Two-stage approach for prediction of small-for-gestational-age neonate and adverse perinatal outcome by routine ultrasound examination at 35-37 weeks' gestation

Background Justification of prenatal screening for small-for-gestational-age (SGA) fetuses near term is based on, first, evidence that such fetuses/neonates are at increased risk of stillbirth and adverse perinatal outcome, and, second, the expectation that these risks can be reduced by medical interventions, such as early delivery. However, there are no randomized studies demonstrating that routine screening for SGA fetuses and appropriate interventions in the high-risk group can reduce adverse perinatal outcome. Before such meaningful studies can be undertaken, it is essential that the best approach for effective identification of SGA neonates is determined, and that the contribution of SGA neonates to the overall rate of adverse perinatal outcome is established. In a previous study of pregnancies undergoing routine ultrasound examination at 35+ 0 to 36+6weeks' gestation, we found that, first, screening by estimated fetal weight (EFW) <10th percentile provided poor prediction of SGA neonates and, second, prediction of >85% of SGA neonates requires use of EFW <40th percentile. Objectives To examine the contribution of SGA fetuses to the overall rate of adverse perinatal outcome and, to propose a two-stage approach for prediction of a SGA neonate at routine ultrasound examination at 35+0 to 36+6weeks' gestation. Methods This was a prospective study of 45 847 singleton pregnancies undergoing routine ultrasound examination at 35+ 0 to 36+ 6weeks' gestation. First, we examined the relationship between birth-weight percentile and adverse perinatal outcome, defined as stillbirth, neonatal death or admission to the neonatal unit for >= 48 h. Second, we used a two-stage approach for prediction of a SGA neonate and adverse perinatal outcome; in the first stage, fetal biometry was used to distinguish between pregnancies at very low risk (EFW >= 40th percentile) and those at increased risk (EFW < 40th percentile) and, in the second stage, the pregnancies with EFW < 40th percentile were stratified into high-, intermediate- and low-risk groups based on the results of EFW and pulsatility index in the uterine arteries, umbilical artery and fetal middle cerebral artery. Different percentiles of EFW and Doppler indices were used to define each risk category, and the performance of screening for a SGA neonate and adverse perinatal outcome in pregnancies delivered at <= 2, 2.1-4 and > 4weeks after assessment was determined. We propose that the high-risk group would require monitoring from initial assessment to delivery, the intermediate-risk group would require monitoring from 2weeks after initial assessment to delivery, the low-risk group would require monitoring from 4weeks after initial assessment to delivery, and the very low-risk group would not require any further reassessment. Results First, although in neonates with low birth weight (< 10th percentile) the risk of adverse perinatal outcome is increased, 84% of adverse perinatal events occur in the group with birth weight >= 10th percentile. Second, in screening by EFW < 10th percentile, the predictive performance for a SGA neonate is modest for those born at <= 2weeks after assessment (83% and 69% for neonates with birth weight < 3rd and < 10th percentiles, respectively), but poor for those born at 2.1- 4 weeks (65% and 45%, respectively) and > 4weeks (40% and 30%, respectively) after assessment. Third, improved performance of screening, especially for those delivered at > 2weeks after assessment, is potentially achieved by a proposed new approach for stratifying pregnancies into management groups based on findings of EFW and Doppler indices (prediction of birth weight < 3rd and < 10th percentiles for deliveries at <= 2, 2.1- 4 and > 4weeks after assessment: 89% and 75%, 83% and 74%, and 88% and 82%, respectively). Fourth, the predictive performance for adverse perinatal outcome of EFW < 10th percentile is very poor (26%, 9% and 5% for deliveries at <= 2, 2.1- 4 and > 4weeks after assessment, respectively) and this is improved by the proposed new approach (31%, 22% and 29%, respectively). Conclusions This study presents an approach for stratifying pregnancies undergoing routine ultrasound examination at 35+0 to 36+6 weeks' gestation into four management groups based on findings of EFW and Doppler indices. This approach potentially has a higher predictive performance for a SGA neonate and adverse perinatal outcome than that of screening by EFW < 10th percentile. Copyright (C) 2019 ISUOG. Published by John Wiley & Sons Ltd.