Small for

gestational age
Dr.V.Ravimohan
SpR
• Definition
• Implications
• Causes
• Diagnosis
• management
 Definition
SGA refers to a fetus that has failed to achieve a
specific biometric or estimated weight threshold by
a specific gestational age.

10 th centile

Abdominal circumference

Estimated fetal weight

 One of most frequently sited
suboptimal care is the failure

 to suspect growth restriction in a mother

with a previous history
 to detect
 to act on
 to monitor
 Implications
• stillbirth
• birth hypoxia
• neonatal complications
• Neurodevelopment delay
• type 2 (non-insulin-dependent) diabetes
and hypertension in adult life.
 Small for gestational babies
Small for gestational babies

Fetal growth
Fetal growth
restriction
restriction30%
30% constituninal small babies

constitutional
Fetal growth restriction

constituninal
small babies Fetal growth restrictio
constitutional
70%

70%

Ott Wj.The diagnosis of altered fetal growth.Obstet Gynecol Clin North Am 1988;15:237-63
 population sensitivity specificity
SFH General 27% 88%

customised General 48%

fundal chart
ultrasound High risk 72.9–94.5% 50.6–83.8%
scan
biometry(AC)
 Improving sensitivity…

– Use customised ultrasound

charts(maternal weight, maternal
height, ethnic group and parity)

– Use growth velocity in addition to size

biometric tests biophysical tests

designed to predict size fetal wellbeing

•abdominal palpation •Doppler

•symphyseal fundal height •Amniotic fluid index
•ultrasound biometry •CTG
•ultrasound estimated fetal
weight

diagnosis of SGA more indicative of FGR than

SGA
 Management
• (I) aetiology(ex.chromosomal defects)
• (ii)arrange surveillance
• (iii) delivery-
» when?
» how?
» where?
 Causes of Growth restriction

6%
8%

12%
Severe UP dysf uction
Chromosomal abnormality
Structural malf ormation
Congenital inf ection
54% miscellaneous

20%

High risk pregnancy management options 2nd edition p300

 Chromosomal abnormalities

th
10 Centile 7%

th
5 Centile 19%
 Surveillance
• Umbilical artery doppler is the primary
surveillance tool
– frequency of monitoring in SGA fetuses
with normal Doppler need not generally
be more than once every fortnight.
 Doppler indices
S/D ratio Systolic peak velocity
diastolic peak velocity
Systolic-end diastolic peak velocity
Resistance index
systolic peak velocity

Systolic-end diastolic peak velocity

Pulsatility index
Mean systolic velocity
 Doppler

EDF present
Absent/Reverse EDF
Delay delivey till 37w*

<34 weeks
>34 weeks (i)Admission
deliver (ii)Closed surveillance
(iii)steroids
 <34 weeks with RED/AED
• Daily CTG/Biophysical profile/Venous
doppler
• Consider delivery
» Pathological CTG
» Biophysical score <4
» Reversal of doppler velocities in ductus venosus
during atrial contraction or umbilical vein pulsations
• My web site:www.mrcogexam.net

• MY blog :http://mrcogfacts.blogspot.com/
Survival by birth weight
Survival by gestation
 Growth Restriction Intervention
Trial (GRIT)
• Hypothesis:early delivery,to pre-empt
intrauterine hypoxia,would alter brain
development compared with delaying
delivery for as long as possible ,to gain
maturity.
 588 babies
(fetal compromise
between 24-36
weeks)

Immediate delivery Delivery when obstetrician

no longer uncertain
(296) (292)
 D e a t h a n d s e v e r e d i s a b il i t y a t 2 y r s

I m m e d ia t e d e liv e r y 5 5 ( 1 9 % ) D e la y e d d e liv e r y 4 4 ( 1 6 % )

OR 1.1(0.7-1.8)
 Conclusion
• The present study should discourage
doctors who deliver fetuses (<30 weeks)
before at which they delivery can be
delayed no longer.
 Mode of delivery
Indications for LSCS
(I)late decelerations in antenatal CTG
(II)Reversed End diastolic flow
(III)thick meconium during induction of
labour

Clinical obstetrics and Gynaecology

40:4:1997;p822
 Summary
• Definition
• Implications
• Causes
• Diagnosis
• management