RESULTS OF A NATIONAL SURVEY AHMET BASCHAT1, CHRISTOPHER ... normal umbilical artery Doppler (24%) or an abdominal circumference 5th %ile. ... Doppler, or an abnormal cerebroplacental Doppler ratio predicted all 4 SB within.
SMFM Abstracts 621
HOW SHOULD THE GROWTH RESTRICTED (FGR) FETUS BE MONITORED BEFORE DELIVERY? RESULTS OF A NATIONAL SURVEY AHMET BASCHAT1, CHRISTOPHER HARMAN1, JULIAN ROBINSON2, HENRY L. GALAN3, 1University of Maryland at Baltimore, Baltimore, Maryland, 2Harvard Medical School, Boston, Massachusetts, 3 University of Colorado Health Sciences Center, Denver, Colorado OBJECTIVE: To determine diagnostic criteria and typical surveillance management of pregnancies complicated by FGR by perinatologists practicing in the US. STUDY DESIGN: An internet questionnaire investigating practice patterns pertaining to the management of FGR was sent to 1123 Society for Maternal Fetal Medicine (MFM) members. RESULTS: 368/443 respondents were MFM Board certified (83%) and 52% (231) in fulltime academic practice. 62% (273) had highest level NICU available. 44% managed between 10-20 FGR ⬍32 weeks annually. (226, 51%) based FGR diagnosis on an estimated fetal weight (SFW) ⬍10th %, by Hadlock formula (343. 77%). Other FGR criteria were any growth abnormality in combination with abnormal umbilical artery Doppler (24%) or an abdominal circumference ⬍5th %ile. Growth was assessed at 2 - 3 week intervals by 92% (362). Karyotyping by amniocentesis (73%), TORCH titer (63%) and thrombophilia studies (56%) were the most common added tests. The most common surveillance combination was weekly umbilical artery Doppler and twice weekly NST/AFI (74% of responses) When NST or NST/AFI are used as primary surveillance tools these are performed twice weekly (77%) whereas umbilical artery Doppler, BPP and other Doppler studies are performed weekly. Umbilical artery Doppler status (88%), amniotic fluid volume (77%) and maternal disease (73%) were the primary factors modifying testing frequency. There were no differences in any of these responses between academic and private practice. CONCLUSION: For FGR fetuses primary surveillance is based on biophysical parameters while cardiovascular fetal factors and maternal disease impact the frequency of testing. The testing schemes chosen appear surprisingly uniform. This suggests that perinatologists may not take advantage of more sophisticated testing protocols to individualize management of FGR.
www.AJOG.org 623
FUNDAL HEIGHT: A USEFUL SCREENING TOOL FOR SMALL- AND LARGE-FORGESTATIONAL-AGE AT TERM? TERESA JONES1, YVONNE CHENG1, BLAKE MCLAUGHLIN2, TANIA ESAKOFF1, CAUGHEY AARON1, 1University of California, San Francisco, San Francisco, California, 2University of California, San Francisco, California OBJECTIVE: To determine the test characteristics of serial fundal height measurements as a screening tool for small-for-gestational-age (SGA) and large-forgestational-age (LGA) neonates. STUDY DESIGN: A retrospective cohort study of women with term, singleton pregnancies who received prenatal care and delivered at a single academic institution during 2002 and 2003. Of the 1710 medical records reviewed, 155 women had ultrasounds performed during the third trimester to rule out size unequal to dates by clinical suspicion via fundal height measurements. The sentivity, specificity, and relative risk ratios of abnormal fundal height for macrosomia (birthweight ⬎4000g, LGA ⬎90th centile) and growth restriction (birthweight ⬍2500g, SGA ⬍10th centile) were calculated. RESULTS: Of the 155 women who screened positive for abnormal intrauterine growth by fundal height, 19 had LGA neonates and 25 had neonates weighing ⬎4000g. Similarly, 20 women were found to have SGA neonates and 13 had neonates weighing ⬍2500g. The sensitivity, specificity, and positive and negative predictive values of fundal height for each of these outcomes were calculated (see table below). CONCLUSION: The sensitivity of fundal height as a predictor of SGA and LGA is relatively low, but screening by fundal height has a high specificity. Although fundal height is routinely used, other screening modalities for SGA and LGA should be explored.
LGA (⬎ 90%) BWt ⬎4000g SGA (⬍10%) BWt ⬍2500g
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.648
Sensitivity
Specificity
PPV
NPV
RR (95% CI)
33.3 22.3 28.1 38.2
87.6 87.6 87.6 87.4
24% 32% 26% 17%
96% 91% 94% 98%
2.69 (1.81–4.02) 1.79 (1.23–2.63) 2.27 (1.51–3.39) 3.02 (1.92–4.76)
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.650 622
INTEGRATED FETAL TESTING PREDICTS ALL UNEXPECTED STILLBIRTHS IN FETAL GROWTH RESTRICTION (FGR) AHMET BASCHAT1, OZHAN TURAN1, CHRISTOPH BERG2, SIFA TURAN3, DOLORES MOYANO4, AMARNATH BHIDE5, BASKARAN THILAGANATHAN6, SARAH BOWER4, HENRY GALAN7, ULRICH GEMBRUCH2, KYPROS NICOLAIDES4, CHRISTOPHER HARMAN1, 1University of Maryland at Baltimore, Baltimore, Maryland, 2Friedrich Wilhelm University, Bonn, Obstetrics & Prenatal Medicine, Bonn, Germany, 3University of Maryland, Baltimore, Baltimore, Maryland, 4King’s College Hospital, London, United Kingdom, 5St George’s Hospital Medical School, Fetal Medicine Unit, London, United Kingdom, 6St Georges Hospital Medical School, London, United Kingdom, 7University of Colorado Health Sciences center, Denver, Colorado OBJECTIVE: Stillbirth (SB) rate in the week following normal biophysical profile (BPP) is 0.9/1000 tests. As growth restricted fetuses deteriorate, they show characteristic cardiovascular responses that not detectable by BPP application, leading to unexpected SB if testing intervals are not adjusted. We tested the hypothesis that combined Doppler and BPP (integrated fetal testing⫽IFT) predicts these unexpected stillbirths in FGR. STUDY DESIGN: Prospective longitudinal multicenter observational study of FGR (Abdominal Circumference ⬍5%ile, high umbilical artery (UA) Doppler). IFTwas performed at each visit. All cases of SB within one week of a normal BPP (8 or 10/10) were studied, using proportional distribution and regression analyses to test the hypothesis. RESULTS: 1330 of 1722 exams performed in 584 FGR fetuses yielded a normal BPP (8/10⫽838 48.7%, 10/10⫽516, 30%). SB rate after normal BPP was 11/1330 (3 with abruption). All those who died unexpectedly had abnormal Doppler. The spectrum of Doppler abnormalities predicting SB differed significantly with gestation. Accordingly, before 34 weeks, DV Doppler was abnormal in 496 tests (36%) and correctly predicted all 7 SB within 5 days (sensitivity 100%, specificity 67%, positive predictive value (PPV) 15%, likelihood ratio (LR) 3.2, p⬍0.0001). After 34 weeks, abnornal was less common (only 18%), but abnormal middle cerebral artery Doppler, or an abnormal cerebroplacental Doppler ratio predicted all 4 SB within 6 days (sensitivity 100%, specificity 65%, PPV 4%, LR 2.9, p⬍0.05). CONCLUSION: Growth restricted fetuses are at risk for cardiovascular deterioration with manifestations that vary with gestational age. When Biophysical profile scoring is used as a solitary monitoring tool such deterioration is undetected resulting in a tenfold rise in unexpected stillbirths. In preterm FGR abnormal venous Doppler mandates increased testing frequency. Near term onset of cerebral Doppler abnormality also calls for twice weekly testing. Combining BPP and multivessel in the form of integrated fetal testing will optimize FGR monitoring.
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ISOLATED OLIGOHYDRAMNIOS PRESENTS CLINICAL SCENARIOS FOR WHICH OPTIMAL MANAGEMENT IS DEBATABLE NADAV SCHWARTZ1, RAESHELL SWEETING1, BRUCE YOUNG1, 1NYU School of Medicine, New York, New York OBJECTIVE: Optimal management of isolated oligohydramnios (IO) remains debatable. We sought to query SMFM members regarding their opinions and practice patterns on this topic. STUDY DESIGN: Questionnaires were mailed to all SMFM members in the US. IO was defined as sonographically diagnosed low fluid per the practitioner=s definition in the absence of IUGR, fetal anomaly or significant maternal co-morbidity. RESULTS: The overall response rate was 35% (n-632). Only questions with at least a 95% response rate were used for analysis. 91.6% of responders consider IO to be a risk factor for various adverse outcomes. Half of responders (48.8%) believe that hydration should be used in an attempt to correct the oligohydramnios prior to deciding to intervene. In addition, 95.4% consider IO at 40 weeks to be an indication for induction and only 20% are willing to allow the pregnancy to progress past 40 weeks if the cervix was unfavorable. With a favorable cervix, 33.8% and 82.1% would consider inducing labor prior to 37 and 39 weeks, respectively, even without documented lung maturity. In fact, 35.4% of responders feel that fetal lung maturity need not be documented prior to delivering a patient for IO prior to 37 weeks. However, when asked whether induction of labor in cases of IO reduces perinatal morbidity, 45.2% of SMFM members were unsure and 21.4% thought it would not. Only 33.4% of responders felt that induction could decrease potential adverse outcomes associated with IO. CONCLUSION: There remains a significant divergence regarding the management of isolated oligohydramnios. Despite being unsure of its utility in improving outcomes, practitioners appear to lean towards intervention. Prospective studies are needed to help identify the optimal management. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.651
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.649
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American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2007
