Improving detection of small infants during pregnancy

ISRCTN	ISRCTN67698474
DOI	https://doi.org/10.1186/ISRCTN67698474
Protocol serial number	20296
Sponsor	Comprehensive Clinical Trials Unit at UCL
Funders	Tommy's Baby Charity, Stillborn and Neonatal Death Charity, Guy's and St Thomas' Charity

Submission date: 27/06/2016
Registration date: 02/11/2016
Last edited: 09/01/2024

Recruitment status: No longer recruiting
Overall study status: Completed
Condition category: Pregnancy and Childbirth

Prospectively registered

Protocol

Statistical analysis plan

Results

Individual participant data

Plain English summary of protocol

Background and study aims
Stillbirth is when a baby dies in the womb and has to be delivered. It is a tragedy with lifelong consequences for parents and their family and friends. In the UK the number of babies stillborn has not fallen in the past 20 years, and currently affects 1 in every 200 pregnancies. This means that stillbirth in the UK is amongst the highest in Europe. Doctors, midwives and politicians want to change this, and recently reducing stillbirths has been identified as a priority. Most babies that die before birth are normal, but many weigh less than expected. One of the most common reasons for these baby deaths is poor growth in the womb. Often this has gone unnoticed by the doctors and midwives. A baby’s growth in the womb relies on the placenta (afterbirth) working well and providing all the nutrients the baby needs. There are many reasons why the placenta does not work well, and in most cases, with the exception of stopping cigarette smoking, there is little the mother can do to improve this. But most small babies are healthy and growing normally. They are small because of genes inherited from their parents. Factors like parents’ body size and ethnic background are likely to help doctors and midwives work out which babies are small but growing normally and which are small because their placenta is not working well. These babies could be at risk of being stillborn. Previously, a large study has suggested that a package known as Growth Assessment Protocol (GAP), which takes these factors into account, has reduced the stillbirth rates in three regions of the UK. However, there are many other possible reasons other than the GAP that could have led to the reduction in stillbirths in this study. The aim of this study is to look at the impact of the GAP, and whether it really does reduce stillbirths, so that doctors, midwives and policy makers will know whether they should put resources in place to use GAP in all NHS hospitals.

Who can participate?
Pregnant women delivering their baby at a participating hospital.

What does the study involve?
Participating maternity units are randomly allocated to one of two groups. Those in the first group will provide care according to the GAP programme (immediate implementation). For participating women, this involves a standardized way of having their risk of having a baby that is too small for its age assessed at 12 weeks and screening for small infants after 24 weeks using customized centiles (measurements) according to GAP principles. Those in the second group receive usual care, which could involve having their risk of having a baby that is too small for its age assessed at 12 weeks and screening methods for small babies after 24 weeks bases as per routine care. Participants in both groups are followed up until delivery by the clinical team in their hospital to find out if they had a small baby.

What are the possible benefits and risks of participating?
There are no direct benefits or risks involved with participating in this study.

Where is the study run from?
Maternity units across 13 NHS Trusts in England (UK)

When is the study starting and how long is it expected to run for?
January 2015 to October 2018

Who is funding the study?
Tommys (UK)

Who is the main contact?
Dr Matias Costa Vieira
matias.vieira@kcl.ac.uk

Contact information

Dr Matias Costa Vieira
Scientific

Division of Women's Health
King's College London
10th Floor North Wing
St Thomas' Hospital
Westminster Bridge Road
London
SE1 7EH
United Kingdom

ORCID ID	0000-0002-8076-4275
Phone	+44 7188 7188 ext. 52545
Email	matias.vieira@kcl.ac.uk

Study information

Primary study design	Interventional
Study design	Randomised; Interventional; Design type: Screening, Diagnosis, Complex Intervention
Secondary study design	Cluster randomised trial
Study type	Participant information sheet
Scientific title	The DESiGN Trial: Detection of small for gestational age fetus (SGA) – a cluster randomised controlled trial to evaluate the effect of the Growth Assessment Protocol (GAP) programme
Study acronym	DESiGN
Study objectives	The GAP programme improves the detection of small for gestational age fetuses when compared to currant clinical practice.
Ethics approval(s)	London - Bloomsbury Research Ethics Committee, 29/02/2016, ref: 15/LO/1632
Health condition(s) or problem(s) studied	Specialty: Reproductive health and childbirth, Primary sub-specialty: Reproductive and sexual medicine
Intervention	Hospitals will be randomized to one of two groups. The method of allocation is the random permutation of clusters within each of two equally sized strata; clusters are divided in the two strata according to their size (deliveries per year in 2013-2014) and then randomized to either early or delayed implementation. Early implementation arm: The GAP programme will be immediately implemented with training and the use of protocols consistent with the principles of GAP. Women in this study arm will be risk assessed for SGA and managed as per GAP protocol. Low risk women will be seen routinely in antenatal clinic. At these visits standardised FH measurements will be performed from 28 weeks. In high risk women serial ultrasounds after 24 weeks will be recommended. Customised FH and ultrasound charts will be generated at the first trimester ultrasound visit. FH measurements will be plotted on the customised FH chart. In low risk women any deviation in growth on these charts will result in recommendation for ultrasound measurement. Estimated fetal weight (EFW) from ultrasound measurements will be plotted on customised EFW charts for both low or high risk women whenever an ultrasound is done. Delayed implementation arm: Women will have a risk assessment according to routine practice (if available) and screening for SGA according to local protocol (if available) and use of population charts as reference for diagnosis of SGA in antenatal ultrasounds. GAP will be introduced after the data collection for outcomes. Majority of participating women will not be required to return for additional research visits but some women in the study will be approached by the research team and invited to take part in interviews to explore the experience of receiving care in line with GAP programme. Source of data will vary according to the outcome assessed. Most of the data will be acquired from routine hospital data. This will include manly electronic records but also review of some clinical notes. Data will be obtained from hospital maternity electronic systems which record antenatal, ultrasound, intrapartum, postnatal and neonatal information. Data obtained manually from clinical notes will be entered into a trial database. For the implementation component of the study primary data collection from interviews and focus groups will be performed.
Intervention type	Other
Primary outcome measure(s)	Detection rate of SGA infants measured by ultrasound after 24 weeks* is assessed using data from the maternity and ultrasound system between months 13 to 18 of study. * The antenatal charts used for ultrasound detection (numerator) will depend on the allocation arm of the trial. The denominator for the estimation of detection in each arm of the trial will be the same population of SGA infants (birthweight <10th centile) by both customised and population
Key secondary outcome measure(s)	1. Detection rate (sensitivity), specificity, false positive and false negative of SGA by customised centiles measured by ultrasound after 24 weeks 2. Detection rate (sensitivity), specificity, false positive and false negative of SGA by population centiles measured by ultrasound after 24 weeks Clinical outcomes: Neonatal: 1. Gestational age measured in weeks at birth 2. Birthweight measured in grams at birth 3. Head circumference measured in centimeters at birth 4. Apgar score <7 measured using Apgar scale at birth 5. Metabolic acidosis defined as an arterial cord ph<7.1 at birth 6. Rate or need of respiratory support in delivery room at birth 7. Rate of neonatal intensive care after birth 8. Length of stay in neonatal intensive care unit (NICU) measured in days 9. Level of care needed in NICU 10. Rate of major neonatal morbidity defined as one or more of the following: intraventricular haemorrhage, supplementary oxygen requirements > 28 days, necrotizing enterocolitis, sepsis, retinopathy of prematurity 11. Length of stay in transitional care measured in days 12. Rate of neonatal morbidity defined as one or more of the following: hypothermia, hypoglycaemia, nasogastric tube feeding 13. Rate or stillbirth (antepartum and intrapartum) 14. Rate of neonatal death (early and late) 15. Rate of neonatal death before discharge (after 28 days of birth) Maternal: 1. Rate of induction of labour measured at birth 2. Rate of caesarean section measured at birth 3. Rates of postpartum haemorrhage (>1000ml) measured at birth 4. Rate of severe perineal trauma (3rd / 4th degree tear) measured at birth 5. Length of stay in hospital measured in days 6. Method of breast feeding measured at discharge Health economics outcomes: 1. Number of ultrasound scans after 24 weeks measured at delivery (as average of ultrasound per women) 2. Number of antenatal clinic / antenatal day unit measured at delivery (as average of ultrasound per women) Process evaluation of implementation outcomes: 1. Proportion of staff trained measured at the end of training period (expected to be at month 6 of study) 2. Proportion of staff assessed for GAP training at the end of training period (expected to be at month 6 of study) 3. Proportion of women assessed with GAP programme measured throughout the study by review of notes of a sample of participants 4. Adherence to SGA risk stratification and management protocols and missed case analysis measured throughout the study and assessed by hospital level data (data available from risk assessment) Outcomes for other methods of assessments of antenatal detection of SGA: 1. Detection rate of SGA (birthweight<5th centile) measured by ultrasound after 24 weeks 2. Detection of SGA infants measured as clinical detection before birth (review of notes)
Completion date	30/11/2019

Eligibility

Participant type(s)	Patient
Age group	Adult
Sex	All
Target sample size at registration	108
Key inclusion criteria	Hospitals: 1. Willing to implement GAP 2. Willing to participate in the trial Patients: 1. Pregnant women 2. Delivering at one of the participating hospitals during the study period
Key exclusion criteria	Hospitals that have fully implemented or will not be introducing GAP.
Date of first enrolment	01/12/2016
Date of final enrolment	30/04/2018

Locations

Countries of recruitment

United Kingdom
England

Study participating centres

Guy's and St Thomas' NHS Foundation Trust

Great Maze Pond
London
SE1 9RT
United Kingdom

Homerton University Hospital NHS Foundation Trust

Homerton Row
London
E9 6SR
United Kingdom

University College London Hospitals NHS Foundation Trust

250 Euston Road
London
NW1 2PG
United Kingdom

St George's Healthcare NHS Trust

Blackshaw Road
London
SW17 0QT
United Kingdom

Kingston Hospital NHS Trust

Galsworthy Road
Kingston upon Thames
KT2 7QB
United Kingdom

Croydon Health Services NHS Trust

London Road
Thornton Heath
CR7 7YE
United Kingdom

Imperial College Healthcare NHS Trust

Pread Street
London
W2 1NY
United Kingdom

The Hillingdon Hospitals NHS Foundation Trust

Pield Heath Road
Uxbridge
UB8 3NN
United Kingdom

North West London Hospitals NHS Trust

Watford Road
Harrow
HA1 3UJ
United Kingdom

West Middlesex University Hospital NHS Trust

Twickenham Road
Isleworth
TW7 6AF
United Kingdom

Royal Surrey County Hospital NHS Foundation Trust

Egerton Road
Guildford
GU2 7XX
United Kingdom

North Middlesex University Hospital NHS Trust

Sterling Way
London
N18 1QX
United Kingdom

Chesterfield Royal Hospital NHS Foundation Trust

Chesterfield Road
Chesterfield
S44 5BL
United Kingdom

Results and Publications

Individual participant data (IPD) Intention to share	Yes
IPD sharing plan summary	Stored in repository
IPD sharing plan	The anonymised data will be stored centrally by the sponsor (Clinical Trials Unit at University College London).

Study outputs

Output type	Details	Date created	Date added	Peer reviewed?	Patient-facing?
Results article		05/09/2022	06/09/2022	Yes	No
Results article	Health economics outcomes	07/07/2022	09/01/2024	Yes	No
Protocol article	protocol	04/03/2019	07/03/2019	Yes	No
HRA research summary			28/06/2023	No	No
Interim results article	sub-study results	08/03/2021	10/03/2021	Yes	No
Participant information sheet	Participant information sheet	11/11/2025	11/11/2025	No	Yes

Editorial Notes

09/01/2024: Publication reference added.
06/09/2022: Publication reference added.
10/03/2021: Publication reference added.
07/03/2019: Publication reference added.
30/11/2018: The overall trial end date has been changed from 30/11/2018 to 30/11/2019.
08/08/2018: The following changes have been made:
1. SANDS and Guy's and St Thomas' Charity have been added as funders.
2. The overall trial end date has been changed from 31/10/2018 to 30/11/2018.
3. The intention to publish date has been changed from 31/12/2018 to 28/02/2020.