Death and severe morbidity in isolated periviable small‐for‐gestational‐age fetuses

Abstract

Objective This study aims to predict perinatal death or severe sequelae in isolated small‐for‐gestational‐age fetuses, diagnosed at a periviable gestational age, based on ultrasound and Doppler parameters at diagnosis. Design Observational study. Setting A tertiary perinatal centre. Population A cohort of singleton non‐malformed fetuses suspected to be small for gestational age (estimated fetal weight, EFW, <10th centile) diagnosed at 22.0–25.6 weeks of gestation. The following parameters were recorded at diagnosis: severe smallness (<3rd centile); absent or reversed end‐diastolic velocity in umbilical artery; abnormal middle cerebral artery Doppler; abnormal cerebroplacental ratio; abnormal uterine artery Doppler; and absent or reversed end‐diastolic velocity in the ductus venosus. Methods Logistic regression analysis. Main outcome measures Predictive performance of EFW and Doppler parameters for short‐term adverse outcome of perinatal morbimortality and composite serious adverse outcomes (death, neurological impairment or severe bronchopulmonary dysplasia). Results A total of 155 pregnancies were included. There were 13 (8.4%) intrauterine and 11 (7.7%) neonatal deaths. A short‐term adverse perinatal outcome occurred in 40 (25.8%) pregnancies. There were 31 (20%) cases of serious adverse outcomes. For the prediction of serious adverse outcomes, the combination of absent or reversed end‐diastolic velocity in the umbilical artery and impaired middle cerebral artery detected by Doppler evaluation achieved a detection rate of 87%, with a false‐positive rate of 14% (accuracy 86%). Conclusion In periviable isolated small‐for‐gestational‐age fetuses, a Doppler evaluation of the umbilical and fetal brain circulation can accurately predict short‐term adverse perinatal complications and serious adverse outcomes.

A combination of clinical Doppler ultrasound and angiogenic biomarker assessment is currently the best approach for the evaluation of periviable fetal growth restriction

“…Finally, we analysed candidate predictors using multivariate methods, which may explain why uterine Doppler did not maintain an independent association, meaning it was not retained in the final model. For instance, in the series by Li et al, 1 of the 24 cases with abnormal umbilical artery Doppler, 82% also had abnormal uterine Doppler. We agree that the maternal levels of angiogenic factors, not available in our retrospective series, may have improved the prediction capacity of our models.…”

“…3 Another problematic issue is equating association with prediction (which was the aim of our study). As an example, in Li et al, 1 the detection rate of abnormal uterine Doppler for NICU admission was 61% (65/107) but with a 42% (225/538) rate of false positives. Finally, we analysed candidate predictors using multivariate methods, which may explain why uterine Doppler did not maintain an independent association, meaning it was not retained in the final model.…”

“…A combination of clinical Doppler ultrasound and angiogenic biomarker assessment is currently the best approach for the evaluation of periviable fetal growth restriction Dear Dr Papageorghiou, We thank Meler et al for their study assessing clinical ultrasound Doppler criteria in the prediction of fetal/perinatal death and possible neurodevelopmental sequelae in 155 pregnancies with a small-for-gestational fetus diagnosed between 22 +0 and 25 +6 weeks of gestation. 1 Once fetal infections and chromosomal/genetic aetiologies have been excluded, 'placental dysfunction' (PD) is indeed 'the most plausible condition'. But we believe that this conclusion should require an obstetrical history suggesting PD, and that uterine artery Doppler (UtAD) should have a rightful place in this assessment.…”

“…However, we find it problematic to translate results from high-risk pregnancies into the clinical scenario of SGA diagnosed very early in pregnancy. Indeed, in the series by Li et al 1 (which Carbillon et al 2 refer to as support) it is stated that 'only 20% of the fetuses ended up with a birthweight below the 10th centile. In contrast, in our series, 87% of the babies were born small for gestational age.…”

Prediction of perinatal survival in early‐onset fetal growth restriction: role of placental growth factor

“…PI centiles were obtained using a free online calculator (http:// medicinafetalbarcelona.org/calc/) based on the Doppler charts of Arduini and Rizzo 22 , Hecher et al 23 and Baschat and Gembruch 24 . For the predictive purposes of this study, altered Doppler was defined as absent/reversed UA flow and impaired MCA-PI (< 5 th centile) since this combination of parameters has recently shown the best association with perinatal complications in eoFGR, greater than that of uterine artery-PI and DV-PI 8 .…”