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Fetal growth restriction

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Screening: use fundal height 2cm discordant from GA after 20 wks or =2cm ... cellular hyperplasia up to 16 wks. cellular hyperplasia and hypertrophy 16 to 32 wks ... – PowerPoint PPT presentation

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Title: Fetal growth restriction


1
Fetal growth restriction
  • Joseph Breuner, MD
  • 8-08-05

2
Objectives
  • Define risk factors
  • Define screening
  • Define diagnosis
  • Define management

3
Take-home points
  • Risk factors if positive, obtain ultrasound for
    growth 16-24 wks
  • if negative, use fundal height to screen

4
Take-home points
  • Screening use fundal height gt 2cm discordant
    from GA after 20 wks or 2cm discordant from GA
    on serial visits
  • Either risk factor or fundal height discrepancy
    ultrasound
  • both fh and us most accurate 18-34 wks

5
Take-home points
  • Define fetal growth restriction as lt3rdile
  • follow 3-6thile carefully

6
Take-home points
  • Red flags
  • oligo AFI lt 5 deliver
  • systolic/diast ratio gt95th ile deliver
  • asymmetry--HC/AC gt95. Lower threshold for
    delivery, track other parameters closely

7
Risk Factors
  • Fetal
  • birth defect history (genetic syndromes,
    anomalies, karyotype abnormalities)
  • multiple gestation
  • uteroplacental insufficiency

8
Risk factors
  • Maternal disease
  • starvation
  • hypoxemia due to heart/lung disease
  • antiphospholipid Ab syndrome
  • renal disease, chronic htn
  • pre-eclampsia

9
Risk factors
  • Maternal exposure
  • infections prior to 20 wks rubella,
    toxoplasmosis, cmv, vzv, malaria
  • substance abuse smoking, alcohol, drug use
  • meds coumadin, anticonvulsants, antineoplastic
    agents, folic acid antagonists

10
Risk Factors
  • Maternal demographics
  • high altitude
  • race
  • extremes reproductive age
  • nullip or grand multip
  • prior FGR neonate (29 vs 9)
  • prepreg wt lt10ile or no wt gain

11
Risk Factors
  • Conspicuous by their absence
  • maternal wt gain 10-24 lbs

12
Screening
  • Order
  • basic ultrasound from hospital or swedish nuc
    med/ultrasound, because umbilical artery
    measurements are useful by themselves
  • anatomic survey comes with this scan, is useful
    to dx birth defects group

13
Diagnosis
  • Ultrasound EFW based on AC, BPD and FL is best
    single measure to dx FGR and has
  • sensitivity 90
  • specificity 85
  • PPV 80
  • NPV 90

14
Diagnosis
  • Understand three different entities present as
    small baby
  • constitutionally small fetus
  • fetus with structural/chromosomal abn, fetal
    infection
  • uteroplacental insuffiency

15
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16
diagnosis
  • 3 phases of growth
  • cellular hyperplasia up to 16 wks
  • cellular hyperplasia and hypertrophy 16 to 32 wks
  • cellular hypertrophy 32 wks to term

17
diagnosis
  • Use 3 features to dx among 3 different entities
  • symmetric vs. asymmetric
  • AFI
  • umbilical artery velocimetry (S/D ratio)

18
diagnosis
  • Symmetric vs. asymmetric
  • symmetric growth restricted babies are small from
    the beginning, all measurements are equally small
    and grow on their own curve, hence title
  • includes constitutional and birth-defect
  • 20-30 of growth restricted fetuses

19
diagnosis
  • Asymmetric relatively greater decrease in
    abdominal size than head circumference
  • results from redistribution of blood flow to
    vital organs in UPI
  • 70-80 of growth-restricted fetuses

20
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21
Diagnosis
  • Ultrasound use AC, along with HC/AC and FL/AC
    ratios to dx asymmetric FGR
  • HC/AC ratio decreases linearly so is expressed in
    terms of SD above the mean. 2 SD gtmean for GA is
    abnormal
  • FL/AC ratio is independent of GA after 20wks. gt
    23.5 is abnormal

22
Diagnosis
  • Systolic/diastolic ratio of umbilical artery flow
    is abnormal if gt 95ile for GA or absent/reversed
    in gt 18-20 wk fetus
  • for diagnosing FGR, in comparison to US,
  • less sensitive (55 vs. 76)
  • more specific (92 vs 80)
  • higher PPV (73 vs 58)

23
Management
  • Mortality rises quickly with SGA

24
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25
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27
management
  • Severe FGRdelivery gt 32-34 weeks,
  • weigh fetal mortality vs neonatal morbidity at
    earlier GA

28
Management
  • FGR lt6 but gt3rd ile
  • if constitutional, follow to term
  • if birth defect manage per the dx
  • if asymmetric, weigh fetal well-being vs neonatal
    morbidity

29
Management
  • FGR lt6 but gt3rd ile
  • Growth scans every 2-4 weeks
  • Be aggressive re UAV
  • BPP/AFI q wk in some birth defects group and
    all uteroplacental insufficiency
  • increase BPP/AFI to daily if abnl but delivery
    risk gt in utero risk

30
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31
Take-home points
  • Risk factors if positive, obtain ultrasound for
    growth 16-24 wks
  • if negative, use fundal height to screen

32
Take-home points
  • Screening use fundal height gt 2cm discordant
    from GA after 20 wks or 2cm discordant from GA
    on serial visits
  • Either risk factor or fundal height discrepancy
    ultrasound
  • both fh and us most accurate 18-34 wks

33
Take-home points
  • Define fetal growth restriction as lt3rdile
  • follow 3-6thile carefully

34
Take-home points
  • Red flags
  • oligo AFI lt 5 deliver
  • systolic/diast ratio gt95th ile deliver
  • asymmetry--HC/AC gt95. Lower threshold for
    delivery, track other parameters closely

35
references
  • Williams chapter 29 2002 (pocket pc memo avail)
  • Up to date march 2005

36
Case 1
  • 26 yo G3P1SAB1 has normal prenatal course. No FH
    birth defects. You obtain clinic US for gender at
    22 wks and they measure size 20 wks /- 2 wks.
    FH are normal.
  • What do you do?

37
Case 1
  • You decide to obtain a hospital ultrasound 4 wks
    later, now 26 wks by LMP
  • shows EFW 15 ile for LMP
  • GA is 24 wks /-2 wks by biometry
  • umbilical artery S/D ratio is 1.4
  • whats your dx?
  • What do you do?

38
Case 1
  • More results from same US
  • no anatomic defects
  • HC ile close to AC ile, HC/AC and FL/AC
    ratios are normal
  • NOW what do you do?

39
Case 1
  • 2nd scan 4wks later at 30 wks LMP
  • EFW 7ile for LMP
  • symmetric
  • normal UAV
  • what do you do?

40
Case 2
  • 22 yo G1P1 smoker has hx IVDU and remote hx
    hypertension
  • 2nd prenatal visit is 28 wks
  • insists she knows when she got pregnant
  • what do you do?

41
Case 2
  • Maternal tox screen negative
  • Basic US shows EFW 6ile for LMP GA
  • what else do you want to know about US?

42
Case 2
  • Anatomic survey intact
  • AC 4 ile
  • HC/AC ratio 1.6 standard deviations above mean
  • UAV S/D ratio 1.8, normal for this GA
  • Dx ?

43
Case 2
  • Management?

44
Case 2
  • Follow up scan at 31 wks
  • EFW 4ile
  • AC2ile
  • HC/AC gt2 SD
  • FL/AC 28
  • S/D ratio 2.8, abnl is 3 for this GA
  • management?
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