Screening and triage of intrauterine growth restriction (IUGR) in general population and high risk pregnancies: a systematic review with a focus on reduction of IUGR related stillbirths

Aamer Imdad, Mohammad Yawar Yakoob, Saad Siddiqui, Zulfiqar Ahmed Bhutta, Aamer Imdad, Mohammad Yawar Yakoob, Saad Siddiqui, Zulfiqar Ahmed Bhutta

Abstract

Background: There is a strong association between stillbirth and fetal growth restriction. Early detection and management of IUGR can lead to reduce related morbidity and mortality. In this paper we have reviewed effectiveness of fetal movement monitoring and Doppler velocimetry for the detection and surveillance of high risk pregnancies and the effect of this on prevention of stillbirths. We have also reviewed effect of maternal body mass index (BMI) screening, symphysial-fundal height measurement and targeted ultrasound in detection and triage of IUGR in the community.

Methods: We systematically reviewed all published literature to identify studies related to our interventions. We searched PubMed, Cochrane Library, and all World Health Organization Regional Databases and included publications in any language. Quality of available evidence was assessed using GRADE criteria. Recommendations were made for the Lives Saved Tool (LiST) based on rules developed by the Child Health Epidemiology Group. Given the paucity of evidence related to the effect of detection and management of IUGR on stillbirths, we undertook Delphi based evaluation from experts in the field.

Results: There was insufficient evidence to recommend against or in favor of routine use of fetal movement monitoring for fetal well being. (1) Detection and triage of IUGR with the help of (1a) maternal BMI screening, (1b) symphysial-fundal height measurement and (1c) targeted ultrasound can be an effective method of reducing IUGR related perinatal morbidity and mortality. Pooled results from sixteen studies shows that Doppler velocimetry of umbilical and fetal arteries in 'high risk' pregnancies, coupled with the appropriate intervention, can reduce perinatal mortality by 29 % [RR 0.71, 95 % CI 0.52-0.98]. Pooled results for impact on stillbirth showed a reduction of 35 % [RR 0.65, 95 % CI 0.41-1.04]; however, the results did not reach the conventional limits of statistical significance. This intervention could be potentially recommended for high income settings or middle income countries with improving rates and standards of facility based care. Based on the Delphi, a combination of screening with maternal BMI, Symphysis fundal height and targeted ultrasound followed by the appropriate management could potentially reduce antepartum and intrapartum stillbirth by 20% respectively. This estimate is presently being recommended for inclusion in the LiST.

Conclusion: There is insufficient evidence to recommend in favor or against fetal movement counting for routine use for testing fetal well being. Doppler velocimetry of umbilical and fetal arteries and appropriate intervention is associated with 29 % (95 % CI 2% to 48 %) reduction in perinatal mortality. Expert opinion suggests that detection and management of IUGR with the help of maternal BMI, symphysial-fundal height measurement and targeted ultrasound could be effective in reducing IUGR related stillbirths by 20%.

Figures

Figure 1
Figure 1
Box plots of the Delphi results on detection and management of IUGR compared to no identification or action for IUGR
Figure 2
Figure 2
Synthesis of study identification in review of screening and triage of intrauterine growth restriction in general population and high risk pregnancies
Figure 3
Figure 3
Forest plots for impact of Doppler ultrasound versus no ultrasound on stillbirths
Figure 4
Figure 4
Forest plots for impact of Doppler ultrasound versus no ultrasound on perinatal mortality

References

    1. Mandruzzato G, Antsaklis A, Botet F, Chervenak FA, Figueras F, Grunebaum A, Puerto B, Skupski D, Stanojevic M. Intrauterine restriction (IUGR) J Perinat Med. 2008;36(4):277–281. doi: 10.1515/JPM.2008.050.
    1. Bukowski R. Stillbirth and fetal growth restriction. Clin Obstet Gynecol. 2010;53(3):673–680. doi: 10.1097/GRF.0b013e3181eba0db.
    1. Smith GC, Fretts RC. Stillbirth. Lancet. 2007;370(9600):1715–1725. doi: 10.1016/S0140-6736(07)61723-1.
    1. de Onis M, Blossner M, Villar J. Levels and patterns of intrauterine growth retardation in developing countries. Eur J Clin Nutr. 1998;52(Suppl 1):S5–15.
    1. Yakoob MY, Menezes EV, Soomro T, Haws RA, Darmstadt GL, Bhutta ZA. Reducing stillbirths: behavioural and nutritional interventions before and during pregnancy. BMC Pregnancy Childbirth. 2009;9(Suppl 1):S3. doi: 10.1186/1471-2393-9-S1-S3.
    1. Barros FC, Bhutta ZA, Batra M, Hansen TN, Victora CG, Rubens CE. Global report on preterm birth and stillbirth (3 of 7): evidence for effectiveness of interventions. BMC Pregnancy Childbirth. 2010;10(Suppl 1):S3.
    1. Ferro-Luzzi A, Ashworth A, Martorell R, Scrimshaw N. Report of the IDECG Working Group on effects of IUGR on infants, children and adolescents: immunocompetence, mortality, morbidity, body size, body composition, and physical performance. Eur J Clin Nutr. 1998;52(Suppl 1):S97–99.
    1. Bakketeig LS. Current growth standards, definitions, diagnosis and classification of fetal growth retardation. Eur J Clin Nutr. 1998;52(Suppl 1):S1–4.
    1. WHO. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee:Technical Report Series No. 854. Geneva: World Health Organization; 1995. pp. 121–160.
    1. Miller J, Turan S, Baschat AA. Fetal growth restriction. Semin Perinatol. 2008;32(4):274–280. doi: 10.1053/j.semperi.2008.04.010.
    1. Walker N, Fischer-Walker C, Bryce J, Bahl R, Cousens S. Standards for CHERG reviews of intervention effects on child survival. Int J Epidemiol. 2010;39(Suppl 1):i21–31. doi: 10.1093/ije/dyq036.
    1. Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, Guyatt GH, Harbour RT, Haugh MC, Henry D. et al.Grading quality of evidence and strength of recommendations. BMJ. 2004;328(7454):1490. doi: 10.1136/bmj.328.7454.1490.
    1. Alfirevic Z, Stampalija T, Gyte GM. Fetal and umbilical Doppler ultrasound in high-risk pregnancies. Cochrane Database Syst Rev. 2010. p. CD007529.
    1. RevMan. The Cochrane Colloboration. Review Manager (RevMan) 5 for Windows. Oxford, England; 2003.
    1. Haws RA, Yakoob MY, Soomro T, Menezes EV, Darmstadt GL, Bhutta ZA. Reducing stillbirths: screening and monitoring during pregnancy and labour. BMC Pregnancy Childbirth. 2009;9(Suppl 1):S5. doi: 10.1186/1471-2393-9-S1-S5.
    1. WHO. MEETING OF ADVISORY GROUP ON MATERNAL NUTRITION AND LOW BIRTHWEIGHT. Geneva; 2002.
    1. Bricker L, Neilson JP. Routine ultrasound in late pregnancy (after 24 weeks gestation) Cochrane Database Syst Rev. 2000. p. CD001451.
    1. Neilson JP. Ultrasound for fetal assessment in early pregnancy. Cochrane Database Syst Rev. 2000. p. CD000182.
    1. Neilson JP. Symphysis-fundal height measurement in pregnancy. Cochrane Database Syst Rev. 2000. p. CD000944.
    1. Rey H, Ortiz EI, Fajardo L, Pradilla A. Annex: Maternal anthropometry: its predictive value for pregnancy outcome. Bull World Health Organ. 1995;73(Suppl):70–71.
    1. Backstrand JR. Annex: Maternal anthropometry as a risk predictor of pregnancy outcome: the Nutrition CRSP in Mexico. Bull World Health Organ. 1995;73(Suppl):96–98.
    1. Kramer MS, Kakuma R. Energy and protein intake in pregnancy. Cochrane Database Syst Rev. 2003. p. CD000032.
    1. Jehan I, Zaidi S, Rizvi S, Mobeen N, McClure EM, Munoz B, Pasha O, Wright LL, Goldenberg RL. Dating gestational age by last menstrual period, symphysis-fundal height, and ultrasound in urban Pakistan. Int J Gynaecol Obstet.
    1. Bergman E, Axelsson O, Kieler H, Sonesson C, Petzold M. Relative growth estimated from self-administered symphysis fundal measurements. Acta Obstet Gynecol Scand. 2011;90(2):179–185. doi: 10.1111/j.1600-0412.2010.01026.x.
    1. Freire DM, Cecatti JG, Paiva CS. Symphysis-fundal height curve in the diagnosis of fetal growth deviations. Rev Saude Publica. 2010;44(6):1031–1038. doi: 10.1590/S0034-89102010005000044.
    1. Grant A, Elbourne D, Valentin L, Alexander S. Routine formal fetal movement counting and risk of antepartum late death in normally formed singletons. Lancet. 1989;2(8659):345–349. doi: 10.1016/S0140-6736(89)90535-7.
    1. Gomez L, Padilla L, De La Vega G, Bautista F, Villar A. Compliance with a fetal movement chart by high risk patients. American Journal of Obstetrics and Gynecology. 2003;189(6):S179. doi: 10.1016/j.ajog.2003.10.435.
    1. Thomsen SG, Legarth J, Weber T, Kristensen J. Monitoring of normal pregnancies by daily fetal movement registration or hormone assessment. A random allocation study. Journal of Obstetrics and Gynaecology. 1990;10:189–193. doi: 10.3109/01443619009151155.
    1. Freda MC, Mikhail M, Mazloom E, Polizzotto R, Damus K, Merkatz I. Fetal movement counting: which method? MCN Am J Matern Child Nurs. 1993;18(6):314–321. doi: 10.1097/00005721-199311000-00011.
    1. Gomez L, Padilla L, De La Vega G, Bautista F, Villar A. Compliance with a fetal movement chart by high risk patients. American Journal of Obstetrics and Gynecology. 2003;189(6):S179. doi: 10.1016/j.ajog.2003.10.435.
    1. CG62: Antenatal care - Routine care for the healthy pregnant woman, full guideline. 2009.
    1. Hill-Smith I. Professional and patient perspectives of NICE guidelines to abandon maternal monitoring of fetal movements. British Journal of General Practice. 2004;54:858–861.
    1. Moore TR, Piacquadio K. A prospective evaluation of fetal movement screening to reduce the incidence of antepartum fetal death. Am J Obstet Gynecol. 1989;160(5 Pt 1):1075–1080.
    1. Neldam S. Fetal movements as an indicator of fetal wellbeing. Lancet. 1980;1(8180):1222–1224. doi: 10.1016/S0140-6736(80)91681-5.
    1. Westgate J, Jamieson M. Stillbirths and fetal movements. N Z Med J. 1986;99(796):114–116.
    1. Saastad E, Tveit JV, Flenady V, Stray-Pedersen B, Fretts RC, Bordahl PE, Froen JF. Implementation of uniform information on fetal movement in a Norwegian population reduced delayed reporting of decreased fetal movement and stillbirths in primiparous women - a clinical quality improvement. BMC Res Notes. 2010;3(1):2. doi: 10.1186/1756-0500-3-2.
    1. De Muylder X. The kick chart in high-risk pregnancies: a two-year experience in Zimbabwe. Int J Gynaecol Obstet. 1988;27(3):353–357. doi: 10.1016/0020-7292(88)90112-9.
    1. Eggertsen SC, Benedetti TJ. Maternal response to daily fetal movement counting in primary care settings. Am J Perinatol. 1987;4(4):327–330. doi: 10.1055/s-2007-999801.
    1. Valentin L, Marsal K. Pregnancy outcome in women perceiving decreased fetal movement. Eur J Obstet Gynecol Reprod Biol. 1987;24(1):23–32. doi: 10.1016/0028-2243(87)90033-5.
    1. Lema VM, Rogo KO, Mwalali PN. Foetal movements: value in monitoring high-risk pregnancies. East Afr Med J. 1988;65(11):785–792.
    1. Romero G Gutierrez, Sanchez R Cortes, Soto V Pompa, Rodriguez P Flores. Perinatal morbidity and mortality associated with fetal hypomotility. Ginecol Obstet Mex. 1994;62:222–225.
    1. Sinha D, Sharma A, Nallaswamy V, Jayagopal N, Bhatti N. Obstetric outcome in women complaining of reduced fetal movements. J Obstet Gynaecol. 2007;27(1):41–43. doi: 10.1080/01443610601016909.
    1. Davies JA, Gallivan S, Spencer JA. Randomised controlled trial of Doppler ultrasound screening of placental perfusion during pregnancy. Lancet. 1992;340(8831):1299–1303. doi: 10.1016/0140-6736(92)92490-7.
    1. Mason GC, Lilford RJ, Porter J, Nelson E, Tyrell S. Randomised comparison of routine versus highly selective use of Doppler ultrasound in low risk pregnancies. Br J Obstet Gynaecol. 1993;100(2):130–133. doi: 10.1111/j.1471-0528.1993.tb15207.x.
    1. Newnham JP, Evans SF, Michael CA, Stanley FJ, Landau LI. Effects of frequent ultrasound during pregnancy: a randomised controlled trial. Lancet. 1993;342(8876):887–891. doi: 10.1016/0140-6736(93)91944-H.
    1. Omtzigt AM, Reuwer PJ, Bruinse HW. A randomized controlled trial on the clinical value of umbilical Doppler velocimetry in antenatal care. Am J Obstet Gynecol. 1994;170(2):625–634.
    1. Schneider KTM, Renz S, Furstenau U, Amberg-Wendland D, Prochaska D, Graeff H. Doppler flow measurements as a screening Fetal and method during pregnancy: is it worth the effort? Journal of Maternal Fetal Investigation. 1992;1:125.
    1. Whittle MJ, Hanretty KP, Primrose MH, Neilson JP. Screening for the compromised fetus: a randomized trial of umbilical artery velocimetry in unselected pregnancies. Am J Obstet Gynecol. 1994;170(2):555–559.
    1. A randomised controlled trial of Doppler ultrasound velocimetry of the umbilical artery in low risk pregnancies. Doppler French Study Group. Br J Obstet Gynaecol. 1997;104(4):419–424. doi: 10.1111/j.1471-0528.1997.tb11492.x.
    1. Gonsoulin W. Umbilical artery Doppler waveform analysis: a randomized study on effect on outcome. American Journal of Obstetrics and Gynecology. 1991;164:370.
    1. McParland P, Pearce JM. Doppler blood flow in pregnancy. Placenta. 1988;9(4):427–450. doi: 10.1016/0143-4004(88)90055-0.
    1. Almstrom H, Axelsson O, Cnattingius S, Ekman G, Maesel A, Ulmsten U, Arstrom K, Marsal K. Comparison of umbilical-artery velocimetry and cardiotocography for surveillance of small-for-gestational-age fetuses. Lancet. 1992;340(8825):936–940. doi: 10.1016/0140-6736(92)92818-Z.
    1. Biljan M, Haddad N, McVey K, Williams J. Proceedings of 26th British Congress of Obstetrics and Gynaecology. Manchester, UK; 1992. Efficiency of continuous-wave Doppler in screening high risk pregnancies in a district general hospital (a prospective randomized study on 674 singleton pregnancies)
    1. Burke G, Stuart B, Crowley P, Ni Scanaill S, Drumm J. 13th European Congress of Perinatal Medicine. Amsterdam, Netherlands; 1992. Does Doppler ultrasound alter the management of high-risk pregnancy?. Care concern and cure in perinatal medicine; pp. 597–604.
    1. Giles W, Bisits A, O'Callaghan S, Gill A. The Doppler assessment in multiple pregnancy randomised controlled trial of ultrasound biometry versus umbilical artery Doppler ultrasound and biometry in twin pregnancy. BJOG. 2003;110(6):593–597. doi: 10.1046/j.1471-0528.2003.02066.x.
    1. Haley J, Tuffnell DJ, Johnson N. Randomised controlled trial of cardiotocography versus umbilical artery Doppler in the management of small for gestational age fetuses. Br J Obstet Gynaecol. 1997;104(4):431–435. doi: 10.1111/j.1471-0528.1997.tb11494.x.
    1. Hofmeyr GJ, Pattinson R, Buckley D, Jennings J, Redman CW. Umbilical artery resistance index as a screening test for fetal well-being. II: Randomized feasibility study. Obstet Gynecol. 1991;78(3 Pt 1):359–362.
    1. Johnstone FD, Prescott R, Hoskins P, Greer IA, McGlew T, Compton M. The effect of introduction of umbilical Doppler recordings to obstetric practice. Br J Obstet Gynaecol. 1993;100(8):733–741. doi: 10.1111/j.1471-0528.1993.tb14264.x.
    1. Neales K. In: Fetal and umbilical Doppler ultrasound in high-risk pregnancies. Cochrane Database of Systematic Reviews, 2010. 1. Alfirec et al. in: Alfirevic Z ST, Gyte GML., editor. 1994. A randomised controlled study to assess the use of Doppler ultrasound in the management of patients with intrauterine growth retardation, Personal communication. Art. No.: CD007529. DOI: 10.1002/14651858.CD007529 pub2.
    1. Newnham JP, O'Dea MR, Reid KP, Diepeveen DA. Doppler flow velocity waveform analysis in high risk pregnancies: a randomized controlled trial. Br J Obstet Gynaecol. 1991;98(10):956–963. doi: 10.1111/j.1471-0528.1991.tb15332.x.
    1. Nienhuis SJ, Vles JS, Gerver WJ, Hoogland HJ. Doppler ultrasonography in suspected intrauterine growth retardation: a randomized clinical trial. Ultrasound Obstet Gynecol. 1997;9(1):6–13. doi: 10.1046/j.1469-0705.1997.09010006.x.
    1. Norman K, Pattinson RC, Carstens E. Proceedings of 11th Conference on Priorities in Perinatal Care in South Africa. Caledon, South Africa; 1992. Doppler velocimetry in recurrent pregnancy loss: is there a role? pp. 71–74.
    1. Ott WJ, Mora G, Arias F, Sunderji S, Sheldon G. Comparison of the modified biophysical profile to a "new" biophysical profile incorporating the middle cerebral artery to umbilical artery velocity flow systolic/diastolic ratio. Am J Obstet Gynecol. 1998;178(6):1346–1353. doi: 10.1016/S0002-9378(98)70342-4.
    1. Pattinson RC, Norman K, Odendaal HJ. The role of Doppler velocimetry in the management of high risk pregnancies. Br J Obstet Gynaecol. 1994;101(2):114–120. doi: 10.1111/j.1471-0528.1994.tb13075.x.
    1. Trudinger BJ, Cook CM, Giles WB, Connelly A, Thompson RS. Umbilical artery flow velocity waveforms in high-risk pregnancy. Randomised controlled trial. Lancet. 1987;1(8526):188–190. doi: 10.1016/S0140-6736(87)90003-1.
    1. Tyrrell SN, Lilford RJ, Macdonald HN, Nelson EJ, Porter J, Gupta JK. Randomized comparison of routine vs highly selective use of Doppler ultrasound and biophysical scoring to investigate high risk pregnancies. Br J Obstet Gynaecol. 1990;97(10):909–916. doi: 10.1111/j.1471-0528.1990.tb02446.x.
    1. Williams KP, Farquharson DF, Bebbington M, Dansereau J, Galerneau F, Wilson RD, Shaw D, Kent N. Screening for fetal well-being in a high-risk pregnant population comparing the nonstress test with umbilical artery Doppler velocimetry: a randomized controlled clinical trial. Am J Obstet Gynecol. 2003;188(5):1366–1371. doi: 10.1067/mob.2003.305.
    1. Husaini MA, Husaini YK, Sandjaja, Kartono D, Jahari AB, Barizi, Karyadi D. Annex: Maternal anthropometry and pregnancy outcomes in Indonesia. Bull World Health Organ. 1995;73(Suppl):77–79.
    1. Kirksey A, Wang HC. Annex: Maternal anthropometry as a risk predictor of pregnancy outcome: the Nutrition CRSP in Egypt. Bull World Health Organ. 1995;73(Suppl):87–90.
    1. Nahar S, Mascie-Taylor CG, Begum HA. Maternal anthropometry as a predictor of birth weight. Public Health Nutr. 2007;10(9):965–970. doi: 10.1017/S1368980007217975.
    1. Neumann C, Ferguson L, Bwibo NO. Annex: Maternal anthropometry as a risk predictor of pregnancy outcome: the Nutrition CRSP in Kenya. Bull World Health Organ. 1995;73(Suppl):91–95.
    1. Ojha N, Malla DS. Low birth weight at term: relationship with maternal anthropometry. JNMA J Nepal Med Assoc. 2007;46(166):52–56.
    1. Pelletier D, Arimond M, Johnson FC, Liang E, Low J, Mvula P, Msukwa L, Ramakrishnan U, Ross J, Simler K. Annex: Maternal anthropometry predictors of intrauterine growth retardation and prematurity in the Malawi Maternal and Child Nutrition study. Bull World Health Organ. 1995;73(Suppl):80–81.
    1. Alfirevic Z, Roberts D, Martlew V. How strong is the association between maternal thrombophilia and adverse pregnancy outcome? A systematic review. Eur J Obstet Gynecol Reprod Biol. 2002;101(1):6–14. doi: 10.1016/S0301-2115(01)00496-1.
    1. Roos-Hesselink JW, Duvekot JJ, Thorne SA. Pregnancy in high risk cardiac conditions. Heart. 2009;95(8):680–686. doi: 10.1136/hrt.2008.148932.
    1. Westergaard HB, Langhoff-Roos J, Lingman G, Marsal K, Kreiner S. A critical appraisal of the use of umbilical artery Doppler ultrasound in high-risk pregnancies: use of meta-analyses in evidence-based obstetrics. Ultrasound Obstet Gynecol. 2001;17(6):466–476. doi: 10.1046/j.1469-0705.2001.00415.x.
    1. Ashworth A. Effects of intrauterine growth retardation on mortality and morbidity in infants and young children. Eur J Clin Nutr. 1998;52(Suppl 1):S34–41.
    1. Bernstein IM, Horbar JD, Badger GJ, Ohlsson A, Golan A. Morbidity and mortality among very-low-birth-weight neonates with intrauterine growth restriction. The Vermont Oxford Network. Am J Obstet Gynecol. 2000;182(1 Pt 1):198–206. doi: 10.1016/S0002-9378(00)70513-8.
    1. Miskovic B, Vasilj O, Stanojevic M, Ivankovic D, Kerner M, Tikvica A. The comparison of fetal behavior in high risk and normal pregnancies assessed by four dimensional ultrasound. J Matern Fetal Neonatal Med. 2010.
    1. Hoffman C, Galan HL. Assessing the 'at-risk' fetus: Doppler ultrasound. Curr Opin Obstet Gynecol. 2009;21(2):161–166. doi: 10.1097/GCO.0b013e3283292468.
    1. Velazquez MD, Rayburn WF. Antenatal evaluation of the fetus using fetal movement monitoring. Clin Obstet Gynecol. 2002;45(4):993–1004. doi: 10.1097/00003081-200212000-00006.
    1. Cronje HS, Grobler CJF, Visser AA. Obstetrics in Southern Africa. Pretoria: J.A. van Schaik Publishers; 1996.
    1. Heazell AE, Froen JF. Methods of fetal movement counting and the detection of fetal compromise. J Obstet Gynaecol. 2008;28(2):147–154. doi: 10.1080/01443610801912618.
    1. Froen JF. A kick from within--fetal movement counting and the cancelled progress in antenatal care. J Perinat Med. 2004;32(1):13–24. doi: 10.1515/JPM.2004.003.
    1. Sellers PM. Midwifery. Vol. 2. Johannesburg & Cape Town: Juta & Co. Ltd;; 1993.
    1. Mangesi L, Hofmeyr GJ. Fetal movement counting for assessment of fetal wellbeing. Cochrane Database Syst Rev. 2007. p. CD004909.

Source: PubMed

赞助者和合作者

医疗条件

药物干预

3
订阅