Customized GROW vs INTERGROWTH-21st birthweight standards to identify small for gestational age associated perinatal outcomes at term

Abstract

Background: Fetal growth restriction is associated with stillbirth and other adverse pregnancy outcomes, and the use of the correct weight standard is an essential proxy indicator of growth status and perinatal risk.

Objective: This study aimed to assess the performance of two international birthweight standards for their ability to identify perinatal morbidity and mortality indicators associated with small for gestational age infants at term.

Study design: This retrospective cohort study used data from a multicenter perinatal quality initiative, including a multiethnic dataset of 125,826 births from 2012 to 2017. Of the singleton term births, 92,622 had complete outcome data including stillbirth, neonatal death, 5-minute Apgar score <7, neonatal glucose instability and need for newborn transfer to a higher level of care or neonatal intensive care unit admission. The customized GROW and INTERGROWTH-21^st birthweight standards were applied to determine small for gestational age (<10th percentile) according to their respective methods and formulae. The associations with adverse outcomes were expressed as relative risks with 95% confidence intervals and population attributable fractions.

Results: GROW and INTERGROWTH-21^st classified 9578 (10.3%) and 4079 (4.4%) pregnancies as small for gestational age, respectively. For all of the outcomes assessed, GROW identified more small for gestational age infants with adverse outcomes than INTERGROWTH-21^st, including more stillbirths, perinatal deaths, low Apgar scores, glucose instability, newborn seizure, and transfers to a higher level of care. Moreover, 13 of 27 stillbirths (48%) that were small for gestational age by either method were identified as small for gestational age by GROW but not by INTERGROWTH-21^st. Similarly, additional cases of all other adverse outcome indicators were identified by GROW as small for gestational age, whereas INTERGROWTH-21^st identified in only 1 category (glucose instability) 9 of 295 cases (3.1%), which were not identified as small for gestational age by GROW.

Conclusion: Customized assessment using GROW resulted in increased identification of small for gestational age term infants that were at significantly increased risk of an array of adverse pregnancy outcomes.

Keywords: GROW; INTERGROWTH 21(st); customized charts; fetal growth restriction; perinatal morbidity; small for gestational age; stillbirth.