How many sonograms are needed to reliably predict the absence of fetal overgrowth in gestational diabetes mellitus pregnancies?

Abstract

Objective: Serial measurements of the fetal abdominal circumference have been used to guide metabolic management of pregnancies complicated by gestational diabetes mellitus (GDM). A reduction in the number of repeat ultrasound examinations would save resources. Our purpose was to determine the number of serial abdominal circumference measurements per patient necessary to reliably predict the absence of fetal overgrowth.

Research design and methods: Women who had GDM were asked to return for repeat ultrasound at 3- to 4-week intervals starting at initiation of care (mean 26.9 ± 5.7 weeks). Maternal risk factors associated with fetal overgrowth were determined.

Results: A total of 4,478 ultrasound examinations were performed on 1,914 subjects (2.3 ± 1.2 per pregnancy). Of the 518 women with fetal abdominal circumference >90th percentile, it was diagnosed in 73.9% with the first ultrasound examination at entry and in 13.1% with the second ultrasound examination. Of the fetuses, 85.9 and 86.9% of the fetuses were born non-large for gestational age (LGA) when abdominal circumference was <90th percentile at 24-27 weeks and 28-32 weeks, respectively, and 88.0% were born non-LGA when both scans showed normal growth. For those women who had no risk factors for fetal overgrowth (risk factors: BMI >30 kg/m², history of macrosomia, and fasting glucose > 100 mg/dl), the accuracy of prediction of a non-LGA neonate was 90.0, 89.5, and 95.2%. The predictive ability did not increase with more than two normal scans.

Conclusions: The yield of sonographic diagnosis of a large fetus drops markedly after the finding of a fetal abdominal circumference <90th percentile on two sonograms, which excludes with high reliability the risk of a LGA newborn. The ability was enhanced in women who had no risk factors for neonatal macrosomia.

Figure 1

A: Cumulative detection rate of an abdominal circumference ≥90th percentile in all 518 pregnancies with at least one event of fetal abdominal circumference >90th percentile according to the number of the scan when abdominal circumference >90th percentile was diagnosed for the first time (50.4% had two, 26.3% had three, 15.3% had four, and 8.1% had five or six ultrasound examinations). B: Rate of non-LGA newborns (sensitivity) according to number of scans with abdominal circumference <90th percentile. Data are given for the total population and for women with and without maternal risk factors (RF).