1. A comparison of fundal height and handheld ultrasound measured abdominal circumference to screen for fetal growth abnormalities Adriane Haragan, MD Faculty Mentor: Gene Chang, MD

2. Fetal Growth Abnormalities Common, complex in modern obstetrics – Difficult to prevent – Consequences of missed diagnosis – Consequences of false positive screening

3. Background Fetal Growth Restriction Various definitions EFW < 10% 1/2 cases undetected Macrosomia Various definitions EFW > 4000-4500 g Diagnosed at time of delivery ACOG Practice Bulletin No. 12 Mattioli KP, Int J Gynaecol Obstet 2010 Chauhan SP, Am J Perinatol, 2013

4. Background: Screening Fundal height – Pubic symphysis to top of fundus – Measurement in cm correlates to GA +/- 2cm – Screening modality used by majority – Poor sensitivity Persson, B. Br J Obstet Gynaecol 1986 Robert, PJ. Cochrane Data Syst Rev 2012

5. Background: Screening Ultrasound – Fetal Biometry Measurement of: – HC/BPD/AC/FL – Costly and time intensive – Needs further study Zimmer, EZ. Clin Obstet Gynecol 1992 Hadlock, FP. Am J Obstet Gynecol 1985

6. Background: Abdominal Circumference Kayem, G. Ultrasound Obstet Gynecol 2009 Smith, GC. Br J Obstet Gynaecol 1997

7. Background: Screening Handheld ultrasound (GE VScan) – Introduced at MUSC 2011 – Quick assessment Presentation Fetal Heart Rate – Can measure radius of a circle 2πr

8. Hypothesis We hypothesize that using a handheld ultrasound to determine abdominal circumference will be better for detection of fetal growth abnormalities than fundal height measurement.

9. Methods: Patient Population Prospective observational pilot study N = 251 patients Inclusion Criteria – Singleton pregnancy undergoing growth scan – 24-40 weeks – Ultrasound <20w confirming EDC Exclusion Criteria – Congenital anomaly – Known aneuploidy – Multiple gestation – Poor dating

10. Methods Patients enrolled at time of growth scan Study personnel – Measure fundal height in cm – Measurement of AC with handheld ultrasound – Record results from formal growth scan – Record birth weights at time of delivery

11. Methods Demographics and birth outcomes collected Statistical analysis – SAS 9.3 statistical software – Fisher’s exact test – McNemar’s test

12. Demographics

13. Correlation R = 0.939 (p<0.001)

14. Results - Fundal Height 57.8% of our population had BMI > 30

15. Results - HHAC Sn EFW = 25.9%Sn EFW = 29.2%

16. Diagnostic Performance

17. Limitations Wide variety of gestational ages High risk population Prevalence of growth abnormalities low – Inability to adequately compare sensitivity and specificity between two screening modalities – Statistical significance

18. Conclusions HHAC was a superior screening modality for prediction of: EFW < 10th percentile BW < 10th percentile BW > 90th percentile Fundal height was a superior screening modality for prediction of: EFW > 90th percentile HHAC could prove to be quick, effective bedside screening modality Further studies needed in a larger, low risk population Evaluation in obese population

19. References Chauhan SP, Beydoun H, Chang E, Sandlin AT, Dahlke JD, Igwe E, Magann EF, Anderson KR, Abuhamad AZ, Ananth CV. Prenatal Detection of Fetal Growth Restriction in Newborns Classified as Small for Gestational Age: Correlates and Risk of Neonatal Morbidity. Am J Perinatol. 2013 Apr 16. Chen HY, Chauhan SP, Ward TC, Mori N, Gass ET, Cisler RA. Aberrant fetal growth and early, late, and postneonatal mortality: an analysis of Milwaukee births, 1996-2007. Am J Obstet Gynecol 2011; 204: e1, e10 Gordon, M. et al. The immediate and long-term outcome of obstetric birth trauma. Am J Obstet Gynecol 1973;117:51-56. Hadlock FP, Harrist RB, Sharman RS, Deter RL, Park SK. Estimation of fetal weight with the use of head, body, and femur measurements—a prospective study. Am J Obstet Gynecol 1985; 151: 333-337 Mattioli KP, Sanderson M, Chauhan SP. Inadequate identification of small-for-gestational-age fetuses at an urban teaching hospital. Int J Gynaecol Obstet 2010; 109: 140-143 McIntire D. et al. Birth weight in relation to morbidity and mortality among newborn infants. N Engl J Med 1999;340:1234-1238. Robert Peter J, Ho JJ, Valliapan J, Sivasangari S. Symphysial fundal height (SFH) measurement in pregnancy for detecting abnormal fetal growth. Cochrane Database of Systematic Reviews 2012, Issue 7. Art. No.: CD008136. DOI: 10.1002/14651858.CD008136.pub2. Zimmer EZ, Divon MY. Sonographic diagnosis of IUGR-macrosomia. Clin Obstet Gynecol. 1992 Mar;35(1):172-84.

20. Thank you! Drs. Chang, Hawk & Sullivan Keith Willan for ultrasound guidance Dr. Hulsey for statistical support Dr. Newman for editorial support