Articles

Screening for fetal growth restriction using ultrasound and

the sFLT1/PlGF ratio in nulliparous women: a prospective
cohort study
Francesca Gaccioli*, Ulla Sovio*, Emma Cook, Martin Hund, D Stephen Charnock-Jones†, Gordon C S Smith†

Summary
Background Fetal growth restriction is a major determinant of perinatal morbidity and mortality. This condition has Lancet Child Adolesc Health 2018
no gold standard definition, but a widely used proxy is delivery of a small for gestational age infant (<10th percentile) Published Online
combined with an adverse pregnancy outcome. Effective screening for fetal growth restriction is an area of unmet June 7, 2018
http://dx.doi.org/10.1016/
clinical need. We aimed to determine the diagnostic effectiveness of a combination of ultrasonic fetal biometry and S2352-4642(18)30129-9
measurement of the ratio of soluble fms-like tyrosine kinase receptor 1 (sFLT1) to placental growth factor (PlGF) in
See Online/Comment
predicting adverse pregnancy outcomes associated with delivery of a small for gestational age infant. http://dx.doi.org/10.1016/
S2352-4642(18)30167-6
Methods In this prospective cohort study, using serial antenatal blood sampling and blinded ultrasound scans, we *Contributed equally
investigated the association between the combination of an elevated sFLT1/PlGF ratio (>85th percentile) and †Contributed equally
ultrasonically suspected small for gestational age (<10th percentile) at both 28 and 36 weeks of gestational age. The Department of Obstetrics and
outcome following the 28 week measurement was preterm delivery of a small for gestational age infant. The outcome Gynaecology, University of
following the 36 week measurement was subsequent delivery of a small for gestational infant associated with maternal Cambridge, NIHR Cambridge
Comprehensive Biomedical
pre-eclampsia or perinatal morbidity or mortality. All definitions of exposure and outcome were predefined before we Research Centre, Cambridge,
did our data analysis. UK (F Gaccioli PhD, U Sovio PhD,
E Cook BSc,
Findings Between Jan 14, 2008, and July 31, 2012, we recruited 4512 nulliparous women. 4098 women (91%) had a Prof D S Charnock-Jones PhD,
Prof G C S Smith DSc); Centre for
sFLT1/PlGF ratio measurement and estimated fetal weight at 28 or 36 weeks of gestational age, and outcome data Trophoblast Research (CTR),
available. 3981 women were analysed for 28 weeks of gestational age measurements and 3747 women were analysed Department of Physiology,
for 36 weeks of gestational age measurements. At 28 weeks, 47 (1%) of 3981 women had the combination of ultrasonic Development and
small for gestational age and an elevated sFLT1/PlGF ratio. The positive likelihood ratio for preterm delivery of a Neuroscience, University of
Cambridge, Cambridge, UK
small for gestational age infant associated with this combination was 41·1 (95% CI 23·0–73·6), the sensitivity was (F Gaccioli, U Sovio,
38·5% (21·1–59·3), the specificity was 99·1% (98·7–99·3), and the positive predictive value was 21·3% (11·6–35·8). Prof D S Charnock-Jones,
At 36 weeks, 102 (3%) of 3747 women had the combination of ultrasonic small for gestational age and an elevated Prof G C S Smith); and Roche
sFLT1/PlGF ratio. The positive likelihood ratio for delivery of a small for gestational age infant associated with Diagnostics International,
Rotkreuz, Switzerland
maternal pre-eclampsia or perinatal morbidity or mortality was 17·5 (95% CI 11·8–25·9), the sensitivity was (M Hund PhD)
37·9% (26·1–51·4), the specificity was 97·8% (97·3–98·3), and the positive predictive value was 21·6% (14·5–30·8). Correspondence to:
The positive likelihood ratios at both gestational ages were higher than previously described definitions of suspected Prof Gordon C S Smith,
fetal growth restriction using purely ultrasonic assessment. Department of Obstetrics and
Gynaecology, University of
Cambridge, Cambridge
Interpretation The combination of ultrasonically suspected small for gestational age plus an elevated sFLT1/PlGF CB2 0SW, UK
ratio in unselected nulliparous women identified a relatively small proportion of women who have high absolute risks gcss2@cam.ac.uk
of clinically important adverse outcomes. Screening and intervention based on this approach could result in net
benefit and this could be an appropriate subject for a randomised controlled trial.

Funding NIHR Cambridge Comprehensive Biomedical Research Centre, Medical Research Council, and Stillbirth
and neonatal death society (Sands).

Copyright © 2018 Elsevier Ltd. All rights reserved.

Introduction complications, including preterm birth, pre-eclampsia,

Fetal growth restriction is fetal growth that has failed to
reach its genetically determined potential. However, this
condition has no gold standard definition and is studied
using proxies, principally small for gestational age,
generally defined as babies who have birthweights below
the tenth percentile for those of the same gestational age,
plus either ultrasonic evidence of fetal growth restriction
(slow growth or uteroplacental insufficiency) or associated
stillbirth, perinatal asphyxia, and neo-natal morbidity.1
Multiple aspects of obstetric care are influenced by
suspected fetal growth restriction, including antenatal
assessment of fetal wellbeing, maternal assessment for
pre-eclampsia, the interpretation and response to fetal
monitoring in labour, and the timing and method of
delivery.2 However, screening for fetal growth restriction
in the USA and UK is based on clinical grounds;3,4 women

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Research in context
Evidence before this study
We reviewed evidence about screening and intervention for
fetal growth restriction included in the NICE Antenatal Care
Guideline and the Cochrane library. Fetal growth restriction is a
major cause of potentially preventable perinatal morbidity and
mortality. However, there is no clear evidence that screening
for this condition results in improved clinical outcomes. The
NICE Antenatal Care Guideline did systematic reviews of the
diagnostic and clinical effectiveness of screening for small
babies. These reviews did not identify any large-scale study of
the diagnostic effectiveness of screening for fetal growth
restriction that included blinding of the test result and the
NICE Antenatal Care Guideline identified development of
better methods of screening as a priority area for future
research. A meta-analysis of 13 randomised controlled trials,
which recruited around 35 000 women in total, evaluated the
effect of universal ultrasound on obstetric practice and did not
show any improvement in pregnancy outcomes. Furthermore,
there is evidence that use of universal ultrasound, one of the
most obvious approaches to screening, could actually lead to
harm through the adverse effects of iatrogenic prematurity on
false positives. A crucial element for any screening study is a
test that has a low false positive rate and a high positive
likelihood ratio. Many previous studies have reported
associations between placental biomarkers and the risk of fetal
growth restriction; however, the positive predictive values for
are selected for ultrasonographic fetal biometry on the
basis of previous risk factors, acquired complications of
pregnancy, or if they appear small for dates on clinical
examination. Multiple studies5–9 have reported that this
approach has poor sensitivity for detecting small babies,
and undiagnosed fetal growth restriction is a common
finding in audits of perinatal deaths.10,11 An alternative to
this approach is universal ultrasound. However, a meta-
analysis12 of randomised controlled trials, including
13 studies that recruited around 35 000 women in total,
did not show any improvement in outcomes. Specifically,
use of routine late pregnancy ultrasound was not
associated with a reduced risk of perinatal death (stillbirth
or neonatal death) or perinatal morbidity (eg, depressed
Apgar score, neonatal unit admission, and need for
resuscitation). Moreover, a study from France,13 where late
pregnancy ultrasound scan is routine, showed high
iatrogenic prematurity among false positives. Therefore,
better screening for fetal growth restriction is an area of
unmet clinical need.
Expression microarray studies identified upregulation
of fms-like tyrosine kinase 1 (FLT1) as a key change in the
placental transcriptome in pre-eclampsia and this was
mirrored by elevated soluble FLT1 (sFLT1) protein in the
mother’s blood.14 sFLT1 binds placental growth factor
(PlGF); hence, pre-eclampsia is associated with an
elevated sFLT1/PlGF ratio.14 A large-scale, prospective
2 www.thelancet.com/child-adolescent Published online June 7, 2018 http://dx.doi.org/10.1016/S2352-4642(18)30129-9
biomarkers on their own were generally low. We previously
hypothesised that a combination of ultrasonic and biochemical
screening might offer clinically useful prediction when
screening low-risk women.
Added value of this study
The key finding of our study is that a combination of ultrasonic
suspicion of a baby being small and a blood test indicating
placental dysfunction (elevated soluble fms-like tyrosine
kinase 1 to placental growth factor ratio) was strongly predictive
of clinically important adverse pregnancy outcomes. For preterm
birth of a small baby, the positive likelihood ratio was 41 and for
term delivery of a small baby with either maternal pre-eclampsia
or perinatal morbidity or mortality, the positive likelihood ratio
was 17·5. Only 1–3% of the population screened positive at each
gestational age. Both associations were far stronger than the
previously described best performing methods using purely
ultrasonic assessment and the false positive rate was much lower.
Implications of all the available evidence
Trials of screening and intervention based on a combination of
ultrasonic suspicion of a baby being small and a blood test
indicating placental dysfunction have a realistic chance of
showing clinical effectiveness in reducing adverse pregnancy
outcomes associated with fetal growth restriction. Such trials
should be an area for future research.
study15 showed that an elevated sFLT1/PlGF ratio provides
clinically useful assessment of risk in women with
suspected pre-eclampsia, and this test is now recom­
mended in the UK by the National Institute for Health
and Care Excellence (NICE).16 A large body of evidence
also implicates dysfunction of the placenta in many cases
of fetal growth restriction, including those leading to
stillbirth.17 However, whether the sFLT1/PlGF ratio might
be useful in screening for fetal growth restriction
is unclear. We studied a large prospective cohort
of unselected nulliparous women with a singleton
pregnancy to investigate the combination of ultrasonic
fetal biometry and the sFLT1/PlGF ratio as a screening
test to predict delivery of a small for gestational age infant
combined with an adverse pregnancy outcome (preterm
birth, perinatal morbidity or mortality, and maternal pre-
eclampsia).
Methods
Study design and participants
The pregnancy outcome prediction (POP) study was a
prospective cohort study of nulliparous women attending
the Rosie Hospital, Cambridge (UK) for their dating
ultrasound scan between Jan 14, 2008, and July 31, 2012.
Women with a viable singleton pregnancy were eligible
for inclusion. The study has been previously described in
detail.6,18,19 Women were ineligible for the study if they

had any previous births, liveborn or stillborn, at or after
24 weeks of gestational age. Women were recruited
following their dating ultrasound scan (which was
scheduled for approximate gestational age 12 weeks) and
had blood taken on the day of recruitment and at three
subsequent visits at the National Institute of Health
Research (NIHR) Cambridge Clinical Research Facility
(at approximately 20 weeks, 28 weeks, and 36 weeks of
gestational age). At each of these visits an ultrasound
scan was also done, and at the 20 weeks of gestational
age visit a questionnaire was completed through an
interview by a research midwife or research sonographer
to retrieve demo­graphic data and medical history.
Cambridgeshire 2 Research Ethics Committee gave
ethical approval for the study (reference number
07/H0308/163) and all participants provided written
informed consent. The reporting of this study conforms
to the STARD 2015 guidelines for reporting diagnostic
accuracy studies and we have included a completed
checklist (appendix).
Procedures
Our analysis focused on the research ultrasound scan data
and blood sampling done at 28 and 36 weeks of gestational
age. The conduct, analysis, and reproducibility of the
ultrasound data have previously been described in detail.6
Fetal biometry was done at 20, 28 and 36 weeks of
gestational age. The measurements made were the fetal
biparietal diameter, the head circumference, the
abdominal circumference, the femur length and the
amniotic fluid index. At each gestational age, we calculated
an estimated fetal weight using the equations described
by Hadlock and colleagues,20 and converted this into a
percentile for gestational age.21 Additionally, Doppler flow
velocimetry of the uterine and umbilical arteries was
done. Women and clinicians were masked to the results of
the research ultrasound scan unless there was one or
more of the following: breech presentation (at 36 weeks of
gestational age only), previously unrecognised congenital
anomaly, previously unrecognised placenta praevia, or
severe oligohydramnios, defined as an amniotic fluid
index less than 5.
Serum samples were collected as previously reported,18
stored at −80°C, and sFLT1/PlGF were measured using
Roche Elecsys assays on the electrochemi­luminescence
immunoassay platform Cobas e411 (Roche Diagnostics,
Basel, Switzerland).22 Using this system, the intra-assay
coefficient of variation for human serum samples is less
than 2% for sFLT1/PlGF, and the inter-assay coefficients
of variation are 2·3–4·3% for the sFLT1 assay and
2·7–4·1% for the PlGF assay.
Women were screened with ultrasound and blood
testing at 28 and 36 weeks of gestational age. At
28 weeks, we defined screen positive as an estimated
fetal weight below the tenth percentile and a sFLT1/
PlGF ratio greater than 5·78. At 36 weeks, we defined
screen positive as an estimated fetal weight below the
www.thelancet.com/child-adolescent Published online June 7, 2018 http://dx.doi.org/10.1016/S2352-4642(18)30129-9 3
Articles
tenth percentile and a sFLT1/PlGF ratio greater than 38.
The 38 threshold had been previously described in
multicentre development and validation studies.15
However, we did not use greater than 38 for the
28 weeks of gestational age measurement because it
would represent an extreme elevation at that age
(>99·5th percentile22). The two thresholds of sFLT1 to
PlGF ratio used were the 85th percentile at each of the
gestational ages.
We compared the associations with the above
definitions of screen positivity with purely ultrasonic
methods. Specifically, we analysed ultrasonic estimated
fetal weight below the tenth percentile plus low ab-
dominal circumference growth velocity as defined in a
previous analysis of the cohort,6 and definitions of fetal
growth restriction (both early onset and late onset) based
on biometry, growth velocity, and Doppler flow
velocimetry described following a Delphi procedure23 For the STARD 2015 guidelines
(see appendix for diagnostic criteria). see http://www.stard-statement.
org/
All classification of outcomes was done blind to the
results of the research ultrasound scan and maternal See Online for appendix
serum concentrations of sFLT1/PlGF. The definitions of
all exposures, outcomes, and statistical methods were
agreed before data analysis and are documented in
signed and dated analysis plans (appendix).
Outcomes
The primary outcome following the 28 weeks of
gestational age assessment was subsequent preterm
delivery (<37 weeks of gestational age) of a small for
gestational age infant (birthweight below the tenth
percentile). Preterm small for gestational age was defined
using a customised reference standard using the
Gestation-Related Optimal Weight version 6.7.8.1 bulk For more on the Gestation-
calculator (Perinatal Institute, Birmingham, UK). Our Related Optimal Weight (UK)
bulk calculator see http://www.
rationale for using this reference standard was that this gestation.net/
is a widely used method for calculating birthweight
percentile using a fetal growth standard, and use of a
fetal growth standard might be more appropriate than a
birthweight-based standard when assessing preterm
births. The basis for this view is the observation that
babies born preterm are more likely to have reduced
growth velocity;24,25 hence, it is problematic to derive a
normal birthweight range for preterm deliveries on the
basis of observed birthweights. A sensitivity analysis
addressed the effect of using a non-customised,
birthweight-based growth standard in the definition of
preterm small for gestational age.
The primary outcome following the 36 weeks of
gestational age assessment was subsequent delivery of a
small for gestational age infant with complications
(perinatal morbidity, non-anomalous perinatal death, or
maternal pre-eclampsia). At this gestational age, a small
for gestational age infant was defined as an infant with a
birthweight below the tenth percentile for sex and
gestational age using a population-based UK reference
range.26
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Preterm small for gestational Small for gestational age plus All others (n=4014)
age (n=26) complication* (n=58)
Maternal characteristics
Age†, years 30 (25–35) 31 (27–35) 30 (27–33)
Age when stopped full-time education, years 19 (18–22) 21 (18–22) 21 (18–23)
Data missing 1 (4%) 1 (2%) 120 (3%)
Height, cm 164 (160–167) 162 (158–167) 165 (161–169)
Deprivation quartile‡
1 (lowest) 4 (15%) 18 (31%) 975 (24%)
2 5 (19%) 8 (14%) 962 (24%)
3 9 (35%) 18 (31%) 957 (24%)
4 (highest) 7 (27%) 11 (19%) 956 (24%)
Data missing 1 (4%) 3 (5%) 164 (4%)
Ethnicity
Non-white 1 (4%) 1 (2%) 225 (6%)
White 25 (96%) 57 (98%) 3721 (93%)
Data missing 0 0 68 (2%)
Married 17 (65%) 38 (66%) 2733 (68%)
Smoker 1 (4%) 9 (16%) 191 (5%)
Any alcohol consumption 1 (4%) 4 (7%) 181 (5%)
Data missing 0 0 1 (<1%)
Body-mass index, kg/m² 27 (22–30) 24 (22–27) 24 (22–27)
Data missing 0 0 1 (<1%)
Type 1 or type 2 diabetes 0 0 14 (<1%)
Chronic hypertension 6 (23%) 8 (14%) 198 (5%)
Renal disease 0 2 (3%) 38 (1%)
Birth outcomes
Birthweight, g 1840 (1510–2130) 2588 (2335–2845) 3433 (3125–3745)
Birthweight, centile (population-based) 11·0 (3·0–15·1) 3·4 (1·2–5·7) 44·7 (25·2–67·0)
Birthweight, centile (customised) 3·9 (0·8–5·2) 2·5 (0·7–6·5) 45·9 (24·6–69·7)
Gestational age, weeks 34·2 (33·3–36·0) 40·1 (39·0–41·1) 40·3 (39·3–41·1)
Induction of labour 4 (15%) 26 (45%) 1280 (32%)
Method of delivery
Spontaneous vaginal 4 (15%) 19 (33%) 1977 (49%)
Operative vaginal 3 (12%) 15 (26%) 948 (24%)
Pre-labour caesarean 18 (69%) 12 (21%) 378 (9%)
Intrapartum caesarean 1 (4%) 12 (21%) 701 (17%)
Data missing 0 0 10 (<1%)
Gestational age at scan, weeks
12 week scan 12·6 (12·0–13·1) 12·7 (12·1–13·1) 12·6 (12·1–13·1)
20 week scan 20·3 (20·0–20·7) 20·3 (20·1–20·6) 20·3 (20·0–20·6)
Data missing 0 0 4 (<1%)
28 week scan 28·1 (27·9–28·3) 28·3 (28·0–28·6) 28·3 (28·0–28·6)
Data missing 0 0 20 (<1%)
36 week scan 36·0 (35·7–36·1) 36·1 (36·0–36·4) 36·1 (36·0–36·4)
Data missing 20 (77%) 0 209 (5%)
(Table 1 continues on next page)

We defined perinatal morbidity as at least one of the
following: a 5-min Apgar score less than 7, metabolic
acidosis (cord pH <7·10 with a base deficit >10 mEq/L),
or admission to the neonatal unit (ie, the intensive care
unit, high dependency unit, or special care baby unit) at
term for 48 h or more within 48 h of delivery. We also
studied a subgroup of infants who had severe adverse
perinatal outcome, defined as at least one of the
following: non-anomalous stillbirth or term livebirth
associated with neonatal death, hypoxic ischaemic
encephalopathy, severe metabolic acidosis (a cord blood
pH <7·0 and a base deficit of >12 mEq/L), or treatment

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Preterm small for gestational Small for gestational age plus All others (n=4014)
age (n=26) complication* (n=58)
(Continued from previous page)
Exposures at 28 weeks of gestational age
Estimated fetal weight centile 13·2 (4·1–28·1) 17·4 (10·1–29·2) 39·6 (22·0–60·9)
Estimated fetal weight below the tenth percentile 12 (46%) 13 (22%) 303 (8%)
Data missing 0 1 (2%) 25 (1%)
sFLT1, pg/mL 2408 (1407–4322) 1982 (1349–2581) 1489 (1078–2038)
Data missing 0 0 110 (3%)
PlGF, pg/mL 137 (51–222) 315 (181–546) 542 (374–789)
Data missing 0 0 110 (3%)
sFLT1/PlGF ratio 15·9 (5·5–70·3) 5·6 (2·8–9·8) 2·7 (1·8–4·2)
sFLT1/PlGF ratio >5·78 19 (73%) 28 (48%) 548 (14%)
Data missing 0 0 110 (3%)
Estimated fetal weight below the tenth percentile and 10 (38%) 4 (7%) 33 (1%)
sFLT1/PlGF ratio >5·78
Data missing 0 1 (2%) 116 (3%)
Ultrasonic estimated fetal weight below the tenth 3 (12%) 4 (7%) 83 (2%)
percentile and lowest decile of abdominal
circumference growth velocity
Data missing 0 1 (2%) 44 (1%)
Delphi procedure definition of fetal growth restriction 12 (46%) 8 (14%) 99 (2%)
Data missing 1 (4%) 2 (3%) 128 (3%)
Exposures 36 weeks of gestational age
Estimated fetal weight centile 0·9 (0·5–2·2) 5·9 (2·4–11·7) 37·3 (18·8–63·3)
Estimated fetal weight below the tenth percentile 6 (23%) 39 (67%) 492 (12%)
Data missing 20 (77%)§ 0 221 (6%)
sFLT1, pg/mL 5896 (4250–6314) 5284 (3356–9051) 3013 (2209–4267)
Data missing 21 (81%) 0 301 (7%)
PlGF, pg/mL 97 (77–102) 139 (71–209) 260 (155–447)
Data missing 21 (81%) 0 301 (7%)
sFLT1/PlGF ratio 58·0 (55·3–65·0) 40·4 (17·1–102·2) 11·7 (5·3–24·5)
sFLT1/PlGF ratio >38 4 (15%) 31 (53%) 531 (13%)
Data missing 21 (81%) 0 301 (7%)
Estimated fetal weight below the tenth percentile and 4 (15%) 22 (38%) 76 (2%)
sFLT1/PlGF ratio >38
Data missing 21 (81%) 0 330 (8%)
Ultrasonic estimated fetal weight below the tenth 4 (15%) 18 (31%) 142 (4%)
percentile and lowest decile of abdominal
circumference growth velocity
Data missing 20 (77%) 0 236 (6%)
Delphi procedure definition of fetal growth restriction 6 (23%) 35 (60%) 385 (10%)
Data missing 20 (77%) 1 (2%) 280 (7%)

Data are expressed as median (IQR) or n (%). For fields where there is no category labelled as missing, data were 100% complete. All maternal characteristics, except age at
recruitment, were defined by self-report in a questionnaire at 20 weeks, from examination of the clinical case record, or linkage to the hospital’s electronic databases. For
birthweight, a customised reference was used to define preterm small for gestational age (ie, the primary outcome for the analysis based on the 28 weeks of gestational age
measurements) and a population-based reference was used to define small for gestational age plus complication at or near term (ie, the primary outcome for the analysis
based on the 36 weeks of gestational age measurements). sFLT1=soluble fms-like tyrosine kinase 1. PlGF=placental growth factor. *Complication was defined as perinatal
morbidity, mortality, or pre-eclampsia. †Age at recruitment. ‡Socioeconomic status was quantified using the Index of Multiple Deprivation (IMD) 2007, which is based on
census data from the area of the mother’s postcode.31 §The high rate of missing values reflects the fact that 77% of these women delivered before their scheduled 36 weeks of
gestational age research visit.

Table 1: Study cohort characteristics by primary outcome status

with inotropes or mechanical ventilation. Pre-eclampsia Statistical analysis

was defined and classified on the basis of The sample size for the present study was determined by
the 2013 American College of Obstetricians and recruitment to the POP study. Power calculations
Gynecologists criteria (appendix).27 showed that with 4000 women in the analysis and a

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True positive/ True negative/ Positive Negative Sensitivity Specificity Positive predictive Negative
false positive false negative likelihood ratio likelihood ratio (95% CI) (95% CI) value predictive value
(95% CI) (95% CI) (95% CI) (95% CI)
Ultrasonic estimated fetal weight below 12/308 3647/14 5·9 0·58 46·2% 92·2% 3·8% 99·6%
the tenth percentile (3·9–9·1) (0·41–0·83) (27·3–66·2) (91·3–93·0) (2·1–6·5) (99·4–99·8)
sFLT1/PlGF ratio >5·78 19/574 3381/7 5·0 0·31 73·1% 85·5% 3·2% 99·8%
(3·9–6·4) (0·17–0·59) (51·7–87·3) (84·4–86·6) (2·1–5·0) (99·6–99·9)
Ultrasonic estimated fetal weight below 10/37 3918/16 41·1 0·62 38·5% 99·1% 21·3% 99·6%
the tenth percentile and sFLT1/PlGF ratio (23·0–73·6) (0·46–0·84) (21·1–59·3) (98·7–99·3) (11·6–35·8) (99·3–99·8)
>5·78
Ultrasonic estimated fetal weight below 3/85 3852/23 5·3 0·90 11·5% 97·8% 3·4% 99·4%
the tenth percentile and lowecst decile (1·8–15·8) (0·79–1·04) (3·5–32·1) (97·3–98·3) (1·1–10·3) (99·1-99·6)
of abdominal circumference growth
velocity*
Delphi procedure definition of early fetal 12/106 3747/13 17·4 0·53 48·0% 97·2% 10·2% 99·7%
growth restriction* (11·1–27·3) (0·37–0·78) (28·4–68·2) (96·7–97·7) (5·8–17·2) (99·4–99·8)

Small for gestational age was defined as a customised birthweight below the tenth percentile (see Methods). sFLT1=soluble fms-like tyrosine kinase 1. PlGF=placental growth factor. *See appendix for definitions.

Table 2: Ultrasonic and biochemical screening test diagnostic effectiveness at 28 weeks of gestational age for preterm delivery of a small for gestational age infant (n=3981)

four-times increase in risk associated with an exposure

A affecting 5% of the population, we had 74% power to
25 Screen positive detect an association if the incidence of the condition
Screen negative
was 0·65%, and 94% power if the incidence was 1·5%.
Cumulative incidence (births per 100 women)

20 We excluded women who had missing screen positive

status or outcome from the analyses (appendix). We
assessed screening performance using 2 × 2 tables and
15
standard summary statistics when the exposures were
treated categorically. We estimated 95% CIs for the
10 positive and negative likelihood ratios using the method
described by Simel and colleagues.28 For other screening
statistics (sensitivity, specificity, and positive and
5 negative predictive values), we calculated 95% CIs using
a method (logit-transformed) to ensure the interval was
0 always within the possible range (0–100%).29 When
28 29 30 31 32 33 34 35 36 37 screening measurements were treated as continuous
Number at risk variables, we quantified discrimination by the area
Screen positive 18 44 47 47 46 42 39 39 39 37 under the receiver operating characteristic (ROC) curve
Screen negative 1249 3694 3919 3920 3916 3912 3905 3892 3861 3783
and we compared the areas under the curve using the De
B Long test. Additionally, we did time-to-event analysis.
25 Delivery with the given outcome was the event and
delivery without the outcome was treated as competing
Cumulative incidence (births per 100 women)

20

Figure 1: Cumulative incidence graphs

15 (A) Preterm delivery of a small for gestational age infant (birthweight below the
tenth customised percentile) following 28 weeks of gestational age measurement
by screening status. Screen positivity was defined as estimated fetal weight below
10 the tenth percentile for gestational age, combined with a sFLT1/PlGF ratio greater
than 5·78. Number at risk 3934 screen negatives and 47 screen positives.
(B) Delivery of a small for gestational age infant plus a complication following
5 36 weeks of gestational age measurement by screening status. Screen positivity
was defined as an estimated fetal weight below the tenth percentile for gestational
age, combined with sFLT1/PlGF ratio more than 38. Number at risk 3645 screen
0
negatives and 102 screen positives. Small for gestational age was defined as
birthweight below the tenth population-based percentile and a complication was
36 37 38 39 40 41 42 43 defined as one or more of the following: non-anomalous perinatal death, any
Gestational age (weeks) neonatal morbidity, or maternal pre-eclampsia. The number at risk increases before
Number at risk
it decreases because the majority of women had their scan and blood sample taken
Screen positive 35 92 82 63 37 13 2 0
Screen negative 1163 3455 3446 3047 2275 1204 208 0 after 28 weeks and zero days (A) or after 36 weeks and zero days (B). sFLT1=soluble
fms-like tyrosine kinase 1. PlGF=placental growth factor.

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True True Positive Negative Sensitivity Specificity Positive Negative

positive/false negative/false likelihood ratio likelihood ratio (95% CI) (95% CI) predictive value predictive value
positive negative (95% CI) (95% CI) (95% CI) (95% CI)
Ultrasonic estimated fetal weight below 39/482 3207/19 5·1 0·38 67·2% 86·9% 7·5% 99·4%
the tenth percentile (4·2–6·3) (0·26–0·54) (53·8–78·3) (85·8–88·0) (5·5–10·1) (99·1–99·6)
sFLT1/PlGF ratio >38 31/532 3157/27 3·7 0·54 53·4% 85·6% 5·5% 99·2%
(2·9–4·8) (0·41–0·72) (40·3–66·1) (84·4–86·7) (3·9–7·7) (98·8–99·4)
Ultrasonic estimated fetal weight below the 22/80 3609/36 17·5 0·63 37·9% 97·8% 21·6% 99·0%
tenth percentile and sFLT1/PlGF ratio >38 (11·8–25·9) (0·52–0·78) (26·1–51·4) (97·3–98·3) (14·5–30·8) (98·6–99·3)
Ultrasonic estimated fetal weight below 18/143 3532/40 8·0 0·72 31·0% 96·1% 11·2% 98·9%
the tenth percentile and lowest decile of (5·3–12·1) (0·60–0·85) (20·2–44·4) (95·4–96·7) (7·1–17·1) (98·5–99·2)
abdominal circumference growth velocity*
Delphi procedure definition of late fetal 35/377 3257/22 5·9 0·43 61·4% 89·6% 8·5% 99·3%
growth restriction* (4·7–7·4) (0·31–0·60) (47·9–73·4) (88·6–90·6) (6·2–11·6) (99·0–99·6)

Small for gestational age was defined using a non-customised birthweight standard (see Methods). sFLT1=soluble fms-like tyrosine kinase 1. PlGF=placental growth factor. *See appendix for definitions.

Table 3: Ultrasonic and biochemical screening test diagnostic effectiveness at 36 weeks of gestational age for subsequent delivery of a small for gestational age infant associated with
either maternal pre-eclampsia or perinatal morbidity or mortality (n=3747)

risk. This analysis was done using Stata package stcrreg,
followed by stcurve, with option cif to generate
cumulative incidence plots of the outcome from the
time of measurement, using gestational age as the
timescale. The stcrreg package uses a semiparametric
partial likelihood based time-to-event regression model
with competing risks, and the method is described in
detail elsewhere.30 Analyses were done using Stata 14.2
and Stata 15.1.
Role of the funding source
The funders of the study had no role in study design,
data collection, data analysis, data interpretation, or
writing of the report. US and GCSS (corresponding
author) had full access to all the data in the study. The
corresponding author had final responsibility for the
decision to submit for publication.
Results
Between Jan 14, 2008, and July 31, 2012, we identified
8028 eligible women, of whom we recruited 4512 to the
study. A study profile has previously been published.6
The study group for the present analysis included
4098 women (91% of those recruited) who had a
measurement of the sFLT1/PlGF ratio and estimated
fetal weight at 28 or 36 weeks of gestational age and
outcome data available. We included 3981 women in
the analysis based on 28 weeks of gestational age
measurements and 3747 women were included based on
36 weeks of gestational age measurements. In total,
84 (2%) women had one of the primary outcomes, and
we tabulated the characteristics of the study group based
on this (table 1).
At 28 weeks of gestational age, 320 women (8%) had
an ultrasonic estimated fetal weight below the tenth
percentile, 593 women (15%) had an sFLT1/PlGF ratio
greater than 5·78, and 47 women (1%) screened positive
for both tests (table 2). The positive likelihood ratio for
preterm delivery of a small for gestational age
infant associated with this combination was 41·1
(95% CI 23·0–73·6), the positive predictive value was
21·3% (11·6–35·8), and the screen positive group
included over a third of the women who had a preterm
delivery of a small for gestational age infant (table 2).
Delivery occurred 2 or more weeks after the 28 week
gestational age measurements in around 95% of
cases (figure 1). At 36 weeks of gestational age,
521 (14%) women had an ultrasonic estimated fetal
weight below the tenth percentile, 563 (15%) women
had an sFLT1/PlGF ratio greater than 38, and
102 women (3%) screened positive in both tests (table 3).
The positive likelihood ratio for delivery of a small for
gestational age infant associated with maternal pre-
eclampsia, or perinatal morbidity or mortality associated
with the combination, was 17·5 (95% CI 11·8–25·9;
table 3). The positive predictive value was
21·6% (14·5–30·8), and the screen positive group
included over a third of the women who had a delivery
of a small for gestational age infant with complications.
Delivery oc­curred 2 or more weeks after the 36 weeks of
gestational age measurements in around 80% of cases
(figure 1).
We compared the predictive ability of a combination of
ultrasonic small for gestational age and an elevated
sFLT1/PlGF ratio with two other previously described
indicators of fetal growth restriction—low abdominal
circumference growth velocity6 and a composite measure
generated by a Delphi procedure.23 At both 28 and
36 weeks of gestational age, the positive predictive value
was around twice as high for combined ultrasonic and
biochemical screening compared with the best
performing purely ultrasonic method (tables 2, 3).
We did a prespecified subgroup analysis in which we
analysed the relationship between the sFLT1/PlGF ratio
and the risk of pre-eclampsia, with or without small for
gestational age, using ROC curve analysis (figure 2). The

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A B
1·0

0·75
Sensitivity

0·50

0·25

Area under ROC curve 0·95 Area under ROC curve 0·66
95% CI 0·90–1·00 95% CI 0·53–0·79
0

C D
1·0

0·75
Sensitivity

0·50

0·25

Area under ROC curve 0·95 Area under ROC curve 0·77
95% CI 0·92–0·99 95% CI 0·74–0·81
0
0 0·25 0·5 0·75 1·00 0 0·25 0·5 0·75 1·00
1–specificity 1–specificity

Figure 2: ROC curve analysis

(A) Relationship between the sFLT1/PlGF ratio at 28 weeks of gestational age and the risk of pre-eclampsia with delivery of a preterm small for gestational age infant
(birthweight below the tenth customised percentile; n=12 cases). (B) Relationship between the sFLT1/PlGF ratio at 28 weeks of gestational age and the risk of pre-
eclampsia with delivery of a preterm non-small for gestational age infant (birthweight at or above the tenth customised percentile; n=14 cases). (C) Relationship
between the sFLT1/PlGF ratio at 36 weeks of gestational age and the risk of pre-eclampsia with delivery of a small for gestational age infant (birthweight below the
tenth population-based percentile; n=21 cases). (D) Relationship between the sFLT1/PlGF ratio at 36 weeks of gestational age and the risk of pre-eclampsia with
delivery of a non-small for gestational age infant (birthweight at or above the tenth population-based percentile; n=203 cases). ROC=receiver operating characteristic.
sFLT1=soluble fms-like tyrosine kinase 1. PlGF=placental growth factor.

association between the sFLT1/PlGF ratio at 28 weeks of
gestational age and pre-eclampsia leading to preterm
birth was very strong when the infant was small for
gestational age, compared to when the infant was not
small for gestational age (figure 2). Similarly, the
sFLT1/PlGF ratio at 36 weeks of gestational age was very
strongly associated with pre-eclampsia when combined
with small for gestational age (figure 2).
We did a series of other prespecified secondary and
sensitivity analyses (tables 4, 5, 6). On its own, PlGF at
28 weeks of gestational age was equally predictive of
preterm small for gestational age as the sFLT1/PlGF

8 www.thelancet.com/child-adolescent Published online June 7, 2018 http://dx.doi.org/10.1016/S2352-4642(18)30129-9

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True positive/ True negative/ Positive likelihood Negative likelihood Sensitivity Specificity Positive Negative
false positive false negative ratio (95% CI) ratio (95% CI) predictive value predictive value
Highest decile sFLT1/PlGF ratio 19/377 3578/7 7·7 (6·0–9·9) 0·30 (0·16–0·56) 73·1% 90·5% 4·8% 99·8%
Highest decile sFLT1 12/385 3570/14 4·7 (3·1–7·3) 0·60 (0·42–0·85) 46·2% 90·3% 3·0% 99·6%
Lowest decile PlGF 21/376 3579/5 8·5 (6·9–10·5) 0·21 (0·10–0·47) 80·8% 90·5% 5·3% 99·9%
Highest decile sFLT1 (multiples of the 13/385 3570/13 5·1 (3·5–7·6) 0·55 (0·38–0·81) 50·0% 90·3% 3·3% 99·6%
median)
Lowest decile PlGF (multiples of the 20/377 3578/6 8·1 (6·4–10·2) 0·26 (0·13–0·51) 76·9% 90·5% 5·0% 99·8%
median)

Multiples of the median were adjusted for the exact gestational age and maternal weight. The cutoff points of the highest decile were 6·90 for the sFLT1/PlGF ratio, 2788·5 for the sFLT1, and 1·83 for the sFLT1
multiples of the median. The cutoff points for the lowest decile of the PlGF were 252·7 and 0·48 for the PlGF multiples of the median. sFLT1=soluble fms-like tyrosine kinase 1. PlGF=placental growth factor.

Table 4: Biochemical screening diagnostic effectiveness for preterm delivery of a small for gestational age infant using absolute concentrations, and gestational age and maternal weight
adjusted multiples of the median of sFLT1 and PlGF at 28 weeks of gestational age

True positive/ True negative/ Positive likelihood Negative likelihood Sensitivity Specificity Positive Negative
false positive false negative ratio (95% CI) ratio (95% CI) predictive value predictive value
Highest decile sFLT1/PlGF ratio 25/347 3342/33 4·6 (3·4–6·3) 0·63 (0·50–0·79) 43·1% 90·6% 6·7% 99·0%
Highest decile sFLT1 24/349 3340/34 4·4 (3·2–6·0) 0·65 (0·52–0·80) 41·4% 90·5% 6·4% 99·0%
Lowest decile PlGF 25/348 3341/33 4·6 (3·3–6·2) 0·63 (0·50–0·79) 43·1% 90·6% 6·7% 99·0%
Highest decile sFLT1 (multiples of the median) 24/349 3340/34 4·4 (3·2–6·0) 0·65 (0·52–0·80) 41·4% 90·5% 6·4% 99·0%
Lowest decile PlGF (multiples of the median) 24/349 3340/34 4·4 (3·2–6·0) 0·65 (0·52–0·80) 41·4% 90·5% 6·4% 99·0%

Multiples of the median were adjusted for exact gestational age and maternal weight. The cutoff points of the highest decile were 49·8 for the sFLT1/PlGF ratio, 6266 for the sFLT1, and 2·06 for the sFLT1
multiples of the median. The cutoff points for the lowest decile of the PlGF were 104·4 and 0·42 for the PlGF multiples of the median. sFLT1=soluble fms-like tyrosine kinase 1. PlGF=placental growth factor.

Table 5: Biochemical screening diagnostic effectiveness for subsequent delivery of a small for gestational age infant associated with either maternal pre-eclampsia, perinatal morbidity,
or mortality using absolute concentrations, and gestational age and maternal weight adjusted multiples of the median of sFLT1 and PlGF at 36 weeks of gestational age

28 weeks of gestational age 36 weeks of gestational age

Area under ROC curve (95% CI) p value from comparison Area under ROC curve (95% CI) p value from comparison
with sFLT1/PlGF ratio* with sFLT1/PlGF ratio*
sFLT1/PlGF ratio 0·89 (0·82–0·97) NA 0·77 (0·70–0·84) NA
sFLT1 0·74 (0·62–0·85) 0·0012 0·73 (0·66–0·81) 0·089
PlGF 0·89 (0·81–0·98) 0·93 0·75 (0·69–0·82) 0·42
sFLT1 (multiples of the median) 0·75 (0·64–0·86) 0·0024 0·73 (0·65–0·80) 0·032
PlGF (multiples of the median) 0·88 (0·79–0·97) 0·56 0·76 (0·70–0·83) 0·82

The area under the ROC curve for sFLT1/PlGF ratio to predict the Delphi procedure definition of ultrasonic diagnosis of fetal growth restriction was 0·55 (95% CI 0·50–0·61) at
28 weeks of gestational age and 0·57 (95% CI 0·54–0·60) at 36 weeks of gestational age. ROC=receiver operating characteristic. sFLT1=soluble fms-like tyrosine kinase 1.
PlGF=placental growth factor. NA=not applicable. Multiples of the median were adjusted for gestational age and maternal weight. *p value is from the De Long test for the
equality of the area under the ROC curve.

Table 6: ROC curve analysis of continuous biochemical exposures measured at 28 and 36 weeks of gestational age and respective primary outcomes

ratio, whereas sFLT1 was a considerably weaker
predictor of preterm small for gestational age than the
sFLT1/PlGF ratio (tables 4, 5). Similarly, at 36 weeks of
gestational age PlGF was equally predictive of late fetal
growth restriction as the sFLT1/PlGF ratio. However,
sFLT1 was only slightly weaker or similar as a predictor
compared to the sFLT1/PlGF ratio at 36 weeks
(tables 5, 6). Adjustment of the PlGF/sFLT1 values for
the exact gestational age or maternal weight at the
measurement made little or no difference to the results
(tables 4, 5, 6). We also found that use of a non-
customised and birthweight-based standard to define
preterm delivery of a small for gestational age infant
resulted in a stronger association with the combination
of estimated fetal weight below the tenth percentile and
an elevated sFLT1/PlGF ratio; the positive likelihood
ratio was 53·4 (29·6–96·4) and the sensitivity was
54% (appendix). The combination was similarly
predictive of the primary outcome when the women
who had their research scan result revealed were
excluded (9 women at 28 weeks and 214 women at
36 weeks of gestational age; 5% in total); positive
likelihood ratios were 41·0 (22·9–73·4) for preterm
delivery of small for gestational age infant and 17·4
(11·5–26·4) for subsequent delivery of a small for
gestational age infant with a complication. Other

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prespecified secondary analyses and additional analyses
are presented in the appendix.
Discussion
In our study, we evaluated the combination of ultrasonic
suspicion of small for gestational age plus an elevated
sFLT1/PlGF ratio as a screening test for delivery of a
small for gestational age infant combined with an
adverse pregnancy outcome. We found that this
combination was strongly predictive for preterm
delivery of a small for gestational age infant when
measured at 28 weeks of gestational age and for term
delivery of a small for gestational age infant with
maternal pre-eclampsia or perinatal morbidity or
mortality when measured at 36 weeks of gestational age.
Screening for fetal growth restriction is an area of
unmet clinical need. Previous studies using purely
ultrasonic methods of screening did not show that
screening prevented adverse outcomes, such as
perinatal morbidity and mortality.12 Detailed analysis of
data from France,13 where universal ultrasound
screening was implemented despite the absence of
supportive trial data, indicated an excess of adverse
outcomes (eg, caesarean delivery, need for neonatal
resuscitation, and admission to a neonatal unit) among
pregnancies incorrectly suspected to be affected by a
small for gestational age infant (ie, false positives).
Screening did not appear to result in an overall
improvement in outcomes, as any benefit arising from
identifying true positives was outweighed by harm
caused to false positives. Using the combination of
ultrasonic fetal biometry and the sFLT1/PlGF ratio, we
found that the positive predictive value was more than
20% at 28 and 36 weeks of gestational age, and the false
positive rate was 0·9% at 28 weeks and 2% at 36 weeks.
Hence, this approach identified women with high
absolute risks of adverse pregnancy outcome, with very
low false positive rates in the healthy population.
Clinically effective screening also requires that the
screening test is coupled with an intervention. At
28 weeks of gestational age, women who were identified
as high risk by this screening test could be offered
enhanced fetal assessment with the option of medically
indicated delivery, as done for women with suspected
fetal growth restriction identified using targeted ultra­
sound. High-quality evidence has been reported that
assessment of high-risk pregnancies using serial
umbilical artery Doppler reduces the risk of perinatal
death.32 Moreover, identification of high-risk fetuses
could allow optimisation of other aspects of care,
including use of antenatal steroids and timing and
method of delivery. At 36 weeks of gestational age,
identifying late fetal growth restriction has the advantage
that the primary intervention to prevent stillbirth
(ie, medically indicated delivery, principally induction of
labour) has reduced potential to cause harm through
iatrogenic prematurity. We believe that a randomised
10 www.thelancet.com/child-adolescent Published online June 7, 2018 http://dx.doi.org/10.1016/S2352-4642(18)30129-9
controlled trial assessing clinical outcomes after
screening and intervention using this approach is an
appropriate area for future research.
An issue with some studies reporting novel diagnostic
methods is that the definition of screen positive is based
on observed patterns of association within the population.
This approach can lead to overly optimistic estimates of
screening performance, as there is the potential to set
the thresholds defining screening status based on
associations observed in a given study. Therefore, the
findings of such studies require external validation.
However, this was not the case in our study. The
definition of screen positive was based on two previously
described and widely accepted thresholds, namely an
estimated fetal weight below the tenth percentile and an
sFLT1/PlGF ratio greater than 38. Estimated fetal weight
below the tenth percentile is a widely accepted definition
for small for gestational age.1 The sFLT1/PlGF ratio
greater than 38 threshold was obtained from previous
multicentre development and validation studies.15 The
only mod­ ification made in our study was to use a
different threshold at 28 weeks of gestational age, as the
greater than 38 level of the ratio represented a much
more extreme elevation at 28 weeks than at 36 weeks.
However, this and all other thresholds and definitions
used in our study were predefined in an analysis plan
that was finalised before any analysis of the associations
with fetal growth restriction. Given that all analyses were
pre­specified, there is no capacity for data-driven analyses
in our primary exposures and outcomes, hence there is
no novel algorithm that requires external validation.
We did a series of secondary analyses. In contrast to the
primary analysis, these analyses should be treated as
hypothesis generating rather than hypothesis testing.
One such analysis addressed use of lower thresholds of
estimated fetal weight and sFLT1/PlGF ratio to define
screen positives. We found that when the thresholds for
screen positives were lowered to cause a similar false
positive rate to the Delphi-derived ultrasonic definition
of fetal growth restriction, the positive and negative
likelihood ratios were similar for the two methods. Any
false result in a diagnostic test has the potential to cause
harm. However, the relative concerns about false
positives and false negatives depend on the context. The
Delphi-derived definition of fetal growth restriction was
obtained from a process of surveying maternal fetal
medicine specialists. Such professionals will generally be
scanning in the context of a high-risk pregnancy and the
result of a negative test might be to reduce the level of
surveillance in a high-risk woman. In this context, a false
negative result might be more concerning than a false
positive. However, the context for our analysis is
screening low-risk women. The result of a negative test
would simply be that a woman would continue to receive
the low-risk care that she would have received had she
not had the test. In the context of screening low-risk
women, false positive results might be of particular

concern, as they will generate unnecessary anxiety and
health-care costs, and could lead to short-term and long-
term harm through iatrogenic prematurity. Hence, we
believe that the screening performance achieved using a
combination of estimated fetal weight and the
sFLT1/PlGF ratio could be particularly suitable for
screening low-risk populations. Another aspect of this
approach is that the test could be applied sequentially;
women could initially have the blood test and ultrasound
might then only be done if the sFLT1/PlGF ratio is above
the given threshold. This approach would lead to less
pressure on imaging services. By contrast, screening
using the Delphi-derived ultrasonic approach would
require serial use of ultrasound in the whole population.
Whether health-care systems have the capacity to deliver
these imaging procedures at this scale is unclear.
Moreover, the Delphi-derived ultrasonic approach also
depends on uteroplacental Doppler, which is highly
operator dependent, and implementation of these
methods across the entire obstetric population might be
problematic.
We found that the combination of small for
gestational age and pre-eclampsia was exceptionally
strongly associated with the sFLT1/PlGF ratio. At
both 28 and 36 weeks of gestational age, the area under
the ROC curve was 0·95, indicating that elevation of the
ratio was almost invariably observed in this group. This
observation is consistent with the hypothesis that there
are distinct placental and maternal phenotypes of pre-
eclampsia33 and suggests that the sFLT1/PlGF ratio might
also help to define different subtypes of disease. The
pathophysiological pathways leading to fetal growth
restriction are complex and have recently been reviewed.34
The sFLT1/PlGF ratio clearly identifies one phenotype of
fetal growth restriction with extremely high predictive
accuracy. Other markers might reflect different causes of
fetal growth restriction. For example, we have previously
shown that maternal concentrations of delta-like
homologue-1 (DLK1) were invariably lower in small for
gestational age infants with abnormal umbilical artery
blood flow compared with matched controls.35 Related
animal studies showed that maternal DLK1 was derived
from the fetus, unlike sFLT1, which is synthesised by the
placenta. We speculate that panels of biochemical markers
might allow identification of multiple different causes of
fetal growth restriction and measurement of such panels,
combined with ultrasonic estimated fetal weight, might
result in future tests with higher sensitivity but similarly
low false positive rates. Finally, secondary analyses showed
that PlGF on its own was similarly predictive for these
outcomes as the sFLT1/PlGF ratio, particularly at 28 weeks
of gestational age, and further studies might address
whether the combination of ultrasonic suspicion of small
for gestational age plus a low PlGF might be a more cost-
effective method of screening for fetal growth restriction.
Our study had several strengths. First, the study was
sufficiently large to be powered for relatively uncommon
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Articles
adverse pregnancy outcomes. Second, the results of
ultrasonographic fetal biometry were blinded. Few
studies have evaluated prenatal ultrasonography with
blinding, which is one of the key characteristics for a
study of diagnostic effectiveness. Third, the biochemical
analyses of the sFLT1/PlGF ratio also had a number of
strengths. These analyses were also done blind to clinical
outcome; were done using an automated, clinical grade,
and widely available immunoassay platform; the ratio
can readily be calculated without complex corrections for
maternal characteristics; and the threshold used for
screen positivity at 36 weeks of gestational age was
previously generated for pre-eclampsia from a large-scale
study and validated in another study.15,22 Fourth, the
primary exposures, primary outcomes, and analyses
were defined in prespecified analysis plans. Finally, as
the cohort was selected on the basis of nulliparity and
singleton pregnancy alone, it included many low-risk
women. Studies can overestimate the positive predictive
value of a screening test by extrapolating the results of
selected and high-risk cohorts to the general population.36
Therefore, given that our study used a cohort with a large
proportion of low-risk women drawn from a largely
healthy population, the combination of estimated fetal
weight below the tenth percentile and sFLT1/PlGF ratio
above the 85th percentile might be at least equally
predictive in other populations, and could even be more
strongly predictive of fetal growth restriction when
investigated in other settings.
Our study also has limitations. We revealed the results
of the research ultrasound scan in 5% of the study
group (most cases were for breech presentation at
36 weeks of gestational age). However, the main
findings were the same when the analysis was confined
to women who did not have their research scan results
revealed. Second, the study was confined to first and
singleton pregnancies. Hence, the results cannot be
extrapolated to multiparous women or multiple
pregnancies and further studies will be required for
these populations. However, the selection of nulliparous
women was purposeful, as these women have higher
rates of adverse outcomes and the most informative
method of assessing risk of obstetric complications—
namely, past obstetric history—is not available. Another
issue that limits the external validity of the data for
some populations is that the pregnancy outcome
prediction study cohort was largely of white ethnicity.
However, both elements of the screening test are likely
to be applicable in other populations, as fetal growth is
quite consistent across different ethnic groups37 and
previous reports have indicated that the sFLT1/PlGF
ratio is similarly associated with pre-eclampsia in
black Africans38 and with placental dysfunction in a US
population where more than 90% of women were
African American.39 A further limitation is the relatively
small number of events following each of the screening
assessments, despite the large number of women in the
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cohort. The low event rate partly reflects the fact that the
outcomes studied were clinically significant, hence
uncommon. The small number of cases introduces
some uncertainty in the exact screening properties of
the test, and this is illustrated by the 95% CI. However,
examination of the 95% CI shows that the lower limit of
the positive predictive value at both gestational ages is
more than 10. This observation indicates that screen
positive women are at significant risk. Secondly, the
lower limit of the specificity is more than 97% at both
timepoints, indicating that the false positive rate is less
than 3% even with the most pessimistic assessment of
our results. A final relative weakness is that the data
were generated using a single immunoassay platform,
and the optimal cutoff sFLT1/PlGF ratio might differ
when other assays are used.
In conclusion, our study showed that the combination
of an ultrasonically suspected small for gestational age
fetus and an elevated maternal sFLT1/PlGF ratio is
strongly predictive of adverse pregnancy outcome
associated with fetal growth restriction. The predictive
performance of this approach improves upon previously
described methods of screening using purely ultrasonic
methods. We hypothesise that screening using a
combination of ultrasound and measurement of
placental biomarkers in the mother’s blood could
improve maternal and perinatal outcomes when coupled
with an appropriate management plan for women with
positive screening results. This novel method of
screening could be tested against the current standard of
care in a randomised controlled trial where the primary
outcome was delivery of a small for gestational age infant
associated with an adverse pregnancy outcome.
Contributors
GCSS conceived and designed the study. FG, EC, and MH acquired the
data. US, DSC-J, and GCSS analysed and interpreted that data.
FG, US, and GCSS drafted the manuscript. All authors critically
reviewed the manuscript for important intellectual content and approved
the final version for publication.
Declaration of interests
FG, US, EC, DSC-J, and GCSS report grants from the National Institute
for Health Research (NIHR) Cambridge Comprehensive Biomedical
Research Centre, grants from the Medical Research Council, grants from
the Stillbirth and neonatal death society (Sands), non-financial support
from Roche Diagnostics Ltd, non-financial support from GE Healthcare,
and non-financial support from NIHR Cambridge Clinical Research
Facility, all during the conduct of the study. GCSS reports grants from
the Scottish Government (Chief Scientist Office Division), grants and
personal fees from GlaxoSmithKline, and personal fees from Roche
Diagnostics, all outside the submitted work. Additionally, GCSS has a
patent pending (PCT/EP2014/062602). MH reports being an employee of
Roche Diagnostics and holding stock in F Hoffmann-La Roche.
Acknowledgments
We are extremely grateful to all the participants in the pregnancy
outcome prediction study. We thank Leah Bibby, Samudra Ranawaka,
Katrina Holmes, Josephine Gill, and Ryan Millar for technical assistance
with the biochemical assays. We thank Alison Dacey, Amanda Rowley,
Maxine Snaith, Sam Everett, Sonia Cumming, and Jan Nelder for
performing the research ultrasound scans. This study was funded by the
National Institute for Health Research (NIHR) Cambridge
Comprehensive Biomedical Research Centre (Women’s Health theme),
12 www.thelancet.com/child-adolescent Published online June 7, 2018 http://dx.doi.org/10.1016/S2352-4642(18)30129-9
and project grants from the Medical Research Council (UK; grant no
G1100221) and the Stillbirth and neonatal death society (Sands). The study
was also supported by Roche Diagnostics (provision of equipment and
reagents for analysis of soluble fms-like tyrosine kinase 1 and placental
growth factor), by GE Healthcare (donation of two Voluson i ultrasound
systems for this study), and by the NIHR Cambridge Clinical Research
Facility, where all research visits took place. US and GCSS had full access
to all the data in the study and take responsibility for the integrity of the
data and the accuracy of the data analysis. Elements of the content of this
paper were presented at the Society for Maternal-Fetal Medicine,
Las Vegas (2017) and Dallas (2018).
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