Volume 52, Issue 1, January 2023, 102514Author links open overlay panelAbstractObjective

To evaluate the perinatal outcome associated with severe and isolated intrauterine growth restriction (IUGR) diagnosed before 25 weeks and to describe factors related to fetal death.

Methods

This retrospective study included singleton pregnancies with an estimated fetal weight (EFW) ≤ 3rd centile between 21 + 0 and 24 + 6 weeks’ gestation referred between 2013 and 2020. All fetuses with morphological or chromosomal abnormalities were excluded. We constituted three groups based on perinatal outcomes to highlight poor prognostic factors: live birth, fetal death and termination of pregnancies (TOP).

Results

We included 98 pregnancies with an overall survival rate of 61.2% (60/98). There were 63.2% (62/98) live births, 24.5% (24/98) TOP, and 12.2% (12/98) fetal death. Of the live births, 27.4% (17/62) of fetuses were born before 32 weeks, and two died in the neonatal period (2/62; 3.2%). The fetal death rate was higher with the presence of an EFW below the first percentile (83.3% of fetal death Vs 33.8% of live births; p = 0.002), Doppler abnormalities (83.3% of fetal death Vs 6.4% of live births; p<0.001), and oligoamnios (41.9% of fetal death Vs 11.3% of live births; p = 0.05).

Conclusion

Severe growth restriction detected before 25 weeks was associated with poor perinatal outcomes. There were more often EFW <1st percentile, abnormal Doppler and oligoamnios in cases of fetal death compared to live births.

Introduction

Intra Uterine Growth Restriction (IUGR) is defined as the failure of the fetus to meet its growth potential; it affects up to 10% of pregnancies, with early-onset IUGR, defined by onset <32 weeks' gestation, accounting for 0.5–1% [1]. Recent improvements in perinatal survival for these fetuses are detailed in prospective studies such as TRUFFLE, GRIT or EPICURE [2], [3], [4]. However, it is still a leading cause of perinatal mortality, induced preterm delivery and short- and long-term morbidity [1]. According to the metanalysis of Pels et al. about 2895 fetuses with early-onset growth restriction before 32 weeks of gestation (GW): 12% died antenatally, 8% died in the neonatal period, and 81% of children survived [5]. Nevertheless, counselling parents with severe early-onset IUGR about perinatal prognosis is difficult because of widespread data. Each study that has been published is limited in their applicability due to the lack of consistency in their inclusion criteria (fetal weight and gestational age, for instance).

Counselling is even more complicated before 25 weeks of gestation because of two major risk factors for morbidity: pathological smallness and extreme prematurity (for fetal distress or maternal preeclampsia) [6,7]. There are only a few data to help counsel regarding the prognosis of these very severe and early-onset IUGR. According to Lawin-O'Brien's study on 245 cases of IUGR identified between 22 + 0 and 25 + 6 GW: 41% of patients survived the neonatal period; 36% underwent in-utero fetal demise, 9% died neonatally, and 14% of pregnancies were terminated [6].

The main objective of this study was to describe the perinatal outcomes in case of severe early-onset IUGR and to identify prognostic factors leading to fetal death.

Section snippetsPatients and methods

This is a retrospective, monocentric, and observational cohort study leading in the fetal medicine center of Nancy Maternity University Hospital. In France, a routine mid-trimester fetal ultrasound scan is proposed for every woman between 22 and 24 GW. In our center, women with early-onset IUGR routinely received a detailed sonographic exam. They were offered genetic testing, including CGH and research for congenital infections (detection of CMV by PCR in the amniotic fluid and detection of

Results

In total, 102 singleton pregnancies were identified during the study period, of which 98 met the inclusion criteria (Fig. 1).

The mean gestational age at the sentinel scan was 22.7 ± 0.8 GW. The mean maternal age was 30.5 ± 6.2 years (table 1). 61.2% (60/98) of the women were nulliparous, 13.3% had a history of IUGR, 36.7% were smokers, and 3.0% had previous chronic hypertension (table 1). Of the 98 cases included, 64,2% (63/98) underwent amniocentesis, confirming normal genetic results and no

Discussion

We described the outcomes of a retrospective cohort of severe and early growth-restricted fetuses; there needs to be more data on this population in the literature. The overall survival rate of these fetuses is 61.2%, which is much higher than previously described by Lawin-O'Brien et al. but lower than the metanalysis of Pels et al. (41% and 81% respectively) [5,6]. The difference in the outcome between our study and the metanalysis could be due to the precocity of our cases: before 25 GW Vs

Conclusion

Severe growth-restricted fetuses detected before 25 weeks were associated with poor obstetrical outcomes. There were more often EFW <1st percentile, abnormal Doppler and oligoamnios in cases of fetal death compared to live births. A multidisciplinary approach is advisable to help parents in these ethically challenging situations.

Author contributions

All authors contributed to data collection, manuscript writing, review, and approval.

Declaration of Competing Interest

All authors declare that they have no conflicts of interest.

Acknowledgments

Special thanks go to all healthcare staff who have worked with devotion to improve the health standards of patients.

References (19)I. Monier et al.Indications leading to termination of pregnancy between 22+0 and 31+6 weeks of gestational age in France: a population-based cohort study

Eur J Obstet Gynecol Reprod Biol

(2019)

N. Melamed et al.FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction

Int J Gynaecol Obstet

(2021)

C.M. Bilardo et al.Severe fetal growth restriction at 26-32 weeks: key messages from the TRUFFLE study

Ultrasound Obstet Gynecol

(2017)

K.L. Costeloe et al.Short term outcomes after extreme preterm birth in England: comparison of two birth cohorts in 1995 and 2006 (the EPICure studies)

BMJ

(2012)

A randomised trial of timed delivery for the compromised preterm fetus: short term outcomes and Bayesian interpretation

BJOG

(2003)

A. Pels et al.Early-onset fetal growth restriction: a systematic review on mortality and morbidity

Acta Obstet Gynecol Scand

(2020)

A.R. Lawin-O'Brien et al.Short-term outcome of periviable small-for-gestational-age babies: is our counseling up to date?

Ultrasound Obstet Gynecol

(2016)

J.E. Bamfo et al.Diagnosis and management of fetal growth restriction

J Pregnancy

(2011)

C.C. Lees et al.ISUOG Practice Guidelines: diagnosis and management of small-for-gestational-age fetus and fetal growth restriction

Ultrasound Obstet Gynecol

(2020)

There are more references available in the full text version of this article.

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