Research into fetal growth restriction

Fetal growth restriction (FGR) is a condition in which a baby's growth slows or stops when they are in the womb. It occurs in around five percent of all pregnancies.

The Manchester Placenta Clinic was established in 2009 as part of a project to improve the speed at which discoveries in placental research were translated into better care.

The placenta is a major organ of pregnancy, and malfunction can cause serious problems for mother and baby. The majority of cases of fetal growth restriction (FGR) are caused by failure of the placenta.

Once FGR is detected, the worst outcome, stillbirth, is usually preventable through intensive monitoring and early delivery. The problem comes when trying to detect FGR in 'low-risk' pregnant women who are currently not offered scanning in the last trimester of pregnancy in the UK.

The clinic was launched by obstetricians Dr Edward Johnstone and Dr Clare Tower, and research midwives Dr Tracey Mills and Suzanne Thomas. As well as providing improved diagnosis, the clinic allows patients to be recruited to studies involving MRI, placental science and ultrasound biomarkers. In addition, all antenatal and outcome data is logged on a special database and tissue and blood are stored in a long-term biobank.

The women are also entered into a register, so that development of their infants can be followed up.

The clinic has already provided specialised care to more than 440 women at high risk of fetal growth restriction. Some of these women are now returning in subsequent pregnancies. This is important as it shows development of women at high risk who will be able to trial future therapies.

Finding women at risk in time

It is already known that women with abnormal levels of certain hormones in pregnancy are at increased risk of FGR, but measuring these hormones alone is not enough to narrow down those with FGR, as around 80 percent of them will have a normal pregnancy.

The researchers at the Placenta Clinic have been using data from Canada suggesting that if the placenta is small or abnormally shaped following abnormal hormone measurements this can be an indication that the baby will fail to grow later in pregnancy and should be followed up with more ultrasound scanning. Initial results suggest that using these two tests, 95 percent of cases of FGR can be detected.

Lead investigator Dr Edward Johnstone says: 'We plan to further validate our results with a prospective trial in the coming year. Should this be successful, we will have succeeded in directly translating our scientific knowledge of placental function into real improvements in clinical care.'

Dr Edward Johnstone talks about FGR

In addition to developing predictive tests, are you also working on treatments for FGR and other placenta problems, such as pre-eclampsia?

Yes, we are. Unfortunately the situation is very similar to pre-eclampsia, and while we can reduce the severity of FGR in some women with predisposing conditions, sometimes there is nothing we can do. We are likely to be joining an international trial of one potential therapy next year, and we anxiously await the results of our and other groups’ animal work. Progress is frustratingly slow!

What kind of care do you give to women who are at high risk of FGR?

The main focus of the clinic at present is improving the detection of FGR so that Natasha’s FGR infant would have been recognised as such and delivered before the stillbirth occured.

For women who are clearly high risk we provide emotional support before and during pregnancy, getting women into the best state they can be before pregnancy, if possible, and then carefully ‘dragging’ the pregnancy out for as long as possible. There are some who we cannot help, but the majority leave with a baby. Our biggest strength is continuity. The women only ever see two doctors and two midwives throughout the entire course of their pregnancy. We are also flexible in our contact arrangements and would never let a woman wait more than a day before seeing her if she had concerns.

Do you think recent placenta research has led to greater understanding of the placenta and its problems?

As our group of women grows, it is very clear to us that we are dealing with multiple different types of FGR within our group of women. In cases where there has been true placental failure the women nearly all go forward for basic science research, and demonstrable differences are clearly present. As we get learn more we will become closer to narrowing down the best ways of treating women. That’s a long-winded way of saying yes, I guess!

Our main ‘breakthrough’ is that, along with others in the group, we are increasingly able to characterise placentas as being abnormal or normal both before and after delivery. This means that we are getting ever closer to being able to identify ‘high-risk’ pregnancies before the onset of FGR.

Do you think we are anywhere close to developing effective treatments for pre-eclampsia and FGR?

Depends what you mean by close! Five years?

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