The National Standard for Normal Fetal Growth

Summary and aims:

Normal fetal growth is a critical component of a healthy pregnancy and the long-term health
of the offspring. Pivotal to understanding the dynamics of human fetal growth and to defining
normal and abnormal fetal growth is the development of standards for fetal anthropometric
parameters measured longitudinally throughout gestation, which, in turn, can be used to
develop interval velocity curves and customized for genetic and physiological factors. We
propose to conduct a multi-center prospective observational study (1) to establish a standard
for normal fetal growth (velocity) and size for gestational age in the U.S. population; (2)
to create an individualized standard for fetal growth potential; and (3) to improve accuracy
of fetal weight estimation.

Eligibility:

• Healthy, low-risk pregnant women (both obese and nonobese) between the ages of 18 and 40
from each of the following four self-identified race/ethnicity backgrounds: African American,
Asian, Caucasian, and Hispanic.

Design:

- Observational cohort design where pregnant women are recruited prior to 13 weeks
gestation and followed throughout pregnancy and delivery for women having livebirths.

- After a sonogram at enrollment (10-13 weeks), women were randomized to receive sonograms
according to one of the following four schedules: schedule A: 16, 24, 30, 34, and 38
weeks; schedule B: 18, 26, 31, 35, and 39 weeks; schedule C: 20, 28, 32, 36, and 40
weeks; schedule D: 22, 29, 33, 37, and 41 weeks.

- An enrollment interview was followed by depression screening, physical activity,
anthropometric assessment and ultrasonology screening for measurement of fetal growth,
and at each of the 5 subsequent visits.

- Uterine artery and fetal Doppler studies at selected gestational weeks.

- Women were asked to provide blood samples at enrollment and at follow-up visits at 16-22
weeks, 24-29 weeks, and 34-37 weeks of gestation.

- Neonatal anthropometry completed for all infants within 12-24 hours after birth.

- Cord blood, plasma, and placenta samples were collected for a smaller subsample of
newborns.

- Post-study evaluations: Women who were diagnosed with gestational diabetes during
pregnancy were asked to return for a follow-up visit 6 weeks after delivery.

Enrollment:

Final recruitment included 2,802 women with singleton pregnancies of which 2,334 were
healthy, low-risk women with pre-pregnancy body mass indices (BMI) between 19-29.9 kg/m2. The
racial/ethnic distribution of participating women were: Caucasians (n=614), African American
(n=611), Hispanics (n=649), and Asians (n=460), and reflects natality characteristics of
contemporary U.S. births. An additional 468 obese women (BMI 30-44.9 kg/m2) were also
recruited.

Quality Control:

The quality of the ultrasound measures was guaranteed by implementation of: (1) a
comprehensive quality control protocol for ante hoc training and credentialing of all site
sonographers, developed by the sonology center at Columbia University, and (2) a rigorous
protocol for post hoc quality control, whereby a random sample of all scans, stratified by
clinical site and visit, was re-measured for accuracy and reliability.

- INCLUSION CRITERIA:

- Singleton, viable pregnancy

- 8 plus 0 - 13 plus 6 weeks of gestation

- Maternal age 18 - 40 years

- BMI 19.0 -29.9kg/m(2) for low risk group; BMI 30.0 - 45.0kg/m(2) for obese group

- Firm LMP

- LMP-date and ultrasound date match within 5 days for gestation estimates between 8
weeks + 0 days and 10 weeks + 6 days, 6 days for those between 11 weeks + 0 days and
12 weeks + 6 days, and 7 days for estimates between 13 weeks + 0 days and 13 weeks + 6
days

- No confirmed or suspected fetal congenital structural or chromosomal anomalies

- Expect to deliver at one of the participating hospitals

- No previous participation in the NICHD Fetal Growth Study

EXCLUSION CRITERIA:

- Smoked cigarettes or used illicit drugs in the six months

- Used illicit drugs in the past year

- Having at least 1 alcoholic drink per day

- Conception by ovulation stimulation drugs or assisted reproductive technology

- Chronic hypertension or renal disease under medical supervision

- Asthma requiring weekly medication

- Diabetes mellitus

- Thyroid disease under medical supervision

- Autoimmune disorder (rheumatoid arthritis, lupus, antiphospholipid antibody
syndrome,scleroderma)

- Hematologic disorders (chronic anemia, sickle cell disease thrombocytopenia
coagulation defects, thrombophilia)

- Cancer

- HIV or AIDS

- Epilepsy or seizure on medication or occurrence within 2 years

- Psychiatric disorder (bipolar disorder, depression, anxiety disorder currently
requiring medication)

- Current anorexia nervosa or bulimia

- Previous severe preclampsia, eclampsia, HELLP syndrome

- Previous stillbirth or neonatal death

- Previous very preterm birth (less than 34 weeks)

- Previous low birthweight (less than 2,500 g)

- Previous macrosomia (greater than or equal to 4,500 g)

The following criteria apply only to obese women only:

- Chronic hypertension or high blood pressure requiring two or more medications

- Diabetes while not pregnant

- Chronic renal disease under medical supervision

- Autoimmune disease (rheumatoid arthritis, lupus, antiphospholipid antibody syndrome,
scleroderma)

- Psychiatric disorder (bipolar disorder, depression, anxiety disorder currently
requiring medication)

- Cancer (currently receiving treatment)

- HIV or AIDS