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Fetal growth restriction

Fetal growth restriction. Joseph Breuner, md March 15, 2011. Teaching points. 16 wk rule Small vs in trouble Safer out or in: <34 wks use normal UA flow by DV to continue >34 wks deliver if Maternal htn Growth arrest x 3-4 wks Bpp low (<6/8) DV UA reversed or absent. Teaching points.

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Fetal growth restriction

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  1. Fetal growth restriction Joseph Breuner, md March 15, 2011

  2. Teaching points • 16 wk rule • Small vs in trouble • Safer out or in: • <34 wks use normal UA flow by DV to continue • >34 wks deliver if • Maternal htn • Growth arrest x 3-4 wks • Bpp low (<6/8) • DV UA reversed or absent

  3. Teaching points • 16 wk rule • Small vs in trouble • Safer out or in: • <34 wks use normal UA flow by DV to continue • >34 wks deliver if • Maternal htn • Growth arrest x 3-4 wks • Bpp low (<6/8) • DV UA reversed or absent

  4. outline Risk factors Diagnosis Evaluation management

  5. Risk factors Fetal Placental maternal

  6. fetal • Genetic-SGA parent, sibling • Chromosomal abnormality • Congenital anomalies • Multiple gestation • infection

  7. Placental risk factors • Ischemic placental disease=preeclampsia, FGR, abruption or combination • Small placenta- • Confined placental mosaicism

  8. Maternal factors 1 • Uteroplacental insufficiency: htn, renal dz, diabetes, CVD, SLE, antiphospholipid syndrome, preeclampsia • Diminished caloric intake • Hypoxemia-pulm dz, cyanotic heart dz, severe anemia, high altitude

  9. Maternal factors 2 • Hematologic d/o-sickle • Substance use-smoking, alcohol, stimulants • Toxins-meds warfarin, anticonvulsants, chemo, mtx • Caffeine • radiation

  10. Maternal factors 3 • ART • Uterine malformations • Extremes of reproductive age • Short interpregnancy interval

  11. outline Risk factors Diagnosis Evaluation management

  12. 16 week rule 1st 16 weeks: all cell division, uniform 2nd 16 weeks (16-32) combo cell division and growth, much more variability 32-40 primarily cell growth

  13. 16 week rule 1st 16 weeks: all cell division, uniform 2nd 16 weeks (16-32) combo cell division and growth, much more variability 32-40 primarily cell growth

  14. definition <10%ile (50-70% will be constitutionally small) Some malnourished fetuses will be >10th%ile <5%ile Severe<3%ile

  15. GA • Needs early US • Accuracy of Ultrasound decreases with advancing GA: • 1st TM: ± 3-5 days • 14-20 weeks: ± 7-10 days • 20-26 weeks: 2-3 weeks • Beyond 36 weeks: 3-4.5 weeks

  16. Fundal height • Define by > 2cm discrepancy after 20 wks • Best when • Same clinician • Unmarked side of tape

  17. Symmetric/asymmetric Symmetric-all organs decreasd proportionally due to hyperplasia(division) impairment Asymmetric-relatively greater decrease in abdominal size(liver volume/sq fat) than head circumference. Redistribution of blood flow to head

  18. Symmetric-3 causes • Constitutionally small • Aneuploidy/congenital anomalies • Early infection

  19. asymmetric • Always substrate deficiency

  20. For fetuses <10th%ile 70% 20% 10%

  21. For fetuses <5th%ile 40% 40% 20%

  22. For fetuses <3th%ile 20% 53% 27%

  23. ultrasound Crucial tool to Confirm/exclude dx Differentiate symmetric/asymmetric Verify fetal tolerance/well being

  24. biometry Purpose of biometry is to detect FGR

  25. Who gets an ultrasound? • >2cm FH discrepancy once • 2 cm FH discrepancy more than once • Or following RF’s

  26. US Screening for IUGR • Previous IUGR fetus • Maternal medical condition • CHTN, autoimmune disorders, asthma, APS • Multiples • Uterine anomaly • Placental abnormality • Marginal/velamentous cord • Ongoing bleeding • Chronic abruption, previa • Abnormal serum screening analytes

  27. AC most sensitive 3616 preg >25 wks gestation Single us within two wks delivery Predicted <10th%ile for GA with Sens 61% Spec 95% Ppv 86% Npv 83%

  28. AC • More predictive of FGR than • HC • BPD • Combination

  29. AC • More sensitive in asymmetric than symmetric GR (73%vs59%) • GA-more sensitive later in gestation • Sn/PPV at 29-31 wks 41/51%, at term 88/71% • More sensitive when interval between measurements >2wks. FP rates for interexam intervals 1,2,4 wks 31,17,3%

  30. EFW Best algorithm uses ac,bpd,fl EFW within 10% of actual bw 75% of time Sn/sp/ppv/npv 90/85/80/90 Sens increases with worsening GR Log10 BW = 1.335 - 0.0034(AC)(FL) + 0.0316(BPD) +0.0457(AC) + 0.1623(FL)

  31. Growth velocity • Small vs in trouble • Falling %iles shd raise alarm

  32. ratios • HC/AC • FL/AC • TCD/AC

  33. Diagnosis summary • Of four entities described-AC, EFW, growth velocity, and ratios • Dx depends on EFW • Log10 BW = 1.335 - 0.0034(AC)(FL) + 0.0316(BPD) +0.0457(AC) + 0.1623(FL)

  34. Diagnosis summary • 10%ile-at risk • 5th%ile act • 3rd%ile

  35. Evaluation and management • H+P-etoh,tobacco, maternal vasc dz • Anatomic survey/fetal echo • Karyotype for <32 wks, <3rd %ile, polyhydramnios or structural anomalies • Ab testing for cmv/rubella/vzv only if maternal symptoms suggestive or US shows echo/calcification of liver, brain, or hydrops

  36. follow • Fetal wt for growth velocity q 2-4 wks • BPP 1-2x/wk • Amniotic fluid volume weekly (part of bpp) • doppler

  37. doppler • Cochrane review • Doppler vs no doppler in FGR pregnancies • Reduced perinatal deaths by 29% (OR 0.71, CI 0.5-1.01)

  38. Umbilical artery • Increasing systolic/diastolic ratio, f/b • Absent or reversed end-diastolic flow

  39. Middle cerebral artery • Reported as umbilical/intracranial ratio, or • Peak velocity of middle cerebral artery

  40. Umbilical vein or ductus venosus • Ductus venosus flow reverses • Umbilical vein develops pulsatile flow

  41. Sample us report from inpt • Indication: IUGR with estimated weight on the 3rd percentile on 3/11/2011. Admitted for treatment. Comparison: 12/3/2010 through 3/11/2011. Expected menstrual age of 32 weeks 5 days with EDD 5/3/2011. The fetus is vertex with an anterior normal appearing placenta of normal thickness. The amniotic fluid is decreasing. AFI is 6 to 7 today done 3 times. The AFI was 10 on 3/11/2011. Fetal Doppler: Performed because of IUGR The umbilical arterial systolic diastolic ratio of 2.5 is normal. The umbilical/intracranial Doppler ratio of 0.5 is normal. The ductus venosus waveform was technically difficult to obtain because of fetal position, but limited adequate samples appear normal.

  42. Sample us report • Based on EDD 5/13/2011, the expected menstrual age is 31 weeks. Twin live intrauterine fetuses identified. The presenting twin is in breech position and the nonpresenting twin is in cephalic position. Confluent posterior placenta is identified. Separating membrane is visualized. • The amount of amniotic fluid appears normal for twin A with the amniotic fluid index of 11. The amount of amniotic fluid appears normal for twin B with the amniotic fluid index of 12. There is no evidence for hydrops fetalis for either twin. • OB DOPPLER performed, per request, because of monochorionicity. Twin A: Umbilical artery Doppler shows normal systolic to diastolic ratio of 2.5. Umbilical/intracranial Doppler ratio of 0.4 is normal. Middle cerebral artery peak systolic velocity 55 cm/sec is 1.3 multiples of the median and normal. Twin B: Umbilical artery Doppler shows normal systolic to diastolic ratio of 2.9. Umbilical/intracranial Doppler ratio of 0.4 is normal. Middle cerebral artery peak systolic velocity 42 cm/sec is 1.0 multiples of the median and normal.

  43. steroids • Two large studies conflict • Reasonable to administer • Likely the very impaired fetus can’t respond

  44. Delivery timing • Growth Restriction Intervention Trial (GRIT) • 580 women 24-34 wks • Randomly assigned to immediate or delayed delivery groups if ob uncertain when to intervene • 90%FGR • 40% absent or reversed end diast UA flow

  45. GRIT • Immediate delivery: when ob uncertain • Delayed delivery: when ob no longer uncertain (average delay 4.9d) • Deaths prior to hospital d/c same 29/27 • Immediate fewer stillbirths (2 v 9) but more neonatal/infant deaths (27 v 18)

  46. Recommended management • Remote from term <34 wks • Follow doppler. Prolong pregnancy if UA flow normal. Deliver if absent/reversed • Some experts await abnormal venous flow in very preterm-investigational

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