Z Geburtshilfe Neonatol 2019; 223(05): 289-296
DOI: 10.1055/a-0882-7425
Original Article
© Georg Thieme Verlag KG Stuttgart · New York

A Cut-off Value for Gestational Week at Birth for Better Perinatal Outcomes in Early- and Late-Onset Fetal Growth Restriction

Mehmet Sinan Beksac
1   Department of Obstetrics and Gynecology, Division of Perinatal Medicine, Hacettepe University, Ankara, Turkey
,
Erdem Fadiloglu
1   Department of Obstetrics and Gynecology, Division of Perinatal Medicine, Hacettepe University, Ankara, Turkey
,
Atakan Tanacan
1   Department of Obstetrics and Gynecology, Division of Perinatal Medicine, Hacettepe University, Ankara, Turkey
,
Apostolos Mamopoulos
2   Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
,
Merve Basol
3   Department of Biostatistics, Hacettepe University, Ankara, Turkey
,
Daniel Muresan
4   Department of Obstetrics and Gynecology, Universitatea de Medicina si Farmacie Iuliu Hatieganu, Cluj-Napoca, Romania
,
Apostolos Athanasiadis
2   Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
› Author Affiliations
Further Information

Publication History

received 05 November 2018

accepted 14 March 2019

Publication Date:
17 May 2019 (online)

Abstract

Objective Prediction of cut-off value for gestational week at birth for better perinatal outcomes in early- and late-onset fetal growth restriction (FGR).

Materials and Methods This study consists of 83 singleton pregnancies with FGR that were diagnosed antenatally and confirmed postnatally between January 2017–April 2018. We used the 34th gestational week as a cut-off for early- and late-onset FGR discrimination.

Results Early- and late-onset FGRs were detected in 22 (26.5%) and 61 (73.5%) of the cases, respectively. Expectant management significantly improved birth weight and Apgar scores at the 1st, 5th, and 10th minute in early-onset FGR cases (p=0.001, p=0.019, p=0.002, and p=0.001,respectively). Similar analysis revealed no significant improvements in late-onset FGR (p=0.151, p=0.727, p=0.951 and p=0.477, respectively). Umbilical cord blood gas pH was found to be similar between management modalities in both the early- and late-onset groups (p=0.186 and p=0.456, respectively). Gestational week 33.5 was found to be the threshold for better Apgar scores at the 1st, 5th, and 10th minute according to ROC curve analysis. Percentiles of 4.5, 2.5, and 4.5 were cut-off values for better Apgar scores at the 1st, 5th, and 10th minute, respectively.

Conclusion Expectant management must be the first choice to improve Apgar scores in early-onset FGR cases, and gestational week 33.5 must be considered as a threshold for delivery. Immediate delivery might be the choice in late-onset FGR in necessary cases. However, etiology-based management and perinatal surveillance might also be considered to improve prematurity-related neonatal complications.

Condensed Content

 
  • References

  • 1 Lackman F, Capewell V, Gagnon R. et al. Fetal umbilical cord oxygen values and birth to placental weight ratio in relation to size at birth. Am J Obstet Gynecol 2001; 185: 674-682 doi:10.1067/mob.2001.116686
  • 2 Boers KE, Vijgen SMC, Bijlenga D. et al. Induction versus expectant monitoring for intrauterine growth restriction at term: Randomised equivalence trial (DIGITAT). BMJ 2010; 341. doi:10.1136/bmj.c7087
  • 3 Tanacan A, Unal C, Yucesoy HM. et al. Management and evaluation of pregnant women with Takayasu arteritis. Arch Gynecol Obstet 2019; 299: 79-88
  • 4 Getahun D, Ananth CV, Kinzler WL. Risk factors for antepartum and intrapartum stillbirth: a population-based study. Am J Obstet Gynecol 2007; 196: 499-507. doi:10.1016/j.ajog.2006.09.017
  • 5 Ego A, Subtil D, Grange G. et al. Customized versus population-based birth weight standards for identifying growth restricted infants: A French multicenter study. Am J Obstet Gynecol 2006; 194: 1042-1049. doi:10.1016/j.ajog.2005.10.816
  • 6 Gardosi J, Madurasinghe V, Williams M. et al. Maternal and fetal risk factors for stillbirth: population based study. BMJ 2013; 346: f108. doi:10.1136/bmj.f108
  • 7 Figueras F, Caradeux J, Crispi F. et al. Diagnosis and surveillance of late-onset fetal growth restriction. Am J Obstet Gynecol 2018; 218: S790-S802.e791. doi:10.1016/j.ajog.2017.12.003
  • 8 ACOG. ACOG Practice bulletin no. 134: Fetal growth restriction. Obstet Gynecol 2013; 121: 1122-1133. doi:10.1097/01.AOG.0000429658.85846.f9
  • 9 Silver RM. Examining the link between placental pathology, growth restriction, and stillbirth. Best Pract Res Clin Obstet Gynaecol 2018; 49: 89-102. doi:https://doi.org/10.1016/j.bpobgyn.2018.03.004
  • 10 Fadiloglu E, Unal C, Beksac MS. Management and the pregnancy outcomes of patients positive for anti-parietal cell antibody. Hum Antibodies 2018; 1-6
  • 11 Orgul G, Aktoz F, Beksac MS. Behcet’s disease and pregnancy: What to expect?. J Obstet Gynaecol 2018; 38: 185-188
  • 12 Savchev S, Figueras F, Sanz-Cortes M. et al. Evaluation of an optimal gestational age cut-off for the definition of early- and late-onset fetal growth restriction. Fetal Diagn Ther 2014; 36: 99-105. doi:10.1159/000355525
  • 13 Figueras F, Gratacós E. Update on the diagnosis and classification of fetal growth restriction and proposal of a stage-based management protocol. Fetal Diagn Ther 2014; 36: 86-98
  • 14 Krebs C, Macara LM, Leiser R. et al. Intrauterine growth restriction with absent end-diastolic flow velocity in the umbilical artery is associated with maldevelopment of the placental terminal villous tree. Am J Obstet Gynecol 1996; 175: 1534-1542. doi:10.1016/S0002-9378(96)70103-5
  • 15 Baschat AA. Arterial and venous Doppler in the diagnosis and management of early-onset fetal growth restriction. Early Hum Dev 2005; 81: 877-887
  • 16 Baschat AA. Fetal growth restriction – from observation to intervention. J Perinat Med 2010; 38: 239-246. doi: 10.1515/jpm.2010.041
  • 17 Figueras F, Gratacos E. Stage-based approach to the management of fetal growth restriction. Prenat Diagn 2014; 34: 655-659
  • 18 Hadlock FP, Harrist RB, Martinez-Poyer J. In utero analysis of fetal growth: a sonographic weight standard. Radiology 1991; 181: 129-133. doi: 10.1148/radiology.181.1.1887021
  • 19 Benyo DF, Smarason A, Redman CW. et al. Expression of inflammatory cytokines in placentas from women with preeclampsia. J Clin Endocrinol Metab 2001; 86: 2505-2512
  • 20 Ness RB, Sibai BM. Shared and disparate components of the pathophysiologies of fetal growth restriction and preeclampsia. Am J Obstet Gynecol 2006; 195: 40-49
  • 21 Huppert B. Different failures of placentation lead to preeclampsia or intrauterine growth retardation – a new concept. Z Geburtshilfe Neonatol 2009; 213: A20
  • 22 Turgal M, Gumruk F, Karaagaoglu E. et al. Methylenetetrahydrofolate reductase polymorphisms and pregnancy outcome. Geburtshilfe Frauenheilkd 2018; 78: 871-878
  • 23 Beksaç K, Örgül G, Çağan M. et al. Retrospective evaluation of pregnant women with celiac disease. J Turk Ger Gynecol Assoc 2017; 18: 56
  • 24 Beksac K, Orgul G, Can GS. et al. Management of inflammatory bowel disease and pregnancy using prophylactic low dose low molecular weight heparin and corticosteroids. J Clin Diagn Res 2017; 11: 1-3
  • 25 Bujold E, Roberge S, Lacasse Y. et al. Prevention of preeclampsia and intrauterine growth restriction with aspirin started in early pregnancy: A meta-analysis. Obstet Gynecol 2010; 116: 402-414. doi: 10.1097/AOG.0b013e3181e9322a
  • 26 Wat JM, Audette M, Kingdom JC. Molecular actions of heparin and their implications in preventing preeclampsia. J Thromb Haemost 2018. doi:10.1111/jth.14191
  • 27 Triunfo S, Arranz A, Sureda-Rodriguez V. et al. OP13. 03: Prediction of delivery of small-for-gestational age neonates and adverse perinatal outcomes by angiogenic factors at 37 weeks' gestation. Ultrasound Obstet Gynecol 2017; 50: 88-89
  • 28 Crovetto F, Triunfo S, Crispi F. et al. First-trimester screening with specific algorithms for early- and late-onset fetal growth restriction. Ultrasound Obstet Gynecol 2016; 48: 340-348 doi:10.1002/uog.15879
  • 29 Kienast C, Moya W, Rodriguez O. et al. 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. J Matern Fetal Neonatal Med 2016; 29: 537-543. doi:10.3109/14767058.2015.1012063
  • 30 Aardema MW, Oosterhof H, Timmer A. et al. Uterine artery Doppler flow and uteroplacental vascular pathology in normal pregnancies and pregnancies complicated by pre-eclampsia and small for gestational age fetuses. Placenta 2001; 22: 405-411. doi:10.1053/plac.2001.0676
  • 31 Monier I, Ancel PY, Ego A. et al. Gestational age at diagnosis of early-onset fetal growth restriction and impact on management and survival: a population-based cohort study. BJOG 2017; 124: 1899-1906. doi:10.1111/1471-0528.14555
  • 32 Boers KE, van Wyk L, van der Post JA. et al. Neonatal morbidity after induction vs expectant monitoring in intrauterine growth restriction at term: A subanalysis of the DIGITAT RCT. Am J Obstet Gynecol 2012; 206: 344.e341-347. doi:10.1016/j.ajog.2012.01.015
  • 33 Bond DM, Gordon A, Hyett J. et al. Planned early delivery versus expectant management of the term suspected compromised baby for improving outcomes. The Cochrane Database Syst Rev 2015; DOI: 10.1002/14651858.CD009433.pub2.
  • 34 Groom KM, Poppe KK, North RA. et al. Small-for-gestational-age infants classified by customized or population birthweight centiles: Impact of gestational age at delivery. Am J Obstet Gynecol 2007; 197: 239.e231-235. doi:10.1016/j.ajog.2007.06.038
  • 35 Raju TN, Mercer BM, Burchfield DJ. et al. Periviable birth: executive summary of a joint workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists. Obstet Gynecol 2014; 123: 1083-1096. doi:10.1097/aog.0000000000000243
  • 36 Schwarze A, Gembruch U, Krapp M. et al. Qualitative venous Doppler flow waveform analysis in preterm intrauterine growth-restricted fetuses with ARED flow in the umbilical artery – correlation with short-term outcome. Ultrasound Obstet Gynecol 2005; 25: 573-579. doi:10.1002/uog.1914
  • 37 Vergani P, Roncaglia N, Andreotti C. et al. Prognostic value of uterine artery Doppler velocimetry in growth-restricted fetuses delivered near term. Am J Obstet Gynecol 2002; 187: 932-936
  • 38 Mureșan D, Rotar IC, Stamatian F. The usefulness of fetal Doppler evaluation in early versus late onset intrauterine growth restriction. Review of the literature. Med Ultrason 2016; 18: 103-109
  • 39 Esercan A, Karakuş R, Özgü Erdinç AS. Aortic isthmus Doppler for fetal assessment. Gynecol Obstet Reprod Med 2016; 19: 197-202
  • 40 Apgar V. The newborn (Apgar) scoring system. Pediatr Clin North Am 1966; 13: 645-650
  • 41 Casey BM, McIntire DD, Leveno KJ. The continuing value of the Apgar score for the assessment of newborn infants. N Engl J Med 2001; 344: 467-471
  • 42 Nelson KB, Ellenberg JH. Apgar scores as predictors of chronic neurologic disability. Pediatrics 1981; 68: 36-44
  • 43 Leinonen E, Gissler M, Haataja L. et al. Low Apgar scores at both one and five minutes are associated with long-term neurological morbidity. Acta Paediatr 2018; 107: 942-951
  • 44 Ehrenstein V, Pedersen L, Grijota M. et al. Association of Apgar score at five minutes with long-term neurologic disability and cognitive function in a prevalence study of Danish conscripts. BMC Pregnancy Childbirth 2009; 9: 14. doi:10.1186/1471-2393-9-14
  • 45 Ernest E, Wainstock T, Sheiner E. et al. Apgar score and long-term respiratory morbidity of the offspring: A population-based cohort study with up to 18 years of follow-up. Eur J Pediatr 2019; DOI: 10.1007/s00431-018-03311-6.
  • 46 Unterscheider J, Daly S, Geary MP. et al. Optimizing the definition of intrauterine growth restriction: the multicenter prospective PORTO Study. Am J Obstet Gynecol 2013; 208: 290.e291-296. doi:10.1016/j.ajog.2013.02.007
  • 47 Savchev S, Figueras F, Cruz-Martinez R. et al. Estimated weight centile as a predictor of perinatal outcome in small-for-gestational-age pregnancies with normal fetal and maternal Doppler indices. Ultrasound Obstet Gynecol 2012; 39: 299-303. doi:10.1002/uog.10150