Preventing harm: A balance measure for improving the detection of fetal growth restriction

Abstract

Background Increasing the detection of fetal growth restriction (FGR), while reducing stillbirth, also leads to unnecessary early intervention, and associated morbidity, for normally grown babies who are incorrectly suspected of FGR. Aims We sought to design a balance measure that addresses the specificity of FGR detection. Methods A retrospective cohort study on all singleton births ≥32 weeks gestation in 2016 and 2017 in Victoria. We compared two balance measures for the detection of FGR, defined as the proportion of all babies iatrogenically delivered before 39 weeks gestation for suspected FGR that had a birthweight ≥10th centile (balance measure 1) or ≥25th centile (balance measure 2). Hospital level performance on each balance measure was derived and compared to an existing performance measure for severe FGR detection in Victoria. Results Of the 38 hospitals analysed, 12 (32%) had a favourable performance on an existing indicator of FGR detection, seven (18%) hospitals had a favourable performance on balance measure 1, and 15 (39%) had a favourable performance on balance measure 2. There was a moderate correlation between hospital performance on the existing indicator and on balance measure 1 (r = 0.447, P = 0.005) but not balance measure 2 (r = −0.063, P = 0.71). There was no difference in perinatal mortality between high performing hospitals and low performing hospitals. Conclusion Introducing a balance measure into routine reporting may bring greater awareness to the unintended harm associated with increased detection of FGR.

Association Between Iatrogenic Delivery for Suspected Fetal Growth Restriction and Childhood School Outcomes

“…Adding to the clinician’s challenge is that many infants suspected of having FGR have normal growth and for these infants early intervention carries no benefit, only risk. This is because the clinical tools for detecting FGR—symphysis-fundal height measurement and ultrasound assessment of fetal size—perform poorly .…”

“…4,5 When compounded by the risks of neurocognitive and intellectual impairment associated with FGR alone, 6,7 the attending clinician faces a challenging dilemma-either intervene early to prevent a small risk of stillbirth but potentially cause immediate and lifelong harm to the child or accept the increasing risk of stillbirth associated with prolonging the pregnancy to avoid more common neonatal and longer-term morbidities. 2 Adding to the clinician's challenge is that many infants suspected of having FGR have normal growth 2,8,9 and for these infants early intervention carries no benefit, only risk. This is because the clinical tools for detecting FGR-symphysisfundal height measurement and ultrasound assessment of fetal size-perform poorly.…”

Fetal size classified using gestational days rather than gestational weeks improves correlation with stillbirth risk: A statewide population study

“…Moreover, for many years, there has been increasing concern about the high rates of obstetric intervention and the potential for iatrogenic harm [41][42][43]. Here, we provide a simple method by which SGA classification can be improved to correlate better with perinatal outcomes without inflating the proportion of pregnancies considered at risk.…”

Etiologic evaluation and pregnancy outcomes of fetal growth restriction (FGR) associated with structural malformations: experience from a tertiary referral center

“…General, FGR is diagnosed when fetal abdominal circumference (AC) or estimated fetal weight (EFW) for a given gestational age falls below the 10th centile or 2 standard deviations (2 SD). Some FGR pregnancies may be actually normal small for gestational age (SGA), and evidences have shown that many FGR fetuses have unexpectedly normal growth afterbirth [1][2][3][4] . However, once FGR is suspected, conducting a etiology evaluation is crucial for making informed decisions about the pregnancy and assessing the prognosis.…”