Doppler ultrasound of umbilical and middle cerebral artery in third trimester small-for-gestational age fetuses to decide on timing of delivery for suspected fetal growth restriction: A cohort with nested RCT (DRIGITAT).

OBJECTIVE: To assess the association of the umbilicocerebral ratio (UCR) with adverse perinatal outcome in late preterm small-for-gestational age (SGA) fetuses and to investigate the effect on perinatal outcomes of immediate delivery. DESIGN: Multicentre cohort study with nested randomised controlled trial (RCT). SETTING: Nineteen secondary and tertiary care centres. POPULATION: Singleton SGA pregnancies (estimated fetal weight [EFW] or fetal abdominal circumference [FAC] <10th centile) from 32 to 36+6 weeks. METHODS: Women were classified: (1) RCT-eligible: abnormal UCR twice consecutive and EFW below the 3rd centile at/or below 35 weeks or below the 10th centile at 36 weeks; (2) abnormal UCR once or intermittent; (3) never abnormal UCR. Consenting RCT-eligible patients were randomised for immediate delivery from 34 weeks or expectant management until 37 weeks. MAIN OUTCOME MEASURES: A composite adverse perinatal outcome (CAPO), defined as perinatal death, birth asphyxia or major neonatal morbidity. RESULTS: The cohort consisted of 690 women. The study was halted prematurely for low RCT-inclusion rates (n = 40). In the RCT-eligible group, gestational age at delivery, birthweight and birthweight multiple of the median (MoM) (0.66, 95% confidence interval [CI] 0.59-0.72) were significantly lower and the CAPO (n = 50, 44%, p < 0.05) was more frequent. Among patients randomised for immediate delivery there was a near-significant lower birthweight (p = 0.05) and higher CAPO (p = 0.07). EFW MoM, pre-eclampsia, gestational hypertension and Doppler classification were independently associated with the CAPO (area under the curve 0.71, 95% CI 0.67-0.76). CONCLUSIONS: Perinatal risk was effectively identified by low EFW MoM and UCR. Early delivery of SGA fetuses with an abnormal UCR at 34-36 weeks should only be performed in the context of clinical trials.

Unisex and Sex-Specific Prescriptive Fetal Growth Charts for Improved Detection of Small-for-Gestational-Age Babies in a Low-Risk Population: A post hoc Analysis of a Cluster-Randomized Study.

INTRODUCTION: Our aim was to develop and evaluate the performance of population-based sex-specific and unisex prescriptive fetal abdominal circumference growth charts in predicting small-for-gestational-age (SGA) birthweight, severe SGA (sSGA) birthweight, and severe adverse perinatal outcomes (SAPO) in a low-risk population. METHODS: This is a post hoc analysis of the Dutch nationwide cluster-randomized IRIS study, encompassing ultrasound data of 7,704 low-risk women. IRIS prescriptive unisex and IRIS sex-specific abdominal circumference (AC) fetal growth charts were derived using quantile regression. As a comparison, we used the descriptive unisex Verburg chart, which is commonly applied in the Netherlands. Diagnostic parameters were calculated based on the 34-36 weeks' ultrasound. RESULTS: Sensitivity rates for predicting SGA and sSGA birthweights were more than twofold higher based on the IRIS prescriptive sex-specific (respectively SGA 43%; sSGA 59%) and unisex (SGA 39%; sSGA 55%) charts, compared to the Verburg chart (SGA 16%; sSGA 23% both p < 0.01). Specificity rates were highest for Verburg (SGA 99%; sSGA 98%) and lowest for IRIS sex-specific (SGA 94%; sSGA 92%). Results for predicting SGA with SAPO were similar for the prescriptive charts (44%), and again higher than the Verburg chart (20%). The IRIS sex-specific chart identified significantly more males as SGA and sSGA (respectively, 42%; 60%, p < 0.001) than the IRIS unisex chart (respectively, 35%; 53% p < 0.01). CONCLUSION: Our study demonstrates improved performance of both the IRIS sex-specific and unisex prescriptive fetal growth compared to the Verburg descriptive chart, doubling detection rates of SGA, sSGA, and SGA with SAPO. Additionally, the sex-specific chart outperformed the unisex chart in detecting SGA and sSGA. Our findings suggest the potential benefits of using prescriptive AC fetal growth charts in low-risk populations and emphasize the importance of considering customizing fetal growth charts for sex. Nevertheless, the increased sensitivity of these charts should be weighed against the decrease in specificity.

Associations of severe adverse perinatal outcomes among continuous birth weight percentiles on different birth weight charts: a secondary analysis of a cluster randomized trial.

OBJECTIVE: To identify neonatal risk for severe adverse perinatal outcomes across birth weight centiles in two Dutch and one international birth weight chart. BACKGROUND: Growth restricted newborns have not reached their intrinsic growth potential in utero and are at risk of perinatal morbidity and mortality. There is no golden standard for the confirmation of the diagnosis of fetal growth restriction after birth. Estimated fetal weight and birth weight below the 10th percentile are generally used as proxy for growth restriction. The choice of birth weight chart influences the specific cut-off by which birth weight is defined as abnormal, thereby triggering clinical management. Ideally, this cut-off should discriminate appropriately between newborns at low and at high risk of severe adverse perinatal outcomes and consequently correctly inform clinical management. METHODS: This is a secondary analysis of the IUGR Risk Selection (IRIS) study. Newborns (n = 12 953) of women with a low-risk status at the start of pregnancy and that received primary antenatal care in the Netherlands were included. We examined the distribution of severe adverse perinatal outcomes across birth weight centiles for three birth weight charts (Visser, Hoftiezer and INTERGROWTH) by categorizing birth weight centile groups and comparing the prognostic performance for severe adverse perinatal outcomes. Severe adverse perinatal outcomes were defined as a composite of one or more of the following: perinatal death, Apgar score < 4 at 5 min, impaired consciousness, asphyxia, seizures, assisted ventilation, septicemia, meningitis, bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, or necrotizing enterocolitis. RESULTS: We found the highest rates of severe adverse perinatal outcomes among the smallest newborns (< 3rd percentile) (6.2% for the Visser reference curve, 8.6% for the Hoftiezer chart and 12.0% for the INTERGROWTH chart). Discriminative abilities of the three birth weight charts across the entire range of birth weight centiles were poor with areas under the curve ranging from 0.57 to 0.61. Sensitivity rates of the various cut-offs were also low. CONCLUSIONS: The clinical utility of all three charts in identifying high risk of severe adverse perinatal outcomes is poor. There is no single cut-off that discriminates clearly between newborns at low or high risk. TRIAL REGISTRATION: Netherlands Trial Register NTR4367 . Registration date March 20th, 2014.

[Euglycemic diabetic ketoacidosis during pregnancy]. / Euglykemische diabetische ketoacidose tijdens de zwangerschap.

BACKGROUND: Diabetic ketoacidosis (DKA) can have an atypical presentation during pregnancy. In the case of euglycemic DKA, relatively normal blood glucose levels can hinder a quick diagnosis. CASE DESCRIPTION: A 34-year-old DM1 patient, 31 weeks pregnant, was admitted because of reduced fetal movements and nausea. She had reduced the amount of insulin that her insulin pump administered and had a severe euglycemic DKA. The CTG was abnormal and there was a threat of preterm birth. She was treated with insulin, glucose and bicarbonate. A month later the patient underwent an emergency cesarean section because of an abnormal CTG. A daughter was born that weighed 4820 grams, the Apgar score was 5/8/8, and the pH was 7.14. The girl required intravenous glucose for a week. CONCLUSION: Euglycemic DKA during pregnancy requires swift recognition and treatment but this remains challenging.