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Table 3 Additional diagnostic tests in case of suspected IUGR in obstetrician-led care after referral from midwife-led care at a gestational ageĀ ā‰„Ā 26Ā weeks 0Ā days: opinion per level of care

From: Multidisciplinary consensus on screening for, diagnosis and management of fetal growth restriction in the Netherlands

Statement

Answer

Midwife-led Care

Obstetrician-led Care

Consensus total group

n (%)

n (%)

2.1. An ultrasound biometry and assessment of amniotic fluid volume is to be repeated immediately after referral to obstetrician-led care, even if this is within 2Ā weeks of the previous scan (in midwife-led care).

A

12 (60%)

20 (80%)

No consensus

D

8 (40%)

5 (20%)

N

3

1

M

4

3

2.2. As fetal growth can only be evaluated through serial measurements, we will advise to plot EFW on the CGC in obstetrician-led care as well (as in midwife-led care). We will also advise to be alert for asymmetrical growth based on the ratios of AC, FL, BPD and HC.

A

23 (100%)

20 (80%)

Consensus: agree

D

0

5 (20%)

N

0

2

M

4

2

2.3. In obstetrician-led care, decreased amniotic fluid volume should be defined using the same cut-off values as in midwife-led care.

A

23 (100%)

24 (96%)

Consensus: agree

D

0

1 (4%)

N

0

1

M

4

3

2.4. Suspicion of IUGR is an indication for measuring the umbilical artery Doppler in obstetrician-led care. Which measurement is the first abnormal sign for fetal deterioration?

(multiple options)

Pulsatility Index (PI)

10 (91%)

23 (92%)

Consensus: Pulsatility Index (PI)

No consensus on the other answers

Resistance Index (RI)

4 (36%)

0

Absent diastolic flow

2 (18%)

20 (80%)

Reversed diastolic flow

3 (27%)

18 (72%)

Other

0

0

N

16

0

M

0

4

2.5. A PI of the umbilical artery Doppler ā‰„ P95 is abnormal (and management of pregnancy should be adjusted).

A

11 (92%)

24 (96%)

Consensus: agree

D

1 (8%)

1 (4%)

N

11

1

M

4

3

2.6. In the IRIS study it will be advised to assess the PI of the middle cerebral artery Doppler when IUGR is suspected.

A

10 (100%)

21 (88%)

Consensus: agree

D

0

3 (12%)

N

13

3

M

4

2

2.7. The ductus venosus Doppler should be measured when IUGR is suspected.

A

5 (83%)

6 (46%)

No consensus

D

1 (17%)

7 (54%)

N

17

13

M

4

3

2.8. In the IRIS study we will recommend a FAS in case of IUGR, if not previously performed.

A

22 (100%)

24 (89%)

Consensus: agree

D

0

3 (11%)

N

1

0

M

4

2

2.9. At which degree of IUGR, defined by centiles of EFW on the CGC, should a FAS be offered to the pregnant woman?

ā‰¤ P5

12 (60%)

12 (50%)

No consensus

ā‰¤ P2.3

7 (35%)

10 (42%)

Degree of IUGR is not relevant for the assessment of fetal anatomical anomalies

1 (5%)

2 (8%)

N

3

3

M

4

2

2.10. A FAS because of suspected IUGR, should be performed by:

A sonographer in secondary care, who is trained for FAS. Depending on the results, referral for advanced sonography in tertiary care will take place

11 (55%)

6 (22%)

No consensus

An obstetric ultrasound specialist, trained for advanced sonography (under the responsibility of tertiary care)

9 (45%)

21 (78%)

N

3

0

M

4

2

2.11. In the IRIS study, in case of suspicion of IUGR, it will be advised not to commence CTG monitoring as long as there is no decrease in fetal movements nor a hypertensive disorder and no abnormal Doppler profiles.

A

18 (90%)

23 (85%)

Consensus: agree

D

2 (10%)

4 (15%)

N

3

0

M

4

2

2.12. At which degree of IUGR, defined by centiles of EFW on the CGC, should assessment for specific fetal infections be advised?

< P10

2 (12%)

1 (4%)

No consensus

< P5

5 (29%)

7 (27%)

< P2.3

10 (59%)

16 (61%)

At another P-value

0

2 (8%)

N

6

1

M

4

2

2.13. Gestational age, in addition to degree of IUGR, determines whether one should check for specific fetal infections

A

2 (12%)

4 (16%)

Consensus: disagree

D

15 (88%)

21 (84%)

N

8

1

M

2

3

2.14. If fetal infections are to be checked for because of suspicion of IUGR than test for:

Coxsackie Virus

A

3 (14%)

0

Consensus: disagree

D

18 (86%)

23 (100%)

N

6

2

M

0

4

Cytomegalovirus

A

19 (90%)

20 (87%)

Consensus: agree

D

2 (10%)

3 (13%)

N

6

2

M

0

4

Malaria

A

1 (5%)

0

Consensus: disagree

D

20 (95%)

23 (100%)

N

6

2

M

0

4

Toxoplasmosis

A

17 (100%)

19 (76%)

Consensus: agree

D

0

6 (24%)

N

6

1

M

4

3

Rubella

A

14 (88%)

11 (55%)

No consensus

D

2 (12%)

9 (45%)

N

7

6

M

4

3

Herpes

A

13 (100%)

12 (55%)

No consensus

D

0

10 (45%)

N

10

4

M

4

3

Parvo B19

A

18 (100%)

14 (70%)

Consensus: agree

D

0

6 (30%)

N

5

6

M

4

3

Syphilis

A

11 (79%)

8 (40%)

No consensus

D

3 (21%)

12 (60%)

N

9

6

M

4

3

2.15. In the IRIS study, offering invasive prenatal testing will not be advised routinely in case of IUGR; but rather individual risk factors and gestational age should be considered.

A

22 (100%)

25 (93%)

Consensus: agree

D

0

2 (7%)

N

1

0

M

4

2

2.16. In the IRIS study, invasive prenatal testing will be offered to the couple if the EFWĀ ā‰¤Ā P2.3.

A

18 (95%)

23 (85%)

Consensus: agree

D

1 (5%)

4 (15%)

N

4

0

M

4

2

  1. A agree, D disagree, N no opinion/expertise, M missing: panellist has not participated in this round or has not answered this question, ConsensusĀ =Ā ā‰„70% of panellists per level of care agree and both groups agree upon the same. Percentages do not always add up to 100% due to rounding error
  2. IUGR intrauterine growth restriction, EFW estimated fetal weight, CGC customised growth chart, AC abdominal circumference, FL femur length, BPD biparietal diameter, HC head circumference, PI Pulsatility Index, IRIS IUGR risk selection, FAS fetal anomaly scan, CTG cardiotocography