Multidisciplinary consensus on screening for, diagnosis and management of fetal growth restriction in the Netherlands

Abstract

BackgroundScreening for, diagnosis and management of intrauterine growth restriction (IUGR) is often performed in multidisciplinary collaboration. However, variation in screening methods, diagnosis and management of IUGR may lead to confusion. In the Netherlands two monodisciplinary guidelines on IUGR do not fully align. To facilitate effective collaboration between different professionals in perinatal care, we undertook a Delphi study with uniform recommendations as our primary result, focusing on issues that are not aligned or for which specifications are lacking in the current guidelines.MethodsWe conducted a Delphi study in three rounds. A purposively sampled selection of 56 panellists participated: 27 representing midwife-led care and 29 obstetrician-led care. Consensus was defined as agreement between the professional groups on the same answer and among at least 70% of the panellists within groups.ResultsPer round 51 or 52 (91% - 93%) panellists responded. This has led to consensus on 27 issues, leading to four consensus based recommendations on screening for IUGR in midwife-led care and eight consensus based recommendations on diagnosis and eight on management in obstetrician-led care. The multidisciplinary project group decided on four additional recommendations as no consensus was reached by the panel. No recommendations could be made about induction of labour versus expectant monitoring, nor about the choice for a primary caesarean section.ConclusionsWe reached consensus on recommendations for care for IUGR within a multidisciplinary panel. These will be implemented in a study on the effectiveness and cost-effectiveness of routine third trimester ultrasound for monitoring fetal growth. Research is needed to evaluate the effects of implementation of these recommendations on perinatal outcomes.Trial registration NTR4367.

Effectiveness of routine third trimester ultrasonography to reduce adverse perinatal outcomes in low risk pregnancy (the IRIS study): nationwide, pragmatic, multicentre, stepped wedge cluster randomised trial

“…Intervention strategy=prenatal screening for fetal growth restriction based on routine biometry scans in third trimester in combination with serial fundal height measurements and ultrasonography if clinically indicated. Control strategy=prenatal screening for fetal growth restriction based on serial fundal height measurements and ultrasonography only if clinically indicated.SGA=small for gestational age (birth weight <10th centile (<P10) of Dutch national (Perined) birth weight curve27); AC <P10=abdominal circumference estimated by fetal biometry scan <P10 on Dutch growth curve24; slow growth=decrease of ≥20 centiles of abdominal circumference on Dutch growth curve with interval of at least two weeks from gestational age ≥26 weeks and 0 days 13*Numbers for routine biometry scans at 28-30 weeks’ gestation and at 34-36 weeks’ gestation differ slightly because of missing values.†χ 2 tests showed that sensitivities of AC <P10 or slow growth (P<0.001), AC <P10 (P<0.001), and slow growth (P=0.010) were significantly higher in the intervention strategy than in the control strategy, whereas specificities of these measures were significantly higher in the control strategy (all P<0.001).‡A McNemar test revealed no differences in sensitivity between the fetal biometry scan at 28-30 weeks’ gestation and 34-36 weeks’ gestation (P=0.38).§A McNemar test showed a higher specificity of the fetal biometry scan at 34-36 weeks’ gestation compared with the scan at 28-30 weeks’ gestation (P<0.001).…”

“…We defined prenatal SGA as a fetal abdominal circumference below the 10th centile based on a population based Dutch reference growth curve 24. Slow fetal abdominal growth was defined as a decrease in abdominal circumference of at least 20 centiles (eg, from the 70th to 50th centile, with a minimum interval of two weeks) on the Dutch reference curve 1324. A volume of amniotic fluid of less than 2 cm in the deepest vertical pocket was also an indication of suspected fetal growth restriction.…”

“…In both strategies, women with suspected fetal growth restriction were referred to obstetrician led care for further diagnosis and management. Suspected fetal growth restriction was detected and managed based on a protocol specifically developed for this study in a Delphi study incorporating recommendations from national and international guidelines (see appendix 1) 13141725…”

“…Because many SGA infants can be constitutionally small but healthy, this proxy is unsatisfactory 11. To improve the detection of fetal growth restriction prenatally, repeated measurements of fetal growth are recommended 121314…”

“…We therefore conducted a large pragmatic trial, the IUGR Risk Selection (IRIS) study, to evaluate the effects of offering routine ultrasonography in the third trimester to low risk pregnant women in the Netherlands. For this trial, we developed a multidisciplinary protocol based on consensus for detecting and managing suspected fetal growth restriction 13. We chose a cluster randomised design to roll-out the intervention and to avoid contamination bias due to the women’s preferences for or against ultrasound scans 20.…”