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Fetal growth restriction

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

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  1. Fetal growth restriction Joseph Breuner, MD 8-08-05

  2. Objectives • Define risk factors • Define screening • Define diagnosis • Define management

  3. Take-home points • Risk factors: if positive, obtain ultrasound for growth 16-24 wks • if negative, use fundal height to screen

  4. 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

  5. Take-home points • Define fetal growth restriction as <3rd%ile • follow 3-6th%ile carefully

  6. 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

  7. Risk Factors • Fetal: • birth defect history (genetic syndromes, anomalies, karyotype abnormalities) • multiple gestation • uteroplacental insufficiency

  8. Risk factors • Maternal disease • starvation • hypoxemia due to heart/lung disease • antiphospholipid Ab syndrome • renal disease, chronic htn • pre-eclampsia

  9. 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

  10. 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

  11. Risk Factors • Conspicuous by their absence: • maternal wt gain 10-24 lbs

  12. 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

  13. 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%

  14. Diagnosis • Understand three different entities present as small baby: • constitutionally small fetus • fetus with structural/chromosomal abn, fetal infection • uteroplacental insuffiency

  15. 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

  16. diagnosis • Use 3 features to dx among 3 different entities • symmetric vs. asymmetric • AFI • umbilical artery velocimetry (S/D ratio)

  17. 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

  18. 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

  19. 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

  20. 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%)

  21. Management • Mortality rises quickly with SGA

  22. management • Severe FGR=delivery > 32-34 weeks, • weigh fetal mortality vs neonatal morbidity at earlier GA

  23. 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

  24. 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

  25. Take-home points • Risk factors: if positive, obtain ultrasound for growth 16-24 wks • if negative, use fundal height to screen

  26. 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

  27. Take-home points • Define fetal growth restriction as <3rd%ile • follow 3-6th%ile carefully

  28. 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

  29. references • Williams chapter 29 2002 (pocket pc memo avail) • Up to date march 2005

  30. 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?

  31. 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?

  32. 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?

  33. Case #1 • 2nd scan 4wks later at 30 wks LMP: • EFW 7%ile for LMP • symmetric • normal UAV • what do you do?

  34. 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?

  35. Case #2 • Maternal tox screen negative • Basic US shows EFW 6%ile for LMP GA • what else do you want to know about US?

  36. 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: ?

  37. Case #2 • Management?

  38. 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?

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