FETAL GROWTH RESTRICTION

OBJECTIVE
Identify true FGRs . Identify the underlying cause and moniter. When to terminate ? How to terminate ?

DEFINITIONS
SGA : EFW at or below 10th percentile for the specific gestational age and for the specific population . Constitutionally Small Fetus True IUGR
Symmetrical IUGR (20%) 2. Asymmetrical IUGR (80%)
1.
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Parameters

Costitutionally small fetus (40%)

Symmetric FGR (20%)

Asymmetric FGR (40%)

PATHOLOGI NONE CAL INSULT BIOMETRY NORMAL

EARLY

LATE

NORMAL

ABNORMAL

DOPPLER

NORMAL

ABNORMAL

ABNORMAL

PROGNOSI S

GOOD

V.POOR

POOR

CAUSES
MATERNAL Chronic hypertension Pregnancy-associated hypertension Cyanotic heart disease Class F or higher diabetes Hemoglobinopathies Autoimmune disease Protein-calorie malnutrition Smoking Substance abuse Uterine malformations Thrombophilias Prolonged high-altitude exposure FETOPLACENTAL Twin-to-twin transfusion syndrome Placental abnormalities Chronic abruption Placenta previa Abnormal cord insertion Cord anomalies Multiple gestations

IDENTIFICATION OF HIGH RISK & F/U

IDENTIFICATION History Poor maternal weight gain . Abdominal palpation (30%) SFH (27-80% & 80%) Early preeclampsia F/U USG Uterine artery doppler screening UA doppler .

BIOMETRY

BPD

AC

FL

PRINCIPLE OF DOPPLER

UTERINE ARTERY

NORMAL WAVEFORM

EARYL DIASTOLIC NOTCHING

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Uterine artery conti.

i. ii. iii. iv. v.

Role in screening 16- 24 wks Two staged test FGR/ preeclampsia :

Persistent early diastolic notching >24 wks RI > 0.56 (18-24 wks) PI >1.45 (22-24 wks) S/D >2.18 (18 wk) Severe notching

NPV 99%
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UTERINE ARTERY

EARYL DIASTOLIC NOTCHING

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UMBILICAL ARTERY

1. 2. 3.

1st vessel to be studied gestation flow during diastole Indices :

S/D (4 20 wks, <3 >30, 2 at term ) PI = S-D/A RI = S-D/D PEDF RedEDF AEDF REDF Monitoring & diagnosis

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UMBILICAL ARTERY

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UMBILICAL WAVEFORM

PEDF

REDF

AEDF

REDF
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MCA WAVEFORM

NORMAL MCA WAVEFORM

ABNORMAL MCA WAVEFORM

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MCA WAVEFORM
Angle of insonation 0 . PI & PSV PI reflects brain sparing effect . Loss of cephalisation = PI and PSV (impending demise). Cerebroplacental ratio - gradient of redistribution . < 1.08 poor prognosis .
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VENOUS WAVEFORM
S
D

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VENOUS WAVEFORM
DV,IVC,UV Abn when fetus severely compromised. Late changes cardiac failure

1. End diastolic pulsations in the UV 2. Interrupted flow in DV. 3. reverse velocity during atrial contraction in IVC.
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DIAGNOSIS & MONITORING TOOLS

I) Determination of gestational age . II) Biometry (USG) Gestational age HC/AC GCA FL/AC BPD Ponderal index HC AFI/AFV AC EFW FL III) DFMR
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DIAGNOSIS & MONITORING TOOLS Cont

IV) NST /CST /VAST /BPP /MBPP V) Doppler VI) Invasive testing :
Amniocentesis . Umbilical cord blood sampling . G/V

F. erythropoeitin

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Slow Growth

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Normal Growth

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SEQUENCE OF EVENTS
Placental resistance
Efw<10th Ut A notching UA S/D UA/MCA >1 N variability in FHR UA/MCA <1 BPP =8 N variability AEDF variability No acc. BPP=6 Interrupted frward DV REDF UV pulsations Omnious FHR BPP =4 /2 Reverse art flow DV.

Plt. Insufficiency wth adq f.compensation.

Plt. Insufficiency wth f.decompensation.

Impending f. death

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MANAGEMENT
Umbilical art doppler

Normal

Reduced

Absent / Reversed

Liquor vol. Group C Group D

Normal (Group A)

Reduced (Group B)

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Group A
Absence of risk factors & EFW 3rd to 10th centile rescan at 4 weeks. If risk factors +nt then rescan at 3 weeks . EFW < 3rd centile detailed scan , karyotyping and congenital infection screen : rescan at 3 weeks . At nxt scan : Grth velocity and othr parameters n no f/u. Indices n , grth velocity red- karyotyping and infections. AC 10mm/wk If bth abn shift to higher grp accordingly .

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GROUP B
> 37 wks Deliver < 37 wks rpt scan at 3weeks , manage as grp A

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GROUP C
Rpt scan at 2 weeks . Rpt doppler weelky . CTG or BPP monitoring twice weekly. >36 wks wth poor fetal grth and deterioaration of UA doppler Deliver. Steriods if <36 wks .

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GROUP D
Admit and monitor as inpatient . Steriods >32 wks Deliver. CTG daily / twice wkly Short term variability < 3.5 or 2 successive non reactive NST Deliver. Doppler weekly . UV pulsations / reversed DV pulsations Deliver
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Labour
Inutero transportation CTG monitoring Early ARM Early cord clamping Skilled neonatologist, NICU

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INDICATIONS FOR LSCS

Prelabour evidence of F. acidemia,spont. Decelerations. Late dece. Wth minimal ut activity. AEDF/REDF in UA wth S. iugr Poor bishops AFI

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FETAL & NEONATAL COMPLICATIONS

Fetal hypoxia & acidosis Oligohydramnios Stillbirth RDS MAS IVH Hypo- glycemia,calcemia,thermia Hyperviscosity sydrm Encephalopathy Persistent fetal circulation
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COMPLICATIONS IN ADULT LIFE

Obesity NIDDM Hypertension Cardiovascular diseases fgr babies

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THERAPEUTIC TREATMENT
Behavioral strategies Balanced nutritional supplements Bed rest Aspirin Maternal estrogen administration Maternal hyperoxygenation

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Points to Ponder
Commonest aneuploidy trisomy 18 a/w severe iugr. Gestational age the key factor for diagnosis & termination . Use of customized growth charts good practice . PI & RI useful also when absent diastolic flow absent Early onset FGR usually true FGRs.
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Points to Ponder
Smaller the F size true FGRs. Early onset FGRs can have AFI in extremes of values Invasive testing for karyotyping extremes of AFI ;clear structural defects ; screen for infectns ; lung maturity . Balance the risk d/t IUD acidosisprematurity.

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Points to Ponder
In v.severe FGR cont. the preg till the point just b4 damage occurs . Normalization of cerebral flow after brain sparing effect- ominous sign . Completion of behavioral milestones at 32 wks 80% show reactive NST . >30% placental damage leads to dopller indices. >60% AEDF /REDF.
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Points to Ponder
CTG mean minute variation <3.5 msec ph <7.2. Sequence of loss of BPS NST + BM f/b FM + tone( acidotic).

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