 1.5-fold increased risk of any adverse perinatal outcome (P < 0.05). The screen-positive rate of EFW < 10th percentile varied from 6.8% (NICHD) to 24.4% (FMF). EFW < 10th percentile, according to all standards, was associated with an increased risk for each of the adverse perinatal outcomes considered (P < 0.05 for all). The highest RRs associated with EFW < 10th percentile for each adverse outcome were 5.1 (95% CI, 2.1-12.3) for perinatal mortality (WHO); 5.0 (95% CI, 3.2-7.8) for perinatal hypoglycemia (NICHD); 3.4 (95% CI, 2.4-4.7) for mechanical ventilation (NICHD); 2.9 (95% CI, 1.8-4.6) for 5-min Apgar score < 7 (GROW); 2.7 (95% CI, 2.0-3.6) for neonatal intensive care unit (NICU) admission (NICHD); and 2.5 (95% CI, 1.9-3.1) for composite adverse perinatal outcome (NICHD). Although the RR CIs overlapped among all standards for each individual outcome, the RR of composite adverse perinatal outcome in pregnancies with EFW < 10th percentile was higher according to the NICHD (2.46; 95% CI, 1.9-3.1) than the FMF (1.47; 95% CI, 1.2-1.8) standard. The sensitivity for composite adverse perinatal outcome varied substantially between standards, ranging from 15% for NICHD to 32% for FMF, due mostly to differences in FPR; this variation subsided when the FPR was set to the same value (10%). Analysis of AUC revealed significantly better performance for the prediction of perinatal mortality by the PRB/NICHD standard (AUC = 0.70) compared with the Hadlock (AUC = 0.66) and FMF (AUC = 0.64) standards. Evaluation of partial AUC (FPR < 10%) demonstrated that the INTERGROWTH-21st standard performed better than the Hadlock standard for the prediction of NICU admission and mechanical ventilation (P < 0.05 for both). Although fetuses with EFW > 90th percentile were also at risk for any adverse perinatal outcome according to the INTERGROWTH-21st (RR = 1.4; 95% CI, 1.0-1.9) and Hadlock (RR = 1.7; 95% CI, 1.1-2.6) standards, many times fewer cases (2-5-fold lower sensitivity) were detected by using EFW > 90th percentile, rather than EFW < 10th percentile, in screening by these standards. CONCLUSIONS Fetuses with EFW < 10th percentile or EFW > 90th percentile were at increased risk of adverse perinatal outcomes according to all or some of the eight growth standards, respectively. The RR of a composite adverse perinatal outcome in pregnancies with EFW < 10th percentile was higher for the most-stringent (NICHD) compared with the least-stringent (FMF) standard. The results of the complementary analysis of AUC suggest slightly improved detection of adverse perinatal outcome by more recent population-based (INTERGROWTH-21st ) and customized (PRB/NICHD) standards compared with the Hadlock and FMF standards. Published 2019. This article is a U.S. Government work and is in the public domain in the USA.
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Affiliation(s)
- Doron Kabiri
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS)
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS)
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI
- Corresponding authors: Roberto Romero, MD, D.Med.Sci., Perinatology Research Branch, NICHD/NIH/DHHS, Hutzel Women’s Hospital, 3990 John R Street, 4 Brush, Detroit, Michigan 48201; telephone: (313) 993-2700; fax: (313) 577-6294; . Adi L. Tarca, PhD, Perinatology Research Branch, NICHD/NIH/DHHS, Hutzel Women’s Hospital, 3990 John R Street, 4 Brush, Detroit, Michigan 48201; telephone: (313) 577-5305; fax: (313) 577-6294;
| | - Dereje W. Gudicha
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS)
| | - Edgar Hernandez-Andrade
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS)
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Percy Pacora
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS)
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Neta Benshalom-Tirosh
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS)
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Dan Tirosh
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS)
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Lami Yeo
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS)
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Offer Erez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS)
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
- Maternity Department “D”, Division of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Sonia S. Hassan
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS)
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
- Department of Physiology, Wayne State University School of Medicine, Detroit, MI
| | - Adi L. Tarca
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services (NICHD/NIH/DHHS)
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
- Department of Computer Science, Wayne State University College of Engineering, Detroit, MI
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Ramezani Tehrani F. Cost effectiveness of different screening strategies for gestational diabetes mellitus screening: study protocol of a randomized community non-inferiority trial. Diabetol Metab Syndr 2019; 11:106. [PMID: 31890040 PMCID: PMC6921504 DOI: 10.1186/s13098-019-0493-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/09/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND There is lack of ideal and comprehensive economic evaluations of various GDM strategies. The aim of this study is to the compare efficacy and cost-effectiveness of five different methods of screening for gestational diabetes mellitus (GDM). METHODS This study is a randomized community non-inferiority trial among 30,000 pregnant women in five different geographic regions of Iran, who were randomly assigned to one of the five GDM screening methods. All first trimester pregnant women, seeking prenatal care in governmental health care systems, who met our eligibility criteria were enrolled. The criteria suggested by the International-Association-of-Diabetes-in-Pregnancy-Study-Group, the most intensive approach, were used as reference. We used the non-inferiority approach to compare less intensive strategies to the reference one. Along with routine prenatal standard care, all participants were scheduled to have two phases of GDM screening in first and second-trimester of pregnancy, based on five different pre-specified protocols. The screening protocol included fasting plasma glucose in the first trimester and either a one step or a two-step screening method in the second trimester of pregnancy. Pregnant women were classified in three groups based on the results: diagnosed with preexisting pre-gestational overt diabetes; gestational diabetes and non-GDM women. Each group received packages for standard-care and all participants were followed till delivery; pregnancy outcomes, quality of life and cost of health care were recorded in detail using specific standardized questionnaires. Primary outcomes were defined as % birth-weight > 90th percentile and primary cesarean section. In addition, we assessed the direct health care direct and indirect costs. RESULTS This study will enable us to compare the cost effectiveness of different GDM screening protocols and intervention intensity (low versus high). CONCLUSION Results which if needed, will also enable policy makers to optimize the national GMD strategy as a resource for enhancing GDM guidelines.Trial registration Name of the registry: Iranian Registry of Clinical Trials. Trial registration number: IRCT138707081281N1. Date of registration: 2017-02-15. URL of trial registry record: https://www.irct.ir/trial/518.
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Affiliation(s)
- Fahimeh Ramezani Tehrani
- Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No 24, Parvane Street, Yaman Street, Velenjak, P.O.Box: 19395-4763, Tehran, Iran
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Nasri K, Hantoushzadeh S, Hugh O, Heidarzadeh M, Habibelahi A, Shariat M, Tara F, Kashanian M, Radmehr M, Yekaninejad MS, Homeira VC, Francis A, Gardosi J. Customized birthweight standard for an Iranian population. J Matern Fetal Neonatal Med 2019; 34:3651-3656. [PMID: 31766924 DOI: 10.1080/14767058.2019.1689557] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To produce a customized birthweight standard for Iran.Method: Retrospective study of a pregnancy database collected from five hospitals across Iran. The cohort consisted of 4994 consecutive term births with complete data, delivered between July 2013 and November 2014. Coefficients were derived using a backwards stepwise multiple regression technique.Results: Maternal height, weight in early pregnancy and parity as well as the baby's sex were identified as significant physiological variables affecting birthweight. Paternal height and weight were also significant although weaker factors. The expected 280-day birthweight, free from pathological influences, of a standard size mother (height 163 cm, weight 64 kg) in her first pregnancy was 3390 g. Pathological factors found to affect birthweight in this cohort included village housing, anemia, preexisting and gestational diabetes and preeclampsia.Conclusion: The analysis confirmed the main physiological variables that affect birthweight in other countries and shows paternal factors also to be significant variables. Development of a country-specific customized birthweight standard will aid clinicians in Iran to distinguish between fetuses that are either constitutionally or pathologically small, thereby avoiding unnecessary interventions, and improving identification of at-risk pregnancies and perinatal outcome.
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Affiliation(s)
- K Nasri
- Department of Obstetrics and Gynecology, Arak University of Medical Sciences, Arak, Iran
| | - S Hantoushzadeh
- Maternal-Fetal & Neonatal and Breast-Feeding Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - O Hugh
- Perinatal Institute, Birmingham, UK
| | | | | | - M Shariat
- Maternal-Fetal & Neonatal and Breast-Feeding Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - F Tara
- Department of Obstetrics and Gynecology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - M Kashanian
- Department of Obstetrics and Gynecology, Iran University of Medical Sciences and Health Services, Akbar Abadi Teaching Hospital, Tehran, Iran
| | - M Radmehr
- Clinical Research Center, Milad General Hospital, Tehran, Iran
| | - M S Yekaninejad
- Department of Epidemiology & Biostatistics, Tehran University of Medical Sciences, Tehran, Iran
| | - V C Homeira
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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A new customised placental weight standard redefines the relationship between maternal obesity and extremes of placental size and is more closely associated with pregnancy complications than an existing population standard. J Dev Orig Health Dis 2019; 11:350-359. [PMID: 31587680 DOI: 10.1017/s2040174419000576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Placental weight is a valuable indicator of its function, predicting both pregnancy outcome and lifelong health. Population-based centile charts of weight-for-gestational-age and parity are useful for identifying extremes of placental weight but fail to consider maternal size. To address this deficit, a multiple regression model was fitted to derive coefficients for predicting normal placental weight using records from healthy pregnancies of nulliparous/multiparous women of differing height and weight (n = 107,170 deliveries, 37-43 weeks gestation). The difference between actual and predicted placental weight generated a z-score/individual centile for the entire cohort including women with pregnancy complications (n = 121,591). The association between maternal BMI and placental weight extremes defined by the new customised versus population-based standard was investigated by logistic regression, as was the association between low placental weight and pregnancy complications. Underweight women had a greater risk of low placental weight [<10thcentile, OR 1.84 (95% CI 1.66, 2.05)] and obese women had a greater risk of high placental weight [>90th centile, OR 1.98 (95% CI 1.88, 2.10)] using a population standard. After customisation, the risk of high placental weight in obese/morbidly obese women was attenuated [OR 1.17 (95% CI 1.09, 1.25)]/no longer significant, while their risk of low placental weight was 59%-129% higher (P < 0.001). The customised placental weight standard was more closely associated with stillbirth, hypertensive disease, placental abruption and neonatal death than the population standard. Our customised placental weight standard reveals higher risk of relative placental growth restriction leading to lower than expected birthweights in obese women, and a stronger association between low placental weight and pregnancy complications generally. Further, it provides an alternative tool for defining placental weight extremes with implications for the placental programming of chronic disease.
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Pritchard NL, Hiscock RJ, Lockie E, Permezel M, McGauren MFG, Kennedy AL, Green B, Walker SP, Lindquist AC. Identification of the optimal growth charts for use in a preterm population: An Australian state-wide retrospective cohort study. PLoS Med 2019; 16:e1002923. [PMID: 31584941 PMCID: PMC6777749 DOI: 10.1371/journal.pmed.1002923] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 09/09/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Preterm infants are a group at high risk of having experienced placental insufficiency. It is unclear which growth charts perform best in identifying infants at increased risk of stillbirth and other adverse perinatal outcomes. We compared 2 birthweight charts (population centiles and INTERGROWTH-21st birthweight centiles) and 3 fetal growth charts (INTERGROWTH-21st fetal growth charts, World Health Organization fetal growth charts, and Gestation Related Optimal Weight [GROW] customised growth charts) to identify which chart performed best in identifying infants at increased risk of adverse perinatal outcome in a preterm population. METHODS AND FINDINGS We conducted a retrospective cohort study of all preterm infants born at 24.0 to 36.9 weeks gestation in Victoria, Australia, from 2005 to 2015 (28,968 records available for analysis). All above growth charts were applied to the population. Proportions classified as <5th centile and <10th centile by each chart were compared, as were proportions of stillborn infants considered small for gestational age (SGA, <10th centile) by each chart. We then compared the relative performance of non-overlapping SGA cohorts by each chart to our low-risk reference population (infants born appropriate size for gestational age [>10th and <90th centile] by all intrauterine charts [AGAall]) for the following perinatal outcomes: stillbirth, perinatal mortality (stillbirth or neonatal death), Apgar <4 or <7 at 5 minutes, neonatal intensive care unit admissions, suspicion of poor fetal growth leading to expedited delivery, and cesarean section. All intrauterine charts classified a greater proportion of infants as <5th or <10th centile than birthweight charts. The magnitude of the difference between birthweight and fetal charts was greater at more preterm gestations. Of the fetal charts, GROW customised charts classified the greatest number of infants as SGA (22.3%) and the greatest number of stillborn infants as SGA (57%). INTERGROWTH classified almost no additional infants as SGA that were not already considered SGA on GROW or WHO charts; however, those infants classified as SGA by INTERGROWTH had the greatest risk of both stillbirth and total perinatal mortality. GROW customised charts classified a larger proportion of infants as SGA, and these infants were still at increased risk of mortality and adverse perinatal outcomes compared to the AGAall population. Consistent with similar studies in this field, our study was limited in comparing growth charts by the degree of overlap, with many infants classified as SGA by multiple charts. We attempted to overcome this by examining and comparing sub-populations classified as SGA by only 1 growth chart. CONCLUSIONS In this study, fetal charts classified greater proportions of preterm and stillborn infants as SGA, which more accurately reflected true fetal growth restriction. Of the intrauterine charts, INTERGROWTH classified the smallest number of preterm infants as SGA, although it identified a particularly high-risk cohort, and GROW customised charts classified the greatest number at increased risk of perinatal mortality.
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Affiliation(s)
- Natasha L. Pritchard
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Richard J. Hiscock
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Elizabeth Lockie
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael Permezel
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Monica F. G. McGauren
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Amber L. Kennedy
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Brittany Green
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Susan P. Walker
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Anthea C. Lindquist
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
- * E-mail:
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Teoh SSY, Wang Y, Li Y, Leemaqz SYL, Dekker GA, Roberts CT, Nie G. Low Serum Levels of HtrA3 at 15 Weeks of Gestation Are Associated with Late-Onset Preeclampsia Development and Small for Gestational Age Birth. Fetal Diagn Ther 2019; 46:392-401. [PMID: 31013509 DOI: 10.1159/000497144] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 01/21/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the potential utility of serum HtrA1 and HtrA3, serine proteases that are highly expressed in the developing placenta, at 15 and 20 weeks of gestation for predicting later development of adverse pregnancy outcomes of preeclampsia (PE), gestational hypertension (GHT), preterm birth (PTB), and small for gestational age (SGA) birth. METHODS This is a nested case control study of 665 samples (330 controls, 335 cases) from the Adelaide SCOPE cohort. The cases included were 92 PE, 71 GHT, 56 PTB, and 116 SGA. Samples were assessed by ELISA and data adjusted for maternal age, BMI, socioeconomic index, hCG, and smoking status. Multivariate logistic regression was performed with other biochemical and biophysical parameters available for these samples. RESULTS HtrA1 did not differ between the controls and cases. In contrast, HtrA3 was significantly lower at 15 weeks in pregnancies that later developed late-onset PE (LPE) or resulted in SGA birth, with an area under the ROC curve (AUC) of 0.716 and 0.790, respectively. The combination of HtrA3 with PAPP-A, uterine, and umbilical Doppler improved the AUC to 0.755 for LPE and 0.844 for SGA. CONCLUSION HtrA3 at 15 weeks is associated with, and may be useful for, the early detection of LPE development and SGA birth.
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Affiliation(s)
- Sonia Soo Yee Teoh
- Implantation and Placental Development Laboratory, Centre for Reproductive Health, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Molecular and Translational Sciences, Monash University, Clayton, Victoria, Australia
| | - Yao Wang
- Implantation and Placental Development Laboratory, Centre for Reproductive Health, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Molecular and Translational Sciences, Monash University, Clayton, Victoria, Australia
| | - Ying Li
- Implantation and Placental Development Laboratory, Centre for Reproductive Health, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Molecular and Translational Sciences, Monash University, Clayton, Victoria, Australia
| | - Shalem Yiner-Lee Leemaqz
- Robinson Research Institute and School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Gus A Dekker
- Robinson Research Institute and School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Claire T Roberts
- Robinson Research Institute and School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Guiying Nie
- Implantation and Placental Development Laboratory, Centre for Reproductive Health, Hudson Institute of Medical Research, Clayton, Victoria, Australia,
- Department of Molecular and Translational Sciences, Monash University, Clayton, Victoria, Australia,
- Department of Biochemistry and Molecular Biology, Monash University, Clayton, Victoria, Australia,
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Ismail KI, Hannigan A, Kelehan P, Fitzgerald B, O'Donoghue K, Cotter A. Small for gestational age infants and the association with placental and umbilical cord morphometry: a digital imaging study. J Matern Fetal Neonatal Med 2019; 33:3632-3639. [PMID: 30760075 DOI: 10.1080/14767058.2019.1582628] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: Individual placental and umbilical cord morphometry have been previously identified to have an association with fetal growth. This study aims to identify which of the morphometric measurements in combination are associated with pregnancies with small for gestational age (SGA) infants using digital imaging of the delivered placenta.Material and methods: This study examined 1005 placentas from consecutively delivered singleton pregnancies in a tertiary center. Standardized images of each placenta were taken. Placental weight and thickness; umbilical cord length and diameter were measured on gross examination. Distance from the placental cord insertion site to placental margin, length and breadth of the placenta and placental chorionic surface area were measured digitally using ImageJ software. Logistic regression models and area under the curve (AUC) were used to identify the best subset of morphometric measurements to classify infants as SGA (<10th centile).Results: Overall, 141 (14%) infants were SGA. The morphometric measurements at delivery most strongly associated with the classification of infants as SGA were placental weight (AUC = 0.806) and placental surface area (AUC = 0.749). Of the potential antenatal morphometric measurements, umbilical cord diameters, both placental (AUC = 0.644) and fetal end (AUC = 0.629) were most strongly associated with SGA. A logistic regression model with maternal age, smoking status, current history of preeclampsia, umbilical cord length, placental weight, birthweight-to-placental weight ratio and umbilical cord diameter (placental end) had a sensitivity of 53% and a false-positive rate of 2% (AUC = 0.945) for the classification of infants as SGA.Conclusion: Placental and umbilical cord morphometry measured at delivery are different between SGA and non-SGA infants. Further studies are warranted to investigate the feasibility and accuracy of ultrasound to measure placental and umbilical cord morphometry during pregnancy.
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Affiliation(s)
- Khadijah I Ismail
- Obstetrics and Gynecology Department, Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Ailish Hannigan
- Biostatistics Department, Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Peter Kelehan
- Pathology Department, National Maternity Hospital, Dublin, Ireland
| | | | - Keelin O'Donoghue
- Obstetrics and Gynecology Department, University College Cork, Cork, Ireland
| | - Amanda Cotter
- Obstetrics and Gynecology Department, Graduate Entry Medical School, University of Limerick, Limerick, Ireland
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Aiken CEM, Hone L, Murphy HR, Meek CL. Improving outcomes in gestational diabetes: does gestational weight gain matter? Diabet Med 2019; 36:167-176. [PMID: 29932243 DOI: 10.1111/dme.13767] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2018] [Indexed: 01/24/2023]
Abstract
AIM Excessive gestational weight gain increases risk of gestational diabetes mellitus (GDM) but it remains unclear whether weight control after GDM diagnosis improves outcomes. We assessed whether: (1) total gestational weight gain during pregnancy (0-36 weeks); (2) early gestational weight gain (0-28 weeks, before GDM diagnosis); or (3) late gestational weight gain (28-36 weeks, after diagnosis) are associated with maternal-fetal outcomes. METHODS Some 546 women with GDM who delivered viable singleton infants at a single UK obstetric centre (October 2014 to March 2017) were included in this retrospective observational study. RESULTS Higher total gestational weight gain was associated with Caesarean section [n = 376; odds ratio (OR) 1.05; confidence intervals (CI) 1.02-1.08, P < 0.001] and large for gestational age (OR 1.08; CI 1.03-1.12, P < 0.001). Higher late gestational weight gain (28-36 weeks; n = 144) was associated with large for gestational age (OR 1.17; CI 1.01-1.37, P < 0.05), instrumental deliveries (OR 1.26; CI 1.03-1.55, P < 0.01), higher total daily insulin doses (36 weeks; beta coefficient 4.37; CI 1.92-6.82, P < 0.001), and higher post-partum 2-h oral glucose tolerance test concentrations (beta coefficient 0.12; CI 0.01-0.22, P < 0.05). Women who avoided substantial weight gain after GDM diagnosis had 0.7 mmol/l lower postnatal 2-h glucose and needed half the amount of insulin/day at 36 weeks compared with women with substantial weight gain after diagnosis. There were no significant associations between early gestational weight gain (0-28 weeks) and pregnancy outcomes. CONCLUSIONS These findings suggest that controlling gestational weight gain should be a priority following GDM diagnosis to optimize pregnancy outcomes and improve maternal postnatal glucose homeostasis. The period after diagnosis of GDM (often 28 weeks gestation) is not too late to offer lifestyle advice or intervention to improve weight management and pregnancy outcomes.
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Affiliation(s)
- C E M Aiken
- Department of Obstetrics, Cambridge University Hospitals, Rosie Hospital, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - L Hone
- University of Cambridge, Cambridge, UK
| | - H R Murphy
- Wolfson Diabetes and Endocrinology Clinic, Cambridge, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - C L Meek
- Wolfson Diabetes and Endocrinology Clinic, Cambridge, UK
- Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, UK
- Department of Clinical Biochemistry, Cambridge University Hospitals, Cambridge, UK
- Department of Chemistry, Peterborough City Hospital, Peterborough, UK
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Kapaya H, Dimelow ER, Anumba D. Women's experience of wearing a portable fetal-electrocardiogram device to monitor small-for-gestational age fetus in their home environment. ACTA ACUST UNITED AC 2019; 14:1745506518785620. [PMID: 29968515 PMCID: PMC6048658 DOI: 10.1177/1745506518785620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To determine the acceptability, to women, of wearing a portable fetal
electrocardiogram recording device at different stages of pregnancy and to
gain insight into their experience of its use for long-periods of monitoring
of small-for-gestational fetuses in the home environment. Methods: A qualitative study using both a questionnaire and focus group involving
women with singleton pregnancy >24 weeks gestation, no evidence of fetal
malformation and an estimated fetal weight below 10th gestational centile on
ultrasound scan. Fetal heart rate recordings were collected for up to
20 h. Results: In total, 59 questionnaires were completed; 35 after wearing the monitor for
the first time and an additional 24 from the women who wore the device for a
second time. Six women participated in the focus group; the principal theme
identified related to the practicality of the fetal electrocardiogram
device. Other themes identified were the discomfort that resulted from
wearing the monitor and the reassurance provided in knowing that the baby’s
heart rate was being monitored. Conclusion: Long-term ambulatory fetal electrocardiogram monitoring is an acceptable
method of monitoring small-for-gestational fetuses. Overall, women concluded
that benefits of wearing the device outweighed any discomfort it caused.
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Affiliation(s)
- Habiba Kapaya
- 1 Academic Unit of Reproductive & Developmental Medicine, Department of Oncology & Metabolism, The University of Sheffield, Sheffield, UK
| | | | - Dilly Anumba
- 1 Academic Unit of Reproductive & Developmental Medicine, Department of Oncology & Metabolism, The University of Sheffield, Sheffield, UK
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Pritchard N, Lindquist A, Siqueira IDA, Walker SP, Permezel M. INTERGROWTH-21st compared with GROW customized centiles in the detection of adverse perinatal outcomes at term. J Matern Fetal Neonatal Med 2018; 33:961-966. [PMID: 30372647 DOI: 10.1080/14767058.2018.1511696] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: INTERGROWTH-21st charts provide standards for infants born under optimal pregnancy conditions. However, their validity in a general obstetric population is unclear. We aimed to identify whether INTERGROWTH-21st charts, compared with gestation related optimal weight (GROW) charts customized on maternal height, weight, and parity, better identified the at-risk infant.Methods: We performed a retrospective cohort analysis of all term women who gave birth at a single tertiary obstetric center during the period 1994-2016. Routinely collected maternity data was used for analysis. The primary outcome was an Apgar score <7 at 5 min. Secondary outcomes included Apgar score <5 at 5 min, stillbirth or admission to the neonatal intensive care unit (NICU). Populations of newborns were identified as SGA by: (a) INTERGROWTH-21st <10th centile (SGAIG10th); (b) INTERGROWTH-21st z-score < -1 (SGAIGzscore); and (c) GROW customized charts <10th (SGAcust). The subgroups identified by only one chart were also specifically examined. Each SGA group was compared to infants appropriate for gestational age (AGA) on all charts (non-SGA).Results: Data for 71,487 births were available for analysis after exclusion of women with missing height or weight data. Only 3280 (4.6%) newborns were considered SGAIG10th, with 5878 (8.2%) SGAIGzscore and 7599 (10.6%) SGAcust. INTERGROWTH-21st identified only 110 additional infants (0.15%) that were not identified by customized charts; none of these experienced any adverse outcomes. Customized centiles identified a further 4429 (6.2%) SGA infants (SGAcust-only) that were not identified as SGAIG10th, and who did demonstrate an increased risk of Apgar score <7 (OR 1.33, 95%CI 1.08-3.28) and stillbirth (OR 2.47, 95%CI 1.41-4.44) compared to the non-SGA infant. Significantly more obese women had infants considered SGAcust (19.3%) than SGAIG10th (10.0%) or SGAIGzscore (9.9%).Conclusions: Amongst our general obstetric study population, the 10th centile of INTERGROWTH-21st identified only 4.6% of infants as SGA and was less likely to identify infants of obese women as SGA. Customized centiles identified almost all SGA-IG infants, including an additional group (SGAcust-only) at higher risk of stillbirth and adverse outcomes compared with non-SGA infants.
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Affiliation(s)
- Natasha Pritchard
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Melbourne, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Anthea Lindquist
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Melbourne, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Isabela Dos Anjos Siqueira
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Susan P Walker
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Melbourne, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Michael Permezel
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Melbourne, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
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Jayawardena L, Sheehan P. Introduction of a customised growth chart protocol increased detection of small for gestational age pregnancies in a tertiary Melbourne hospital. Aust N Z J Obstet Gynaecol 2018; 59:493-500. [PMID: 30302752 DOI: 10.1111/ajo.12902] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 08/22/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Growth charts customised for maternal height, weight, ethnicity and parity have been proposed as more effective at detecting infants who are small for gestational age (SGA) than routine screening with symphysio-fundal height measurement alone. Our non-randomised, prospective cohort study assessed antenatal SGA detection rates in a general maternity cohort following the introduction of the Perinatal Institute's Growth Assessment Protocol (GAP) program (consisting of customised growth chart software for plotting symphysio-fundal height, staff training and serial auditing). METHODS The GAP program was implemented into the routine antenatal schedule of 882 women who delivered at The Royal Women's Hospital, Melbourne, during our study period. SGA detection was compared to 936 women from the same team who delivered prior to the intervention. Secondary outcomes assessed were infant gestation at birth and method of delivery, neonatal Apgar scores and admission to the Neonatal Intensive and Special Care nursery (NISC). RESULTS Identification of SGA infants increased from 21% to 41% with the introduction of the GAP program (OR 2.6, 95% CI 1.3-4.9, P < 0.05). This was not associated with an increase in false-positive rates. Following the introduction of the GAP Program, SGA babies were more likely to be born by vaginal delivery (OR 2.7; 95% CI 1.4-5.1, P < 0.005). There was no overall increase in the induction of labour or caesarean delivery rates. Overall rates of admission to NISC were reduced. CONCLUSIONS In our increasingly culturally heterogenous society, the use of the GAP program is a safe and potentially more sensitive tool for detecting in utero growth restriction.
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Affiliation(s)
- Lulusha Jayawardena
- Maternity Services, The Royal Women's Hospital Parkville, Melbourne, Australia
| | - Penelope Sheehan
- Maternity Services, The Royal Women's Hospital Parkville, Melbourne, Australia.,Pregnancy Research Centre, The University of Melbourne, Melbourne, Australia
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KNEITEL AW, TREADWELL MC, O’BRIEN LM. Effects of maternal obstructive sleep apnea on fetal growth: a case-control study. J Perinatol 2018; 38:982-988. [PMID: 29785058 PMCID: PMC6092194 DOI: 10.1038/s41372-018-0127-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 04/01/2018] [Accepted: 04/12/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To investigate whether maternal obstructive sleep apnea (OSA) is associated with changes in fetal growth trajectory. STUDY DESIGN Retrospective review of pregnant women who underwent overnight polysomnography. Fetal growth was estimated using sonographic biometric measurements obtained during routine prenatal care. Customized estimated fetal weight and birth weight centiles were calculated and impaired fetal growth was defined as birth weight <10th centile or a slowing of fetal growth by >33% during the last trimester. Logistic regression models were used to determine the relationship between maternal OSA and altered fetal growth after adjusting for potential covariates. RESULTS There were 48 women without and 31 women with OSA. There were no differences in the proportion of infants with birth weight <10th centile between women with and without OSA (23 vs. 25%, p = 1.0), However, the presence of maternal OSA was predictive of impaired fetal growth (aOR 3.9, 95% CI 1.2-12.6). Logistic regression models were repeated using only a slowing of fetal growth in the 3rd trimester (excluding birth weight <10th centile) and OSA predicted a slowing in fetal growth across the 3rd trimester (aOR 3.6, 95% CI 1.4-9.4). Fourteen additional women were treated with positive airway pressure during pregnancy; fetal growth was not significantly different in these women compared to controls. CONCLUSION Obstructive sleep apnea is independently associated with altered fetal growth, which appears to be ameliorated with use of positive airway pressure.
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Affiliation(s)
- Anna W. KNEITEL
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | | | - Louise M. O’BRIEN
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI,Sleep Disorders Center, Department of Neurology, University of Michigan, Ann Arbor, MI
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Easter SR, Eckert LO, Boghossian N, Spencer R, Oteng-Ntim E, Ioannou C, Patwardhan M, Harrison MS, Khalil A, Gravett M, Goldenberg R, McKelvey A, Gupta M, Pool V, Robson SC, Joshi J, Kochhar S, McElrath T. Fetal growth restriction: Case definition & guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine 2018; 35:6546-6554. [PMID: 29150060 PMCID: PMC5710982 DOI: 10.1016/j.vaccine.2017.01.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 01/13/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Sarah Rae Easter
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Linda O Eckert
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Nansi Boghossian
- Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Rebecca Spencer
- Consultant in Obstetrics, Institute for Women's Health, University College London, UK
| | | | - Christos Ioannou
- Consultant in Obstetrics and Fetal Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Manasi Patwardhan
- Division of Maternal-Fetal Medicine, Wayne State University, Detroit, MI, USA
| | - Margo S Harrison
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, USA
| | - Asma Khalil
- Consultant in Obstetrics and Subspecialist in Fetal Medicine, St George's University of London, London, UK
| | - Michael Gravett
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Robert Goldenberg
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, USA
| | - Alastair McKelvey
- Consultant in Obstetrics and Fetal Medicine, Norfolk and Norwich University Hospital, Norwich, UK
| | - Manish Gupta
- Consultant Obstetrician, Subspecialist in Maternal and Fetal Medicine, Barts Health NHS Trust, London, UK
| | - Vitali Pool
- Director of Scientific and Medical Affairs, Sanofi Pasteur, Swiftwater, PA, USA
| | - Stephen C Robson
- Professor of Fetal Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Jyoti Joshi
- Deputy Director of Immunization Technical Support Unit, Public Health Fund of India, New Delhi, India
| | - Sonali Kochhar
- Global Healthcare Consulting, New Delhi, India; Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tom McElrath
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Small for gestational age: Case definition & guidelines for data collection, analysis, and presentation of maternal immunisation safety data. Vaccine 2018; 35:6518-6528. [PMID: 29150057 PMCID: PMC5710996 DOI: 10.1016/j.vaccine.2017.01.040] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 01/13/2017] [Indexed: 12/13/2022]
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Vieira MC, McCowan LME, North RA, Myers JE, Walker JJ, Baker PN, Dekker GA, Kenny LC, Poston L, Pasupathy D. Antenatal risk factors associated with neonatal morbidity in large-for-gestational-age infants: an international prospective cohort study. Acta Obstet Gynecol Scand 2018; 97:1015-1024. [PMID: 29753307 DOI: 10.1111/aogs.13362] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 04/27/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Large-for-gestational-age infants are associated with increased risk of neonatal morbidity and mortality. However, most of them will not have adverse outcomes. Our aim was to identify antenatal clinical factors associated with neonatal morbidity in large-for-gestational-age infants. MATERIAL AND METHODS Nulliparous women from the Screening for Pregnancy Endpoints (SCOPE) study were included. We compared maternal and fetal factors between large-for-gestational-age infants (birthweight >90th customized centile) with and without neonatal morbidity, defined as admission to a neonatal intensive care unit or severe neonatal morbidity. Factors were selected based on a priori hypotheses of association and included maternal demography, anthropometric measures and self-reported physical activity (15 and 20 weeks), fetal biometry (20 weeks), and clinical information. Multivariable logistic regression was used to identify risk factors. Stratified analyses were performed by maternal obesity and physical activity. RESULTS Among term pregnancies, prevalence of large-for-gestational-age infants was 9.3% (491/5255), with 11.8% (58/491) prevalence of neonatal morbidity. Random glucose at 20 weeks (odds ratio 1.52; 95% confidence interval 1.17-1.97, per 1 mmol/L increase) and no regular physical activity at 20 weeks (odds ratio 3.93; 95% confidence interval 1.75-8.83) were associated with increased risk of neonatal morbidity after adjustment for birthweight, gestational age at delivery and gestational diabetes. The increased risk associated with higher glucose levels was not evident in women with regular physical activity or without obesity. CONCLUSIONS Regular physical activity in mid-pregnancy is associated with lower risk for neonatal morbidity in large-for-gestational-age infants and seems to offer protection against the increased risk associated with higher maternal glucose levels.
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Affiliation(s)
- Matias C Vieira
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College, London, UK.,School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Lesley M E McCowan
- Department of Obstetrics and Gynecology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Robyn A North
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College, London, UK
| | - Jenny E Myers
- Faculty of Medical and Human Sciences, Maternal & Fetal Health Research Center, Institute of Human Development, Manchester Academic Health Science Center, University of Manchester, Manchester, UK
| | - James J Walker
- Department of Obstetrics and Gynecology, Leeds Institute of Biomedical & Clinical Sciences, University of Leeds, Leeds, UK
| | - Philip N Baker
- College of Medicine, Biological Sciences & Psychology, University of Leicester, Leicester, UK
| | - Gustaaf A Dekker
- Women's and Children's Division Lyell McEwin Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Louise C Kenny
- The Irish Center for Fetal and Neonatal Translational Research (INFANT), Department of Obstetrics and Gynecology, University College Cork, Cork University Maternity Hospital, Cork, Ireland
| | - Lucilla Poston
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College, London, UK.,NIHR Biomedical Research Center at Guy's and St Thomas' NH Foundation Trust and King's College London, King's College London, London, UK
| | - Dharmintra Pasupathy
- Department of Women and Children's Health, Faculty of Life Sciences and Medicine, School of Life Course Sciences, King's College, London, UK.,NIHR Biomedical Research Center at Guy's and St Thomas' NH Foundation Trust and King's College London, King's College London, London, UK
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Fetal biometry to assess the size and growth of the fetus. Best Pract Res Clin Obstet Gynaecol 2018; 49:3-15. [DOI: 10.1016/j.bpobgyn.2018.02.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 02/14/2018] [Indexed: 01/13/2023]
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Pugh SJ, Hinkle SN, Kim S, Albert PS, Newman R, Grobman WA, Wing DA, Grantz KL. Combined Influence of Gestational Weight Gain and Estimated Fetal Weight on Risk Assessment for Small- or Large-for-Gestational-Age Birth Weight: A Prospective Cohort Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:935-940. [PMID: 28960393 PMCID: PMC6065252 DOI: 10.1002/jum.14430] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 07/13/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To evaluate the frequency with which gestational weight gain and estimated fetal weight do not track across gestation and to assess the risk of small-for-gestational-age (SGA) and large-for-gestational-age (LGA) birth weight as a function of tracking. METHODS This study included a pregnancy cohort (2009-2013) of 2438 women from 4 racial/ethnic groups in the United States. We calculated race- and trimester-specific gestational weight gain and estimated fetal weight z scores. The prevalence of how often gestational weight gain and estimated fetal weight did not or did directly track was examined by grouping z scores into measure-specific categories (<-1 SD, -1 to + 1 SD, and >1 SD) and then examining 2-measure combinations. Trimester-specific relative risks for SGA and LGA births were estimated with a gestational weight gain and estimated fetal weight z score interaction. We estimated coefficients for selected gestational weight gain and estimated fetal weight values (-1 SD, 0 SD, and +1 SD) compared with the referent of 0 SD for both measures. Small and large for gestational age were calculated as birth weight below the 10th and at or above the 90th percentiles, respectively. RESULTS Gestational weight gain and estimated fetal weight were within 1 SD 55.5%, 51.5%, and 48.2% of the time in the first, second, and third trimesters, respectively. There was no significant interaction between gestational weight gain and estimated fetal weight on the risk of SGA in the first and second trimesters (interaction term P = .48; P = .79). In the third trimester, there was a significant interaction (P = .002), resulting in a 71% (95% confidence interval, 1.45-2.02) increased risk of SGA when estimated fetal weight was low and gestational weight gain was high. These relationships were similar for the risk of LGA. CONCLUSIONS Deviations in either measure, even in the presence of average gestational weight gain or estimated fetal weight, still suggest an increased risk of SGA and LGA.
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Affiliation(s)
- Sarah J Pugh
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Stefanie N Hinkle
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Sungduk Kim
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Paul S Albert
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Roger Newman
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - William A Grobman
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Deborah A Wing
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Irvine, School of Medicine, Orange, California, USA
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Miller Children's Hospital/Long Beach Memorial Medical Center, Long Beach, California, USA
| | - Katherine L Grantz
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
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Williams M, Turner S, Butler E, Gardosi J. Fetal growth surveillance - Current guidelines, practices and challenges. ULTRASOUND : JOURNAL OF THE BRITISH MEDICAL ULTRASOUND SOCIETY 2018; 26:69-79. [PMID: 30013607 DOI: 10.1177/1742271x18760657] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 01/11/2018] [Indexed: 11/17/2022]
Abstract
Antenatal surveillance of fetal growth is an essential part of good maternity care, as lack of detection of fetal growth restriction is directly associated with stillbirth and perinatal morbidity. New algorithms and guidelines provide care pathways which rely on regular third trimester ultrasound biometry and plotting of estimated fetal weight in pregnancies considered to be at increased risk, and their implementation has increased pressures on ultrasound resources. Customised growth charts have improved the distinction between constitutional and pathological smallness and reduced unnecessary referrals. Their introduction, together with clinicians' training, e-learning and audit as the key elements of the growth assessment protocol, has resulted in increased antenatal detection of small for gestational age babies and a reduction in avoidable stillbirths. However, missed case audits highlight that further improvements are needed, and point to the need to address quality assurance and resource issues in ultrasound services.
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van de Kamp K, Pajkrt E, Zwinderman A, van der Post J, Snijders R. Validation of Reference Charts for Mid-Trimester Fetal Biometry. Fetal Diagn Ther 2018. [DOI: 10.1159/000486094] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Desforges M, Rogue A, Pearson N, Rossi C, Olearo E, Forster R, Lees M, Sebire NJ, Greenwood SL, Sibley CP, David AL, Brownbill P. In Vitro Human Placental Studies to Support Adenovirus-Mediated VEGF-D ΔNΔC Maternal Gene Therapy for the Treatment of Severe Early-Onset Fetal Growth Restriction. HUM GENE THER CL DEV 2018; 29:10-23. [PMID: 29228803 DOI: 10.1089/humc.2017.090] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Severe fetal growth restriction (FGR) affects 1 in 500 pregnancies, is untreatable, and causes serious neonatal morbidity and death. Reduced uterine blood flow (UBF) is one cause. Transduction of uterine arteries in normal and FGR animal models using an adenovirus (Ad) encoding VEGF isoforms increases UBF and improves fetal growth in utero. Understanding potential adverse consequences of this therapy before first-in-woman clinical application is essential. The aims of this study were to determine whether Ad.VEGF-DΔNΔC (1) transfers across the human placental barrier and (2) affects human placental morphology, permeability and primary indicators of placental function, and trophoblast integrity. Villous explants from normal term human placentas were treated with Ad.VEGF-DΔNΔC (5 × 107-10 virus particles [vp]/mL), or virus formulation buffer (FB). Villous structural integrity (hematoxylin and eosin staining) and tissue accessibility (LacZ immunostaining) were determined. Markers of endocrine function (human chorionic gonadotropin [hCG] secretion) and cell death (lactate dehydrogenase [LDH] release) were assayed. Lobules from normal and FGR pregnancies underwent ex vivo dual perfusion with exposure to 5 × 1010 vp/mL Ad.VEGF-DΔNΔC or FB. Perfusion resistance, para-cellular permeability, hCG, alkaline phosphatase, and LDH release were measured. Ad.VEGF-DΔNΔC transfer across the placental barrier was assessed by quantitative polymerase chain reaction in DNA extracted from fetal-side venous perfusate, and by immunohistochemistry in fixed tissue. Villous explant structural integrity and hCG secretion was maintained at all Ad.VEGF-DΔNΔC doses. Ad.VEGF-DΔNΔC perfusion revealed no effect on placental permeability, fetoplacental vascular resistance, hCG secretion, or alkaline phosphatase release, but there was a minor elevation in maternal-side LDH release. Viral vector tissue access in both explant and perfused models was minimal, and the vector was rarely detected in the fetal venous perfusate and at low titer. Ad.VEGF-DΔNΔC did not markedly affect human placental integrity and function in vitro. There was limited tissue access and transfer of vector across the placental barrier. Except for a minor elevation in LDH release, these test data did not reveal any toxic effects of Ad.VEGF-DΔNΔC on the human placenta.
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Affiliation(s)
- Michelle Desforges
- 1 Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester , Manchester, United Kingdom .,2 St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust , Manchester Academic Health Science Centre, Manchester, United Kingdom
| | | | - Nick Pearson
- 4 Pharmaceutical Sciences, pRED, F Hoffmann-La Roche , Basel, Switzerland
| | - Carlo Rossi
- 5 Magnus Growth , London, United Kingdom .,6 Institute for Women's Health, University College London (UCL) , London, United Kingdom
| | - Elena Olearo
- 6 Institute for Women's Health, University College London (UCL) , London, United Kingdom
| | | | - Mark Lees
- 5 Magnus Growth , London, United Kingdom
| | - Neil J Sebire
- 7 Institute of Child Health, University College London (UCL) , London, United Kingdom
| | - Susan L Greenwood
- 1 Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester , Manchester, United Kingdom .,2 St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust , Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Colin P Sibley
- 1 Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester , Manchester, United Kingdom .,2 St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust , Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Anna L David
- 6 Institute for Women's Health, University College London (UCL) , London, United Kingdom
| | - Paul Brownbill
- 1 Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester , Manchester, United Kingdom .,2 St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust , Manchester Academic Health Science Centre, Manchester, United Kingdom
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Gardosi J, Francis A, Turner S, Williams M. Customized growth charts: rationale, validation and clinical benefits. Am J Obstet Gynecol 2018; 218:S609-S618. [PMID: 29422203 DOI: 10.1016/j.ajog.2017.12.011] [Citation(s) in RCA: 145] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 12/04/2017] [Accepted: 12/06/2017] [Indexed: 11/28/2022]
Abstract
Appropriate standards for the assessment of fetal growth and birthweight are central to good clinical care, and have become even more important with increasing evidence that growth-related adverse outcomes are potentially avoidable. Standards need to be evidence based and validated against pregnancy outcome and able to demonstrate utility and effectiveness. A review of proposals by the Intergrowth consortium to adopt their single international standard finds little support for the claim that the cases that it identifies as small are due to malnutrition or stunting, and substantial evidence that there is normal physiologic variation between different countries and ethnic groups. It is possible that the one-size-fits-all standard ends up fitting no one and could be harmful if implemented. An alternative is the concept of country-specific charts that can improve the association between abnormal growth and adverse outcome. However, such standards ignore individual physiologic variation that affects fetal growth, which exists in any heterogeneous population and exceeds intercountry differences. It is therefore more logical to adjust for the characteristics of each mother, taking her ethnic origin and her height, weight, and parity into account, and to set a growth and birthweight standard for each pregnancy against which actual growth can be assessed. A customized standard better reflects adverse pregnancy outcome at both ends of the fetal size spectrum and has increased clinicians' confidence in growth assessment, while providing reassurance when abnormal size merely represents physiologic variation. Rollout in the United Kingdom has proceeded as part of the comprehensive Growth Assessment Protocol (GAP), and has resulted in a steady increase in antenatal detection of babies who are at risk because of fetal growth restriction. This in turn has been accompanied by a year-on-year drop in stillbirth rates to their lowest ever levels in England. A global version of customized growth charts with over 100 ethnic origin categories is being launched in 2018, and will provide an individualized, yet universally applicable, standard for fetal growth.
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McCowan LM, Figueras F, Anderson NH. Evidence-based national guidelines for the management of suspected fetal growth restriction: comparison, consensus, and controversy. Am J Obstet Gynecol 2018; 218:S855-S868. [PMID: 29422214 DOI: 10.1016/j.ajog.2017.12.004] [Citation(s) in RCA: 256] [Impact Index Per Article: 42.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 11/20/2017] [Accepted: 12/01/2017] [Indexed: 11/25/2022]
Abstract
Small for gestational age is usually defined as an infant with a birthweight <10th centile for a population or customized standard. Fetal growth restriction refers to a fetus that has failed to reach its biological growth potential because of placental dysfunction. Small-for-gestational-age babies make up 28-45% of nonanomalous stillbirths, and have a higher chance of neurodevelopmental delay, childhood and adult obesity, and metabolic disease. The majority of small-for-gestational-age babies are not recognized before birth. Improved identification, accompanied by surveillance and timely delivery, is associated with reduction in small-for-gestational-age stillbirths. Internationally and regionally, detection of small for gestational age and management of fetal growth problems vary considerably. The aim of this review is to: summarize areas of consensus and controversy between recently published national guidelines on small for gestational age or fetal growth restriction; highlight any recent evidence that should be incorporated into existing guidelines; and identify future research priorities in this field. A search of MEDLINE, Google, and the International Guideline Library identified 6 national guidelines on management of pregnancies complicated by fetal growth restriction/small for gestational age published from 2010 onwards. There is general consensus between guidelines (at least 4 of 6 guidelines in agreement) in early pregnancy risk selection, and use of low-dose aspirin for women with major risk factors for placental insufficiency. All highlight the importance of smoking cessation to prevent small for gestational age. While there is consensus in recommending fundal height measurement in the third trimester, 3 specify the use of a customized growth chart, while 2 recommend McDonald rule. Routine third-trimester scanning is not recommended for small-for-gestational-age screening, while women with major risk factors should have serial scanning in the third trimester. Umbilical artery Doppler studies in suspected small-for-gestational-age pregnancies are universally advised, however there is inconsistency in the recommended frequency for growth scans after diagnosis of small for gestational age/fetal growth restriction (2-4 weekly). In late-onset fetal growth restriction (≥32 weeks) general consensus is to use cerebral Doppler studies to influence surveillance and/or delivery timing. Fetal surveillance methods (most recommend cardiotocography) and recommended timing of delivery vary. There is universal agreement on the use of corticosteroids before birth at <34 weeks, and general consensus on the use of magnesium sulfate for neuroprotection in early-onset fetal growth restriction (<32 weeks). Most guidelines advise using cardiotocography surveillance to plan delivery in fetal growth restriction <32 weeks. The recommended gestation at delivery for fetal growth restriction with absent and reversed end-diastolic velocity varies from 32 to ≥34 weeks and 30 to ≥34 weeks, respectively. Overall, where there is high-quality evidence from randomized controlled trials and meta-analyses, eg, use of umbilical artery Doppler and corticosteroids for delivery <34 weeks, there is a high degree of consistency between national small-for-gestational-age guidelines. This review discusses areas where there is potential for convergence between small-for-gestational-age guidelines based on existing randomized controlled trials of management of small-for-gestational-age pregnancies, and areas of controversy. Research priorities include assessing the utility of late third-trimester scanning to prevent major morbidity and mortality and to investigate the optimum timing of delivery in fetuses with late-onset fetal growth restriction and abnormal Doppler parameters. Prospective studies are needed to compare new international population ultrasound standards with those in current use.
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Milner J, Arezina J. The accuracy of ultrasound estimation of fetal weight in comparison to birth weight: A systematic review. ULTRASOUND (LEEDS, ENGLAND) 2018; 26:32-41. [PMID: 29456580 PMCID: PMC5810856 DOI: 10.1177/1742271x17732807] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 08/20/2017] [Indexed: 11/15/2022]
Abstract
Ultrasound estimation of fetal weight is a highly influential factor in antenatal management, guiding both the timing and mode of delivery of a pregnancy. Although substantial research has investigated the most accurate ultrasound formula for calculating estimated fetal weight, current evidence indicates significant error levels. The aim of this systematic review was to identify the most accurate method, whilst identifying sources of inaccuracy in order to facilitate recommendations for future practice. Seven studies met the inclusion criteria and 11 different formulae were assessed; ultrasound calculation of fetal weight was most commonly overestimated. The Hadlock A formula produced the most accurate results, with the lowest levels of random error. Methods incorporating just two measurement parameters were inconsistent, producing large random errors across multiple studies. Key sources of inaccuracy included difficulties obtaining accurate fetal measurements in late gestation; the remainder were operator dependent, including lack of experience and insufficient training and audit. The accuracy of ultrasound estimated fetal weight has improved in the last decade, though a lack of consistency remains evident. National implementation of a rigorous audit programme would likely improve accuracy further, and increase the confidence and clinical value of the method.
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Cheung NW, Jiang S, Athayde N. Impact of the IADPSG criteria for gestational diabetes, and of obesity, on pregnancy outcomes. Aust N Z J Obstet Gynaecol 2018; 58:553-559. [DOI: 10.1111/ajo.12772] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 12/06/2017] [Indexed: 12/19/2022]
Affiliation(s)
- N. Wah Cheung
- Department of Diabetes & Endocrinology; Westmead Hospital; Sydney New South Wales Australia
- University of Sydney; Sydney New South Wales Australia
| | - Shan Jiang
- Department of Diabetes & Endocrinology; Westmead Hospital; Sydney New South Wales Australia
| | - Neil Athayde
- Women's and Newborn Services; Westmead Hospital; Sydney New South Wales Australia
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