BACKGROUND AND PURPOSE:

• Selvaratnam et al. (JAMA, 2021) examined the association between iatrogenic delivery for suspected FGR and childhood school outcomes

METHODS:

• Retrospective whole-population cohort study (Between 2003 an 2013)
  • Deidentified birth data from the Victorian Perinatal Data Collection
  • Linked to developmental and educational outcomes
• Population
  • Births at ≥32 weeks’ gestation
• Exposures
  • Suspected FGR vs no suspected FGR
  • Presence vs absence of iatrogenic delivery for FGR (induction or cesarean)
  • Presence vs absence of small for gestational age (SGA) | Birth weight <3rd percentile
• Study design
  • Infants’ birth data were linked to their developmental and educational test scores at preparatory school, and grades 3, 5, and 7
• Primary outcomes
  • Being in the bottom 10^th percentile on 2 or more (of 5) developmental domains at school entry
  • Being below the national minimum standard on 2 or more (of 5) educational domains in grades 3, 5, or 7

RESULTS:

• 705,937 infants
  • Mean (SD) gestation at birth: 39.1 (1.5) weeks
  • Mean (SD) birth weight: 3426 (517) grams
  • Children with developmental results: 181,902 | Children with educational results: 425,717
• Compared with infants who had severe SGA but were not suspected of having FGR, infants who had severe SGA and were delivered for suspected FGR were born earlier
  • SGA only: 39.4 weeks
  • SGA and suspected FGR delivery: 37.9 weeks
• Infants with SGA and suspected FGR had significantly increased risk of poor developmental outcomes
  • At school entry
    • SGA only: 12.7%
    • SGA and suspected FGR delivery: 16.2%
    • Absolute difference 3.5% (95% CI, 0.5 to 6.5%)
    • Adjusted odds ratio (aOR) 1.36 (95% CI, 1.07 to 1.74)
  • At grades 3, 5, and 7 | For example, the following was found at grade 7
    • SGA: 10.5%
    • SGA and suspected FGR delivery: 13.4%
    • Absolute difference 2.9% (95% CI, 0.4 to 5.5)
    • aOR 1.33 (95% CI, 1.04 to 1.70)
• Infants with normal growth who were delivered for suspected FGR were born earlier than infants with normal growth that did not have suspected FGR
  • Normal growth: 39.1 weeks
  • Normal growth and suspected FGR delivery: 38.0 weeks
  • However, no significant difference found for educational or developmental outcome
    • Normal growth: 8.1%
    • Normal growth and suspected FGR delivery: 8.6%
    • Absolute difference 0.5% (95% CI −1.1 to 2.0)
    • aOR 1.17 (95% CI 0.95 to 1.45)
• Further analysis of the data based on gestational age at delivery or preeclampsia did not alter the results

CONCLUSION:

• Iatrogenic delivery of infants with severe SGA and suspected FGR had poorer developmental and educational outcomes than infants with severe SGA who were not suspected of having FGR
• When infants had normal growth, earlier delivery with suspected FGR was not associated with worse outcomes, compared to normal growth infants with no suspicion of FGR
• Significant limitations include lack of information related to fetal biometry, including Doppler studies | BMI and maternal smoking were not recorded prior to 2009
• The authors note that the outcomes were stratified by age and suggest that

A more plausible explanation for the poorer outcomes for infants with severe SGA who were iatrogenically delivered for suspected FGR is that iatrogenic prematurity was harmful. This work suggests there may be a need to both better time delivery for infants with severe SGA and to target early childhood interventions toward improving child neurocognitive development in this high-risk cohort 

Learn More – Primary Sources:

Association Between Iatrogenic Delivery for Suspected Fetal Growth Restriction and School Outcomes

Related ObG Topics:

SMFM Recommendations: FGR Diagnosis and Management

Fetal Growth Restriction: Definition, Evaluation and Management

STRIDER RCT Results: Sildenafil for Fetal Growth Restriction

Does Magnesium Sulfate Provide Neuroprotection in Preterm Fetuses with Growth Restriction?

Cesarean or Vaginal Delivery for Preterm Fetal Growth Restriction?