Early onset fetal growth restriction without abnormal fetal dopplers heralds significant maternal illness
Maksym K., Spencer R., Dyer J., David A.L. on behalf of EVERREST consortium
The finding of a very small fetus prompts a detailed examination of fetal structures and dopplers. We hypothesized that maternal pathology may also underlie the diagnosis which may not be detected in routine care.
Singleton pregnant women were prospectively recruited in four Fetal Medicine centres (London, UK; Lund, Sweden; Hamburg, Germany; Barcelona, Spain) whose fetus had an estimated fetal weight (EFW) <3rd centile, <600g, 20+0-26+6 weeks gestation, regardless of fetal Doppler studies. We excluded women with known fetal chromosomal or structural abnormalities or virus infections. Blood was collected at enrolment for biochemistry, haematology and liver function. Women were seen initially weekly until 28 weeks and then every two weeks if fetal growth was maintained. Maternal blood pressure was measured and urine was assessed for proteinuria at each appointment.
Outcome data was available for 91 of 114 participants: median maternal age 34 years (19-48 years), 50 (55%) primigravid, 66% Caucasian, >50% were overweight or obese (median BMI 26 kg/m2), 16% pregnancies were achieved using assisted reproduction. Nearly half (46%) of participants had pre-existing medical conditions; chronic hypertension, asthma and hypothyroid were most common. At enrolment (20+2 – 26+6 weeks of gestation) 29% had abnormal liver function, mostly elevated LDH in 42%. 14 (15%) developed asymptomatic hypertension. Nearly one-quarter of participants (24%) developed pre-eclampsia, 5% gestational diabetes, 7 (8%) had a placental abruption.
Failed placentation in women with pre-existing medical conditions, even if subclinical, leads to increased risk of early onset severe intrauterine growth restriction. Diagnosis of early onset severe intrauterine growth restriction should trigger detailed analysis of maternal conditions with enhanced monitoring throughout the pregnancy.