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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

Fetal growth restriction

Joseph Breuner, md

March 15, 2011

teaching points
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 points4
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
outline
outline

Risk factors

Diagnosis

Evaluation

management

risk factors
Risk factors

Fetal

Placental

maternal

fetal
fetal
  • Genetic-SGA parent, sibling
    • Chromosomal abnormality
  • Congenital anomalies
  • Multiple gestation
  • infection
placental risk factors
Placental risk factors
  • Ischemic placental disease=preeclampsia, FGR, abruption or combination
  • Small placenta-
  • Confined placental mosaicism
maternal factors 1
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
maternal factors 2
Maternal factors 2
  • Hematologic d/o-sickle
  • Substance use-smoking, alcohol, stimulants
  • Toxins-meds warfarin, anticonvulsants, chemo, mtx
    • Caffeine
    • radiation
maternal factors 3
Maternal factors 3
  • ART
  • Uterine malformations
  • Extremes of reproductive age
    • Short interpregnancy interval
outline13
outline

Risk factors

Diagnosis

Evaluation

management

16 week rule
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

16 week rule16
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

definition
definition

<10%ile (50-70% will be constitutionally small)

Some malnourished fetuses will be >10th%ile

<5%ile

Severe<3%ile

slide18
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
fundal height
Fundal height
  • Define by > 2cm discrepancy after 20 wks
  • Best when
    • Same clinician
    • Unmarked side of tape
symmetric asymmetric
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

symmetric 3 causes
Symmetric-3 causes
  • Constitutionally small
  • Aneuploidy/congenital anomalies
  • Early infection
asymmetric
asymmetric
  • Always substrate deficiency
ultrasound
ultrasound

Crucial tool to

Confirm/exclude dx

Differentiate symmetric/asymmetric

Verify fetal tolerance/well being

biometry
biometry

Purpose of biometry is to detect FGR

who gets an ultrasound
Who gets an ultrasound?
  • >2cm FH discrepancy once
  • 2 cm FH discrepancy more than once
  • Or following RF’s
us screening for iugr
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
ac most sensitive
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%

slide32
AC
  • More predictive of FGR than
    • HC
    • BPD
    • Combination
slide33
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%
slide34
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)

growth velocity
Growth velocity
  • Small vs in trouble
    • Falling %iles shd raise alarm
ratios
ratios
  • HC/AC
  • FL/AC
  • TCD/AC
diagnosis summary
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)
diagnosis summary38
Diagnosis summary
  • 10%ile-at risk
  • 5th%ile act
  • 3rd%ile
evaluation and management
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
follow
follow
  • Fetal wt for growth velocity q 2-4 wks
  • BPP 1-2x/wk
  • Amniotic fluid volume weekly (part of bpp)
  • doppler
doppler
doppler
  • Cochrane review
    • Doppler vs no doppler in FGR pregnancies
      • Reduced perinatal deaths by 29% (OR 0.71, CI 0.5-1.01)
umbilical artery
Umbilical artery
  • Increasing systolic/diastolic ratio, f/b
  • Absent or reversed end-diastolic flow
middle cerebral artery
Middle cerebral artery
  • Reported as umbilical/intracranial ratio, or
  • Peak velocity of middle cerebral artery
umbilical vein or ductus venosus
Umbilical vein or ductus venosus
  • Ductus venosus flow reverses
  • Umbilical vein develops pulsatile flow
sample us report from inpt
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.
sample us report
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.
steroids
steroids
  • Two large studies conflict
    • Reasonable to administer
    • Likely the very impaired fetus can’t respond
delivery timing
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
slide49
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)
recommended management
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
recommended management51
Recommended management
  • Term or late preterm >34 wks deliver if
      • Maternal htn
      • Growth arrest x 3-4 wks
      • Bpp low (<6/8)
      • DV UA reversed or absent
intrapartum management
Intrapartum management
  • Higher sensitivity to fetal heart rate patterns suggestive of hypoxia
delivery
Delivery
  • Route of delivery determined by severity of fetal/maternal condition
  • Decision often made based on anticipated difficulty inducing labor
  • Risk of metabolic acidemia and FHT abnormalities highest with abnormal Dopplers
  • IUGR is a relative contraindication to cervical ripening with PGs
    • When in doubt perform a CST
  • Cesarean delivery without TOL indicated for:
    • Evidence of fetal acidemia
    • Spontaneous late decelerations
    • Late decelerations with minimal uterine activity
long term outcomes
Long term outcomes
  • Catch up growth
    • Most have normal growth curves, slightly reduced adult size (especially late onset)
    • Early onset in utero, continue to lag behind
  • Small independent risk factor for CP
  • Possible long term neurologic sequelae
    • Depends on degree of IUGR, time of onset (earlier worse) and impact on head growth
gestational programing of growth restricted offspring
Gestational Programing of Growth-Restricted Offspring
  • Infants born growth restricted have an increased risk for (metabolic syndrome):
    • Obesity
    • CHTN
    • DM
    • Hypercholesterolemia
  • Proposed mechanism:
    • Adaptation to adverse environment through molecular signaling
subsequent pregnancies
Subsequent pregnancies
  • Treat modifiable risk factors: smoking, etoh, maternal illness
  • Consider ASA before 17 wks, most useful in preeclampsia
teaching points57
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
references
references
  • Up to date:
    • Overview of causes of and risk factors for fetal growth restriction divon, ferber, sept 2010
    • Diagnosis of fetal growth restriction divon, ferber, sept 2010
    • Fetal growth restriction: Evaluation and management resnik sept 2010
references59
references

Warsof SL, Cooper DJ, Little D, Campbell S. Routine ultrasound screening for antenatal detection of intrauterine growth retardation.Obstet Gynecol. 1986;67(1):33-9