François Goffinet

Poor effectiveness of antenatal detection of fetal growth restriction and consequences for obstetric management and neonatal outcomes: a French national study

To assess the proportion of small for gestational age (SGA) and normal birthweight infants suspected of fetal growth restriction (FGR) during pregnancy, and to investigate obstetric and neonatal outcomes by suspicion of FGR and SGA status at birth.

Thrombophilia and immunological disorders in pregnancies as risk factors for small for gestational age infants

Objectives To determine if inherited thrombophilia and immunological disorders represent risk factors for small for gestational age infants, and to assess their relationship with neonatal status.

Newborn shoulder width: a prospective study of 2222 consecutive measurements.

Objectives To relate maternal and infant characteristics to newborn shoulder width and to evaluate the predictive value of newborn shoulder width measurement in cases of shoulder dystocia.

Does the Presence of Risk Factors for Fetal Growth Restriction Increase the Probability of Antenatal Detection? A French National Study.

BACKGROUND Screening for fetal growth restriction (FGR) is a major component of prenatal care. We investigated whether the presence of maternal and pregnancy risk factors for FGR improves the antenatal suspicion of FGR for infants born small-for-gestational age (SGA) as well as their impact on screening specificity. METHODS Data are from a representative sample of births from the 2010 French National Perinatal Survey (n = 14 100). Detection of FGR was determined by a suspicion of FGR noted in medical charts. Analyses were performed for singleton infants with birthweight under the 10th percentile (SGA), under the 3rd percentile (severely SGA), and above the 10th percentile (false positives) of French references. We studied risk factors for FGR (medical and obstetric conditions, advanced maternal age, nulliparity, body mass index and smoking) using multivariable Poisson regression to derive adjusted risk ratios (aRR). RESULTS Of SGA infants, 21.7% were suspected of FGR. The presence of obstetric and medical risk factors for FGR was associated with higher suspicion among SGA infants [RR 2.1, 95% confidence interval (CI) 1.7, 2.7]. However, despite the presence of these factors, 60% and 40% of SGA and severely SGA infants, respectively, were not suspected of FGR. Two per cent of normal birthweight infants were suspected of FGR, increasing to 5% when obstetric and medical risk factors were present. Smoking and older maternal age were unrelated to suspicion while females were more likely to be suspected of FGR. CONCLUSION Our results suggest that better risk assessment could improve antenatal identification of FGR. Sex-specific fetal growth references should be used to avoid systematic bias linked to sex.

Fetal and neonatal outcomes of preterm infants born before 32 weeks of gestation according to antenatal vs postnatal assessments of restricted growth

BACKGROUND: Fetal growth restriction is defined using ultrasound parameters during pregnancy or as a low birthweight for gestational age after birth, but these definitions are not always concordant. OBJECTIVE: The purpose of this study was to investigate fetal and neonatal outcomes based on antenatal vs postnatal assessments of growth restriction. STUDY DESIGN: From the EPIPAGE 2 population‐based prospective study of very preterm births in France in 2011, we included 2919 singleton nonanomalous infants 24–31 weeks gestational age. We constituted 4 groups based on whether the infant was suspected with fetal growth restriction during pregnancy and/or was small for gestational age with a birthweight <10th percentile of intrauterine norms by sex: 1) suspected with fetal growth restriction/small for gestational age 2) not suspected with fetal growth restriction/small for gestational age 3) suspected with fetal growth restriction/not small for gestational age and 4) not suspected with fetal growth restriction/not small for gestational age. We estimated relative risks of perinatal mortality and morbidity for these groups adjusting for maternal and neonatal characteristics. RESULTS: We found that 22.2% of infants were suspected with fetal growth restriction/small for gestational age, that 11.4% infants were not suspected with fetal growth restriction/small for gestational age, that 3.0% infants were suspected with fetal growth restriction/not small for gestational age, and that 63.4% infants were not suspected with fetal growth restriction/not small for gestational age. Compared with infants who were not suspected with fetal growth restriction/not small‐for‐gestational‐age infants, small‐for‐gestational‐age infants suspected and not suspected with fetal growth restriction had higher risks of stillbirth or termination of pregnancy (adjusted relative risk, 2.0 [95% confidence interval, 1.6–2.5] and adjusted relative risk, 2.8 [95% confidence interval, 2.2–3.4], respectively), in‐hospital death (adjusted relative risk, 2.8 [95% confidence interval, 2.0–3.7] and adjusted relative risk, 2.0 [95% confidence interval, 1.5–2.8], respectively), and bronchopulmonary dysplasia (adjusted relative risk, 1.3 [95% confidence interval, 1.2–1.4] and adjusted relative risk, 1.3 [95% confidence interval, 1.1–1.4], respectively), but not severe brain lesions. Risks were not increased for infants suspected with fetal growth restriction but not small‐for‐gestational‐age. CONCLUSION: Antenatal and postnatal assessments of fetal growth restriction were not concordant for 14% of very preterm infants. In these cases, birthweight appears to be the more relevant parameter for the identification of infants with higher risks of adverse short‐term outcomes.

Risk factors for chronic post-traumatic stress disorder development one year after vaginal delivery: a prospective, observational study

Our study aimed to assess the prevalence of post-traumatic stress disorder (PTSD) after childbirth one year after vaginal delivery and to identify characteristics of women and deliveries associated with it. Questionnaires were mailed a year after delivery to 1103 women with prospectively collected delivery and postpartum data, including a question on day 2 assessing their experience of childbirth. PTSD was assessed a year later by the Impact of Event and Traumatic Event Scales; 22 women (4.2%, 95%CI 2.7–6.3%) met the PTSD diagnostic criteria and 30 (5.7%; 95%CI 3.9–8.0%) PTSD profile criteria. Factors associated with higher risk of PTSD profile were previous abortion (aOR 3.6, 95%CI 1.4–9.3), previous postpartum hemorrhage (Aor 5.3, 95%CI 1.3–21.4), and postpartum hemoglobin <9 g/dl (aOR 2.7, 95%CI 1.0–7.5). Among 56 women (10.3%) reporting bad childbirth memories at day 2 postpartum, 11 (21.1%) met PTSD diagnosis and 11 (21.1%) PTSD profile criteria a year later, compared with 11 (2.4%) (P < 0.001) and 18 (3.8%) (P < 0.001), respectively, of the 489 (87.7%) women with good memories. PTSD is not rare at one year after vaginal delivery in a low-risk population. A simple question at day 2 post partum may identify women most at risk of PTSD and help determine if early intervention is needed.

Gestational age at diagnosis of early‐onset fetal growth restriction and impact on management and survival: a population‐based cohort study

To investigate the impact of gestational age (GA) at diagnosis of fetal growth restriction (FGR) on obstetric management and rates of live birth and survival for very preterm infants with early‐onset FGR.

More validation is needed before widespread adoption of INTERGROWTH-21st fetal growth reference standards in France

The French College of Obstetrics and Gynecology recommends universal fetal growth screening during pregnancy followed by closer surveillance of fetuses with an estimated fetal weight (EFW) < 10th percentile, in line with other national professional societies1,2. Prenatal care in France includes a routine third-trimester ultrasound examination between 30 and 34 weeks of gestation, principally for this purpose. However, research has shown that the performance of antenatal screening for detecting high-risk fetuses needs to be improved3,4. Effective antenatal screening relies on accurate biometric references for identifying fetuses with suboptimal growth. Stirnemann et al.5 are to be commended for their study on the performance of the new INTERGROWTH (IG)-21st standards in a French low-risk population. The ‘flash’ methodology, which allows for a rapid response, is well suited to the challenge of obtaining timely information and introducing new evidence into practice. However, while offering some arguments in favor of the IG-21st standards, this study’s findings do not justify their widespread adoption in France. The authors find that head circumference (HC) is similar between the IG-21st population and their sample, as shown by the closely aligned 10th, 50th and 90th percentiles and the fact that 11.2% and 3.7%, respectively, of their low-risk sample were below the 10th and 3rd percentiles. In contrast, the fit is not good for abdominal circumference (AC) or femur length (FL), for which, respectively, 4.1% and 3.1% of their sample were below the 10th percentile and 18.5% and 19.1% were over the 90th centile. Given these differences, the authors should also have provided a comparison of the percentile references for AC and FL. Comparing means does not make it possible to assess the 3rd, 10th, 90th and 97th centiles, which would be used for identifying infants that require further monitoring. Furthermore, the discordance between the HC and the FL and AC requires further comment and investigation. A final issue concerns the absence of validation of IG-21st EFW reference standards. The use of one summary measure to assess fetal growth has been recommended for antenatal screening1,2. Also, fetal weight references can be used for newborns, as recommended for preterm infants, and can be customized to take into consideration maternal characteristics. These reasons were behind the development of new French references based on modeled fetal growth, which have been evaluated using a nationally representative sample of births6. While the concept of universal standards is appealing from a theoretical point of view, more rigorous evaluation of the IG-21st standards is needed before they are implemented in France, including assessment of the EFW standards7. The stakes are high, as standards which do not correspond to the percentile thresholds recommended for screening will undermine efforts to reduce stillbirth and child morbidity linked with suboptimal growth and may also lead to unnecessary interventions, with the associated iatrogenic health effects, parental anxiety and costs.