Routine ultrasound at 32 vs 36 weeks' gestation: prediction of small-for-gestational-age neonates

Objective To evaluate and compare the performance of routine ultrasonographic estimated fetal weight (EFW) and fetal abdominal circumference (AC) at 31+0 to 33+6 and 35+0 to 36+6 weeks' gestation in the prediction of a small-for-gestational-age (SGA) neonate. Methods This was a prospective study of 21 989 singleton pregnancies undergoing routine ultrasound examination at 31+0 to 33+6 weeks' gestation and 45 847 undergoing routine ultrasound examination at 35+0 to 36+6 weeks' gestation. In each case, the estimated fetal weight (EFW) from measurements of fetal head circumference, AC and femur length was calculated using the Hadlock formula and expressed as a percentile according to The Fetal Medicine Foundation fetal and neonatal population weight charts. The same charts were used for defining a SGA neonate with birth weight <10th and <3rd percentiles. For each gestational-age window, the screen-positive and detection rates, at different EFW percentile cut-offs between the 10th and 50th percentiles, were calculated for prediction of delivery of a SGA neonate with birth weight <10th and <3rd percentiles within 2 weeks and at any stage after assessment. The areas under the receiver-operating characteristics curves (AUC) in screening for a SGA neonate by EFW and AC at 31+0 to 33+6 and at 35+0 to 36+6 weeks' gestation were compared. Results First, the AUCs in screening by EFW for a SGA neonate with birth weight <10th and <3rd percentiles delivered within 2 weeks and at any stage after screening at 35+0 to 36+6 weeks' gestation were significantly higher than those at 31+0 to 33+6 weeks (P<0.001). Second, at both 35+0 to 36+6 and 31+0 to 33+6 weeks' gestation, the predictive performance for a SGA neonate with birth weight <10th and <3rd percentiles born at any stage after screening was significantly higher using EFW Z-score than AC Z-score. Similarly, at 35+0 to 36+6 weeks, but not at 31+0 to 33+6 weeks, the predictive performance for a SGA neonate with birth weight <10th and <3rd percentiles born within 2 weeks after screening was significantly higher using EFW Z-score than AC Z-score. Third, screening by EFW <10th percentile at 35+0 to 36+6 weeks' gestation predicted 70% and 84% of neonates with birth weight <10th and <3rd percentiles, respectively, born within 2 weeks after assessment, and the respective values for a neonate born at any stage after assessment were 46% and 65%. Fourth, prediction of >85% of SGA neonates with birth weight <10th percentile born at any stage after screening at 35+0 to 36+6 weeks' gestation requires use of EFW <40th percentile. Screening at this percentile cut-off predicted 95% and 99% of neonates with birth weight <10th and <3rd percentiles, respectively, born within 2 weeks after assessment, and the respective values for a neonate born at any stage after assessment were 87% and 94%. Conclusions The predictive performance for a SGA neonate of routine ultrasonographic examination during the third trimester is higher if, first, the scan is carried out at 35+0 to 36+6 weeks' gestation than at 31+0 to 33+6 weeks, second, the method of screening is EFW than fetal AC, third, the outcome measure is birth weight<3rd than <10th percentile, and, fourth, if delivery occurs within 2 weeks than at any stage after assessment. Prediction of a SGA neonate by EFW <10th percentile is modest and prediction of >85% of cases at 35+0 to 36+6 weeks' gestation necessitates use of EFW <40th percentile. Copyright (c) 2019 ISUOG. Published by John Wiley & Sons Ltd.