Perinatal outcome of fetuses predicted to be large‐for‐gestational age on universal third‐trimester ultrasound in non‐diabetic pregnancy

Abstract

ABSTRACTObjectiveTo describe the perinatal outcome of fetuses predicted to be large‐for‐gestational age (LGA) on universal third‐trimester ultrasound in non‐diabetic pregnancies of women attempting vaginal delivery.MethodsThis was a prospective population‐based cohort study of patients from a single tertiary maternity unit in the UK offering universal third‐trimester ultrasound and practicing expectant management of suspected LGA until 41–42 weeks. All women with a singleton pregnancy and an estimated due date between January 2014 and September 2019 were included. Women delivering before 37 weeks, those having a planned Cesarean delivery, those with pre‐existing or gestational diabetes, those with fetal abnormalities and those who did not undergo a third‐trimester scan were excluded from the assessment of perinatal outcome of cases with LGA predicted on ultrasound after implementation of the universal scan period. Association of LGA on universal third‐trimester ultrasound screening and perinatal adverse outcome was assessed, with the exposures of interest being estimated fetal weight (EFW) at the 90th–95th, > 95th and > 99th percentile. The reference group was composed of fetuses with EFW at the 30th–70th percentile. Analysis was performed using multivariate logistic regression. The evaluated adverse perinatal outcomes included a composite outcome of admission to neonatal intensive care unit, Apgar score < 7 at 5 min and arterial cord pH < 7.1 (CAO1) and a composite outcome of stillbirth, neonatal death and hypoxic ischemic encephalopathy (CAO2). Secondary maternal outcomes were induction of labor, mode of delivery, postpartum hemorrhage, shoulder dystocia and obstetric anal sphincter injury.ResultsCases with EFW > 95th percentile on universal third‐trimester scan were at increased risk of CAO1 (adjusted odds ratio (aOR), 2.18 (95% CI, 1.69–2.80)) and CAO2 (aOR, 2.58 (95% CI, 1.05–6.34)). Cases with EFW at the 90th–95th percentile had a less pronounced increase in the risk of CAO1 (aOR, 1.35 (95% CI, 1.02–1.78)) and were not at increased risk of CAO2. All pregnancies with a fetus predicted to be LGA were at increased risk of all of the evaluated secondary maternal outcomes except for obstetric anal sphincter injury. The risk of adverse maternal outcome was typically higher with increasing EFW. Post‐hoc exploration of data suggested that shoulder dystocia had a limited contribution to composite adverse perinatal outcomes in LGA cases (population attributable fraction of 10.8% for CAO1 and 29.1% for CAO2).ConclusionsCases with EFW > 95th percentile are at increased risk of severe adverse perinatal outcome, such as death and hypoxic ischemic encephalopathy. These findings should aid antenatal counseling regarding the associated risk and delivery options. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.