Objective: Antenatal growth assessment using ultrasound aims to identify small fetuses that are at higher risk of perinatal morbidity and mortality. This study explored whether the association between suboptimal fetal growth and adverse perinatal outcome varies with different definitions of fetal growth restriction (FGR) and different weight charts/standards.Methods: This was a retrospective cohort study of 17 261 singleton non‐anomalous pregnancies at ≥ 24 + 0 weeks' gestation that underwent routine ultrasound at a tertiary referral hospital. Estimated fetal weight (EFW) and Doppler indices were converted into percentiles using a reference standard (INTERGROWTH‐21^st (IG‐21)) and various reference charts (Hadlock, Fetal Medicine Foundation (FMF) and Swedish). Test characteristics were assessed using the consensus definition, Society for Maternal–Fetal Medicine (SMFM) definition and Swedish criteria for FGR. Adverse perinatal outcome was defined as perinatal death, admission to the neonatal intensive care unit at term, 5‐min Apgar score < 7 and therapeutic cooling for neonatal encephalopathy. The association between FGR according to each definition and adverse perinatal outcome was compared. Multivariate logistic regression analysis was used to test the strength of association between ultrasound parameters and adverse perinatal outcome. Ultrasound parameters were also tested for correlation.Results: IG‐21, Hadlock and FMF fetal size references classified as growth‐restricted 1.5%, 3.6% and 4.6% of fetuses, respectively, using the consensus definition and 2.9%, 8.8% and 10.6% of fetuses, respectively, using the SMFM definition. The sensitivity of the definition/chart combinations for adverse perinatal outcome varied from 4.4% (consensus definition with IG‐21 charts) to 13.2% (SMFM definition with FMF charts). Specificity varied from 89.4% (SMFM definition with FMF charts) to 98.6% (consensus definition with IG‐21 charts). The consensus definition and Swedish criteria showed the highest specificity, positive predictive value and positive likelihood ratio in detecting adverse outcome, irrespective of the reference chart/standard used. Conversely, the SMFM definition had the highest sensitivity across all investigated growth charts. Low EFW, abnormal mean uterine artery pulsatility index (UtA‐PI) and abnormal cerebroplacental ratio were significantly associated with adverse perinatal outcome and there was a positive correlation between the covariates. Multivariate logistic regression showed that UtA‐PI > 95^th percentile and EFW < 5^th percentile were the only parameters consistently associated with adverse outcome, irrespective of the definitions or fetal growth chart/standard used.Conclusions: The apparent prevalence of FGR varies according to the definition and fetal size reference chart/standard used. Irrespective of the method of classification, the sensitivity for the identification of adverse perinatal outcome remains low. EFW, UtA‐PI and fetal Doppler parameters are significant predictors of adverse perinatal outcome. As these indices are correlated with one other, a prediction algorithm is advocated to overcome the limitations of using these parameters in isolation. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Objective: To describe the incidence, clinical features and perinatal outcome of late‐onset fetal growth restriction (FGR) associated with genetic syndrome or aneuploidy, structural malformation or congenital infection.Methods: This was a retrospective multicenter cohort study of patients who attended one of four tertiary maternity hospitals in Italy. We included consecutive singleton pregnancies between 32 + 0 and 36 + 6 weeks' gestation with either fetal abdominal circumference (AC) or estimated fetal weight < 10^th percentile for gestational age or a reduction in AC of > 50 percentiles from the measurement at an ultrasound scan performed between 18 and 32 weeks. The study group consisted of pregnancies with late‐onset FGR and a genetic syndrome or aneuploidy, structural malformation or congenital infection (anomalous late‐onset FGR). The presence of congenital anomalies was ascertained postnatally in neonates with abnormal findings on antenatal investigation or detected after birth. The control group consisted of pregnancies with structurally and genetically normal fetuses with late‐onset FGR. Composite adverse perinatal outcome was defined as the presence of at least one of stillbirth, 5‐min Apgar score < 7, admission to the neonatal intensive care unit (NICU), need for respiratory support at birth, neonatal jaundice and neonatal hypoglycemia. The primary aims of the study were to assess the incidence and clinical features of anomalous late‐onset FGR, and to compare the perinatal outcome of such cases with that of fetuses with non‐anomalous late‐onset FGR.Results: Overall, 1246 pregnancies complicated by late‐onset FGR were included in the study, of which 120 (9.6%) were allocated to the anomalous late‐onset FGR group. Of these, 11 (9.2%) had a genetic syndrome or aneuploidy, 105 (87.5%) had an isolated structural malformation, and four (3.3%) had a congenital infection. The most frequent structural defects associated with late‐onset anomalous FGR were genitourinary malformations (28/105 (26.7%)) and limb malformation (21/105 (20.0%)). Compared with the non‐anomalous late‐onset FGR group, fetuses with anomalous late‐onset FGR had an increased incidence of composite adverse perinatal outcome (35.9% vs 58.3%; P < 0.01). Newborns with anomalous, compared to those with non‐anomalous, late‐onset FGR showed a higher frequency of need for respiratory support at birth (25.8% vs 9.0%; P < 0.01), intubation (10.0% vs 1.1%; P < 0.01), NICU admission (43.3% vs 22.6%; P < 0.01) and longer hospital stay (median, 24 days (range, 4–250 days) vs 11 days (range, 2–59 days); P < 0.01).Conclusions: Most pregnancies complicated by anomalous late‐onset FGR have structural malformations rather than genetic abnormality or infection. Fetuses with anomalous late‐onset FGR have an increased incidence of complications at birth and NICU admission and a longer hospital stay compared with fetuses with isolated late‐onset FGR. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Objective: Uteroplacental dysfunction may not only result in pre‐eclampsia (PE) but also in preterm birth (PTB), small‐for‐gestational‐age (SGA) birth and stillbirth. The aim of this study is to evaluate the positive predictive value (PPV) of first‐trimester combined PE screening for all of these placenta‐mediated adverse pregnancy outcomes.Design: Retrospective cohort study.Setting: Tertiary referral maternity unit.Sample: A total of 13 211 singleton pregnancies.Methods: First‐trimester combined screening for preterm PE using the Fetal Medicine Foundation (FMF) algorithm.Main outcomes measures: Hypertensive disorders of pregnancy (HDP), PTB, SGA birth and stillbirth were combined to assess composite adverse and severe adverse pregnancy outcomes (CAPO and CAPO‐S). The PPVs for CAPO and CAPO‐S were calculated for women with a combined risk for preterm PE of ≥1 in 50 and ≥1 in 100.Results: First‐trimester combined screening identified 2215 women (16.8%) with a risk of ≥1 in 100 for preterm PE. The PPVs for a risk of ≥1 in 100 for CAPO and CAPO‐S were 38.8% and 18.2%, respectively. The equivalent PPVs for a risk of ≥1 in 50 were 45.1% and 21.1%, respectively.Conclusions: Women identified at high risk of preterm PE are also at increased risk of other placenta‐mediated adverse pregnancy outcomes, such as PTB, SGA birth and stillbirth. Women at high risk for preterm PE after first‐trimester screening may benefit from a higher surveillance care pathway, with interventions to mitigate all the adverse outcomes associated with placental dysfunction.

Objective: To evaluate the relative importance of ethnicity and socioeconomic deprivation in determining the likelihood and prevalence of placentally derived composite of adverse pregnancy outcomes (CAPO) and composite of severe adverse pregnancy outcomes (CAPO‐S). Methods: This was a single‐center retrospective cohort study of data obtained in a tertiary maternity unit. Data regarding ethnicity and socioeconomic deprivation (as measured with indices of multiple deprivation) were collected for 13 165 singleton pregnancies screened routinely in the first trimester for pre‐eclampsia using the Fetal Medicine Foundation combined risk‐assessment algorithm. CAPO was defined as the presence of one or more interrelated outcomes associated with placental dysfunction, namely, hypertensive disorders of pregnancy, preterm birth, birth weight ≤ 10 ^th centile and stillbirth. CAPO‐S was defined as the presence of one or more of the following: hypertensive disorders of pregnancy at < 37 + 0 weeks, preterm birth at < 34 + 0 weeks, birth weight ≤ 5 ^th centile and stillbirth at < 37 + 0 weeks. Results: The prevalence of CAPO was 16.3% in white women, 29.3% in black women and 29.3% in South Asian women. However, half (51.7%) of all CAPO cases occurred in white women. There was a strong interaction between ethnicity and socioeconomic deprivation, with a correlation coefficient of −0.223. Both ethnicity and socioeconomic deprivation influenced the prevalence of CAPO and CAPO‐S, with the contribution of ethnicity being the strongest. Conclusions: Black and Asian ethnicity, as well as socioeconomic deprivation, influence the prevalence of placenta‐mediated adverse pregnancy outcomes. Despite this, most adverse pregnancy outcomes occur in white women, who represent the majority of the population and are also affected by socioeconomic deprivation. For these reasons, inclusion of socioeconomic deprivation should be considered in early pregnancy risk assessment for placenta‐mediated CAPO. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Objective: To evaluate whether routine mid‐gestational uterine artery Doppler (UtAD) modifies the risk for preterm pre‐eclampsia after first‐trimester combined pre‐eclampsia screening.Design: Retrospective cohort study.Setting: London Tertiary Hospital.Population: A cohort of 7793 women with singleton pregnancies, first‐trimester pre‐eclampsia screening using the Fetal Medicine Foundation (FMF) algorithm and UtAD pulsatility index (PI) assessment at the mid‐gestation ultrasound.Methods: Pregnancies were divided into four groups: high risk in both trimesters (H¹H²), high risk in the first but not in the second trimester (H¹L²), low risk in the first but high risk in the second trimester (L¹H²) and low risk in both trimesters (L¹L²).Main outcome measures: Small for gestational age (SGA), hypertensive disorders of pregnancy (HDP) and stillbirth.Results: In this cohort, 600 (7.7%) and 620 (7.9%) women were designated as being at high risk in the first and second trimesters, respectively. Preterm pre‐eclampsia was more prevalent in the H¹L² group (4.5%) than in women considered at low risk in the first trimester (0.4%, p < 0.0001). The prevalence of preterm pre‐eclampsia in the L¹H² group (3.3%) was significantly lower than that in women considered at high risk in the first trimester (7.0%, p = 0.0076), and was higher than that observed in the L¹L² group (0.2%, p < 0.0001). The prevalence of SGA and term HDP followed similar trends.Conclusions: Pre‐eclampsia risk after first‐trimester FMF pre‐eclampsia screening may be stratified through mid‐gestational routine UtAD assessment. Pregnancy care should not be de‐escalated for low mid‐gestational UtAD resistance in women classified as being at high risk in the first trimester. The escalation of care may be justified in women at low risk but with high mid‐gestational UtAD resistance.