What Factors Lead to Increased Risk of Missing a Growth-Restricted Fetus?
BACKGROUND AND PURPOSE:
While antenatal detection of fetal growth restriction (FGR) has benefits, it remains a challenge
Diksha et al. (Australian and New Zealand Journal of Obstetrics and Gynaecology, 2018) aimed to identify factors linked with failure to deliver severely growth-restricted fetuses (FGR) in a planned fashion prior to 40 weeks
Retrospective case-control study
<3rd centile for gestation age
Infants were separated in to two groups
‘Planned birth’ group: Planned delivery for FGR between 37w0d and 39w6d
‘Undelivered group’: Still undelivered by 40w0d
Variables assessed included
Presence of risk factors for FGR
Model of care: Low-risk models defined as shared care and midwifery-led care vs traditional collaborative models
SF height measurements
3rd trimester ultrasound results
187 women in planned group | 233 women in undelivered group
‘High-risk’ for FGR on history equivalent between groups (P = 0.187)
Planned: 31.3% high risk factors
Undelivered: 38.0% high risk factors
Equal likelihood to smoke, drink alcohol, or have had a previous SGA baby <10th centile
Illicit substances during pregnancy were more likely to be in the planned birth group
All women who had a low PAPP-A (n=8) were in the planned birth group (protocol for 3rd trimester ultrasound when PAPP-A <0.4 MoM)
Women cared for in low-risk models were significantly more likely to be in the undelivered group (P < 0.001)
Women in the undelivered group were less likely to have received a third trimester ultrasound (P < 0.001)
Women in the undelivered group were more likely to have had a reassuring ultrasound with an EFW or AC >10th centile (P < 0.001)
The authors identified the following as sources of increased risk to deliver a growth-restricted fetus beyond ≥40 weeks rather than plan appropriately for an earlier delivery
Failure to receive 3rd trimester ultrasound
Falsely reassuring ultrasound results
Low-risk model of care
In 50% of cases, high-risk factors did not trigger a 3rd trimester scan
All cases of low PAPP-A resulted appropriately in a 3rd trimester scan, “and may reflect the importance of a local guideline endorsed by the hospital’s obstetricians and midwives”
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