Abstract:
Objective: To derive and test the implications of a
sex-specific fetal growth standard.
Design: Secondary analysis of a prospective observational
cohort.
Setting: Eight U.S. centers.
Population or Sample: Nulliparas followed longitudinally
through pregnancy. A lower-risk subgroup (exclusions: chronic
hypertension, pre-gestational diabetes, suspected aneuploidy, preterm
delivery) was selected for fetal growth equation derivation.
Methods: Fetal weights at 14-20 weeks, 22-29 weeks, and birth
were used to derive a sex-specific fetal growth equation. We compared
rates of SGA and LGA by sex using the sex-specific and sex-neutral
(Hadlock) standards. Using the full unselected cohort, we assessed
outcomes and clinical management according to SGA and LGA status.
Main outcome measures: Proportion considered SGA and LGA;
obstetric interventions relevant to SGA and LGA.
Results: We derived a sex-specific equation using 7,280
infants. The sex-neutral standard diagnosed SGA more often in female and
LGA more often in male newborns. The sex-specific standard resolved
these disparities. Using the full unselected cohort (N=8,339), newborns
reclassified from SGA to AGA by the sex-specific standard were more
likely to be delivered for growth restriction with comparable risk of
morbidity compared to newborns considered AGA by both methods. Newborns
reclassified from AGA to LGA by the sex-specific standard had higher
rates of cesarean for arrest of descent, cesarean for arrest of
dilation, and shoulder dystocia than newborns considered AGA by both
methods.
Conclusions: The sex-neutral standard generates sex disparities
in SGA and LGA at birth. A sex-specific standard resolves these
disparities and may improve growth pathology risk stratification.
Tweetable abstract: Sex-neutral fetal growth standards
disproportionately mislabel female newborns as too small. Sex-specific
standards correct this and may better reflect morbidity risk.
Funding: This work was funded by the Eunice Kennedy
Shriver National Institute for Child Health and Human Development
(award numbers U10 HD063020, U10 HD063037, U10 HD063041, U10 HD063046,
U10 HD063047, U10 HD063048, U10 HD063053, U10 HD063072, 2K12
HD085816-07).
Key words: fetal growth, small for gestational age, large for
gestational age, fetal sex, birth weight