Letter to the Editor in Response to “Fetal Growth Restriction: A Pragmatic Approach”

Our suggestion that optimal outcomes require surveillance via frequent electronic fetal heart rate monitoring is supported by comparing the results of the TRUFFLE trial[1] with a contemporaneous American study[2] of 72 children that were delivered with severe early-onset growth restriction (after eliminating 32 deaths for a 28% mortality) which were primarily monitored by biophysical profile (BPP) as shown in the [Table 1]. The proportion of fetuses with absent or reversed end diastolic flow in the umbilical artery and the gestational age at delivery was similar in the two studies, although the average birth weight was about 100 g more in the TRUFFLE trial.

The outcomes of the TRUFFLE trial were much better, with only 8% mortality, a large decrease in neonatal morbidity, and much better neurodevelopmental outcomes. The incremental benefit of monitoring the ductus venosus waveform in addition to frequent electronic fetal heart rate monitoring was relatively small in comparison.

The difference between 34/113 (30%) neurologically intact survivors in the American study compared to 252/337 (75%) and 111/166 (67%) in fetuses monitored with and without ductus venosus waveform, respectively, in the TRUFFLE trial is so large that it's difficult to attribute to inherent differences in the study populations and is more likely due to the difference in surveillance. ([Table 1])

Table 1 Comparison of a study relying largely on BPP surveillance[2] to the results of the TRUFFLE trial[1]

	BPP surveillance	TRUFFLE EHRM	TRUFFLE DV
Population (n)	113	166	337
Died	32 (28%)	13 (8%)	28 (8%)
Lost to follow-up	9	22	38
Survivors with follow-up	72
A/R EDF	32 (44%)	62 (37%)	147 (44%)
Gestational age at delivery (wk)	30.4	30.6	30.7
Birth weight (g)	933	998	1030
Major neonatal morbidity	28 (39%)	38 (23%)	80 (24%)
Survivors with follow-up		131	271
Neurodevelopmental delay	38 (53%)	20 (15%)	19 (7%)
No neurodevelopmental delay	34 (47%)	111 (85%)	252 (93%)
Survivors without neurodevelopmental delay	34/113 (30%)	111/166 (67%)	252/337 (75%)

Abbreviations: BPP, biophysical profile; A/R EDF, absent or reversed end diastolic flow on umbilical artery Doppler; TRUFFLE EHRM, fetuses randomized to surveillance by electronic heart rate monitoring only; TRUFFLE DV, fetuses randomized to surveillance by ductus venosus waveform with electronic heart rate monitoring as a backup.

Publication History

Received: 18 February 2025

Accepted: 26 February 2025

Accepted Manuscript online:
27 February 2025

Article published online:
29 March 2025

• References

• 1 Lees CC, Marlow N, van Wassenaer-Leemhuis A. et al; TRUFFLE study group. 2 year neurodevelopmental and intermediate perinatal outcomes in infants with very preterm fetal growth restriction (TRUFFLE): a randomised trial. Lancet 2015; 385 (9983) 2162-2172
• 2 Baschat AA, Viscardi RM, Hussey-Gardner B, Hashmi N, Harman C. Infant neurodevelopment following fetal growth restriction: relationship with antepartum surveillance parameters. Ultrasound Obstet Gynecol 2009; 33 (01) 44-50