Deliveries between 1985 and 1996 were included. How often do we identify fetal abnormalities during routine third-trimester ultrasound? In low-risk pregnancies, routine ultrasonography in the third trimester detected more babies who were small for gestational age compared with usual care alone: 32% (179/556) versus 19% (78/407), though still fewer than a third of those found to be small for gestational age. Neonates of the participating women were born between June 2015 and August 2016. Two dichotomous maternal composite outcomes were defined as secondary outcomes. Routine ultrasonography was associated with a higher incidence of induction of labour. OBJECTIVE: An adequate and contemporary randomized trial is needed to resolve whether routine third trimester ultrasound followed by adapted perinatal management … Secondly, in many trials, only the ultrasound screening strategy was described and the subsequent clinical management of suspected fetal growth restriction was unclear.15 Biometry screening alone cannot prevent adverse perinatal outcomes unless screening is combined with effective clinical management.11 Thirdly, the ultrasound technology used in most of the earlier randomised studies is outdated.15. Routine third trimester biometry ultrasound scans predict SGA at birth substantially better than care as usual, i.e. Flow chart of IRIS study. Author information: (1)Obstetrics and Gynecology, Ultrasound Unit, University Women's Hospital of Basel, Basel, Switzerland. Study design: Two university clinics using routine ultrasound screening in the third trimester were compared with seven county or district hospitals with no routine screening. women's med., (ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10199. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Although the accuracy of ultrasonography in detecting low birth weight is higher than that of fundal height measurement, systematic errors in the prediction of SGA neonates using fetal abdominal circumference or estimated fetal weight limit its accuracy because these predictions are based on an estimation with an algorithm.35 Nevertheless, even if not used routinely, fetal biometry is frequently performed. The authors found that an incidental fetal anomaly … In Canada, a routine third trimester ultrasound scan is not offered in the low-risk pregnancy population. Challenges for future research are to identify the most appropriate fetal growth and birth weight charts and to develop more sensitive and effective methods to detect fetal growth restriction. | Sort by Date Showing results 1 to 50. Our pragmatic nationwide trial found that routine ultrasonography in the third trimester of pregnancy and with a multidisciplinary protocol for detecting and treating fetal growth restriction was associated with a moderately increased antenatal detection of SGA neonates and induction of labour. Additional fetal anomalies diagnosed after two previous unremarkable ultrasound examinations. View options for downloading these results. Epub 2017 Sep 7. Fourth, to propose a two-stage strategy for identifying pregnan-cies with a LGA fetus that may benefit from iatrogenic delivery during the 38th gestational week. Is a routine ultrasound in the third trimester justified? •A 1998 to 2008 study scanned 5044 fetuses between 28 and 32 … Severe adverse perinatal (composite) outcome and secondary neonatal outcomes, Maternal outcomes and peripartum interventions. Design Pragmatic, multicentre, stepped wedge cluster randomised trial. The maternal cervix and adnexa should be examined as clinically appropriate when technically feasible. Secondary outcomes were two composite measures of severe maternal morbidity, and spontaneous labour and birth. The first theme, the third trimester routine ultrasound as a bonus, showed that the third trimester routine ultrasound plays a different role for women than the routine ultrasounds in the first two trimesters. For this trial, we developed a multidisciplinary protocol based on consensus for detecting and managing suspected fetal growth restriction.13 We chose a cluster randomised design to roll-out the intervention and to avoid contamination bias due to the women’s preferences for or against ultrasound scans.20 The stepped wedge design facilitated the participation of a large number of midwifery practices, even if they had a preference for one of the screening strategies. 139-143. Hospital files were selected in cases of perinatal death, a low Apgar score (<4) at five minutes, a birth weight less than the 2.3rd centile,27 (or a birth weight between the 2.3rd and 5th centile and) neonatal admission for more than three days, and referral to a neonatologist if the admission data were missing or were not clearly registered in Perined. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. Please note: your email address is provided to the journal, which may use this information for marketing purposes. •The detection of fetal structural abnormalities is a routine part of antenatal care. 1;31(2):113-9. Report from Norwegian Knowledge Centre for the Health Services (NOKC) No. 2013 Dec;92(12):1353-60. doi: 10.1111/aogs.12249. AdJ is the guarantor. We then conducted a fully adjusted post hoc sensitivity analysis for the primary outcome, comparing women in the intervention strategy, who received two routine ultrasound scans, with women in the control strategy, who received no ultrasound scan. Even if birth weight can be estimated accurately, many small babies are constitutionally small but healthy.11 In the POP study, about 70% of fetuses with an estimated fetal weight below the 10th centile were not growth restricted and had similar perinatal outcomes compared to those with a greater estimated fetal weight.11 Disadvantages associated with routine ultrasound scans in the third trimester might be increased levels of emotional distress in women because of an inaccurate suspicion of fetal growth restriction and increased exposure to additional diagnostic tests, monitoring, and obstetric interventions.3940 That the incidence of most obstetric interventions was not significantly different between the groups is reassuring but we found a higher incidence of induction of labour associated with the intervention strategy, with no evidence of better perinatal outcomes. 2021 Jan;128(2):259-269. doi: 10.1111/1471-0528.16468. Although quality assurance systems have been developed for the anomaly scan, much less attention is paid to developing systems to guarantee the quality of fetal biometry in the third trimester.36 Given that low birth weight is associated with adverse perinatal outcomes, the quality of fetal biometry should be maintained to the highest standard. With gel on your abdomen, the device will show an image of your baby to the sonographer conducting the scan. 2017 Oct;50(4):429-441. doi: 10.1002/uog.17246. In addition to their usual care, women in the intervention strategy received two biometry ultrasound scans in the third trimester, at 28-30 and 34-36 weeks’ gestation, to detect fetal growth restriction. Sonographers met predefined quality criteria, and a multidisciplinary protocol was developed for detecting and managing fetal growth restriction to achieve the best quality care possible in a pragmatic nationwide study.1320. Also, we adjusted our main analyses for potential confounders selected a priori and based on previous literature: maternal age; body mass index; smoking, alcohol, or recreational drug use; parity; educational level; employment status; marital status; infant’s sex; and size of the midwifery practice (≤300 or >300 women annually).3132 Analyses were performed on complete case analysis given that less than 5% of the data on confounders were missing. The second composite outcome was spontaneous labour and birth, defined as a spontaneous vaginal birth with no induction or augmentation of labour, no drug pain relief, no vacuum or forceps assisted birth, and no caesarean section. Table 1 shows the baseline characteristics of the participating midwifery practices. The primary outcome was a dichotomous composite measure of 12 adverse perinatal outcomes occurring up to seven days after birth: perinatal death between 28 weeks’ gestation and seven days after birth; Apgar score <4 at five minutes; impaired consciousness (coma, stupor, or decreased response to pain); asphyxia, with arterial base excess of cord blood less than −12 mmol/L; seizures on at least two occasions within 72 hours of birth; assisted ventilation by endotracheal tube for more than 24 hours started within 72 hours of birth; septicaemia confirmed by blood culture; meningitis confirmed by culture of cerebrospinal fluid; bronchopulmonary dysplasia requiring oxygen after 36 weeks’ gestation and confirmed by radiography; intraventricular haemorrhage grade 3 or 4 confirmed by ultrasonography or autopsy; cystic periventricular leucomalacia confirmed by ultrasonography; or necrotising enterocolitis confirmed by radiography, surgery, or autopsy. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. Description: A well defined, anechoic rounded cystic structure is seen in the fetal lower abdomen. Because of the nature of the intervention, it was not possible to blind participants, care providers, and researchers to group allocation. [2] In 2010, the Dutch Ministry of Health considered introducing routine third trimester biometry as a means to reduce perinatal mortality. From 1 February 2015, 60 midwifery practices participated in the IRIS study (about 12% of practices in the Netherlands). Fetal growth restriction is a risk factor for perinatal mortality and morbidity and cardiovascular disease and neurodevelopmental disorders in adulthood, Routine ultrasonography in the third trimester detects neonates who are small for gestational age (SGA) significantly more often than usual care using serial fundal height measurements combined with clinically indicated ultrasonography, Evidence that routine ultrasonography in the third trimester reduces the incidence of severe adverse perinatal outcomes is lacking, In low risk pregnancies, routine ultrasonography in the third trimester combined with clinically indicated ultrasonography was associated with greater antenatal detection of SGA neonates and induction of labour but was not associated with a reduction in severe adverse perinatal outcomes compared with usual care, Based on these findings, routine ultrasonography has no benefit (or harm) to the neonate but was associated with a moderately increased incidence of induction of labour, These findings do not support routine ultrasonography in the third trimester for low risk pregnancies. We set the level of significance at P<0.05. Deliveries between 1985 and 1996 were included. In the United Kingdom, United States of America, and many European countries, third trimester ultrasound is not performed as routine clinical practice, although this trend is changing, with the primary clinical driver being attempting to … Routine third trimester biometry ultrasound scans predict SGA at birth substantially better than care as usual, i.e. Moreover, nearly one in five women in the intervention and usual care strategies had an indication for an ultrasound scan in the third trimester that was identified at inclusion in the study. View Record in Scopus Google Scholar. Routine ultrasonography was not associated with significantly improved secondary neonatal outcomes or secondary maternal composite peripartum outcomes. Our trial addressed important shortcomings of previous studies.15 Modern ultrasound equipment was used, sonographers met predefined quality criteria, and a multidisciplinary protocol was applied. technical support for your product directly (links go to external sites): Thank you for your interest in spreading the word about The BMJ. HHS Data were retrieved from hospital records for 2339 cases, selected for additional in-depth data collection. Such methods include other ultrasound markers of fetal compromise, maternal and placental biomarkers, and maternal awareness of fetal wellbeing. Maternal outcomes and other obstetric interventions did not differ between the strategies. Similar to the Pregnancy Outcome Prediction (POP) study, we found that sensitivity rates were higher for the intervention strategy with routine ultrasonography compared with usual care strategy with clinically indicated ultrasonography, although specificity rates were lower.11 Thus our findings suggest that repeated ultrasonography measures increase the detection of SGA but are also accompanied by higher false positive rates. Table 3 shows the diagnostic accuracy for detecting SGA at birth (birth weight <10th centile) for both screening strategies. NICE. In the intervention strategy, for an abdominal circumference below the 10th centile or slow growth in abdominal circumference the sensitivity in detecting birth weight below the 10th centile was 32% and the positive predictive value was 22%. These 5840 non-referred pregnant women had a mean number of 1.91 (SD 0.8) scans for the indication biometry. The intervention strategy showed a higher incidence of induction of labour (1.16, 1.04 to 1.30) and a lower incidence of augmentation of labour (0.78, 0.71 to 0.85). Royal College of Obstetricians and Gynaecologists. Objective To compare in low‐risk pregnancies the proportion of small‐for‐gestational‐age (SGA) infants detected by routine third trimester ultrasound versus by selective ultrasound … Fetal gestational age corresponded to 34 weeks. Time of inclusion, divided into four groups according to the crossover from usual care to the intervention strategy, was considered as a fixed factor. We cannot therefore completely rule out that the study lacked the statistical power to determine if routine ultrasonography has a beneficial or harmful effect on perinatal outcomes compared with usual care. Clinical guideline [CG62], 2008. www.rcog.org.uk/en/guidelines-research-services/guidelines/antenatal-care/. In the intervention and control strategies, we used prenatal SGA and slow fetal abdominal growth as indicators for suspected fetal growth restriction. What A Third Trimester Ultrasound Cannot Reveal? •An additional ultrasound for fetal structural anomalies in the 3rd trimester seems important for many reasons ????? The study design has been previously described.20. This site needs JavaScript to work properly. Diagnostic Obstetric Ultrasound. Then we conducted multilevel multivariable logistic regression analyses for the dichotomous primary and secondary outcomes. It also aimed to determine whether the risk of morbidity in SGA fetuses was associated with other ultrasound markers of growth restriction. At the onset of data collection on 1 February 2015 all the midwifery practices (n=60) carried out the control strategy, with a third sequentially crossing over to the intervention strategy at 3, 7, and 10 months (fig 1). Mine doesn't do one unless she detects something that might require a closer look (eg, to confirm that baby is breech etc). J.J. Stirnemann, G. Benoist, L.J. Perinatale Zorg in Nederland 2014. Monitoring fetal growth is part of routine antenatal care, using regular tape measurements from the pubic bone to the top of the uterus. Characteristics of participating midwifery practices, Personal and baseline characteristics of participants. AdJ, AF, HEvdH, PJ, VV, and EP conceived and designed the study. Policies for routine third trimester obstetrical ultrasound examinations differ among countries. Systematic review of first-trimester ultrasound screening for detection of fetal structural anomalies and factors that affect screening performance. Reasons for deviations from these recommendations should be documented. In some units in Sweden, a second ultrasound screening examination is offered in the third trimester to identify small‐for‐gestational age fetuses (SGA). The best performing indicators were the presence of a CPR < 10th centile, a mean UtA-PI > 95th centile or an EFW < 3rd centile . Midwifery practices formed the unit of cluster randomisation. Which third trimester screening strategy is most effective in detecting fetal growth restriction is controversial. Routine third-trimester ultrasounds do not decrease the rate of perinatal death compared with serial fundal height in low-risk pregnancies. Data on severe adverse perinatal outcomes were available for 12 993 of 13 046 (99.6%) women, 7040 in the intervention strategy and 5953 in the control strategy (fig 2). Routine mid-trimester fetal ultrasound scan Consideration must be given to local circumstances and medical practices. Use of third trimester scanning to determine optimal time for delivery; TRUFLE II is an RCT … For continuous secondary outcomes, we ran multivariable linear mixed models. A total of 14 323 pregnant women were invited to participate in the IRIS study (fig 2). Routine ultrasound scans were performed at mean gestational ages of 28.9 (SD 0.6) and 34.7 (SD 0.6) weeks. 2019 Oct;54(4):468-476. doi: 10.1002/uog.20844. Routine antenatal ultrasonography might therefore have little or no added benefit in detecting SGA neonates at risk of adverse outcomes compared with clinically indicated ultrasonography as part of usual care in the third trimester. Sonographers conducted third trimester biometry according to the guidelines of the Dutch Society of Obstetrics and Gynaecology (NVOG).2223 Sonographers who participated in the IRIS study were experienced in performing biometry and held a certificate for structural anomaly screening (73% of 154 participating sonographers) or passed a biometry quality test before the trial (27%), based on four biometry scans assessed by two experienced sonographers; had successfully completed a module on fetal biometry from a national Dutch medical e-learning education programme (see www.medicaleducation.nl); and used ultrasound equipment according to the standards of the Dutch Society of Obstetrics and Gynaecology.14 Two independent and experienced sonographers who were board members of the Dutch Professional Organisation of Sonographers carried out quality assessments of the sonographers during the trial. Finally, our study was conducted in one country (the Netherlands) where primary antenatal care of uncomplicated pregnancies is provided by midwives who are educated, trained, and officially registered as independent health practitioners.21 When risk factors or complications occur, women are referred to obstetrician led care. The intervention entails routine third trimester ultrasound screening combined with serial fundal height measurements and clinically indicated ultrasonography, while the control condition entails CAU (serial fundal height measurements and clinically indicated ultrasonography only). *Crossover postponed after one month because of fewer than expected inclusions †One midwifery practice dropped out in April 2015, after the first randomisation, The logistics of the study and enrolment procedures were piloted in January 2015. As a first step, we conducted univariable logistic regression analyses to see if routine ultrasonography in the third trimester was associated with a reduction in severe adverse perinatal outcomes and adverse secondary neonatal and maternal outcomes. 60. No significant differences were found in maternal morbidity and mortality between the groups (table 5). 2008. The psychological burden of routine prenatal ultrasound on women's state anxiety across the three trimesters of pregnancy Caterina Businelli , Stefano Bembich , Cristina Vecchiet, Caterina Cortivo, Alessia Norcio, Maria Francesco Risso, Mariachiara Quadrifoglio, Tamara Stampalija Based on our findings, we cannot recommend routine ultrasonography in the third trimester in low risk pregnancies. The routine use of 3rd trimester Doppler Ultrasound studies resulted in the identification of an additional 30.28% fetuses in the EFW 10-50th centile or 11.26% of overall screened population (n=76 of 675 fetuses) to be at risk for adverse perinatal outcomes. Acta Obstet Gynecol Scand. | Sort by Date Showing results 1 to 10. Prevention and treatment information (HHS), NLM The non integration of colour Doppler studies and reliance only on fetal biometry and estimated fetal weight will have led us to miss the diagnosis of Stage 1 FGR. Inclusion criteria for women with a low risk pregnancy were: antenatal care in a participating midwifery practice at enrolment, age 16 years or older, a singleton pregnancy, no major obstetric or medical risk factors, and a reliable expected date of delivery based on a dating scan or a reliable first day of the last menstrual period.14 Participants provided written informed consent for data usage. 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