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Fetal Growth Restriction FGR

Fetal Growth Restriction FGR. Woman ’ s Hospital School of Medicine Zhejing University He jin. Definition of FGR. Growth at the 10th or less percentile for weight of all fetuses at that gestational age or>37W<2500g

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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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