Analysis of intrauterine fetal demise—A hospital-based study in Taiwan over a decade

ObjectiveTo identify timing-specified risk factors for stillbirth, in order to help physicians to reduce preventable factors and stillbirths, and improve general outcomes of pregnancy.Materials and MethodsA retrospective analysis was performed of births registered in our hospital, a medical center in Taiwan, between September 1, 1999 and December 31, 2011. We collected basic characteristics from the medical records, including maternal and fetal conditions. All stillbirths were divided into two groups according to gestational age: the second trimester group and the third trimester group. Comparisons were made between these groups.ResultsThere were a total of 12,290 births and 121 stillbirths during our study period. The 121 stillbirths were divided into two groups: 67/121 (55.4%) were in the second trimester group and 54/121 (44.6%) were in the third trimester group. The overall incidence for intrauterine fetal demise was 0.98% (121/12,290). The increased risks in the third trimester stillbirths, as compared with the second trimester group, were significantly associated with males born, increased maternal body mass index (BMI) at delivery, habitual cigarette smoking, previous history of intrauterine fetal demise, and diabetic or hypertensive pregnancies. Unexplained causes (29.85%) were the most common causes of second trimester intrauterine fetal demise and the most common cause of third trimester intrauterine fetal demise was umbilical cord pathology (33.33%).ConclusionManagement of any pregnant patient remains a challenge. Identifying upstream and cost-effective solutions will improve these pregnancy outcomes.     

The possible role of intrauterine infections in unexplained second trimester abortions and macerated stillbirths: a study from a single center.

OBJECTIVE: To investigate the role of intrauterine infections in unexplained second trimester abortions and stillbirths. STUDY DESIGN: Histopathologic and microbiologic evidence of intrauterine infection in the placentas, fetal membranes and fetal lung tissues of 18 unexplained second trimester abortions and macerated stillbirth cases as well as the placentas and fetal membranes of 10 healthy term neonates were investigated in a prospective study conducted in Ankara University School of Medicine, Turkey. RESULTS: Histopathologic chorioamnionitis and placental culture positivity rates in the study and control groups were 64.7 vs 0%. Bacteria were recovered from 90.9% of placentas and 36.4% of fetal lungs of the cases with histopathologic chorioamnionitis. Intrauterine infection was found in 66.7% of the whole study group, in 85.7% of the unexplained second trimester abortions, and in 54.5% of the macerated stillbirths. CONCLUSION: Intrauterine infection may be an important factor in unexplained stillbirths and second trimester abortions in centers where pregnancy follow-ups lack evaluation for asymptomatic infection.     

Etiology of stillbirth at term: a 10-year cohort study

Objective. To examine etiological factors contributing to cases of intrauterine fetal demise in term pregnancies over a 10-year period.

Methods. This was a retrospective cohort analysis of 29 908 term (37⁺⁰ to 41⁺⁶ weeks gestation) infants delivering in a single tertiary-referral university institution over the 10-year period from 1996 to 2005. Cases of stillbirth were identified from a computerized hospital database, and pathological, clinical, and biochemical data were reviewed for all cases. Trends were analyzed using the Cusick test for trend. Categorical data were analyzed using the Fisher's exact test, with the 5% level considered significant.

Results. The incidence of intrauterine fetal demise at term was 1.8 per 1000 at-risk pregnancies. There was no significant downward trend in the rate of term stillbirth between 1996 and 2005 (p = 0.0808). Stillbirths were unexplained in 51% of cases, although in many cases a possible etiological factor was identified but not necessarily proven. There was a significant downward trend in the incidence of unexplained term stillbirths at our institution over the 10-year study period (p = 0.0105). Placental/cord factors accounted for 25% of term stillbirths and did not decrease significantly over the study period (p = 0.0953). Almost 50% of term stillbirths occurred in women who registered late or had no antenatal care. However, suboptimal antenatal care was not predictive of differences in either acceptance of perinatal postmortem or successful identification of stillbirth etiology.

Conclusions. The incidence of stillbirth at term is 2 per 1000 term pregnancies and has not changed significantly in the past 10 years. Almost 50% of term stillbirths occurred in women with suboptimal antenatal care. More than half of cases are unexplained, often resulting from an incomplete diagnostic work-up. Despite this, there has been a significant downward trend in the rates of unexplained stillbirth at term. It is imperative that a complete diagnostic work-up is performed in cases of term stillbirth, to minimize the incidence of unexplained stillbirth.     

Restricted fetal growth in sudden intrauterine unexplained death

BACKGROUND: Unexplained antepartum stillbirth is a common cause of perinatal death, and identifying the fetus at risk is a challenge for obstetric practice. Intrauterine growth restriction (IUGR) is associated with a variety of adverse perinatal outcomes, but reports on its impact on unexplained stillbirths by population-based birthweight standards have been varying, including both unexplained and unexplored stillbirths. AIM: We have studied IUGR, assessed by individually adjusted fetal weight standards, in antepartum deaths that remained unexplained despite thorough postmortem investigations. METHODS: Antenatal health cards from a complete population-based 10-year material of 76 validated sudden intrauterine unexplained deaths were compared to those of 582 randomly selected liveborn controls. Birthweight <10th percentile of the individualized standard adjusted for gestational age, maternal height, weight, parity, ethnicity, and fetal gender was defined as growth restriction. RESULTS: 52% of unexplained stillbirths were growth restricted, with a mean gestational age at death of 35.1 weeks. Suboptimal growth was the most important fetal determinant for sudden intrauterine unexplained death (odds ratio 7.0, 95% confidence interval 3.3-15.1). Concurrent maternal overweight or obesity, high age, and low education further increase the risk. Overweight and obesity increase the risk irrespective of fetal growth, and while high maternal age increases the risk of the normal weight fetus, it is not associated to growth restriction as a precursor of sudden intrauterine unexplained death. CONCLUSIONS: IUGR is an important risk factor of sudden intrauterine unexplained death, and this should be excluded in pregnancies with any other risk factor for sudden intrauterine unexplained death.     

Stillbirth evaluation: What tests are needed?

OBJECTIVE: We sought to investigate what aspects of the stillbirth evaluation are considered to be essential and what tests can potentially be eliminated. STUDY DESIGN: A retrospective analysis of 745 stillbirths occurring from January 1990 to December 1994 was conducted. A stillbirth was defined by an estimated gestational age >20 weeks' gestational age or fetal weight >500 gm. We attempted to arrive at an apparent cause for each stillbirth after evaluation of genetic or chromosomal abnormalities, obstetric history, maternal medical illnesses, laboratory tests, autopsy findings, and placental pathologic conditions. RESULTS: We found that the most important aspects of stillbirth evaluation were placental pathologic conditions and autopsy. When the placenta was examined, a significant abnormality was detected in 30% (160 of 529) of the cases. When autopsy was performed, only 31% of fetal deaths (142 of 462) were unexplained; however, when no autopsy was performed, 44% (125 of 283) were unexplained (p = 0.0002). The following laboratory evaluations that were routinely performed were found to yield little definitive information: antinuclear antibody testing, Kleihauer-Betke test, and screening for congenital infections (toxoplasmosis, other viruses, rubella, cytomegalovirus, and herpes simplex virus). Overall, 36% (267 of 745) of stillbirths still remained unexplained despite a thorough evaluation in most cases. CONCLUSION: The causes of stillbirth are many and varied, with a large proportion having no obvious cause. As this study demonstrates, certain laboratory tests can be eliminated in the workup of fetal death. In the evaluation of stillbirth a complete systematic method that incorporates placental pathologic conditions, as well as autopsy findings, should prove to be beneficial. (Am J Obstet Gynecol 1998;178:1121-5.)     

Association between pregnancy complications and small-for–gestational-age birth weight defined by customized fetal growth standard versus a population-based standard

Objective.?To derive coefficients for developing a customized growth chart for a Mid-Western US population, and to estimate the association between pregnancy outcomes and smallness for gestational age (SGA) defined by the customized growth chart compared with a population-based growth chart for the USA.

Method.?A retrospective cohort study of an ultrasound database using 54,433 pregnancies meeting inclusion criteria was conducted. Coefficients for customized centiles were derived using 42,277 pregnancies and compared with those obtained from other populations. Two adverse outcome indicators were defined (greater than 7 day stay in the neonatal unit and stillbirth [SB]), and the risk for each outcome was calculated for the groups of pregnancies defined as SGA by the population standard and SGA by the customized standard using 12,456 pregnancies for the validation sample.

Results.?The growth potential expressed as weight at 40 weeks in this population was 3524?g (standard error: 402?g). In the validation population, 4055 cases of SGA were identified using both population and customized standards. The cases additionally identified as SGA by the customized method had a significantly increased risk of each of the adverse outcome categories. The sensitivity and specificity of those identified as SGA by customized method only for detecting pregnancies at risk for SB was 32.7% (95% confidence interval [CI] 27.0–38.8%) and 95.1% (95% CI: 94.7–95.0%) versus 0.8% (95% CI 0.1–2.7%) and 98.0% (95% CI 97.8–98.2%)for those identified by only the population-based method, respectively.

Conclusion.?SGA defined by customized growth potential is able to identify substantially more pregnancies at a risk for adverse outcome than the currently used national standard for fetal growth.     

Late preterm and early term: when to induce a growth restricted fetus? A population-based study

Purpose: (1) Compare fetal and neonatal morbidity and mortality associated with induction of labor (IOL) versus expectant management (EM) in women with isolated fetal growth restriction (FGR) between 34^0/7 and 38^6/7 weeks; (2) Determine optimal gestational age for delivery of such fetuses.

Materials and methods: A retrospective population based cohort study of 2232 parturients with isolated FGR, including two groups: (1) IOL (n?=?1428); 2) EM (n?=?804).

Results: IOL group had a lower stillbirth and neonatal death rates (p?=?.042, p?p?=?.001, p?=?.039). In the early term cohort, EM was associated with a higher rate of NRFHR and low 1?min Apgar scores (p?=?.003, p?=?.002). IOL at 37 weeks protected from stillbirth but not from adverse composite neonatal outcomes.

Conclusions: IOL of FGR fetuses at 37?weeks had a protective effect against stillbirth. In addition, at late preterm, it is associated with lower rates of stillbirth, neonatal death, and NRFHR.     

预防可避免死胎,重视死胎病因管理

全球死胎发生率差异较大的原因与死胎定义不一以及各地社会发展不均衡相关;以往研究发现,28周的死胎多与胎儿畸形、妊娠合并症相关;≥28周的死胎多与妊娠并发症有关,尤其胎儿生长受限;分娩过程的死胎,主要与临床监护、处置不当有关。针对不同死胎原因的管理,有望降低死胎发生率。     

Heavy prenatal alcohol exposure and risk of stillbirth and preterm delivery

We prospectively identified 96 women consuming at least 4 drinks/day during pregnancy by screening 9628 pregnant women. In these women with heavy prenatal alcohol use, there were three stillbirths and one preterm delivery; 98 matched nondrinking women had no stillbirths and two preterm births. Preterm rates did not differ significantly. The stillbirth rate was higher in the exposed group (p?=?0.06). Additional investigation showed the stillbirth rate in the exposed population (3.1%) was significantly higher (p?=?0.019) than the reported Chilean population rate (0.45%). Our data suggest that heavy alcohol consumption may increase the risk for stillbirth but not preterm delivery.     

A case-control study of unexplained antepartum stillbirths.

OBJECTIVE: To ascertain factors that will identify women who are at increased risk of unexplained antepartum stillbirth. DESIGN: Matched case-control study. The cases and controls were initially analysed as a whole group and again after dichotomizing into those of low birthweight (< 2500 g) and those of normal birthweight (> or = 2500 g). SETTING: Western Australia 1980-1983. SUBJECTS: Unexplained antepartum stillbirths of > or = 1000 g birthweight (cases) and liveborn infants individually matched for year of birth, plurality, sex and birthweight of infant and race of mother (controls). RESULTS: The case pregnancies had more polyhydramnios (OR 10.83, 95% CI 2.41-48.69) and cord problems (OR 6.57 95% CI 1.36-31.75) than the controls but, paradoxically, other obstetric and medical complications were less common in the cases. The association with polyhydramnios persisted when the analysis was confined to those with low birthweight. With normal birthweight fetal distress was more frequent in the cases (OR 3.65 95% CI 1.36-9.80) but there were few other differences. CONCLUSIONS: The clinical and diagnostic systems currently in use are unable to identify many fetuses at risk of death. Decreases in the rate of unexplained antepartum stillbirths await the discovery of new preventable causes, or of innovations in clinical or laboratory aspects of obstetric care.     

Decorin: a possible marker for fetal growth restriction

The aim of this study was to compare decorin (DCN) levels between pregnancies complicated by idiopathic fetal growth restriction (FGR) and uncomplicated pregnancies and to determine the relationship between DCN levels and clinical parameters. The study population consisted of two groups: control group consisted of 13 women with uncomplicated singleton pregnancies in the third trimester. Study group consisted of 14 singleton pregnancies complicated by idiopathic FGR who were admitted to the hospital for delivery in the third trimester of pregnancy. Maternal and fetal DCN levels were measured. Color Doppler flow assessments were performed. Relationship between DCN levels and clinical parameters was determined. Maternal DCN serum levels were significantly higher in complicated pregnancies by idiopathic FGR (p?=?0.01). A statistically significant negative correlation was observed between maternal DCN serum levels and neonatal birth weight (r?=??0.0506; p?=?0.007). There was a significant correlation between umbilical artery (UA) DCN levels and UA S/D ratio (r?=?0.512; p?=?0.006) and UA RI (r?=?0.405; p?=?0.036). The risk of high DCN maternal serum levels (>7986.6?pg/mL) in pregnancy complicated by FGR was 8.25 times higher (RR?=?8.25; 95% CI, 1.4–46.8). The results of our study showed that the presence of increased DCN levels in women with FGR could contribute to pathogenesis of the disease.     

Association between small for gestational age and intrauterine fetal death: comparing a customized South Korean growth standard versus a population-based fetal growth chart

Objective: To determine if a customized growth standard developed for an ethnically homogeneous South Korean population is better at identifying (SGA) fetuses at risk for intra-uterine fetal death (IUFD), compared with a current population based-growth standard.

Study design: A retrospective cohort study comparing the identification of SGA fetuses at risk for IUFD using a customized versus a population based-chart. The association between a SGA infant defined as a birth weight <10th percentile using the South Korean population chart versus the customized chart and IUFD were compared. Intrauterine fetal death was defined as fetal demise occurring after 20 weeks gestation. Statistical analyses including OR, 95% confidence interval (CI), and screening accuracy using each chart were performed.

Results: The customized singleton chart identified 11 (8.2%) of the SGA pregnancies detected by the population chart and classified 15 additional fetuses as SGA. Those identified as SGA using the customized chart had an OR for IUFD that was approximately 15 times as high as those identified using the population chart. The customized chart also showed a higher sensitivity and specificity for identifying SGA pregnancies at risk for IUFD.

Conclusion: In this ethnically homogenous population, the customized growth chart showed improved discrimination in identifying SGA pregnancies at risk for fetal death than the population-based growth chart.     

Reclassification of unexplained stillbirths using clinical practice guidelines

Background: Twenty-eight per cent of stillbirths in Australia remain unexplained. A clinical practice guideline (CPG) produced by the Perinatal Society of Australia and New Zealand (PSANZ) Perinatal Mortality Special Interest Group is in use to assist clinicians in the investigation and audit of perinatal deaths.
Aims: To describe in a tertiary hospital using the PSANZ stillbirth investigation guidelines: (i) the distribution and classification of stillbirths, and (ii) the compliance with suggested stillbirth core investigations.
Methods: Retrospective cohort of all stillbirths delivered between November 2005 and March 2008. Stillbirths were defined as no sign of life on delivery at ≥ 20 weeks gestation or 400 g birthweight if gestation is unknown. Data were collected via the hospital Perinatal Mortality Audit Committee (PMAC). Cause of death was classified by the PSANZ Perinatal Death Classification.
Results: There were 86 stillbirths (rate 7.2 per 1000 births). The percentage of unexplained stillbirths was 34% and 13% before and after CPG investigations, respectively. Unexplained stillbirths had the highest compliance with the recommended investigations. The initial cause of death documented on the death certificate was changed by the PMAC in 19 cases. The investigations most likely to prompt a change in the cause of death classification were autopsy and placental pathology.
Conclusions: The percentage of unexplained stillbirths is lower than the national average in a hospital using the Perinatal Mortality Audit Guidelines. However, overall compliance is low, suggesting a targeted approach to investigation is used by clinicians despite a policy that aims to be non-selective. Autopsy and placental examination are the most useful investigations in assisting formal classification of cause of death.     

Added value of cerebro-placental ratio and uterine artery Doppler at routine third trimester screening as a predictor of SGA and FGR in non-selected pregnancies

Objectives: The objective of this study is to determine the added value of cerebroplacental ratio (CPR) and uterine Doppler velocimetry at third trimester scan in an unselected obstetric population to predict smallness and growth restriction.

Methods: We constructed a prospective cohort study of women with singleton pregnancies attended for routine third trimester screening (32⁺⁰–34⁺⁶ weeks). Fetal biometry and fetal–maternal Doppler ultrasound examinations were performed by certified sonographers. The CPR was calculated as a ratio of the middle cerebral artery to the umbilical artery pulsatility indices. Both attending professionals and patients were blinded to the results, except in cases of estimated fetal weight Results: A total of 1030 pregnancies were included. The mean gestational age at scan was 33 weeks (SD 0.6). The addition of CPR and uterine Doppler to maternal characteristics plus EFW improved the explained uncertainty of the predicting models for SGA (15 versus 10%, p?p?=?.03). However, the addition of CPR and uterine Doppler to maternal characteristics plus EFW only marginally improved the detection rates for SGA (38 versus 34% for a 10% of false positives) and did not change the predictive performance for FGR.

Conclusions: The added value of CPR and uterine Doppler at 33 weeks of gestation for detecting defective growth is poor.     

First-trimester metabolomic prediction of stillbirth

Background: Stillbirth remains a major problem in both developing and developed countries. Omics evaluation of stillbirth has been highlighted as a top research priority.

Objective: To identify new putative first-trimester biomarkers in maternal serum for stillbirth prediction using metabolomics-based approach.

Methods: Targeted, nuclear magnetic resonance (NMR) and mass spectrometry (MS), and untargeted liquid chromatography-MS (LC-MS) metabolomic analyses were performed on first-trimester maternal serum obtained from 60 cases that subsequently had a stillbirth and 120 matched controls. Metabolites by themselves or in combination with clinical factors were used to develop logistic regression models for stillbirth prediction. Prediction of stillbirths overall, early (<28 weeks and <32 weeks), those related to growth restriction/placental disorder, and unexplained stillbirths were evaluated.

Results: Targeted metabolites including glycine, acetic acid, L-carnitine, creatine, lysoPCaC18:1, PCaeC34:3, and PCaeC44:4 predicted stillbirth overall with an area under the curve [AUC, 95% confidence interval (CI)]?=?0.707 (0.628–0.785). When combined with clinical predictors the AUC value increased to 0.740 (0.667–0.812). First-trimester targeted metabolites also significantly predicted early, unexplained, and placental-related stillbirths. Untargeted LC-MS features combined with other clinical predictors achieved an AUC (95%CI)?=?0.860 (0.793–0.927) for the prediction of stillbirths overall. We found novel preliminary evidence that, verruculotoxin, a toxin produced by common household molds, might be linked to stillbirth.

Conclusions: We have identified novel biomarkers for stillbirth using metabolomics and demonstrated the feasibility of first-trimester prediction.     

Fetal growth restriction and other risk factors for stillbirth in a New Zealand setting

BACKGROUND: Stillbirth affects almost 1% of pregnant women in the Western world but is still not a research priority. AIMS: To assess in a cohort of stillbirths: the demographic risk factors, the prevalence of small for gestational age (SGA) by customised and population centiles, and the classification of death using the Perinatal Society of Australia and New Zealand Perinatal Death Classification (PSANZ-PDC). METHODS: The study population comprised 437 stillborn babies (born from 1993 to 2000 at National Women's Hospital, Auckland, New Zealand) and their mothers. The referent population for demographic factors was live births n=69 173. RESULTS: After multivariable analysis, risk factors for stillbirths were: Indian (odds ratio (OR) 1.85, 95%CI (1.18, 2.91)), or Pacific Islander (OR 1.65, 95%CI (1.27, 2.14)); smoking (OR 1.33, 95%CI (0.99, 1.79)) or unknown smoking status (OR 2.87, 95%CI (2.30, 3.58)); nulliparity (OR 1.42, 95%CI (1.10, 1.83)), and para 2 (OR 1.36, 95%CI (1.01, 1.83)). One hundred and twenty-nine (46%) stillbirths born>or=24 weeks (n=278) were SGA by customised, and 94 (34%) by population centiles. Customised SGA was more common in preterm versus term stillbirths (101 of 198 (51%) vs 28 of 80 (35%), respectively, P=0.02) but rates of population SGA did not differ (72 of 198 (36%) vs 22 of 80 (28%) P=0.16). 'Spontaneous preterm' was the most common cause of stillbirth at <28 weeks and 'unexplained' at >or=28 weeks using PSANZ-PDC classification. CONCLUSIONS: This study again emphasises the importance of suboptimal fetal growth as an important risk factor for stillbirth. Customised centiles identified more stillborn babies as SGA than population centiles especially preterm.     

Association between isolated abnormal levels of maternal serum unconjugated estriol in the second trimester and adverse pregnancy outcomes

Objective: To determine the association between maternal serum unconjugated estriol (uE3) levels in the second trimester and adverse pregnancy outcomes.

Patients and methods: The prospective database of our fetal Down screening program was assessed and reviewed for maternal serum uE3 levels. Pregnancies with medical diseases, abnormal levels of beta-human chorionic gonadotropin, alpha-fetoprotein and fetal chromosomal or structural abnormalities were excluded. The recruited women were categorized into three groups: high (>95th percentile), normal (5–95th percentile) and low (<5th percentile) uE3 levels.

Results: Of 14?212 screened women, 9183 (high; 455, normal; 8271 and low; 457) levels group, were available for outcome analysis. The rates of most adverse outcomes, including preterm birth, low Apgar scores, fetal death, placental abruption, preeclampsia and gestational diabetes mellitus, of the high and normal groups were comparable. Nevertheless, low uE3 levels increased risk of fetal growth restriction (FGR) (RR: 2.36, 95% CI: 1.79–3.10) and low birth weight (LBW) (RR: 1.87, 95% CI: 1.45–2.39), but not preterm birth. Logistic regression analysis indicated that low uE3 level was an independent risk factor for FGR and LBW.

Conclusions: High uE3 levels in the second trimester are not associated with poor outcomes, whereas low levels significantly increase risk of FGR and LBW but not other adverse outcomes.     

Predictive value of angiogenic factors,clinical risk factors and uterine artery Doppler for pre-eclampsia and fetal growth restriction in second and third trimester pregnancies in an Ecuadorian population

Objective: To evaluate the performance of angiogenic factors, maternal risks and uterine artery Doppler (UAD) in the prediction of pre-eclampsia (PE) and fetal growth restriction (FGR) in a high-risk Ecuadorian population.

Methods: Patients with singleton pregnancies (n?=?346) were investigated at two clinical visits (18–25 weeks and 28–32 weeks). Mean uterine artery (UA), pulsatility index (PI) and maternal biomarkers (soluble fms-like tyrosine kinase-1, placental growth factor, sFlt-1/PLGF ratio) were obtained. The main endpoints were PE and FGR. UA PI and angiogenic factor levels were compared for the groups with PE (n?=?34), FGR (n?=?26), PE & FGR (n?=?14) and controls (n?=?272). Multivariable stepwise logistic regression was used to construct prediction models.

Results: Pregnancies with either FGR or PE & FGR exhibited in the second trimester a significantly higher mean UA PI and sFlt-1/PLGF ratio and lower PLGF values compared to controls. In the third trimester, all groups with adverse outcome demonstrated significantly lower PLGF levels and a higher sFlt-1/PLGF ratio compared to normal pregnancies. Differences were most pronounced for pregnancies that developed PE and FGR for both time intervals. The combination of UAD and sFlt-1/PLGF ratio improved the predictive capacity for PE and FGR compared to each parameter alone. The best performance was obtained by integrating anamnestic risk factors, resulting in an area under the receiver operating curve for PE of 0.85 and 0.89 and for FGR of 0.79 and 0.77 in the second and third trimester, respectively.

Conclusion: In a high-altitude Ecuadorian population, angiogenic factors and UA PI were useful tools in the prediction of PE and/or FGR. The highest performance was achieved by the combination of these factors, including obstetric and medical history.     

Comparison of customized and cohort-based birthweight standards in identification of growth-restricted infants in GUSTO cohort study

Background: The aim was to evaluate the ability of customized and cohort birthweight standards in discriminating intrauterine growth retardation (IUGR).

Methods: Birthweights (BWs) of GUSTO singleton infants born at gestational age (GA) 35–41 weeks were converted using two standards: (a) GUSTO cohort-based BW centile adjusted for GA and baby gender; (b) customized BW percentile calculator adjusted for maternal height and weight, race, parity, GA and gender. Infants were classified into three groups: (1)?<?10th BW centile by customization– customized-SGA, (2)?<?10th BW centile by GUSTO– GUSTO-SGA; and (3)?>?10th BW centile by both standards – BOTH-non-SGA.

Results: Of the 1011 infant–mother dyads, 68 were customized-SGA and 104 were GUSTO-SGA, with concordance of 61% (n?= 63) for SGA. While 5 (7%) of customized-SGA were not SGA by GUSTO-charts, 41 (39%) of GUSTO-SGA were not SGA by customized-charts. Customized-SGA had significantly the least growth in abdominal circumference (AC) and highest head circumference (HC): AC growth ratio between second and third trimester; and the lowest mean BW, ponderal index and placental weight than other groups.

Conclusion: Customized-SGA standard was a better discriminator of pathologic fetal growth based on AC growth. It improved strength of association with pathology and in our population reduced false positives (41/104?=?39%) in the assessment of SGA.     

Adverse fetal outcome: is first trimester ultrasound and Doppler better predictor than biomarkers?

Aims and objectives: To evaluate the predictive value of first trimester biomarkers and ultrasound in determining adverse fetal outcomes in a low risk Asian population.

Material and method: All low risk, singleton pregnancies between 11 and 14 weeks gestation underwent ultrasound with uterine artery Doppler along with PAPP-A and free β-hCG estimation, and were followed till delivery to observe the outcome. The adverse fetal outcomes detected were structural anomaly, aneuploidy, intrauterine growth restriction, preterm birth and stillbirth (SB).

Results: Out of 3500 women screened, 417 cases had adverse fetal outcome in the absence of maternal complication, 2151 had normal outcome. Major structural anomaly was detected in first trimester in 17/28 (60.7%) cases. The most important markers for adverse fetal outcome were increased uterine artery pulsatility index (UPI) (p?=?0.028, OR 1.5, 95% CI: 1.05–2.38, AUC 0.56) for IUGR, nuchal translucency (p?=?0.001, OR 1.7, 95% CI: 1.11–2.77, AUC 0.60) for major anomaly and low PAPP-A (p?=?0.017, OR ?0.075, 95% CI: 0.87–0.98, AUC 0.621) for SB.

Conclusion: UPI, NT and PAPP-A in the first trimester are significant markers of adverse fetal outcome, although the sensitivity and specificity are not high they have a high negative predictive value.