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INTRAUTERINE GROWTH RESTRICTION |
Lancet. 2004 Aug 7-13;364(9433):513-20.
Infant wellbeing at 2 years of age in the Growth Restriction Intervention
Trial (GRIT): multicentred randomised controlled trial.
Thornton JG, Hornbuckle J, Vail A, Spiegelhalter DJ, Levene M; GRIT study
group.
Background:
Although delivery is widely used for preterm babies failing to
thrive in utero, the effect of altering delivery timing has never been
assessed in a randomised controlled trial. We aimed to compare the effect of
delivering early with delaying birth for as long as possible.
Methods:
548
pregnant women were recruited by 69 hospitals in 13 European countries.
Participants had fetal compromise between 24 and 36 weeks, an
umbilical-artery doppler waveform recorded, and clinical uncertainty about
whether immediate delivery was indicated. Before birth, 588 babies were
randomly assigned to immediate delivery (n=296) or delayed delivery until
the obstetrician was no longer uncertain (n=292). The main outcome was death
or disability at or beyond 2 years of age. Disability was defined as a
Griffiths developmental quotient of 70 or less or the presence of motor or
perceptual severe disability. Analysis was by intention-to-treat. This trial
has been assigned the International Standard Randomised Controlled Trial
Number ISRCTN41358726. Findings:
Primary outcomes were available on 290
(98%) immediate and 283 (97%) deferred deliveries. Overall rate of death or
severe disability at 2 years was 55 (19%) of 290 immediate births, and 44
(16%) of 283 delayed births. With adjustment for gestational age and
umbilical-artery doppler category, the odds ratio (95% CrI) was 1.1
(0.7-1.8). Most of the observed difference was in disability in babies
younger than 31 weeks of gestation at randomisation: 14 (13%) immediate
versus five (5%) delayed deliveries. No important differences in the median
Griffiths developmental quotient in survivors was seen. Interpretation:
The
lack of difference in mortality suggests that obstetricians are delivering
sick preterm babies at about the correct moment to minimise mortality.
However, they could be delivering too early to minimise brain damage. These
results do not lend support to the idea that obstetricians can deliver
before terminal hypoxaemia to improve brain development.
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