Transcript Causes of FGR

Fetal Growth Restriction
Women's Hospital School of Medicine
Zhejiang University
HeJin
Definition of FGR
 Growth at the 10th or less percentile for
weight of all fetuses at that gestational age
 >37W<2500g
 FGR perinatal mortality rate was 4-6 times
normal fetus.
 About 22% with congenital malformation
small for gestational age
（小于胎龄儿）
 Structure was normal
 no malnutrition
 no adverse perinatal outcomes
 Relating maternal race, parity, weight, height
Causes of FGR——Maternal
 Chronic hypertension 、Pregnancyassociated hypertension
 Cyanotic heart disease
 Serious diabetes
 Autoimmune disease
 Protein-calorie malnutrition
 Smoking
 Uterine malformations
 Thrombophilias
易栓
Causes of FGR——Fetal
 Race
 sex
 Twin-to-twin transfusion syndrome
 Multiple gestations
 Trisomy 21/18/13
 virus infection
 Fetal alcohol syndrome
Causes of FGR——Other
 Placental abnormalities
 Chronic abruption
 Placenta previa
 Abnormal cord insertion
 Cord anomalies
Categories——Endogenous symmetry
 Rare
 Early onset FGR
 harmful factors acting on the zygote or early
pregnancy
 symmetry
 Reason:
chromosomal abnormalities
intrauterine infection
environmentally harmful substances
Categories——Exogenous unsymmetry
 harmful factors acting on second and third
trimester
 most of them because placental abnormal
 PIH, GDM, placenta lesions
 unsymmetry
Categories——Exogenous symmetry
One and two types mixed
Diagnosis
 History:
 Note : risk factors for FGR during this
pregnancy
 appearance of FGR history
 Signs and symptoms:
 Continuous determination: fundal height,
abdominal circumference and maternal
weight
 fundal height:most obvious signs
Diagnosis——B-U
 CRL、BPD、FL、AC！HC
 artery Doppler：contribute to the
identification of fetuses at risk of FGR
 Uterine artery Doppler measurement
 Umbilical artery Doppler measurement
 Middle cerebral artery Doppler
Diagnosis——Amniotic fluid volumes
 Indirect
 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%
Therapeutic Viewpoint
 Defect?
 No effective treatments are known
 Different Phase
 First——behavioral
 Second——nutritional supplements
 Third—— monitor
Treatment
 General treatment
 to correct bad habits
 relax
 increased oxygen concentration
 Treatment of various complications
 intrauterine treatment
 improve uteroplacental blood supply
 zinc, iron, calcium, vitamin E and folic acid, amino
acid compound
 oral low-dose aspirin and heparin
Obstetric management
 chromosomal abnormalities or severe
congenital malformations—— termination of
pregnancy
 intensive care ：NST、AFI、SD
 Improve——continue to term,<40w
 termination of pregnancy:
 fetal distress
 stop growth more than 3 weeks
 pregnancy complications 加重aggravate
Fetal Macrosomia
FMS
 Birth weight of 4000g
 Greater than 90% for gestational age
 Increased dystocia, perinatal mortality
 7-15% of all pregnancies
factors
 Gestational diabetes mellitus(GDM)
 Genetics
 Ethnic
 Duration of gestation
 sex
 Other: nutrition！parity, polyhydramnios
1
1
Diagnosis
 Measure birth weight after delivery
Only
retrospective
 Perinatal diagnosis
difficult
often inaccurate
no risk factors can predict accurately
most FMS do not have identifiable risk
factors
Diagnosis
 BMI ≥ 30 kg/m
 >16kg
 Fundal height larger than the gestational age
in the third trimester 40
inaccurate
influenced by maternal size, the amount of
amniotic fluid, the status of the bladder,
pelvic masses (eg, fibroids), fetal position
Diagnosis——B ultrasound
 BPD>10
 FL>8
 chest circumference/ shoulder diameter
—— shoulder dystocia
 abdominal circumference>35，>37
 FSTT股骨皮下脂肪厚度 >2
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%).
FMS on mothers injury
 Birth canal lacerations：Perineal、Vaginal、
cervical
 Cesarean delivery
 Postpartum hemorrhage (PPH)
 Infection
孕前体重对妊娠结局的影响
剖腹产发生率（%）
孕前高BMI孕妇剖宫产风险更高
P<0.01
BMI ≥29.0
n=452
BMI 19.8-26.0
n=954
PAUL S. KAISER, MSN, CNM； Obesity as a Risk Factor for Cesarean in a Low-Risk Population； Obstet Gynecol 2001;97:39–43.
孕前体重对妊娠结局影响
n/Total(%)
Odds Ratio
BMI≥30.0
579/9731(6.0)
5.2
BMI25.0-29.9
464/17438(2.7)
2.4
BMI20.0-24.9
777/50097(1.6)
1.3
BMI<20.0
231/18878(1.2)
1.0
妊娠糖尿病
子痫 前期
BMI≥30.0
1321/9778(13.5) 3.3
BMI25.0-29.9
1594/17501(9.1) 2.0
BMI20.0-24.9
2866/50212(5.7) 1.3
BMI<20.0
731/18893(3.9)
1.0
BMI≥30.0
119/9778(1.2)
3.0
BMI25.0-29.9
145/17501(0.8)
2.0
BMI20.0-24.9
258/50212(0.5)
1.4
BMI<20.0
68/18893(0.4)
1.0
孕前BMI越高
妊娠并发症发生率越高
子痫
Jared M. Baeten, BA, Elizabeth A；Pregnancy Complications and Outcomes Among Overweight and Obese
Nulliparous Women；(Am J Public Health. 2001;91:436–440
gestation period
 Screening GDM
 Weight Control
 the Institute of Medicine (IOM): guidelines
During delivery
 Cesarean delivery：Consider Multiple
Factors
 Cesarean delivery：>4000-4500
 Vaginal delivery
observation of labor
Forecast Shoulder dystocia
Check up injury
Neonatal treatment
 Fetal macrosomia
 Prevention of low blood sugar——early feed
 Neonatal hypocalcemia ——Calcium
Shoulder Dystocia
Definition of SD
 Uncommon obstetric complication of
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
Antepartum risk factors
 History of SD
 Fetal macrosomia：>3850? >4000? >4500?
 Diabetes
 Excessive weight gain (>30KG)
 Obesity
 Postterm pregnancy
 malformation
Intrapartum risk factors
 Operative vaginal delivery (vacuum or/and forceps)
 Precipitous second stage (<20 min) 危险时刻
 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
Diagnosis
 Deliver the fetal trunk more than customary
traction 用蛮力
 Need ancillary maneuvers to complete
delivery 用帮手
 The turtle sign 乌龟征
 The fetal head retracts against the perineum
after it delivers
Treatment
 Result in bad result for fetal and maternal
 A 6-minute head-to-body interval has been
demonstrated to be safe
 Relax cord
 >6-8m, there is increased risk：neonatal
depression, acidosis, asphyxia, central
nervous system damage, or even death
HELPERR
• H = Help (call for additional assistance) 帮助
• E = Evaluate for episiotomy
评估会阴切开否
• L = Legs (McRoberts Maneuver)腿接近腹部
• P = Pressure (suprapubic)
耻骨上加压
• E = Enter the vagina
手进入阴道
• R = Remove the posterior arm 取后臂
• R = Roll the patient (two hands and knees)翻转
L——McRobert法
P——耻上加压
Suprapubic pressure
E——手进阴道
Rubin maneuver
R ——Remove the Arm
顺着后臂往下达到肘部 ，使手臂弯曲
R = Roll the Patient
“四肢着床”
Fetal Death
Definition of Fetal Death
 Fetal death after 20 weeks
 A fetal weight of 350 g or more
 No stillbirth
 The etiology is unknown : 25-60%
Causes of Fetal Death——fetal hypoxia
 Most common , about 50%
 Maternal：
Small artery insufficiency of blood：PIH
GDM, ICP
Uterine factor
 Fetal：
Severe dysfunction of the cardiovascular system
infection
 Placenta: abruption
 umbilical core abnormality
Causes of Fetal Death——Genetic
 Parents suffering from genetic diseases
 during pregnancy
use of teratogenic drugs
exposure to radiation
chemical poisons
 Embryonic genes and chromosome aberration
 Fetal malformations
Diagnosis of Fetal Death
 Easy:History and physical examination
 Death must be confirmed by BU
visualization of the fetal heart
the absence of cardiac activity
 In fact, the following description is rarely
Macerated fetus侵软胎
fetus compressus压扁胎
fetus papyraceus纸样胎
Management of Fetal Death
 Once the diagnosis has been confirmed，
patient should be informed
 allowing the mother to see the lack of cardiac
activity
 helps mather accept the fact,国外医生一起
 Immediate treatment
Rarely damage to the mother
Labor induction
Management of Fetal Death
 cervical ripening
 intra-amniotic injection
 Mifepristone and prostaglandin induction of
labor
 Patients with a history of a prior cesarean
delivery should be careful
 Dead fetus for 4 ws——DIC