Fetal growth restriction
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Fetal growth restriction Joseph Breuner, MD 8-08-05 Objectives Define risk factors Define screening Define diagnosis Define management Take-home points Risk factors: if positive, obtain ultrasound for growth 16-24 wks if negative, use fundal height to screen Take-home points

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Fetal growth restriction

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Fetal growth restriction l.jpg
Fetal growth restriction

Joseph Breuner, MD

8-08-05


Objectives l.jpg
Objectives

  • Define risk factors

  • Define screening

  • Define diagnosis

  • Define management


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Take-home points

  • Risk factors: if positive, obtain ultrasound for growth 16-24 wks

  • if negative, use fundal height to screen


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Take-home points

  • Screening: use fundal height > 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


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Take-home points

  • Define fetal growth restriction as <3rd%ile

  • follow 3-6th%ile carefully


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Take-home points

  • Red flags:

  • oligo: AFI < 5 deliver

  • systolic/diast ratio >95th %ile deliver

  • asymmetry--HC/AC >95%. Lower threshold for delivery, track other parameters closely


Risk factors l.jpg
Risk Factors

  • Fetal:

    • birth defect history (genetic syndromes, anomalies, karyotype abnormalities)

    • multiple gestation

    • uteroplacental insufficiency


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Risk factors

  • Maternal disease

    • starvation

    • hypoxemia due to heart/lung disease

    • antiphospholipid Ab syndrome

    • renal disease, chronic htn

    • pre-eclampsia


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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


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Risk Factors

  • Maternal demographics

    • high altitude

    • race

    • extremes reproductive age

    • nullip or grand multip

    • prior FGR neonate (29 vs 9%)

    • prepreg wt <10%ile or no wt gain


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Risk Factors

  • Conspicuous by their absence:

    • maternal wt gain 10-24 lbs


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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


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Diagnosis

  • Ultrasound: EFW based on AC, BPD and FL is best single measure to dx FGR and has

  • sensitivity90%

  • specificity85%

  • PPV80%

  • NPV90%


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Diagnosis

  • Understand three different entities present as small baby:

  • constitutionally small fetus

  • fetus with structural/chromosomal abn, fetal infection

  • uteroplacental insuffiency


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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


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diagnosis

  • Use 3 features to dx among 3 different entities

  • symmetric vs. asymmetric

  • AFI

  • umbilical artery velocimetry (S/D ratio)


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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


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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


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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 >mean for GA is abnormal

  • FL/AC ratio is independent of GA after 20wks. > 23.5 % is abnormal


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Diagnosis

  • Systolic/diastolic ratio of umbilical artery flow is abnormal if > 95%ile for GA or absent/reversed in > 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%)


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Management

  • Mortality rises quickly with SGA


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management

  • Severe FGR=delivery > 32-34 weeks,

  • weigh fetal mortality vs neonatal morbidity at earlier GA


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Management

  • FGR <6 but >3rd %ile

  • if constitutional, follow to term

  • if ‘birth defect’ manage per the dx

  • if asymmetric, weigh fetal well-being vs neonatal morbidity


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Management

  • FGR <6 but >3rd %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 > in utero risk


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Take-home points

  • Risk factors: if positive, obtain ultrasound for growth 16-24 wks

  • if negative, use fundal height to screen


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Take-home points

  • Screening: use fundal height > 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


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Take-home points

  • Define fetal growth restriction as <3rd%ile

  • follow 3-6th%ile carefully


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Take-home points

  • Red flags:

  • oligo: AFI < 5 deliver

  • systolic/diast ratio >95th %ile deliver

  • asymmetry--HC/AC >95%. Lower threshold for delivery, track other parameters closely


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references

  • Williams chapter 29 2002 (pocket pc memo avail)

  • Up to date march 2005


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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?


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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

  • what’s your dx?

  • What do you do?


Case 138 l.jpg
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?


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Case #1

  • 2nd scan 4wks later at 30 wks LMP:

  • EFW 7%ile for LMP

  • symmetric

  • normal UAV

  • what do you do?


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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?


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Case #2

  • Maternal tox screen negative

  • Basic US shows EFW 6%ile for LMP GA

  • what else do you want to know about US?


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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: ?


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Case #2

  • Management?


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Case #2

  • Follow up scan at 31 wks

  • EFW 4%ile

  • AC2%ile

  • HC/AC >2 SD

  • FL/AC 28%

  • S/D ratio 2.8, abnl is 3 for this GA

  • management?


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