Transcript Fetal Growth Restriction (FGR)

Definition:
Fetus whose growth velocity slows down or
stops completely because of inadequate
oxygenation or nutrition supply or
utilization
Not all FGR are SGA or all SGA are FGR
Fetus with FGR with adequate birth weight
more about 5th centile (abd. Circumference)
will not suffer from neonatal complications
SGA can be categorized according to the etiology
into:
• Normal SGA: No structural anomalies,
normal liquor, normal Doppler study of
umbilical artery & normal growth velocity.
• Abnormal SGA: those with structural or
genetic abnormalities
• FGR: those with impaired placental function
identified by abnormal UADW & reduced
growth velocity.
SGA is divided into symmetrical or
unsymmetrical according to Biometrial
measurement
AETIOLOGY
1. MATERNAL FACTORS
• Nutrition: BMI<19 starvation
• Smoking: 460 gm lighter than fetus with nonsmoker
woman
• Alcohol and drug abuse
• Maternal therapeutic drugs e.g. B blockers esp. Atenolol in
2nd Trim. Anticonvulsant esp hydrantions
• Maternal dis
o
Cardiorespiratory compromise˃ hypoxemia> ↓ fetal
growth
o
Sickle cell dis, Collagen vascular dis.Antiphospholipid
antibodies →↓placental perfusion
o
Maternal DM ( retinopathy & nephropathy)
o
Maternal chronic hypertension esp if associated with
renal impairment
o
Abnormalities in the uterus
2. FETAL FACTORS
•
Fetal abnormalities
Chromosomal
Structural
Cardiac dis
Gastroschisis
• Infection
Variciella
CMV
Rubella
Syphilis
Toxop
Malaria
3. PLACENTAL FACTORS
Placental mosaicisim –16,22 chrom
PE -- ↓ blood supply to placental bed
PREDICTION
1. HISTORY
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BMI<19
Smoking
Past history of FGR
Congenital uterine abnormalities
Big fibroid
Old mother>40 nullip
PE
Retro placental. hemorrhage in 2nd & 3rd
Trim
2.MATERNAL SERUM SCREENING : 2nd
Tim
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Alfa Feto Protien(AFP) – esp if ↓
E3
Human Placental Lactogen
hCG
3. ULTRASOUND MARKERS
• Abnormal uterine artery Doppler --absent End Diastolic Flow or notching
of wave form
• Bright or echogenic fetal bowl in 2nd
Trim is associated with increase FGR
CLINICAL ASSESSMENT:
• Weight gain in pregnancy
• Fundal height
• Clinical weight estimation of the fetus – liquor
amount estimation
• U/S assessment
• Biometrial measurement of the fetus – abdominal
circumference is the most accurate prediction of
fetal weight
• Biparietal & FL
• One exam does not differentiate between SGA
from FGR , so serial estimation 4wk interval
• Liquor volume due to decrease renal perfusion –
the degree of liquor decrement correlate well
with degree of hypoxia as reflected by pO2 at
cordocentesis
• Umbilical art Doppler velocity study --- reduced
flow – absent End Diastolic Flow –reversed
EDF
MANAGEMENT:
PROPHYLAXIS
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Small dose aspirin
Protein energy
Stop smoking
Anti malaria
Stop medications
MONOTORING
• Monitoring of normal SGA –
UADW better than bio physical
profile & liquor
• CTG – Unclear role – every 2 wk
• Monitoring of GRF
if diagnosis > 34wk → delivery
if diagnosis < 3wk → steroid
• if RDEF → delivery
• if AEDF → controversy
• MCA→ ↑ flow → adaptive
mechanism
• AEDF→ fetal demise( 2 days to wk)
LABOR
• <37wk → C/S because at high risk
of hypoxia & academia
• If normal UAD→>37wk→ induction
– continuous CTG, fetal scalp
monitoring