Screening for fetal growth restriction with universal third trimester ultrasonography in nulliparous women in the Pregnancy Outcome Prediction (POP) study: a prospective cohort study.
Screening for fetal growth restriction with universal third trimester ultrasonography in nulliparous women in the Pregnancy Outcome Prediction (POP) study: a prospective cohort study.
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DOI：
10.1016/s0140-6736(15)00131-2
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发表时间：
2015-11-21
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影响因子：
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通讯作者：
Smith GCS
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作者：
Sovio U;White IR;Dacey A;Pasupathy D;Smith GCS
胎儿生长受限是围产期不良结局的主要决定因素。胎儿生长受限的筛查程序需要识别小婴儿，然后区分健康婴儿和病理性小婴儿。我们试图确定通用超声胎儿生物测量在孕晚期作为小于胎龄儿（SGA）筛查试验的诊断有效性，以及是否存在或不存在胎儿生长受限的超声标记物，与小婴儿相关的发病风险是否不同。妊娠结局预测（POP）研究是一项前瞻性队列研究，研究对象为在超声扫描时有存活单胎妊娠的未经产女性。参与研究的女性按照常规临床护理在妊娠晚期接受了有临床指征的超声检查，并照常报告这些结果（选择性超声检查）。此外，所有参与者都进行了研究超声检查，包括胎龄28周和36周的胎儿生物测量。这些结果未提供给参与者或治疗临床医生（通用超声检查）。我们认为小于胎龄第10百分位数的出生体重为SGA，小于胎龄第10百分位数的超声估计胎儿体重为SGA筛查阳性。胎儿生长受限的标志物包括生物统计学比率、子宫胎盘多普勒和胎儿生长速度。我们评估了参与研究扫描并在28周研究扫描后在Rosie医院（英国剑桥）进行活产的知情参与者的结局。在2008年1月14日至2012年7月31日期间，4512名女性提供了书面知情同意书，其中3977名（88%）有资格进行分析。选择性超声检查检测SGA婴儿的敏感性为20%（95%CI 15-24; 69/352胎），通用超声检查为57%（51-62; 199/352胎）（相对敏感性2.9，95%CI 2.4 - 3.5，p<0.0001）。在3977例胎儿中，562例（14.1%）经通用超声检查发现估计胎儿体重小于第10百分位数，新生儿发病风险增加（相对风险[RR] 1.60，95%CI 1.22 - 2.09，p= 0.0012）。然而，如果胎儿腹围生长速度在最低的十分位数（RR 3.9，95%CI 1.9 - 8.1，p= 0.0001），估计胎儿体重小于第10百分位数仅与新生儿发病风险相关（p相互作用= 0.005）。3977例孕妇中有172例（4%）估计胎儿体重小于第10百分位数，腹围生长速度在最低十分位数，分娩SGA婴儿的相对风险为17.6（9.2 ~ 34.0，p<0.0001）。筛查未经产的妇女与普遍的晚期妊娠胎儿生物测量大约三倍的SGA婴儿的检测。胎儿生物统计学和胎儿生长速度的联合分析确定了SGA胎儿的一个子集，其新生儿发病风险增加。国家健康研究所、医学研究理事会、Sands和GE Healthcare。
Fetal growth restriction is a major determinant of adverse perinatal outcome. Screening procedures for fetal growth restriction need to identify small babies and then differentiate between those that are healthy and those that are pathologically small. We sought to determine the diagnostic effectiveness of universal ultrasonic fetal biometry in the third trimester as a screening test for small-for-gestational-age (SGA) infants, and whether the risk of morbidity associated with being small differed in the presence or absence of ultrasonic markers of fetal growth restriction. The Pregnancy Outcome Prediction (POP) study was a prospective cohort study of nulliparous women with a viable singleton pregnancy at the time of the dating ultrasound scan. Women participating had clinically indicated ultrasonography in the third trimester as per routine clinical care and these results were reported as usual (selective ultrasonography). Additionally, all participants had research ultrasonography, including fetal biometry at 28 and 36 weeks' gestational age. These results were not made available to participants or treating clinicians (universal ultrasonography). We regarded SGA as a birthweight of less than the 10th percentile for gestational age and screen positive for SGA an ultrasonographic estimated fetal weight of less than the 10th percentile for gestational age. Markers of fetal growth restriction included biometric ratios, utero-placental Doppler, and fetal growth velocity. We assessed outcomes for consenting participants who attended research scans and had a livebirth at the Rosie Hospital (Cambridge, UK) after the 28 weeks' research scan. Between Jan 14, 2008, and July 31, 2012, 4512 women provided written informed consent of whom 3977 (88%) were eligible for analysis. Sensitivity for detection of SGA infants was 20% (95% CI 15–24; 69 of 352 fetuses) for selective ultrasonography and 57% (51–62; 199 of 352 fetuses) for universal ultrasonography (relative sensitivity 2·9, 95% CI 2·4–3·5, p<0·0001). Of the 3977 fetuses, 562 (14·1%) were identified by universal ultrasonography with an estimated fetal weight of less than the 10th percentile and were at an increased risk of neonatal morbidity (relative risk [RR] 1·60, 95% CI 1·22–2·09, p=0·0012). However, estimated fetal weight of less than the 10th percentile was only associated with the risk of neonatal morbidity (pinteraction=0·005) if the fetal abdominal circumference growth velocity was in the lowest decile (RR 3·9, 95% CI 1·9–8·1, p=0·0001). 172 (4%) of 3977 pregnancies had both an estimated fetal weight of less than the 10th percentile and abdominal circumference growth velocity in the lowest decile, and had a relative risk of delivering an SGA infant with neonatal morbidity of 17·6 (9·2–34·0, p<0·0001). Screening of nulliparous women with universal third trimester fetal biometry roughly tripled detection of SGA infants. Combined analysis of fetal biometry and fetal growth velocity identified a subset of SGA fetuses that were at increased risk of neonatal morbidity. National Institute for Health Research, Medical Research Council, Sands, and GE Healthcare.