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Predictors of Neonatal Outcome in Early- Onset Placental Dysfunction

From the Departments of ¹Obstetrics, Gynecology and Reproductive Sciences, University of Maryland, Baltimore; ²Obstetrics & Prenatal Medicine, University Hamburg-Eppendorf, Germany; ³Gynecological Sciences and Human Reproduction, University of Padua, Italy; ⁴Obstetrics and Gynecology, Academic Medical Center, Amsterdam, the Netherlands; ⁵Obstetrics and Prenatal Medicine, Friedrich-Wilhelm University, Bonn, Germany; ⁶Obstetrics and Gynecology, University of Milan, Milan, Italy; ⁷Gynecology and Obstetrics, University Schleswig-Holstein, Campus Lübeck, Germany; ⁸Harris Birthright Research Centre for Fetal Medicine, Kings College Hospital, London; ⁹Prenatal Diagnosis and Therapy, Universitäts Frauenklinik Charite, Berlin, Germany; ¹⁰Fetal Medicine Unit, St George’s Hospital Medical School, London, United Kingdom; ¹¹Obstetrics & Gynecology, Hanau City Hospital, Germany; ¹²Obstetrics and Gynecology, University of Colorado Health Sciences Center, Denver, Colorado.

OBJECTIVE: To identify specific estimates and predictors of neonatal morbidity and mortality in early onset fetal growth restriction due to placental dysfunction.

METHODS: Prospective multicenter study of prenataly diagnosed growth-restricted liveborn neonates of less than 33 weeks of gestational age. Relationships between perinatal variables (arterial and venous Dopplers, gestational age, birth weight, acid-base status, and Apgar scores) and major neonatal complications, neonatal death, and intact survival were analyzed by logistic regression. Predictive cutoffs were determined by receiver operating characteristic curves.

RESULTS: Major morbidity occurred in 35.9% of 604 neonates: bronchopulmonary dysplasia in 23.2% (n=140), intraventricular hemorrhage in 15.2% (n=92), and necrotizing enterocolitis in 12.4% (n=75). Total mortality was 21.5 % (n=130), and 58.3% survived without complication (n=352). From 24 to 32 weeks, major morbidity declined (56.6% to 10.5%), coinciding with survival that exceeded 50% after 26 weeks. Gestational age was the most significant determinant (P<.005) of total survival until 26^6/7 weeks (r²=0.27), and intact survival until 29^2/7 weeks (r²=0.42). Beyond these gestational-age cutoffs, and above birth weight of 600 g, ductus venosus Doppler and cord artery pH predicted neonatal mortality (P<.001, r²=0.38), and ductus venosus Doppler alone predicted intact survival (P<.001, r²=0.34).

CONCLUSION: This study provides neonatal outcomes specific for early-onset placenta-based fetal growth restriction quantifying the impact of gestational age, birth weight, and fetal cardiovascular parameters. Early gestational age and birth weight are the primary quantifying parameters. Beyond these thresholds, ductus venosus Doppler parameters emerge as the primary cardiovascular factor in predicting neonatal outcome.

LEVEL OF EVIDENCE: II

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