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Perspective on the paper by Cooke (see page F189)

Purpose The objective of this study is to assess the ultrasound accuracy in fetal weight estimation related to the time distance between the actual weight recorded at delivery and the period of sonography among normal and overweight/obese pregnant women within 3 weeks prior birth at term. Methods Four-hundred and ninety patients with healthy pregnancy were studied in a cohort study. The absolute percent error in estimation was achieved by gestation-adjusted projection method from Hadlock model for weight calculation as measure of accuracy. The mean percentage error variation over the weeks was correlated to maternal body mass index (BMI, Kg/m 2 ) at ultrasound. The relationship between BMI and ultrasound performance was assessed by linear regression. Results The overall proportion of supposed sonographic estimated fetal weight at birth within ±10 % of the birth weight significantly declines over the weeks ( P  = .016). The trend toward a progressive deterioration in ultrasound accuracy is not statistically significant for normal weight women ( P  = .272) but it is for over-weight/obese ( P  = .044). On univariate analysis, the absolute percent error and absolute error are positively related to BMI. Conclusions Accuracy is related to the week at ultrasound scan with a gradual deterioration over the time and it worsens with increasing distance in days between the date of ultrasounds and delivery. The deterioration is greater for BMI ≥ 25.

Objective: To determine whether maternal features affect the accuracy of sonographic estimated fetal weight (SEFW) by evaluating the consistency of the systematic error of SEFW with regards to the birth weight (BW) in two consecutive pregnancies of the same gravida. Methods: The cohort included women with SEFW within 1 week of delivery (32-42 weeks' gestation) in two consecutive singleton pregnancies from 2007 to 2012. The systematic error was calculated as (SEFW - BW)/BW × 100 and expressed as a percentage of the BW. Results: A total of 636 pregnancies (318 gravidas) were eligible for analysis. The BW and SEFW were correlated in both first examined (r = 0.873, p < 0.001) and consecutive (r = 0.843, p < 0.001) pregnancies. There was a significant difference in mean systematic error between first examined and consecutive pregnancies (3.13 ± 8.95 vs. 0.34 ± 8.75%, p < 0.001), with a very weak correlation between the two (r = 0.135, p = 0.16). Nulliparity or multiparity at the first examined pregnancy was not found to be a significant factor, and in both groups the error was higher in the first examined pregnancy. There were no significant differences between parturients with a minor (10% and below) or major (>10%) difference in the systematic error between the two pregnancies. Conclusion: The systematic error between the SEFW and BW in two consecutive pregnancies is inconsistent, suggesting that it is unaffected by maternal biometric features.

Accurate ultrasound estimated fetal weight (EFW) supports key perinatal decisions. This study aimed to compare the accuracy of a population-specific formula with that of a widely used global model in pregnancies examined near delivery. This was a secondary analysis of a prospective Japanese cohort study to develop a new fetal ultrasound biometry reference chart. Fetal ultrasound measurements were obtained by Japan Society of Ultrasonics in Medicine-certified sonographers or under their supervision and submitted to the coordinating center, where EFW was calculated using the Shinozuka and Hadlock-3 formulas. Analyses were restricted to cases with EFW available from both formulas. The primary analysis included examinations within 7 days before delivery; a sensitivity analysis restricted the interval to ≤3 days. A subgroup analysis was performed in fetuses classified as small for gestational age (SGA). In the primary analysis (n = 310), the median signed error was -75.8 g for Shinozuka and -223.3 g for Hadlock-3 (Wilcoxon p < 0.001). The median absolute percentage signed error was 4.81% for Shinozuka and 7.93% for Hadlock-3 (Wilcoxon p < 0.001). The proportion within ±10% of BW was 83.9% with Shinozuka versus 61.6% with Hadlock-3 (McNemar p < 0.001). In the sensitivity analysis (n = 176), similar findings were observed. In the SGA subgroup (n = 40), the signed error and absolute percentage error were significantly lower with the Shinozuka formula than with Hadlock-3. In this multicenter cohort examined near delivery, the population-specific Shinozuka formula produced EFW closer to BW and a higher proportion within ±10% than Hadlock-3, which showed greater systematic underestimation. These findings support the use of locally validated, population-specific EFW formulas when available, particularly for clinical decision-making near delivery.

Introduction Fetal growth assessment by ultrasound is an essential part of modern obstetric care. The formula by Persson and Weldner for estimated fetal weight (EFW), used in Sweden since decades, has not yet been evaluated. The objective of this study was to evaluate accuracy and precision of the formula by Persson and Weldner, and to compare it to two other formulae using biparietal diameter instead of head circumference. Material and methods The study population consisted of 31 521 singleton pregnancies delivered at 22+0 gestational weeks or later, with an ultrasound EFW performed within 2 days before delivery, registered in the Swedish Pregnancy Register between 2014 and 2021. Fetal biometric ultrasound measurements were used to calculate EFW according to the formulae by Persson and Weldner, Hadlock 2 and Shepard. Bland–Altman analysis, systematic error (mean percentage error), random error (standard deviation [SD] of mean percentage error), proportion of weight estimates within ±10% of birthweight, and proportion with underestimated and overestimated weight was calculated. Moreover, calculations were made after stratification into small, appropriate, and large for gestational age (SGA, AGA and LGA), respectively, and gestational age at examination. Results For the formula by Persson and Weldner, MPE was −2.7 (SD 8.9) and the proportion of EFW within ±10% from actual birthweight was 76.0%. MPE was largest for fetuses estimated as severe SGA (<3rd percentile, −5.4) and for the most preterm fetuses (<24 weeks, −5.4). For Hadlock 2 and Shepard's formulae, MPE were 3.9 (SD 8.9) and 3.4 (SD 9.7), respectively, and the proportions of EFW within ±10% from actual birthweight were 69.4% and 67.1%, respectively. MPE was largest for fetuses estimated as severe LGA (>97th percentile), 7.6 and 9.4, respectively. Conclusions The recommended Swedish formula by Persson and Weldner is generally accurate for fetal weight estimation. The systematic underestimation of EFW and random error is largest in extreme preterm and estimated SGA‐fetuses, which is of importance in clinical decision making. The accuracy of EFW with the formula by Persson and Weldner is as good as or better than Hadlock 2 and Shepard's formulae. The currently used Swedish formula to estimate fetal growth by sonography generally estimates fetal weight accurately. Accuracy is lower in extreme preterm and SGA‐fetuses. The formula is as good as or superior to other formulae including biparietal diameter instead of head circumference.

Purpose To evaluate the effect of nitric oxide (NO) donor, in combination with plasma volume expansion, on both fetal and maternal outcomes in pregnancies complicated by early-onset fetal growth restriction (FGR). Methods A total of 40 pregnant women diagnosed with early onset FGR were recruited from Ain Shams University Maternity Hospital between June 2023 to December 2023. The patients were randomly assigned into two groups, 20 in each group. Group A received Nitroderm TTS ® 5 mg for 12 h daily with plasma volume expansion (PVE) in the form of 2.5 L of water per day. Group B represented the control group. The primary endpoint of the study, assessed after 2 weeks of treatment initiation, focused on fetal growth parameters as the primary outcome. In addition, amniotic fluid volume, umbilical artery Doppler changes, development of fetal complications, maternal vital signs, and any side effects, were recorded. At the time of delivery, the following also documented: timing, mode, and interval to delivery, along with neonatal outcomes. Results Group A exhibit statistically significant enhancement in fetal growth compared to Group B in terms of estimated fetal weight, abdominal circumference, head circumference, biparietal diameter, femur length, amniotic fluid volume, and umbilical artery pulsatility index. Furthermore, Group A demonstrated more favorable outcomes in terms of gestational age at delivery, interval to delivery, birth weight, APGAR score and rates of NICU admission. Conclusion The combination of NO donors and PVE has shown promising results in enhancing fetal growth and extending gestation. This study adds to the existing body of evidence supporting the effectiveness of NO donor therapy when used in conjunction with fluid management for managing FGR. Nonetheless, additional research is essential to validate these results and refine the treatment strategy for optimal outcomes in affected pregnancies.

Given the decline in birthweights over the past 30 years in Japan and advancements in ultrasound technology, this study aimed to establish new reference values for ultrasound fetal biometry in Japan and to compare them with international and Asian studies. We conducted a cross-sectional prospective study involving singleton pregnancies who received prenatal checkups at obstetric facilities across Japan. During routine prenatal care, ultrasound measurements—biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL)—were recorded. Estimated fetal weight (EFW) was calculated using both the Shinozuka formula, commonly used in Japan, and the Hadlock-3 formula, widely used internationally. Using the collected data, we developed gestational-age-specific reference values for BPD, HC, AC, FL, and EFW by applying best-fitted fractional polynomial regression, and compared them with existing international standards and reference values from other Asian countries. The mean EFW calculated by the Hadlock formula in this study tended to be smaller than that reported in other international studies, and BPD, HC, AC, and FL were also generally smaller than those observed in other Asian references. These findings indicate that fetal biometry values in the Japanese population are smaller not only than international standards but also compared with those from other Asian countries, and suggest that these population-specific data may contribute to improving the accuracy of fetal growth assessment in Japan and other parts of Asia.

Background Fetal growth monitoring is important for twin pregnancies. However, there has been no clinically validated tool for monitoring fetal growth of twin pregnancies in China. This study aims to develop and validate a chorionicity-specific growth chart of ultrasound estimated fetal weight (EFW) for Chinese twin pregnancies. Methods This retrospective cohort study included all twin pregnancies who delivered two live fetuses with gestational age ≥ 34 weeks without severe obstetric complications at a tertiary hospital from January 2007 to March 2021. The participants were divided into a development set (delivered in or before December 2017) and a validation set (delivered in or after January 2018). Chorionicity-specific growth charts were created using the generalized additive models for location, scale, and shape (GAMLSS) based on the development set. The fetuses from the validation set were classified into three groups based on the last EFW: small-for-gestational-age (SGA) indicated by both the newly established twin charts and the Hadlock singleton chart currently used for twin pregnancies in China, suspected SGA indicated by only the singleton chart, and no SGA indicated by either chart. The incidence of neonatal outcomes among the three groups was then compared accordingly, including intensive care unit (NICU) stay length, respiratory diseases, and neurological disorders. Results The development set included 883 twin pregnancies and a total of 6374 EFW measurements between 16 and 38 weeks of gestation, and the validation set included 801 twin pregnancies and 7630 EFW measurements. In the development set, monochorionic diamniotic (MCDA) twins had a significantly lower EFW compared to dichorionic diamniotic (DCDA) twins beginning at 26 weeks, with the difference gradually increasing thereafter, supporting the establishment of chorionicity-specific growth charts. Of the 1,602 twin neonates in the validation set, 103 (6.4%) were classified into the SGA group, 164 (10.2%) into the suspected SGA group, and 1335 (83.3%) into the no SGA group. The incidence of respiratory diseases and neurological disorders was comparable between the suspected SGA group and the no SGA group, but apparently higher in the SGA group. Meanwhile, NICU stay lengths were consistently longer for twins in the SGA group compared to the no SGA group (difference: 0.57, 95% CI: 0.31–0.83), with no significant differences observed between the suspected SGA and no SGA groups. Conclusions The fetal growth trajectories differed by chorionicity, with a lower EFW for MCDA twins beginning at 26 weeks. The establishment of chorionicity-specific growth chart could reduce overdiagnosis of SGA and improve fetal growth monitoring of twin pregnancies.

Introduction Ultrasound assessment of fetuses subjected to hyperglycemia is recommended but, apart from increased size, little is known about its interpretation, and the identification of which large fetuses of diabetic pregnancy are at risk is unclear. Newer markers of adverse outcomes, abdominal circumference growth velocity and cerebro‐placental ratio, help to predict risk in non‐diabetic pregnancy. Our study aims to assess their role in pregnancies complicated by diabetes. Material and methods This is a retrospective analysis of a cohort of singleton, non‐anomalous fetuses of women with pre‐existing or gestational diabetes mellitus, and estimated fetal weight at the 10th centile or above. Gestational diabetes was diagnosed by selective screening of at risk groups. A universal ultrasound scan was offered at 20 and 36 weeks of gestation. Estimated fetal weight, abdominal circumference growth velocity, presence of polyhydramnios, and cerebro‐placental ratio were evaluated at the 36‐week scan. A composite adverse outcome was defined as the presence of one or more of perinatal death, arterial cord pH less than 7.1, admission to Neonatal Unit, 5‐minute Apgar less than 7, severe hypoglycemia, or cesarean section for fetal compromise. A chi‐squared test was used to test the association of estimated fetal weight at the 90th centile or above, polyhydramnios, abdominal circumference growth velocity at the 90th centile or above, and cerebro‐placental ratio at the 5th centile or below with the composite outcome. Logistic regression was used to assess which ultrasound markers were independent risk factors. Odds ratios of composite adverse outcome with combinations of independent ultrasound markers were calculated. Results A total of 1044 pregnancies were included, comprising 87 women with pre‐existing diabetes mellitus and 957 with gestational diabetes. Estimated fetal weight at the 90th centile or above, abdominal circumference growth velocity at the 90th centile or above, cerebro‐placental ratio at the 5th centile or below, but not polyhydramnios, were significantly associated with adverse outcomes: odds ratios (95% confidence intervals) 1.85 (1.21–2.84), 1.54 (1.02–2.31), 1.92 (1.21–3.30), and 1.53 (0.79–2.99), respectively. Only estimated fetal weight at the 90th centile or above and cerebro‐placental ratio at the 5th centile or below were independent risk factors. The greatest risk (odds ratio 6.85, 95% confidence interval 2.06–22.78) was found where both the estimated fetal weight is at the 90th centile or above and the cerebro‐placental ratio is at the 5th centile or below. Conclusions In diabetic pregnancies, a low cerebro‐placental ratio, particularly in a macrosomic fetus, confers additional risk.

Introduction In 2012, China released its first national guidelines for prenatal ultrasound screening, marking a major step toward standardized and assessable prenatal ultrasound practice nationwide. However, real-world evidence on the effectiveness of these guidelines in clinical practice remains limited, particularly from large-scale, long-term datasets. To address this gap, we aimed to examine temporal trends in the accuracy of ultrasound-based estimated fetal weight (EFW) following the guidelines’ implementation in China. Materials and methods This retrospective cohort study analyzed real-world data from 31,681 singleton pregnancies between 2014 and 2019, drawn from the integrated ultrasound and perinatal databases at a tertiary maternity hospital in southern China. Temporal trends in EFW accuracy, fetal biometric parameters (biparietal diameter, head circumference, abdominal circumference, femur length), and diagnostic performance for fetal growth abnormalities were analysed by calendar quarter from January 2014 to December 2019. Result EFW accuracy improved progressively over time, with the mean percentage error nearing zero and the proportion of estimates within 10% and 15% of birthweight rising from 78.0% to 93.2% in 2014 to 86.2% and 97.3% in 2019 (OR = 1.032 and 1.045; P  < 0.001). Accuracy of all biometric parameters increased, particularly for femur length (β = 0.002). Detection of extreme fetal growth abnormalities based on EFW became more consistent, with detection rates and false-positive rates (FPRs) for severe large-for-gestational-age (EFW > 97th percentile) decreasing from 2.06% to 0.67% (FPRs 1.59% to 0.22%), while fetal growth restriction (EFW <3rd percentile) detection slightly increased from 0.37% to 0.50% (FPRs 0.19% to 0.28%), and false-negative rates remained stable. Similar improvements were observed using absolute birthweight thresholds, with reduced overestimation of macrosomia and enhanced detection of low birthweight, indicating a better balance in EFW’s diagnostic performance across the fetal growth spectrum. Conclusion This large-scale longitudinal study revealed sustained improvements in EFW accuracy, biometric measurement consistency, and fetal growth abnormality detection following China’s 2012 national guidelines. These advances likely reflect standardized protocols, training, quality assurance, and accumulating operator experience. Future multicenter studies are needed to assess their broader clinical impact.