Donigan, Emma C

Abstract Introduction Fetal growth restriction (FGR) is associated with an increased risk of neonatal morbidity and mortality. Current diagnostic criteria for FGR do not discriminate between constitutionally small and pathologically restricted fetuses. Following FGR diagnosis, umbilical artery (UA) Doppler is utilized to monitor fetal well‐being, but its limitations have increased interest in investigating growth velocity as an adjunctive tool. The objective of this study is to compare the predictive ability of UA Doppler studies and growth velocity for adverse neonatal outcomes in growth‐restricted fetuses. Methods This is a secondary analysis of a cohort of pregnancies delivered in a single healthcare network from August 2017 to December 2022, diagnosed antenatally with FGR. The cohort was restricted to those with baseline estimated fetal weight (EFW) between the 3rd and 50th percentiles. All subjects had growth velocity measured (defined as EFW percentile change per week between baseline and subsequent ultrasound). The primary outcome was a composite of neonatal morbidity (neonatal intensive care unit [NICU] admission, low 5‐min Appearance, Pulse, Grimace, Activity, Respiration score [<7], intraventricular hemorrhage, necrotizing enterocolitis, or metabolic acidosis) and severe adverse perinatal events (stillbirth or neonatal death, hypoxic ischemic encephalopathy, mechanical ventilation, or severe metabolic acidosis [pH < 7.0]). Neonatal morbidity and severe adverse perinatal events were analyzed separately as secondary outcomes. Independence between growth velocity and S/D ratio was evaluated. Univariate logistic regression models were then performed, with each outcome of interest as the dependent variable and S/D ratio and growth velocity as independent variables. Receiver operating characteristic (ROC) curves were generated to compare the performance of both tests. Results A total of 172 patients were included in the analysis. UA Doppler data were available for 165 patients, 15.3% of whom had S/D ratio >95th percentile; none demonstrated absent or reversed end‐diastolic flow. There was no correlation observed between S/D ratio percentile and growth velocity, suggesting independence. ROC analysis demonstrated that the discriminatory ability of growth velocity was higher across outcomes with areas under the curve (AUC) ranging from 0.65 to 0.69 while AUC for S/D ratio percentiles ranged from 0.51 to 0.53, approximating the performance of chance. Higher growth velocity was significantly associated with reduced odds of the composite outcome (odds ratio [OR], 0.79; 95% confidence interval [CI], 0.69–0.90), and neonatal morbidity (OR, 0.84; 95% CI, 0.73–0.95). S/D ratio percentile was not associated with these outcomes. Conclusion In pregnancies complicated by growth restriction with forward UA flow, growth velocity outperformed S/D ratio percentile in predicting adverse outcomes. The two tests were independent, indicating that growth velocity may reflect a component of fetal development not captured by UA Doppler. These results suggest that growth velocity could be used in addition to UA Doppler studies for fetal risk assessment, especially in fetuses with forward arterial flow.

Summary Bariatric surgery and glucagon-like peptide-1 receptor agonist medications (GLP-1RAs) are common and effective methods for treating obesity. Since bariatric surgery is associated with an increased risk of malnutrition, there are extensive post-operative dietary recommendations and nutritional monitoring guidelines. There is, however, less evidence regarding the risk of malnutrition with GLP-1RAs and little research on the use of GLP-1RAs in patients post-bariatric surgery. We present a clinical case in which a 39-year-old male on semaglutide therapy presented with severe weakness and inability to ambulate. His symptoms had developed over the prior 3 months following transoral outlet reduction surgery and worsened with an increase of his semaglutide dose to 1.7 mg/week. Physical examination demonstrated severe distal-predominant bilateral lower extremity weakness, loss of lower extremity reflexes, and impaired sensation distal to the T4 dermatome. Laboratory serum testing revealed thiamine and vitamin E deficiencies. Lumbar magnetic resonance imaging demonstrated mild homogeneous enhancement of the cauda equina nerve roots, neural foraminal narrowing, and disc protrusions without significant spinal canal stenosis. Given the absence of structural abnormalities, he was diagnosed with lumbosacral polyradiculopathy due to micronutrient deficiencies. Treatment included discontinuation of semaglutide and initiation of thiamine and vitamin E supplementation. He was admitted for inpatient rehabilitation therapy and demonstrated improvement of motor and sensory symptoms over the next month. With the increasing use of GLP-1RAs, it is crucial for clinicians, dietitians, and pharmacists to understand the risk and pathophysiologic processes of these medications when used in combination with other weight-loss therapies such as bariatric surgery. Learning points While there are robust pre- and post-operative micronutrient screening guidelines for patients undergoing bariatric surgery, nutritional monitoring guidelines are limited for patients on GLP-1 receptor agonist therapy or for patients with a history of bariatric surgery who are on GLP-1 receptor agonist therapy. The use of multiple weight-loss therapies that suppress appetite and nutrient intake may increase the risk of micronutrient deficiencies. Micronutrient deficiencies can have severe neurological manifestations, which may be correctable with nutritional supplementation. Avoid initiating GLP-1 receptor agonist therapy in close proximity to bariatric surgery. Further research is needed focusing on patients using multiple weight-loss therapies. This may contribute to the development of specific nutritional and micronutrient monitoring guidelines for this population. Endocrinologists, bariatric surgeons, and primary care providers must work together to care for patients undergoing weight-loss interventions.