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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

Fetal growth restriction

Joseph Breuner, MD

8-08-05

objectives
Objectives
  • Define risk factors
  • Define screening
  • Define diagnosis
  • Define management
take home points
Take-home points
  • Risk factors: if positive, obtain ultrasound for growth 16-24 wks
  • if negative, use fundal height to screen
take home points4
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
take home points5
Take-home points
  • Define fetal growth restriction as <3rd%ile
  • follow 3-6th%ile carefully
take home points6
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
Risk Factors
  • Fetal:
    • birth defect history (genetic syndromes, anomalies, karyotype abnormalities)
    • multiple gestation
    • uteroplacental insufficiency
risk factors8
Risk factors
  • Maternal disease
    • starvation
    • hypoxemia due to heart/lung disease
    • antiphospholipid Ab syndrome
    • renal disease, chronic htn
    • pre-eclampsia
risk factors9
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
risk factors10
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
risk factors11
Risk Factors
  • Conspicuous by their absence:
    • maternal wt gain 10-24 lbs
screening
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
diagnosis
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%
diagnosis14
Diagnosis
  • Understand three different entities present as small baby:
  • constitutionally small fetus
  • fetus with structural/chromosomal abn, fetal infection
  • uteroplacental insuffiency
diagnosis16
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
diagnosis17
diagnosis
  • Use 3 features to dx among 3 different entities
  • symmetric vs. asymmetric
  • AFI
  • umbilical artery velocimetry (S/D ratio)
diagnosis18
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
diagnosis19
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
diagnosis21
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
diagnosis22
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%)
management
Management
  • Mortality rises quickly with SGA
management27
management
  • Severe FGR=delivery > 32-34 weeks,
  • weigh fetal mortality vs neonatal morbidity at earlier GA
management28
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
management29
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
take home points31
Take-home points
  • Risk factors: if positive, obtain ultrasound for growth 16-24 wks
  • if negative, use fundal height to screen
take home points32
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
take home points33
Take-home points
  • Define fetal growth restriction as <3rd%ile
  • follow 3-6th%ile carefully
take home points34
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
references
references
  • Williams chapter 29 2002 (pocket pc memo avail)
  • Up to date march 2005
case 1
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?
case 137
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
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?
case 139
Case #1
  • 2nd scan 4wks later at 30 wks LMP:
  • EFW 7%ile for LMP
  • symmetric
  • normal UAV
  • what do you do?
case 2
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?
case 241
Case #2
  • Maternal tox screen negative
  • Basic US shows EFW 6%ile for LMP GA
  • what else do you want to know about US?
case 242
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: ?
case 243
Case #2
  • Management?
case 244
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?