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Fetal Growth Restriction FGR

Learn about the definition, causes, diagnosis, and therapeutic options for Fetal Growth Restriction (FGR) in pregnancy, including maternal, fetal, placental factors. Explore the importance of early detection and management strategies for optimal outcomes.

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Fetal Growth Restriction FGR

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  1. Fetal Growth RestrictionFGR Woman’s Hospital School of Medicine Zhejing University He jin

  2. Definition of FGR • Growth at the 10th or less percentile for weight of all fetuses at that gestational age or>37W<2500g • A condition in which a fetus is unable to achieve its genetically determined potential size

  3. FGR • FGR perinatal mortality rate was 4-6 times normal fetus. • About 22% of children with congenital malformation is accompanied by growth restriction.

  4. small for gestational age，SGA • Structure was normal • no malnutrition • no adverse perinatal outcomes • Relating maternal race, parity, weight, height

  5. Causes of FGR • Maternal causes include the following: • Chronic hypertension • Pregnancy-associated hypertension • Cyanotic heart disease • Class F or higher diabetes • Hemoglobinopathies • Autoimmune disease

  6. Causes of FGR • Maternal causes include the following: • Protein-calorie malnutrition • Smoking • Substance abuse • Uterine malformations • Thrombophilias • Prolonged high-altitude exposure

  7. Causes of FGR • Fetal causes include the following: • Race • sex • Twin-to-twin transfusion syndrome • Multiple gestations • Trisomy 21/18/13 • virus infection • Fetal alcohol syndrome

  8. Causes of FGR • Placental or umbilical cord causes include the following: • Placental abnormalities • Chronic abruption • Placenta previa • Abnormal cord insertion • Cord anomalies

  9. Categories • According to fetal growth characteristics, weight and cause • 1. Endogenous symmetry • also known as early onset FGR, Rare • harmful factors acting on the zygote or early pregnancy • Reason: • chromosomal abnormalities • intrauterine infection • environmentally harmful substances

  10. Categories • 2.Exogenous unsymmetry • harmful factors acting on second and third trimester • most of them because the low placental function • PIH, GDM, placenta lesions • 3. Exogenous symmetry • One and two types mixed

  11. Diagnosis • 1. History: • Note : there is any risk factors for FGR during this pregnancy • Asked: appearance of FGR history

  12. Diagnosis • 2. Signs and symptoms: • Continuous determination: • fundal height, abdominal circumference and maternal weight to determine fetal growth. • fundal height • significantly less than the corresponding gestational age • most obvious and most easily identifiable signs

  13. Diagnosis • Amniotic fluid volumes • Amniotic fluid index (AFI) • < 5 cm :the rate of FGR was 19% • > 5 cm :9% • Aaximum vertical pocket (MVP) values • >2 cm : 5% • < 2 cm : 20% • <1 cm :39%

  14. Diagnosis • Uterine artery Doppler measurement • contribute to the identification of fetuses at risk of FGR • Umbilical artery Doppler measurement • absent end-diastolic velocity • reversed end-diastolic velocity • corroborates the diagnosis of FGR • Middle cerebral artery Doppler • MCA-PSV (peak systolic velocity) is a better predictor of FGR-associated perinatal mortality than any other single measurement

  15. Diagnosis and Surveillance • Venous Doppler waveforms • fetal cardiovascular and respiratory responses • Three-dimensional ultrasonography • a 10th percentile femur/ humerus volume threshold

  16. Therapeutic options • No effective treatments are known • First • behavioral strategies to quit smoking result in FGR • Second • balanced nutritional supplements • magnesium and folate supplementation • Third • if malaria is the etiologic agent • maternal treatment of malaria can increase fetal growth

  17. Treatment • Once FGR has been detected---surveillance plan • Maximizes gestational age • Deliver the most mature fetus in the best physiological condition possible • while minimizing the risks of neonatal morbidity and mortality • while minimizing the risk to the mother

  18. Treatment • 1. general treatment(1) to correct bad habits(2) bed rest(3) increased oxygen concentration • 2. positive treatment of various complications

  19. Treatment • 3. intrauterine treatment • (1) improve uteroplacental blood supply • (2) zinc, iron, calcium, vitamin E and folic acid, amino acid compound • (3) oral low-dose aspirin inhibits the synthesis of thromboxane A2

  20. 3. intrauterine treatment • (4) low molecular weight heparin and low-dose aspirin may improve the outcome of FGR • but not yet widely used clinically • requires further clinical trials • (5) the FGR fetus is expected to give birth before 34 weeks • should promote fetal lung maturity

  21. 4 obstetric management • (1) chromosomal abnormalities or severe congenital malformations • should early termination of pregnancy. • (2) Placental function is poor • but the treatment is effective • continue to term • intensive care • should not exceed the expected date of delivery

  22. intensive care • A weekly nonstress test (NST) • AFV determination • Biophysical profiles • Doppler assessments • Severe FGR before 32 weeks' • a poor prognosis • therapy must be highly individualized

  23. 4. obstetric management • (3) termination of pregnancy: • > 34 weeks ,a general treatment is poor • fetal distress, or stop the growth of the fetus more than 3 weeks • pregnancy complications aggravate • < 34 weeks, has been applied to promote fetal lung maturity • (4) the mode of delivery : • fetal malformations • maternal complications of the severity • to evaluate fetal condition

  24. Fetal MacrosomiaFMS

  25. Definition of FMS • Defined in several different ways: • Birth weight of 4000-4500 g (8 lb 13 oz to 9 lb 15 oz) • Greater than 90% for gestational age • Increased dystocia, perinatal mortality • Affects 7-15% of all pregnancies

  26. Influencing factors • Gestational diabetes mellitus(GDM) • class A, B, and C ，26% • Genetics • Racial • Ethnic • Duration of gestation • Neonatal sex • Other: nutrition, parity, polyhydramnios

  27. Diagnosis • Measure birth weight after delivery • Only • retrospective • Perinatal diagnosis difficult • often inaccurate • no risk factors can predict it accurately enough to be used clinically • most FMS do not have identifiable risk factors

  28. Diagnosis 2 • BMI ≥ 30 kg/m、体重增加过多 • Fundal height measurements: 3-4 cm larger than the gestational age in the third trimester • inaccurate • are influenced by maternal size, the amount of amniotic fluid, the status of the bladder, pelvic masses (eg, fibroids), fetal position

  29. Diagnosis • B ultrasound • Biparietal diameter>10 • femur length>8 • chest circumference/ shoulder diameter ：rule out shoulder dystocia • abdominal circumference>33，>35 • FSTT >2

  30. FMS on neonates injury • Neonatal morbidity • Neonatal birth trauma • Intrauterine death (GDM infants) • NICU admissions • ≥4500 g vs ≤4000 g (9.3% vs 2.7%). • Shoulder dystocia was 10 times higher • ≥4500 g vs ≤4000 g (4.1% vs 0.4%).

  31. FMS on mothers injury • Birth canal lacerations • Perineal • Vaginal • cervical • Cesarean delivery • Postpartum hemorrhage (PPH) • Infection

  32. gestation period treatment • Screening GDM • Weight Control • The recommendations for weight gain • the Institute of Medicine (IOM): guidelines published in 1990 • The suggested weight gain • normal BMI : 11.2–15.9 kg (25–35 lb) • overweight : 6.8 –11.2 kg (15–25 lb) • obese : 6.8 kg (15 lb)

  33. Treatment during delivery • Can not simply decide to do Cesarean delivery：Consider Multiple Factors • Cesarean delivery：>4000-4500 • Vaginal delivery • Strengthen the observation of labor • Shoulder dystocia • Birth canal injury

  34. Neonataltreatment • Fetal macrosomia • Prevention of low blood sugar • early inleakage • Aggressive treatment of hyperbilirubinemia • Blu-ray treatment • Neonatal hypocalcemia • Calcium

  35. Shoulder DystociaSD

  36. Definition of SD • An uncommon obstetric complication of cephalic vaginal deliveries • The fetal shoulders do not deliver after the head has emerged from the mother’s introitus • one or both shoulders become impacted against the bones of the pelvis • Emergency in intrapartum

  37. Antepartum risk factors • Listed below in order of importance: • History of SD in a prior vaginal delivery • Fetal macrosomia • having a disproportionately large body compared to head • Diabetes/impaired glucose tolerance • Excessive weight gain (>35 lb) • Obesity • Postterm pregnancy • 胎儿异常

  38. Intrapartum risk factors • Precipitous second stage (<20 min) • Operative vaginal delivery (vacuum, forceps, or both) • Prolonged second stage • Without regional anesthesia • >2 h for nulliparous patients • > 1h for multiparous patients • With regional anesthesia • >3 h for nulliparous patient • >2 h for others • Induction of labor for impending macrosomia

  39. Diagnosis • More than customary traction needed to deliver the fetal trunk • The need to perform ancillary maneuvers to complete delivery • A minority of SD deliveries • The turtle sign • The fetal head retracts against the perineum after it delivers

  40. Treatment • An obstetric emergency • SD can result in significant fetal and maternal harm if not resolved in a competent and expedient manner • A 6-minute head-to-body interval has been demonstrated to be safe • Beyond that time, there is increased risk • neonatal depression, acidosis, asphyxia, central nervous system damage, or even death

  41. Table 1 SD maneuvers

  42. McRoberts maneuver

  43. Suprapubic pressure

  44. Rubin maneuver posterior arm delivery

  45. Fetal Death

  46. Definition of Fetal Death • A death that occurs after 20 weeks constitute a fetal demise or stillbirth. • Many states use a fetal weight of 350 g or more to define a fetal demise • Although this definition of fetal death is the most frequently used in medical literature • it is by no means the only definition in use.

  47. Causes of Fetal Death • The etiology of FD is unknown in 25-60% of all cases • 1. fetal hypoxia • The most common reason, about 50% • maternal factors • fetal factors • Placenta • abnormal cord

  48. Causes of Fetal Death • Maternal： • Small artery insufficiency of blood • Lack of red cells carrying oxygen deficiency • hemorrhagic disease • Uterine factor • GDM, ICP • Fetal： • Severe dysfunction of the cardiovascular system • Fetal malformations

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