Early Term versus Term Delivery in the Management of Fetal Growth Restriction: A Comparison of Two Protocols
02 June 2014
22 October 2014
29 December 2014 (eFirst)
Objective This study aims to compare two management protocols in pregnancies diagnosed with fetal growth restriction (FGR).
Study Design All singleton pregnancies diagnosed and managed with FGR at our institution during two protocol periods were analyzed. The early term protocol (January 2008–February 2010) specified delivery at 370/7 weeks if antenatal testing was reassuring, but did not specify the timing of delivery if umbilical artery (UA) Doppler systolic:diastolic (S:D) ratios were elevated (>95th percentile for gestational age [GA]). The term protocol (March 2010–July 2012) specified delivery at 390/7 weeks with normal S:D ratios and 370/7 weeks with elevated S:D ratios when antenatal testing was reassuring.
Results There were 228 and 312 women in the early term and term protocol, respectively, who met inclusion criteria. Compared with the early term group, the term group had an increased median GA at delivery (37.1 vs. 38.6%, p < 0.001), decreased deliveries less than 370/7 weeks (37 vs. 24%, p = 0.01) and decreased neonatal intensive care unit (NICU) admissions (38 vs. 28%, p = 0.02).
Conclusion A protocol specifying delivery at 390/7 weeks when UA S:D ratios are normal and delivery at 370/7 weeks when UA S:D ratios are elevated when other antenatal testing is reassuring in FGR: (1) prolonged gestation, (2) decreased preterm births, and (3) decreased NICU admissions.
- 1 American College of Obstetricians and Gynecologists. ACOG Practice bulletin no. 134: fetal growth restriction. Obstet Gynecol 2013; 121 (5) 1122-1133
- 2 McIntire DD, Bloom SL, Casey BM, Leveno KJ. Birth weight in relation to morbidity and mortality among newborn infants. N Engl J Med 1999; 340 (16) 1234-1238
- 3 Henriksen T. Foetal nutrition, foetal growth restriction and health later in life. Acta Paediatr Suppl 1999; 88 (429) 4-8
- 4 Gaudier FL, Goldenberg RL, Nelson KG , et al. Acid-base status at birth and subsequent neurosensory impairment in surviving 500 to 1000 gm infants. Am J Obstet Gynecol 1994; 170 (1 Pt 1) 48-53
- 5 Garite TJ, Clark R, Thorp JA. Intrauterine growth restriction increases morbidity and mortality among premature neonates. Am J Obstet Gynecol 2004; 191 (2) 481-487
- 6 Berkley E, Chauhan SP, Abuhamad A ; Society for Maternal-Fetal Medicine Publications Committee. Doppler assessment of the fetus with intrauterine growth restriction. Am J Obstet Gynecol 2012; 206 (4) 300-308
- 7 Acharya G, Wilsgaard T, Berntsen GK, Maltau JM, Kiserud T. Reference ranges for serial measurements of umbilical artery Doppler indices in the second half of pregnancy. Am J Obstet Gynecol 2005; 192 (3) 937-944
- 8 Owen P, Donnet ML, Ogston SA, Christie AD, Howie PW, Patel NB. Standards for ultrasound fetal growth velocity. Br J Obstet Gynaecol 1996; 103 (1) 60-69
- 9 Turan OM, Turan S, Gungor S , et al. Progression of Doppler abnormalities in intrauterine growth restriction. Ultrasound Obstet Gynecol 2008; 32 (2) 160-167
- 10 Baschat AA, Galan HL, Bhide A , et al. Doppler and biophysical assessment in growth restricted fetuses: distribution of test results. Ultrasound Obstet Gynecol 2006; 27 (1) 41-47
- 11 Maulik D. Management of fetal growth restriction: an evidence-based approach. Clin Obstet Gynecol 2006; 49 (2) 320-334
- 12 Neilson JP, Alfirevic Z. Doppler ultrasound for fetal assessment in high risk pregnancies (Cochrane Review). In: The Cochrane Library, Issue 3, 1999. Oxford: Update Software (Meta- analysis).
- 13 Mari G, Hanif F, Treadwell MC, Kruger M. Gestational age at delivery and Doppler waveforms in very preterm intrauterine growth-restricted fetuses as predictors of perinatal mortality. J Ultrasound Med 2007; 26 (5) 555-559 , quiz 560–562
- 14 Dicke JM, Huettner P, Yan S, Odibo A, Kraus FT. Umbilical artery Doppler indices in small for gestational age fetuses: correlation with adverse outcomes and placental abnormalities. J Ultrasound Med 2009; 28 (12) 1603-1610
- 15 Hadlock FP, Harrist RB, Martinez-Poyer J. In utero analysis of fetal growth: a sonographic weight standard. Radiology 1991; 181 (1) 129-133
- 16 Boers KE, Vijgen SM, Bijlenga D , et al; DIGITAT study group. Induction versus expectant monitoring for intrauterine growth restriction at term: randomised equivalence trial (DIGITAT). BMJ 2010; 341: c7087
- 17 Baschat AA, Cosmi E, Bilardo CM , et al. Predictors of neonatal outcome in early-onset placental dysfunction. Obstet Gynecol 2007; 109 (2 Pt 1) 253-261
- 18 Sibai BM, Mercer BM, Schiff E, Friedman SA. Aggressive versus expectant management of severe preeclampsia at 28 to 32 weeks' gestation: a randomized controlled trial. Am J Obstet Gynecol 1994; 171 (3) 818-822
- 19 Odendaal HJ, Pattinson RC, Bam R, Grove D, Kotze TJ. Aggressive or expectant management for patients with severe preeclampsia between 28-34 weeks' gestation: a randomized controlled trial. Obstet Gynecol 1990; 76 (6) 1070-1075
- 20 GRIT Study Group. A randomised trial of timed delivery for the compromised preterm fetus: short term outcomes and Bayesian interpretation. BJOG 2003; 110 (1) 27-32
- 21 Alfirevic Z, Stampalija T, Gyte GM. Fetal and umbilical Doppler ultrasound in high-risk pregnancies. Cochrane Database Syst Rev 2010; 1 (1) CD007529
- 22 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 (4) 290.e1-290.e6
- 23 Spong CY, Mercer BM, D'alton M, Kilpatrick S, Blackwell S, Saade G. Timing of indicated late-preterm and early-term birth. Obstet Gynecol 2011; 118 (2 Pt 1): 323-333
- 24 American College of Obstetricians and Gynecologists. ACOG committee opinion no. 560: Medically indicated late-preterm and early-term deliveries. Obstet Gynecol 2013; 121 (4) 908-910
- 25 Reddy UM, Ko CW, Raju TN, Willinger M. Delivery indications at late-preterm gestations and infant mortality rates in the United States. Pediatrics 2009; 124 (1) 234-240
- 26 Barker DJ, Eriksson JG, Forsén T, Osmond C. Fetal origins of adult disease: strength of effects and biological basis. Int J Epidemiol 2002; 31 (6) 1235-1239