The growth-restricted fetus: risk of mortality by each additional week of expectant management

<p><b>Objective:</b> To compare fetal/infant mortality risk associated with each additional week of expectant management with the infant mortality risk of immediate delivery in growth-restricted pregnancies.</p> <p><b>Methods:</b> A retrospective cohort study was conducted of singleton, nonanomalous pregnancies from the 2005–2008 California Birth Registry comparing pregnancies affected and unaffected by growth restriction, defined using birth weights as a proxy for fetal growth restriction (FGR). Birth weights were subdivided as greater than the 90th percentile, between the 10th percentile and 90th percentile, and less than the 10th percentile. Cases greater than the 90th percentile were excluded from analysis. Cases less than the 10th percentile were considered to have FGR and were further subcategorized into <10th percentile, <5th percentile, and <3rd percentile. We compared the risk of infant death at each gestational age week against a composite risk representing the mortality risk of one additional week of expectant management.</p> <p><b>Results:</b> We identified 1,641,000 births, of which 110,748 (6.7%) were less than 10th percentile. The risk of stillbirth increased with gestational age with the risk of stillbirth at each week of gestation inversely proportional to growth percentile. The risks of fetal and infant mortality with expectant management outweighed the risk of infant death for all FGR categories analyzed beginning at 38 weeks. However, the absolute risks differed by growth percentiles, with the highest risks of infant death and stillbirth in the <3rd percentile cohort. At 39 weeks, absolute risks were low, although the number needed to deliver to prevent 1 death ranged from 413 for <3rd percentile to 2667 in unaffected pregnancies.</p> <p><b>Conclusion:</b> At 38 weeks, the mortality risk of expectant management for one additional week exceeds the risk of delivery across all growth-restricted cohorts, despite variation in absolute risk by degree of growth restriction.</p

When is the optimal time to deliver late preterm IUGR fetuses with abnormal umbilical artery Dopplers?

<div><p></p><p><i>Objective</i>: To determine the optimal timing of delivery in late preterm intrauterine growth restriction (IUGR) fetuses with abnormal umbilical artery Doppler (UAD) indices.</p><p><i>Methods</i>: A decision-analytic model was built to determine the optimal gestational age (GA) of delivery in a theoretic cohort of 10 000 IUGR fetuses with elevated UAD systolic/diastolic ratios diagnosed at 34 weeks. All inputs were derived from the literature. Strategies involving expectant management accounted for the probabilities of stillbirth, spontaneous delivery and induction of labor for UAD absent or reversed end-diastolic flow (AREDF) at each successive week. Outcomes included short- and long-term neonatal morbidity and mortality with quality-adjusted life years (QALYs) generated based on these outcomes. Base case, sensitivity analyses and a Monte Carlo simulation were performed.</p><p><i>Results</i>: The optimal GA for delivery is 35 weeks, which minimized perinatal deaths and maximized total QALYs. Earlier delivery became optimal once the risk of stillbirth was threefold our baseline assumption; our model was also robust until the risk of AREDF at 35 weeks was half our baseline assumption, after which delivery at 36 weeks was preferred. Delivery at 35 weeks was the optimal strategy in 77% of trials in Monte Carlo multivariable sensitivity analysis.</p><p><i>Conclusions</i>: Weighing the risks of iatrogenic prematurity against the poor outcomes associated with AREDF, the ideal GA to deliver late preterm IUGR fetuses with elevated UAD indices is 35 weeks.</p></div

Mean Weight-Length Z Score by Maternal Depression Status.

<p>Values at each timepoint are unadjusted mean values.</p

Percentage Underweight by Maternal Depression Status.

<p>Values at each timepoint are unadjusted mean values.</p

Logistic Mixed Model of the Association between Maternal Depression and Child Overweight (Weight-for-Length Percentile ≥85th) from 6 months to 2 years (n = 186 mother-child pairs).

<p>Logistic Mixed Model of the Association between Maternal Depression and Child Overweight (Weight-for-Length Percentile ≥85th) from 6 months to 2 years (n = 186 mother-child pairs).</p

Weight Parameters in Relation to Maternal Depression Symptom Status at Study Timepoints.

<p>Weight Parameters in Relation to Maternal Depression Symptom Status at Study Timepoints.</p

Logistic Mixed Model of the Association between Maternal Depression and Risk for Failure to Thrive (Weight for Age Percentile <5th) from 6 months to 2 years (n = 186 mother-child pairs).

<p>Logistic Mixed Model of the Association between Maternal Depression and Risk for Failure to Thrive (Weight for Age Percentile <5th) from 6 months to 2 years (n = 186 mother-child pairs).</p

Multivariate Logistic Mixed Model^* of the Association between Maternal Depression and Risk for Child Overweight (Weight-for-Length Percentile ≥85th) from 6 months to 2 years (n = 166 mother-child pairs).

<p>*Models are adjusted for all variables listed in the table.</p

Mixed Model of the Association Between Maternal Depression and Weight for Length Z Scores in Children from Birth to 2 Years of Age (n = 186 mother-child pairs).

<p>Mixed Model of the Association Between Maternal Depression and Weight for Length Z Scores in Children from Birth to 2 Years of Age (n = 186 mother-child pairs).</p

Weight Parameters and Breastfeeding Frequencies at Study Timepoints.

<p>Weight Parameters and Breastfeeding Frequencies at Study Timepoints.</p