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Aim To assess the growth trajectory of preterm small-for-gestational-age (SGA) neonates compared to preterm non-small-for-gestational age neonates in the neonatal intensive care unit and special care nursery. Methods We conducted a retrospective cohort study at a large tertiary hospital in Victoria, Australia, examining neonates ≤34 weeks’ gestation admitted to the neonatal intensive care unit or special care nursery between 2013 and 2017. We categorized neonates according to their birth weight centile: <10th centile (small-for-gestational age) and ≥10th centile (non-small-for-gestational age). Growth trajectory was tracked based on serial weights obtained in the neonatal intensive care unit and special care nursery, using z-scores derived from Fenton preterm growth charts. Our primary outcome was the change in weight z-score from birth to discharge from neonatal intensive care unit or special care nursery. Results Of the 910 babies included, 88 were small-for-gestational age and 822 were appropriate-for gestational age. Both groups had a reduction in their weight z-score; however, SGA babies had a significantly smaller reduction (–0.62 SD compared to −0.85 SD, p < .0001). Small-for-gestational-age neonates were four times more likely to experience an increase in their weight z-score across their admission compared to neonates who were not small-for-gestational age (OR 4.04, 95% CI 2.23–7.48, p < .0001). Small-for-gestational-age neonates had an increased median length of stay, increased incidence of necrotizing enterocolitis but a reduced incidence of intraventricular hemorrhage. Conclusions Preterm SGA babies experience a smaller reduction in their weight trajectory compared to their appropriately grown counterparts in the neonatal intensive care unit or special care nursery. [ABSTRACT FROM AUTHOR]

Background: Increasing the detection of fetal growth restriction (FGR), while reducing stillbirth, also leads to unnecessary early intervention, and associated morbidity, for normally grown babies who are incorrectly suspected of FGR. Aims: We sought to design a balance measure that addresses the specificity of FGR detection. Methods: A retrospective cohort study on all singleton births ≥32 weeks gestation in 2016 and 2017 in Victoria. We compared two balance measures for the detection of FGR, defined as the proportion of all babies iatrogenically delivered before 39 weeks gestation for suspected FGR that had a birthweight ≥10th centile (balance measure 1) or ≥25th centile (balance measure 2). Hospital level performance on each balance measure was derived and compared to an existing performance measure for severe FGR detection in Victoria. Results: Of the 38 hospitals analysed, 12 (32%) had a favourable performance on an existing indicator of FGR detection, seven (18%) hospitals had a favourable performance on balance measure 1, and 15 (39%) had a favourable performance on balance measure 2. There was a moderate correlation between hospital performance on the existing indicator and on balance measure 1 (r = 0.447, P = 0.005) but not balance measure 2 (r = −0.063, P = 0.71). There was no difference in perinatal mortality between high performing hospitals and low performing hospitals. Conclusion: Introducing a balance measure into routine reporting may bring greater awareness to the unintended harm associated with increased detection of FGR. [ABSTRACT FROM AUTHOR]

Aim: Timely delivery of fetal growth restriction (FGR) is a balance between avoiding stillbirth and minimising prematurity. We sought to assess the neonatal outcomes for babies suspected of FGR, both true and false positives. Methods: This population cohort study examined all singleton births in Victoria, Australia from 2000 to 2017 (n = 1 231 415). Neonatal morbidities associated with neonatal intensive care unit (NICU) admission were assessed for babies born ≥32 weeks' with severe FGR (<3rd centile) and babies with birthweight ≥10th centile who were iatrogenically delivered for suspected FGR. Results: Babies with severe FGR iatrogenically delivered for suspected FGR were more likely to require NICU admission than babies with severe FGR who were not detected (3.0% vs. 1.1%, P < 0.001). After adjusting for potential confounders, the odds of NICU admission were increased (adjusted odds ratio (aOR) = 3.00, 95% confidence interval = 2.45–3.67; P < 0.001). Rates of NICU admission were also higher in ≥10th centile babies iatrogenically delivered for suspected FGR than for ≥10th centile babies who entered labour spontaneously (1.8% vs. 0.5%, P < 0.001). After adjustments, the odds of NICU admission were increased (aOR = 3.91, 95% confidence interval = 3.40–4.49; P < 0.001). NICU admissions were associated with morbidities related to iatrogenic prematurity. Conclusions: Detection and planned delivery of FGR reduces stillbirth but may be associated with increased neonatal morbidity related to iatrogenic prematurity. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of increasing obstetric intervention on birthweight centiles.Design: Retrospective cohort study of births in five 2-year epochs: 1983-84, 1993-94, 2003-2004, 2013-2014 and 2016-2017.Population: 665 205 singleton births at ≥32 weeks' gestation.Setting: All maternity services in Victoria, Australia.Methods: For each epoch, we calculated the birthweight cutoffs defining each birthweight centile at 34, 37 and 40 weeks' gestation. We calculated rates of iatrogenic delivery over time. We then calculated the number of babies whose birthweight would have classified them as ≥3rd centile based on 1983-84 centile definitions but as <3rd centile based on 2016-2017 centile definitions.Main Outcome Measures: Birthweight centile, and gestation at delivery.Results: From 1983-84 to 2016-2017, the rate of iatrogenic delivery for singleton pregnancies increased at all term gestations: 1.6-6.4% at 37 weeks', 4.5-18.3% at 38 weeks', 7.6-23.9% at 39 weeks' and 18.4-25.1% at 40 weeks' (all P < 0.001). Over the same period, the birthweight cutoffs defining the 3rd, 5th and 10th centiles increased significantly at term, but not preterm, gestations. This led to increasing numbers of term births being classified as small for gestational age (SGA). Of the 2748 babies born in 2016-2017 at 37-39 weeks' gestation with a birthweight <3rd centile in that period, 1478 (53.8%) would have been classified as ≥3rd centile based on 1983-84 centile definitions.Conclusion: Increasing intervention is shifting the birthweight cutoffs that define birthweight centiles and thereby redefining what constitutes SGA. This undermines the use of population-derived birthweight centiles to audit clinical care.Tweetable Abstract: Increasing obstetric intervention is shifting birthweight centiles and therefore definitions of normality. [ABSTRACT FROM AUTHOR]

Serial third trimester ultrasound examinations for fetal biometry are recommended for women with risk factors of fetal growth restriction (FGR). We conducted a retrospective cohort study on all singleton births in Victoria from 2009 to 2017 to assess how many women with major risk factors for FGR had serial third trimester biometry. Only 19.5% of women with at least one major risk factor for FGR had evidence of serial third trimester ultrasound assessments. The development and implementation of a state‐wide or nationwide guideline for early pregnancy risk factor assessment in FGR may be beneficial. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of publicly reporting a statewide fetal growth restriction (FGR) performance indicator.Design: Retrospective cohort study from 2000 to 2017.Setting: All maternity services in Victoria, Australia.Population: A total of 1 231 415 singleton births at ≥32 weeks of gestation.Methods: We performed an interrupted time-series analysis to assess the impact of publicly reporting an FGR performance indicator on the rate of detection for severe cases of small for gestational age (SGA). Rates of perinatal mortality and morbidity and obstetric intervention were assessed for severe SGA pregnancies and pregnancies delivered for suspected SGA.Main Outcome Measures: Gestation at delivery, obstetric management and perinatal outcome.Results: The public reporting of a statewide FGR performance indicator was associated with a steeper reduction per quarter in the percentage of severe SGA undelivered by 40 weeks of gestation, from 0.13 to 0.51% (P = 0.001), and a decrease in the stillbirth rate by 3.3 per 1000 births among those babies (P = 0.01). Of babies delivered for suspected SGA, the percentage with birthweights ≥ 10th centile increased from 41.4% (n = 307) in 2000 to 53.3% (n = 1597) in 2017 (P < 0.001). Admissions to a neonatal intensive care unit for babies delivered for suspected SGA but with a birthweight ≥ 10th centile increased from 0.8 to 2.0% (P < 0.001).Conclusions: The public reporting of an FGR performance indicator has been associated with the improved detection of severe SGA and a decrease in the rate of stillbirth among those babies, but with an increase in the rate of iatrogenic birth for babies with normal growth.Tweetable Abstract: The public reporting of hospital performance is associated with a reduction in stillbirth, but also with unintended interventions. [ABSTRACT FROM AUTHOR]

Background: Growth charts customised for maternal height, weight, ethnicity and parity have been proposed as more effective at detecting infants who are small for gestational age (SGA) than routine screening with symphysio‐fundal height measurement alone. Our non‐randomised, prospective cohort study assessed antenatal SGA detection rates in a general maternity cohort following the introduction of the Perinatal Institute's Growth Assessment Protocol (GAP) program (consisting of customised growth chart software for plotting symphysio‐fundal height, staff training and serial auditing). Methods: The GAP program was implemented into the routine antenatal schedule of 882 women who delivered at The Royal Women's Hospital, Melbourne, during our study period. SGA detection was compared to 936 women from the same team who delivered prior to the intervention. Secondary outcomes assessed were infant gestation at birth and method of delivery, neonatal Apgar scores and admission to the Neonatal Intensive and Special Care nursery (NISC). Results: Identification of SGA infants increased from 21% to 41% with the introduction of the GAP program (OR 2.6, 95% CI 1.3–4.9, P < 0.05). This was not associated with an increase in false‐positive rates. Following the introduction of the GAP Program, SGA babies were more likely to be born by vaginal delivery (OR 2.7; 95% CI 1.4–5.1, P < 0.005). There was no overall increase in the induction of labour or caesarean delivery rates. Overall rates of admission to NISC were reduced. Conclusions: In our increasingly culturally heterogenous society, the use of the GAP program is a safe and potentially more sensitive tool for detecting in utero growth restriction. [ABSTRACT FROM AUTHOR]

Background Severe fetal growth restriction ( FGR) (< third centile) in a singleton pregnancy undelivered by 40 weeks is one of a number of Victorian Perinatal Services Performance Indicators, which aim to provide a measure of the quality and safety of maternity care. Women of refugee background have been found to have poorer perinatal outcomes compared to others and these outcomes can in part be explained by previous history. However, less access to and engagement with pregnancy care may also be contributing factors. This study examined the impact of likely refugee background on severe FGR in a singleton pregnancy undelivered by 40 weeks. Methods A retrospective study was undertaken utilising data on women who gave birth to a severely growth-restricted infant at Monash Health during January 2013-July 2015. Unadjusted and adjusted analyses were undertaken to examine the association between the mother being of likely refugee background and severe FGR in singletons delivered after 40 weeks. Results There was an association between the mother being of likely refugee background and giving birth to a severely growth-restricted baby after 40 weeks with these mothers at two and half times the odds compared to mothers of non-refugee background (adjusted odds ratio 2.52; 95% confidence interval: 1.44-4.42). Conclusions While detecting FGR is clinically challenging, our findings suggest that maternity services need to be supported to offer care tailored to the specific needs of vulnerable and disadvantaged populations. Providing quality, culturally responsive and accessible care is fundamental to addressing refugee maternal and perinatal health inequalities. [ABSTRACT FROM AUTHOR]

The relationship between maternal exposure to air pollution and birth outcomes is not well characterised where ambient air pollution is relatively low. We aimed to explore the association between maternal exposure to ambient nitrogen dioxide (NO 2) and fine particulate matter (PM 2.5) and a range of birth outcomes in Victoria, Australia. Secondary aims were to explore whether obstetric conditions, such as gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy, were effect modifiers in observed relationships. We included all singleton births occurring in Victoria, Australia from 1st March 2012 to 31st December 2015 using routinely collected government data. Outcomes included birth weight, small for gestational age (SGA), term low birth weight (tLBW), large for gestational age (LGA), and spontaneous preterm birth (sPTB). We estimated exposure to annual ambient NO 2 and PM 2.5 concentrations, assigned to maternal residence at time of birth. Confounders included maternal, meteorological and temporal variables. Multivariable linear regression and log-binomial regression were used for continuous and dichotomous outcomes, respectively. There were 285,594 births during the study period. Average NO 2 exposure was 6.0 parts per billion (ppb, median 5.6; interquartile range (IQR) 3.9) and PM 2.5 was 6.9 μg/m3 (median 7.1, IQR 1.3). IQR increases in ambient NO 2 and PM 2.5 were associated with fetal growth restriction, including decrements in birth weight (NO 2 β −22.8 g; 95%CI -26.0, −19.7; PM 2.5 β −14.8 g; 95%CI -17.4, −12.2) and increased risk of SGA (NO 2 RR 1.08; 95%CI 1.06, 1.10; PM 2.5 RR 1.05; 95%CI 1.04, 1.07) and tLBW (NO 2 RR 1.06; 95%CI 1.01, 1.10; PM 2.5 RR 1.04; 95%CI 1.03, 1.08). Women with GDM and hypertensive disorders of pregnancy had greater decrements in birth weight in association with pollutant exposure. In this exploratory study using an annual metric of exposure, maternal exposure to low-level ambient air pollution was associated with fetal growth restriction, which carries substantial public health implications. • Ambient air pollution is associated with adverse birth outcomes. • Less is known about the importance of maternal exposure to low-level air pollution. • Low-level exposure to NO 2 and PM 2.5 was associated with fetal growth restriction. • Harms were observed at levels below guidelines (mean NO 2 6.0 ppb; PM 2.5 6.9 μg/m3). • Mothers with gestational diabetes and hypertensive disorders were more susceptible. [ABSTRACT FROM AUTHOR]

Background: The management of preterm intrauterine growth restriction is limited to fetal surveillance and timely delivery. Despite the existence of evidence-based guidelines, uncertainty regarding the optimal timing of delivery is common, and management remains individualised for each patient., Aims: To provide recent Australian data on the indications for delivery of moderate to late preterm growth restricted infants and the outcomes of these deliveries., Materials and Methods: Retrospective study of singleton live births delivered between 32 + 0 and 36 + 6 weeks gestation over a three-year period (2012-2014) at a Melbourne Metropolitan Hospital. 'Small for gestational age' (birthweight < 10th centile for gestation) identified intrauterine growth restricted infants. Indications for iatrogenic delivery were broadly categorised into maternal, fetal or pregnancy related. Obstetric and neonatal outcome variables were compared to other preterm infants using logistic regression., Results: Of the 146 (18.6%) small for gestational age infants born during the study period, 103 were iatrogenic deliveries, most commonly due to fetal indications (53.4%). Small for gestational age infants had higher odds of hypoglycaemia (adjusted odds ratio = 1.87, 95% CI: 1.23-2.84, P = 0.003) and jaundice (1.52, 1.01-2.28, P = 0.043) than their appropriately grown counterparts; however, there was no increase in the risk of serious morbidity or mortality., Conclusions: In this cohort, iatrogenic preterm delivery of small for gestational age infants between 32 + 0 and 36 + 6 weeks gestation was most commonly due to fetal indications and did not increase the risk of serious, short-term neonatal outcomes compared to their appropriately grown counterparts., (© 2017 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)