Choosing a growth standard

[Pages:26]Choosing a growth standard

Clare Whitehead

ACCEPTED MANUSCRIPT

Optimising detection of FGR not SGA

% 100

Fetal Growth Restriction, late pregnancy

90

Small but not growth restricted

80

70

Small and growth restricted

D MANUSCRIPT

60

Growth restricted but not small

50

40 SGA

30 20

FGR

AGA

LGA

10

0

0

10

20

30

40

50

60

70

80

90

100

percentile

Which chart you choose will determine what % of babies in your

population are SGA and FGR Ganzevoort, AJOG 2018

1. Is this the right chart?

Which growth chart: birthweight vs fetal weight

h (BW) charts will systematically under-diagnose fetal growth restriction prior to term e babies......

Babies in the NICU are not the same...........

not as A haspbpayb aineds wtheallt remain shed asin t-huetseer boaubnietsi...l term!

DobLbivinesb(riretphlaccheaRrotbsewrtisllasnydstLeamncaatsitcearl)lyaruen ad `elerfdt isakgenwoesde `pFoGpRulpartiioonr to term

Which growth chart: birthweight vs fetal weight

Weight (gr)

3000

2500 2000 1500 1000

Ultrasound Birthweight

500

24

26

28

30

32

34

36

38

40

Kramer, 2001

Weeks

Bwt = Kramer 2001

Which growth chart: Standard vs Reference charts

Growth standards charts describe how a baby should grow.....based on data from only healthy pregnancies Whereas growth reference charts describe how all babies in a population grow including those that subsequently develop

complications

Hadlock Charts

? USA 1991 ? 392 women ? All caucasian ? Single center in Texas ? Only 1 USS per fetus

Growth charts

Weight (gr)

3000 Kramer (BW)

10th

%

Hadlock (EFW)

2500

2000

1500

1000

500

0 22 24 26 28 30 32 34 36 38 40

Gestational age (weeks)

Articles

Intergrowth 21

International standards for fetal growth based on serial

ultrasound measurements: the Fetal Growth Longitudinal

Study of the INTERGROWTH-21st Project

Articles

Lancet 2014

Aris T Papageorghiou, Eric O Ohuma, Douglas G Altman, Tullia Todros, Leila Cheikh Ismail, Ann Lambert, Yasmin A Jaffer, Enrico Bertino,

Michael G Gravett, Manorama Purwar, J Alison Noble, Ruyan Pang, Cesar G Victora, Fernando C Barros, Maria Carvalho, Laurent J Salomon,

Ultrasound based growth standard: Zulfi4q0A0ar A Bhutta*, Stephen H Kenn11B0edy*, Jos? Villar*, for the International Fetal and Newborn Growth Consortium for the 21st Century

(INTE350RGROWTH-21st)

100 90

300 80

250

Sum200 mary

70 60

"Optimal fetal size"

Biparietal diameter (mm)

Head circumference (mm)

Back150ground In 2006, WHO p4500roduced international growth standards for infants and children up to age 5 years on the Lancet 2014; 384: 869?79

4321 low risk women from 8 countries basi1s00 of recommendations f3r0 om a WHO expert committee. Using the same methods and conceptual approach, the See Comment page 835

50

20

Fetal Growth Longitudinal 0 0 14 16 18 20 22 24 26 28 30 32 34 36 38 40

Study (FGLS), 0 0 14 16 18 20 22 24 26 28 30

part of 32 34 36 38 40

the

INTERGROWTH-21st

Project,

aimed

to

develop

international

*Joint senior authors

Gestational age (weeks)

Gestational age (weeks)

grow14C0 th and size standards foDr fetuses. 400

included in final chart (Brazil, UK, Italy, Members listed inthe appendix

Abdominal circumference (mm)

Oman, USA, China, India & Kenya) 120

350

Nuffield Department of

Met1h00 ods The multicentre, p3o00 pulation-based FGLS assessed fetal growth in geographically defined urban populations Obstetrics and Gynaecology,

Occipitofrontal diameter (mm)

in ei80ght countries, in which250 most of the health and nutritional needs of mothers were met and adequate antenatal and Oxford Maternal and

200

care60was provided. We used15u0 ltrasound to take fetal anthropometric measurements prospectively from 14 weeks and

Perinatal Health Institute, Green Templeton College

Linked with WHO infant and childhood 0 da4y0 s of gestation until birt10h0 in a cohort of women with adequate health and nutritional status who were at low risk (AT Papageorghiou MD,

of in200trauterine growth restr500iction. All women had a reliable estimate of gestational age confirmed by ultrasound E O Ohuma MSc,

0 14 16 18 20 22 24 26 28 30 32 34 36 38 40

0 14 16 18 20 22 24 26 28 30 32 34 36 38 40

growth charts up to age 2 yrs measurement of fetal Gestationalage(weeks) E

crown?rump length Gestationalage(weeks)

in

the

first

trimester.

The

five

primary

ultrasound

measures

of

fetal

L Cheikh Ismail PhD,

85

grow75th--head circumference, biparietal diameter, occipitofrontal diameter, abdominal circumference, and femur

A Lambert PhD, Prof S H Kennedy MD,

leng6t5 h--were obtained every 5 weeks (within 1 week either side) from 14 weeks to 42 weeks of gestation. The best Prof J Villar MD), Centre for

55

Femur length (mm)

Dating scan < 14 weeks then scanned fittin45g curves for the five measures were selected using second-degree fractional polynomials and further modelled in Statistics in Medicine, Botnar

a mu35 ltilevel framework to account for the longitudinal design of the study.

Research Centre (E O Ohuma,

25

Prof D G Altman DSc), and

every 5 weeks to 42 weeks 15

Department of Engineering

Findi5ngs We screened 13 108 women commencing antenatal care at less than 14 weeks and 0 days of gestation, of 0

Science (Prof J A Noble DPhil),

whom 4607 (35%) were 0 14 16 18 20 22 24 26 28 30 32 34 36 38 40 Gestational age (weeks)

eligible.

4321

(94%)

eligible

women

had

pregnancies

without

major

complications

and

University of Oxford, Oxford,

874

delivered live singletons without congenital malformations (the analysis population). We documented very low Figure2:Fitted3rd,50th,and97thsmoothedcentilecurvesoffetalmeasurements Fitted 3rd (bottom dashed line), 50th (middle dashed line), and 97th (top dashed line) smoothed centile curves for fetal head circumference (A), fetal biparietal diameter (B), fetal occipitofrontal diameter (C), fetal abdominal circumference (D), and fetal femur length (E) measured by ultrasound according to gestational age. Open red circles show empirical values for each week of gestation and open grey circles show actual observations.

maternal and perinatal mortality and morbidity, confirming that the participants were at low risk of adverse outcomes. Vol 384 September 6, 2014

UK; Universit? degli Studi di Torino, Torino, Italy (T Todros PhD,

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