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IN THE NAME OF GOD

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  1. IN THE NAME OF GOD

  2. SMALL FOR GESTATIONAL AGE

  3. CASE 1 27years G1 GA : 28w 2d (by sono 8w :28w 3d ) Fondal height : 24 cm

  4. Sono 3 days ago • BPD :24W 3D • AC : 22 W • FL : 21 W • AFI : NL • Severe IUGR • BPP: breath:0AF:2 tone:2 • Doppler : increased Umbilical artery RI

  5. Diagnostic criteria • AC < 10% and EFW < 10% : SUSPECTED TO IUGR • AC < 10% and EFW > 10% : at risk to IUGR

  6. 27years ,G1 GA : 28w 2d (by sono 8w :28w 3d ) • C.C : fundal height 24 cm -بیمار مورد شناخته شده تالاسمی اینترمدیا که 10 سال قبل اسپلنکتومی شده است-2هفته بعد از اسپلنکتومی دچار ترومبوفلبیت عروق کبدی می شود و تحت درمان با هپارین و وارفارین تا 1 ماه پس از ترخیص قرار میگیرد-از 10 سال قبل تا کنون آسپیرین مصرف می کند1سال پس از اسپلنکتومی کوله سیستکتومی می شود-از 10 سال قبل تزریق خون نداشته -از ابتدای بارداری تحت درمان با هپارین به صورت 5000 واحد BD بوده است

  7. ultrasonography • Gestational age • BPD ,HC,AC,FL • TCD • EFW • AFI • Doppler sonography • BPP

  8. sonography : after 2days • BPD : 24W • HC : 24W 2D • AC : 24W 1D • FL :23W 3D • EFW : 539 g • AFI : 10cm • Umbilical artery : reversed EDV • Ductusvenosus : NL • BPP : 10/10

  9. symmetric IUGR Associated conditions: - Genetic - Congenital anomalies - Intrauterine infections - Substance abuse - Cigarette smoking - Therapeutic irradiation

  10. management • Anomaly scan • Karyotyping identification : severe early onset IUGR , Symmetrical IUGR ,polyhydramnious ,stractural anomaly . • Echocardiography • Serology :CMV ,RUBELLA , VARICELLA

  11. Algorithm IUGR yes TORCH stigmata  work-up? no yes Dysmorphic features  work-up? no yes Maternal/placental explanation work-up? no yes Maternal drug use tox screen no Unknown cause

  12. Follow up • Growth curve (biometry) • Doppler • BPP • NST

  13. Frequency of fetal surveillance • Normal doppler & AFI : fortnightly • umbilical artery end diastolic flow is present : weekly Doppler BPP twice weekly • Absent or reversed end diastolic flow in the umbilical artery : hospital admission daily BPP and Doppler

  14. BPP daily • FGR < 5 % • Severe oligohydramnious • Absent / reverse EDV • Equivocal BPP ( 6/10 )

  15. Sonographyafter than 18 days • BPP : 26w 5d • HC : 25w 6d • AC : 24w 6d • FL : 24w 2d • EFW : 615 g • AFI : 10 cm • Umbilical artery reversed EDV • DV : flow a wave decreased

  16. GA : 30w 2d • C/S • Female : 630 gr

  17. Indication of C/S • Fetal acidemia • Spontaneous late deceleration • Absent /reverse umbilical artery EDV

  18. CASE 2 40y,G3L2(c/s) • GA : 35w 1d but by sono 8 weeks : 33w 1d • FH : 30 cm • PMH : no problem • OBH : neg • US : BPD : 28w 3d HC : 28w 3d AC : 25w FL : 26w HL : 24w 5d EFW : 746g AFI : 5 cm doppler : NL

  19. intervention • SGA 24+0 and 35+6 weeks before delivery : antenatal corticosteroids. • Magnesium : under 30 week. • smoking cessation. • Antithrombotic therapy appears to be a promising therapy for preventing SGA in high risk women.Howeverthere is insufficient evidence, especially concerning serious adverse effects, to recommend its use.

  20. Sonography after than 16 days • BPD : 29W 3D • AC : 26w • FL : 26W 5D • EFW : 767 g • AFI : 2 cm • BPP : 8/10 • DOPPLER : NL

  21. GA : 33w 1d GA : 35w 3d BPD : 28w 3d HC : 28w 3d AC : 25w (191 mm) FL : 26w HL : 24w 5d EFW : 746g AFI : 5 cm • BPD : 29W 3D • HC : 28w 5d • AC : 26w (200 mm) • FL : 26W 5D • EFW : 767 g • AFI : 2 cm

  22. During 16 days :growth arrest . • GA 35w 3d : C/S • BW : 825gr

  23. Case 3 • 29y , G2ab1 • GA : 30w 4d (by sono 13w : 30w 6d ) • FH=26 cm • PMH : NEG • DH: heparin • Sono : GA : 29 w 6 d BPD=27W 4D HC : 27W 6D AC : 25W 4D FL : 25W 4D EFW: 765 g AFI : 67 mm BPP : 10/10 DOPPLER : NL

  24. Sono( GA : 30w 4d) AFI < 5 cm BPP=6/8 (breath=0) • RI MCA/ RI UMA=0.67/0.79 • Hospitalization

  25. Sono( GA : 31 w 6d ) AFI < 5 cm Doppler : absent EDV in umbilical artery BPP=10/10

  26. After than 15 days AFI =severe oligohydramnious EFW= 997 gr BPP=8/8 در سن حاملگی 32 هفته و 5 روز به صورت اوژانسی به دلیل پره اکلامپسی شدید ترمیناسیون انجام شد

  27. Timing delivery • Abnormal DV(A/R a wave) or umbillical vein(pulsetile) with every GA . • Umbilical artery reverse EDV until 30-32 weeks • Umbilical artery absent EDV until 32-34 weeks • Umbilical artery high RI until 36- 37 weeks • Constitutional IUGR : 37-38 weeks

  28. Indication delivery after than 34 weeks • Maternal comorbidity • arrest of growth • Oligohydramnious • A/R EDV umbilical artery • MCA PI < 5% • BPP < 4 • Recurrent deceleration FHR

  29. Recurrence risk in second pregnancy • First pregnancy AGA : 9% • First pregnancy SGA : 29% • First and second pregnancy SGA : 44%

  30. Management of subsequent pregnancy • cessation of smoking and alcohol intake • balanced energy/protein supplementation • Avoiding a short or long interpregnancy interval

  31. Screening option • Low risk : fundal height (exception large myoma ,BMI > 35) • High risk : ultrasonography • Biochemical : low PAPP-A , high AFP • Uterine artery doppler

  32. MINOR RISK FACTORS • Maternal age > 35 yrs • Nulliparity • BMI <20 • BMI 25-29.9 • Smoker 1-10 per day • Pregnancy interval < 6 mo • Pregnancy interval >30 mo • Paternal SGA

  33. Major risk factors • Maternal age > 40 yrs • Daily vigorous exercise • Previous SGA baby • Smoker >11 per day • Previous stillbirth • Maternal SGA • Preeclampsia • Maternal Medical disease • Heavy bleeding similar to mense • Echogenic bowel • Low maternal weight • Low PAPP-A

  34. RCOG "Advise women at high risk of pre-eclampsia to take 75 mg of aspirin* daily from 12 weeks until the birth of the baby. Women at high risk are those with any of the following: • hypertensive disease during a previous pregnancy • chronic kidney disease • autoimmune disease such as systemic lupus erythematosis or antiphospholipid syndrome • type 1 or type 2 diabetes • chronic hypertension.

  35. RCOG Advise women with more than one moderate risk factor for pre-eclampsia to take 75 mg of aspirin* daily from 12 weeks until the birth of the baby. Factors indicating moderate risk are: • first pregnancy • age 40 years or older • pregnancy interval of more than 10 years • body mass index (BMI) of 35 kg/m² or more at first visit • family history of pre-eclampsia • multiple pregnancy.