F. Figueras

Contingent versus routine third-trimester screening for late fetal growth restriction.

To evaluate the use of third‐trimester ultrasound screening for late fetal growth restriction (FGR) on a contingent basis, according to risk accrued in the second trimester, in an unselected population.

Performance of a third trimester combined screening model for the prediction of adverse perinatal outcome

To explore the potential value of third‐trimester combined screening for the prediction of adverse perinatal outcome (APO) in the general population and among small‐for‐gestational‐age (SGA) fetuses.

Revealed versus concealed criteria for placental insufficiency in an unselected obstetric population in late pregnancy (RATIO37): randomised controlled trial study protocol

Introduction Fetal growth restriction (FGR) affects 5%–10% of all pregnancies, contributing to 30%–50% of stillbirths. Unfortunately, growth restriction often is not detected antenatally. The last weeks of pregnancy are critical for preventing stillbirth among babies with FGR because there is a pronounced increase in stillbirths among growth-restricted fetuses after 37 weeks of pregnancy. Here we present a protocol (V.1, 23 May 2016) for the RATIO37 trial, which evaluates an integrated strategy for accurately selecting at-risk fetuses for delivery at term. The protocol is based on the combination of fetal biometry and cerebroplacental ratio (CPR). The primary objective is to reduce stillbirth rates. The secondary aims are to detect low birth weights and adverse perinatal outcomes. Methods and analysis The study is designed as multicentre (Spain, Chile, Mexico,Czech Republic and Israel), open-label, randomised trial with parallel groups. Singleton pregnancies will be invited to participate after routine second-trimester ultrasound scan (19+0–22+6 weeks of gestation), and participants will be randomly allocated to receive revealed or concealed CPR evaluation. Then, a routine ultrasound and Doppler scan will be performed at 36+0–37+6 weeks. Sociodemographic and clinical data will be collected at enrolment. Ultrasound and Doppler variables will be recorded at 36+0–37+6 weeks of pregnancy. Perinatal outcomes will be recorded after delivery. Univariate (with estimated effect size and its 95% CI) and multivariate (mixed-effects logistic regression) comparisons between groups will be performed. Ethics and dissemination The study will be conducted in accordance with the principles of Good Clinical Practice. This study was accepted by the Clinical Research Ethics Committee of Hospital Clinic Barcelona on 23May 2016. Subsequent approval by individual ethical committees and competent authorities was granted. The study results will be published in peer-reviewed journals and disseminated at international conferences. Trial registration number NCT02907242; pre-results.

Longitudinal growth assessment for prediction of adverse perinatal outcome in fetuses suspected to be small‐for‐gestational age

Fetal growth restriction (FGR) is associated with an increased risk of adverse perinatal outcome. However, distinguishing this condition from small‐for‐gestational age (SGA) remains elusive. A set of criteria has been proposed recently for such a purpose, including the degree of smallness, Doppler parameters and growth velocity. The aim of this study was to establish whether the use of growth velocity adds value to Doppler assessment in predicting adverse perinatal outcome among SGA‐suspected fetuses.

Second‐ to third‐trimester longitudinal growth assessment for prediction of small‐for‐gestational age and late fetal growth restriction

Detection of fetal growth restriction (FGR) remains poor and most screening strategies rely on cross‐sectional evaluation of fetal size during the third trimester. A longitudinal and individualized approach has been proposed as an alternative method of evaluation. The aim of this study was to compare second‐ to third‐trimester longitudinal growth assessment to cross‐sectional evaluation in the third trimester for the prediction of small‐for‐gestational age (SGA) and late FGR in low‐risk singleton pregnancy.This article is protected by copyright. All rights reserved. This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1002/uog.17471 A cc ep te d A rti cl e Background: Detection of fetal growth restriction (FGR) remains poor. Most screening strategies rely on a cross-sectional evaluation of fetal size at one point during the third trimester. A longitudinal and individualized approach may allow a more appropriate evaluation. Objectives: To compare second to third trimester longitudinal growth assessment with cross-sectional evaluation at third trimester in the prediction of SGA and late FGR. Methods: A cohort of 2696 unselected singletons pregnancies scanned at 21±2 and 32±2 weeks was created. Abdominal circumference (AC) measurements were transformed to zvalues according the 21st-INTERGROWTH standards. Longitudinal growth assessment was performed by the calculation of z-velocity and second to third trimester conditional growth centile. Longitudinal assessment was compared to cross-sectional assessment at 32 weeks. Predictive performance for SGA and late FGR was determined by receiver operating characteristic (ROC) curve analysis. Result: A total of 210 (7.8%) newborns were classified as SGA and 103 (3.8%) as late FGR. None of the longitudinal measures (AC z-velocity and conditional AC growth) relevantly improved the association to SGA or late FGR provided by the cross-sectional evaluation of AC z-score at 32 weeks. Both areas under the curve (AUC) of AC z-velocity and conditional AC growth were significantly lower than that of cross-sectional AC z-scores (p<0.001). AC zvelocity performed significantly better than conditional AC growth (p<0.001). Conclusions: Longitudinal assessment of fetal growth from second to third-trimester has a low predictive capacity for SGA and late FGR in the general population.

Prediction of fetal growth restriction using estimated fetal weight vs a combined screening model in the third trimester

To compare the performance of third‐trimester screening, based on estimated fetal weight centile (EFWc) vs a combined model including maternal baseline characteristics, fetoplacental ultrasound and maternal biochemical markers, for the prediction of small‐for‐gestational‐age (SGA) neonates and late‐onset fetal growth restriction (FGR).

Risk of fetal death in growth-restricted fetuses with umbilical and/or ductus venosus absent or reversed end-diastolic velocities before 34 weeks of gestation: a systematic review and meta-analysis

Objective The objective of the study was to establish the risk of fetal death in early‐onset growth‐restricted fetuses with absent or reversed end‐diastolic velocities in the umbilical artery or ductus venosus. Data Sources A systematic search was performed to identify relevant studies published in English, Spanish, French, Italian, or German using the databases PubMed, ISI Web of Science, and SCOPUS, without publication time restrictions. Study Eligibility Criteria The study criteria included observational cohort studies and randomized controlled trials of early‐onset growth‐restricted fetuses (diagnosed before 34 weeks of gestation), with information on the rate of fetal death occurring before 34 weeks of gestation and absent or reversed end‐diastolic velocities in the umbilical artery and/or ductus venosus. Study Appraisal and Synthesis Methods For quality assessment, 2 reviewers independently assessed the risk of bias using the Newcastle‐Ottawa Scale for observational studies and the Cochrane Collaboration’s tool for randomized trials. For the meta‐analysis, odds ratio for both fixed and random‐effects models (weighting by inverse of variance) were used. Heterogeneity between studies was assessed using tau2, χ2 (Cochrane Q), and I2 statistics. Publication bias was assessed by a funnel plot for meta‐analyses and quantified by the Egger method. Results A total of 31 studies were included in this meta‐analysis. The odds ratios for fetal death (random‐effects models) were 3.59 (95% confidence interval, 2.3–5.6), 7.27 (95% confidence interval, 4.6–11.4), and 11.6 (95% confidence interval, 6.3–19.7) for growth‐restricted fetuses with umbilical artery absent end‐diastolic velocities, umbilical artery reversed end‐diastolic velocities, and ductus venosus absent or reversed end‐diastolic velocities, respectively. There was no substantial heterogeneity among studies for any of the analyses. Conclusion Early‐onset growth‐restricted fetuses with either umbilical artery or ductus venosus absent or reserved end‐diastolic velocities are at a substantially increased risk for fetal death.

OP19.07: Fetoplacental Doppler association with placental pathology in pre-eclampsia and fetal growth restriction: Short oral presentation abstracts

L. Youssef1, J. Miranda2, C. Paules2, F. Crovetto2, F. Figueras2, E. Eixarch2, A. Nadal1, C. Rovira3, F. Crispi2, E. Gratacós2 1Pathology, Hospital Clinic-IDIBAPS, Barcelona, Spain; 2BC Natal, Barcelona, Centre for Maternal-Fetal and Neonatal Medicine (Hospital Clı́nic and Hospital Sant Joan de Deu) and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain; 3Pathology, Hospital Sant Joan de Deu, Barcelona, Spain

Added value of cerebro-placental ratio and uterine artery Doppler at routine third trimester screening as a predictor of SGA and FGR in non-selected pregnancies

Abstract Objectives: The objective of this study is to determine the added value of cerebroplacental ratio (CPR) and uterine Doppler velocimetry at third trimester scan in an unselected obstetric population to predict smallness and growth restriction. Methods: We constructed a prospective cohort study of women with singleton pregnancies attended for routine third trimester screening (32+0–34+6 weeks). Fetal biometry and fetal–maternal Doppler ultrasound examinations were performed by certified sonographers. The CPR was calculated as a ratio of the middle cerebral artery to the umbilical artery pulsatility indices. Both attending professionals and patients were blinded to the results, except in cases of estimated fetal weight < p10. The association between third trimester Doppler parameters and small for gestational age (SGA) (birth weight <10th centile) and fetal growth restriction (FGR) (birth weight below the third centile) was assessed by logistic regression, where the basal comparison was a model comprising maternal characteristics and estimated fetal weight (EFW). Results: A total of 1030 pregnancies were included. The mean gestational age at scan was 33 weeks (SD 0.6). The addition of CPR and uterine Doppler to maternal characteristics plus EFW improved the explained uncertainty of the predicting models for SGA (15 versus 10%, p < .001) and FGR (12 versus 8%, p = .03). However, the addition of CPR and uterine Doppler to maternal characteristics plus EFW only marginally improved the detection rates for SGA (38 versus 34% for a 10% of false positives) and did not change the predictive performance for FGR. Conclusions: The added value of CPR and uterine Doppler at 33 weeks of gestation for detecting defective growth is poor.

OC09.03: *Pattern of placental stromal‐vascular lesions in small fetuses with and without pre‐eclampsia

Objectives: To evaluate the effect of the treatment with nitric oxide (NO) donors in pregnant women with small-for-gestational age fetuses. Methods: 48 pregnant women referred for small for gestational age (SGA) fetus underwent a non-invasive hemodynamic measurement and an ultrasonic assessment of fetal growth. We obtained three subgroups according to total vascular resistance (TVR): Group A (high TVR treated, n=13), Group B (high TVR untreated, n=15) and Group C (low TVR untreated, n=20). After 4 weeks, we repeated fetal biometry and maternal cardiovascular assessment. Furthermore our aim was to identify those fetuses which turned their conditions to pathological intrauterine growth restriction (IUGR). Results: In table 1, we reported maternal main hemodynamic parameters in the three groups after 4 weeks of treatment/no treatment. Our data demonstrated that SGA fetuses with high TVR under treatment showed an improvement of maternal hemodynamic parameters after 4 weeks (see graph). Group B patients showed an impaired hemodynamic pattern, having an increased risk to develop IUGR and other complications. Conclusions: Maternal hemodynamic assessment at diagnosis of a SGA fetus might identify patients at risk to turn to pathological growth restriction. The preventive use of NO donors has shown to improve the impaired cardiovascular pattern and fetal outcomes.