Screening for fetal growth restriction · Prediction of small for gestational age neonates at 35-37...

The Fetal Medicine Foundation

Screening for fetal growth restriction

King’s College Hospital and Medway Maritime Hospital, UK


Cnattingius S et al., BMJ, 1998

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• 10 yr population study

• 1,083,367 births

• Excluding fetal defects

• 222,975 FGR

• 26,664 severe FGR

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Neonatal death

Seizures < 24 hrs

Neonatal sepsis

Cord pH < 7.0

Intubation at delivery

Birth weight percentile

McIntyre D et al., NEJM, 1999

Screening for SGA / FGRWhy should we screen ?


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Screening for SGA / FGRAssociation with stillbirth

Screening studyKing’s College + Medway MaritimeMarch 2006 – Oct 2015

Study population (n=113,415)Antepartum stillbirths (n=396)

Impaired placentation (n=230)Unexplained + other (n=166)

Yerlikaya G, Akolekar R, McPherson K, Syngelaki A, Nicolaides KH: Prediction of stillbirth from maternal demographic and pregnancycharacteristics. Ultrasound Obstet Gynaecol 2016; 48:607-612.


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SGA : 71% 44% 27%

Screening for SGA / FGRAssociation with stillbirth

Screening studyKing’s College + Medway MaritimeMarch 2006 – Oct 2015

Study population (n=113,415)Antepartum stillbirths (n=396)

Impaired placentation (n=230)Unexplained + other (n=166)

Yerlikaya G, Akolekar R, McPherson K, Syngelaki A, Nicolaides KH: Prediction of stillbirth from maternal demographic and pregnancycharacteristics. Ultrasound Obstet Gynaecol 2016; 48:607-612.


Starved

The majority of starved fetuses are not SGA

Birth weight percentile0 50th10th 100

Well fed

SGA AGA

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Screening for SGA / FGRAssociation with BW centile


Reduced nutrition

Hypoxia

Birth weight percentile0 50th10th 100

Well fed

SGA AGA

Screening for SGA / FGRAssociation with BW centile


Nicolaides KH, Soothill PW, Rodeck CH, Campbell S. Ultrasound guided sampling of umbilical cord and placental blood to assess fetal wellbeing.Lancet 1986;1:1065

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Soothill PW, Nicolaides KH, Campbell S. Prenatal asphyxia, hyperlacticaemia, hypoglycaemia and erythroblastosis in growth retarded fetuses. BMJ1987;294:1051

‘Birth asphyxia can precede

labor and is not necessarily

due to the process of birth’

Cordocentesis in SGASome SGA fetuses are hypoxic

pO2 ↓, pCO2 ↓, pH ↓, lactate ↑glucose ↓, erythroblasts ↑


Nicolaides KH, Bilardo KM, Soothill PW, Campbell S. Absence of end diastolic frequencies in the umbilical artery a sign of fetal hypoxia and acidosis.BMJ 1988;297:1026

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SGA fetuses with umbilical artery AEDF

If abnormal blood flow in theumbilical artery is as good amarker of prenatal asphyxia inwell grown fetuses as they are insmall fetuses, this test mayreplace measurement of fetal sizefor the antenatal prediction offetal asphyxia

Cordocentesis in SGASome SGA fetuses are hypoxic


Monitoring /timely delivery

12w

36w

22w

Therapy

32w

Lindqvist PG, Molin J: Does antenatal identification of small-for-gestational age fetuses significantly improve their outcome? Ultrasound ObstetGynecol 2005;25:258-264.

Pregnancies n = 26,968

SGA: Prenatal detection n = 681

SGA: Postnatal detection n = 573

Adverse outcome• Death: Fetal / neonatal• Brain damage / hemorrhage• Apgar5


• Reducing smoking in pregnancy

• Raising awareness of reduced movements

• Risk assessment for growth restriction

• Effective monitoring in labour

Saving Babies’ LivesA care bundle for reducing stillbirths

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Lindhart et al., The implications of introducing the symphyseal-fundal height-measurement. A prospective randomized controlled trial. BJOG 1990; 97: 675-680.

Symphysis fundal height (SFH) measurement in pregnancy for detecting abnormal fetal growth. Cochrane Database Syst Rev 2015; 97: CD008136.

No difference between measurementof SFH and abdominal palpation.

Screening for SGA / FGRRCOG Risk assessment


Screening for SGA / FGR1st trimester assesment

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The Fetal Medicine Foundation Preventing stillbirths

Screening for SGA / FGR

Study population:- KCH, MMH 2006 - 2016- Singleton pregnancy- Dating by CRL at 11-13w- Normal neonate

Total n = 116,758Stillbirth n = 484 (0.4%)

Stillbirth:< 32 w: 41%32-36 w: 19%> 37 w: 40%

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20 22 24 26 28 30 32 34 36 38 40 42Gestational age (w)

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FMF BW chart

Stillbirth: SGA+/- PE

< 32 w: 80%32-36 w: 51%> 37 w: 27%


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Tan et al. Prediction and prevention of small for gestational age neonates: evidence from SPREE and ASPRE. Ultrasound Obstet Gynecol 2018. doi: 10.1002/uog.19077.

Stillbirths n = 198

SGA


12 w

22 w

32/36 w

Assessment at 22 w

Moderate-risk(16%)

Low-risk(60%)

High-risk (0.5%)

90% SGA32-36w

90% SGA> 37 weeks

100% SGA < 32w

Review at32-36 wks

Review at 36 wks

Review at 26-28 wks

Not delivered

Not delivered

Poon LC, Lesmes C, Gallo DM, Akolekar R, Nicolaides KH. Prediction of small-for gestational-age neonates: screening by biophysical and biochemical markers at 19-24 weeks. Ultrasound Obstet Gynecol 2015;46:437-45.

Screening for SGA / FGR2nd trimester assessment

The Fetal Medicine Foundation Screening for SGA / FGR

• Use of EFW vs. fetal AC

• Selection of EFW and BW charts

• Gestational age for the 3rd trimester scan

• Additive value of growth velocity

• Additive value of biomarkers

• New proposal for management

3rd trimester assessment


Screening for SGA / FGREFW vs fetal AC

Model Author All BW< 2500 gBW

> 4000 gBPD Willocks et al., 1964 20.5 35.0 20.9AC Hadlock et al., 1984 9.9 13.2 8.1FL Warsof et al., 1977 14.8 21.7 17.7AC, FL Hadlock et al., 1985 8.6 10.0 7.7BPD, AC Warsof et al., 1977 9.5 11.8 8.4HC, AC Hadlock et al., 1984 8.6 10.6 9.4BPD, AC, FL Ben-Haroush et al., 2008 8.9 12.9 8.1HC, AC, FL Hadlock et al., 1985 7.8 9.1 8.2BPD, HC, AC, FL Hadlock et al.,1985 8.3 9.8 7.4

Euclidean distance

Euclidean distance: Measure of the proportion of pregnancies with

EFW within 10% of BW

Hammami A, Mazer Zumaeta A, Syngelaki A, Akolekar R, Nicolaides KH. Ultrasonographic estimation of fetal weight: development of new modeland assessment of performance of previous models. Ultrasound Obstet Gynecol 2018; 52: 35-43.


Screening for SGA / FGRSelection of growth charts

In reported reference ranges the median BWwith gestational age for babies born preterm issubstantially lower than that of the EFW.

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BW chartEFW chart

Nicolaides KH, Wright D, Syngelaki A, Wright A, Akolekar R. Fetal Medicine Foundation fetal and neonatal population weight charts. Ultrasound ObstetGynecol 2018; 52: 44-51.

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EFW and BW have the same median with GA


Screening for SGA / FGRGestational age for the scan

Ciobanu A, Khan N, A, Syngelaki A, Akolekar R, Nicolaides KH. Routine ultrasound at 32 versus 36 weeks’ gestation: prediction of small forgestational age neonates. Ultrasound Obstet Gynecol 2019; doi: 10.1002/uog.20258

Routine ultrasound scan• 31+0 - 33+6 w: n=21,989• 35+0 - 36+6 w: n=45,847

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Screening for SGA / FGRAddition of growth velocity

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Ciobanu A, Formuso C, Syngelaki A, Akolekar R, Nicolaides KH. Prediction of small for gestational age neonates at 35-37 weeks’ gestation: contribution of maternal factors and growth velocity between 20 and 36 weeks. Ultrasound Obstet Gynecol 2019; 53; 488-495.

Ciobanu A, Anthoulakis C, A, Syngelaki A, Akolekar R, Nicolaides KH. Prediction of small for gestational age neonates at 35-37 weeks’ gestation: contribution of maternal factors and growth velocity between 32 and 36 weeks. Ultrasound Obstet Gynecol 2019; 53; 630-637.

Scan at 22 and 36 w n=44,043

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Scan at 32 and 36 w n=14,497

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Screening for SGA / FGRAddition of biomarkers

Ciobanu A, Rouvali, A, Syngelaki A, Akolekar R, Nicolaides KH. Prediction of small for gestational age neonates: screening by maternal factors, fetalbiometry and biomarkers at 35-37 weeks’ gestation. Am J Obstet Gynecol 2019;220:486.e1-11.

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Maternal factors+ Estimated fetal weight+ Biomarkers

Routine ultrasound scan • 35+0 - 36+6 w: n=19,209

• Estimated fetal weight• Uterine artery PI• Umbilical artery PI• Middle cerebral artery PI• Serum PLGF and sFLT-1


Screening for SGA / FGR

Selection of EFW cut-off

Ciobanu A, Khan N, A, Syngelaki A, Akolekar R, Nicolaides KH. Routine ultrasound at 32 versus 36 weeks’ gestation: prediction of small forgestational age neonates. Ultrasound Obstet Gynecol 2019; doi: 10.1002/uog.20258

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Screening for SGA fetusesTwo-stage approach

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≤2 2.1-4 >4

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High-risk 12% (EFW

The Fetal Medicine Foundation Screening for SGA fetuses

• Screen at 12 weeks – Aspirin for high-risk

• Screen at 22 weeks – Stratify for follow-up

• Use of EFW vs. fetal AC

• Selection of FMF EFW and BW charts

• 36 w better than 32 w scan

• No additive value of growth velocity

• Minimal additive value of biomarkers

• New proposal for management

Thank you


Preventing stillbirthsAssessment at 36 weeks

P

Screening for fetal growth restriction · Prediction of small for gestational age neonates at 35-37...

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