1. The document discusses fetal maturity and intrauterine growth restriction (IUGR), including definitions, clinical symptoms, signs, biochemical markers, and fetal maturity tests. Fetal maturity tests assess surfactant levels in amniotic fluid to predict risk of respiratory distress syndrome in newborns. 2. IUGR is defined as fetal weight below the 10th percentile and can be symmetric or asymmetric, early or late onset. It increases risks of complications. Management depends on gestational age and Doppler ultrasound results, with delivery generally between 34-37 weeks. 3. There is no worldwide consensus on specific management strategies for IUGR, and guidelines from organizations like RCOG and ACOG have some differences.

1. Diagnoses of Pregnancy, Fetal
maturity and Intrauterine
Growth Restriction
Themba Hospital FCOG(SA) Part 1 Tutorials
By Dr N.E Manana

2. Introduction
• Important because of advance reproductive
technologies
• Early medical treatment of extra-uterine
pregnancies
• Diagnosis is made accurate by the use of
Biochemistry and U/S

3. Clinical symptoms
• Clinical symptoms and signs should be considered
first in the evaluation of a patient
• Amenorrhea serves as the most common clinical
marker for pregnancy in women with regular
menstrual cycle
• Pregnancy should be considered in any menstrual
cycle aberration (this may indicate an abnormal
pregnancy state)

4. Symptoms
• Abdominal distention
• Fetal movements
• Breast tenderness
• Nausea
• Vomiting
• Urinary complaints
• However physical symptoms are not sufficiently
reliable as diagnoses

5. Signs
• Fetal heartbeat
 Auscultation (By 19 weeks)
 Doppler U/S device (By 10 weeks)
Fetal heartbeat must be differentiated from maternal
heartbeat
• Perception of fetal movements (After 20 weeks)
• Ultrasound findings (TVUS): GS 3w (BHCG 1K) , Fetal
pole with Yolk sac 5w(BHCG 7K), Fetal heart 6w (BHCG
10K)

6. Biochemical
Human Chorionic gonadotropin
Glycoprotein secreted by the syncytiotrophoblast
Molecular weight of 36 700Da, with 30%
carbohydrate composition
Composed of an alpha and a beta chain
Beta subunit confers specific activity
Shares 121 common amino acids with LH, 80%
homology

7. Conti…
Detection in plasma is not possible until 10days
after fertilization
Level double every 36 hrs
Peak 100 00mIU/ml at 10 weeks
At 20weeks its 20 000mIU/ml and remains in that
level for the rest of pregnancy
• Tests: Immunoassay, Radioimmunoassay and Elisa

8. Fetal maturity tests

9. Intro
• Pulmonary surfactant deficiency due to
prematurity is the most common cause of
respiratory distress syndrome (RDS) in newborns.
• The lack of surfactant results in higher surface
tension, causing collapse of small alveoli and
overinflation of large alveoli.
• This leads to atelactasis that results in perfused
but unventilated alveoli that contribute to
hypoxia, hypercapnia and acidemia.

10. Contin…
• The incidence of RDS decreases with
increasing gestational age.
• Therefore, the risk of RDS is highest in
premature infants, with the likelihood >60% at
29 weeks, 20% at 34 weeks

11. Fetal lung maturity testing
• Laboratory tests to estimate fetal lung maturity
(FLM) by measuring surfactant in amniotic fluid
were developed in the 1960s and 1970s.
• Fetal lung liquids contribute to amniotic fluid,
resulting in an exchange of surfactants from the
developing lungs to the amniotic fluid.
• Therefore, amniotic fluid is the required
specimen for FLM testing.
• Currently, all of the available FLM tests assess the
amount of surfactant in amniotic fluid so that a
prediction can be made regarding an infant’s risk
of developing RDS

12. Fetal lung maturity testing
• These tests include the lecithin-to-sphingomyelin
(L/S) ratio, the detection of PG and the lamellar
body count.
• While lecithin increases in concentration
throughout the third trimester, the concentration
of sphingomyelin remains relatively constant.
• Thus, sphingomyelin concentration is used as an
internal standard against which the rising lecithin
concentration can be compared.
• The L/S ratio rises with increasing gestational age,
which correlates with maturation of the fetal lung

13. Fetal lung maturity testing
• lamellar bodies are produced by type II
pneumocytes and secreted into the alveolar
space, where they deliver surfactant to the
interior surface of alveoli.
• In addition, lamellar bodies can pass into the
amniotic cavity, and are thus also found in
amniotic fluid where they can be enumerated as
the lamellar body count (LBC)
• LBC offers distinct advantages, such as ease of
performance, the wide availability of needed
instrumentation and low cost

14. Fetal lung maturity testing
• Despite the excellent performance of the FLM tests,
there has been a recent decline in their usage
• Physicians who responded to these surveys indicated
that the major reason for the decline in FLM test
ordering is that these tests were no longer needed for
patient care
• The 2008 American College of Obstetricians and
Gynecologists (ACOG) practice bulletin concerning fetal
lung maturity does not recommend FLM testing before
32 weeks of gestation or when delivery is mandated

15. Conclusion
• Pulmonary maturity indices are not reliable
predictors of adverse neonatal outcomes
• And modern neonatal medicine continues to
make strides in treatment of infants with RDS
and other preterm-associated morbidities.
• These factors lead to the unavoidable
conclusion that FLM testing in modern
obstetric medicine has come to the end of its
era of usefulness.

16. Intrauterine Growth Restriction

17. Definitions
• IUGR:
– failure to reach biological growth potential
– EFW ,10th centile for GA
• SGA:
– birth weight <10th centile for GA for a
population/customised standard

18. Scope of the Problem
• Suboptimal fetal growth accounts for 28-45% of
stillbirths
• Placental insufficiency major contributor
• SGA infants have increased rates of
– neurodevelopmental delay
– poor school performance
– childhood and adult obesity
– metabolic disease

19. Normal Fetal Growth cont’
• Fetal growth velocity: rate of fetal growth over a
given time interval
• Normal growth in singletons:
– 14-15wk- 5g/day
– 20wk-10g/d
– 32-34wk-35g/d
– >34wk: ↓in daily increase
• EFW velocity peaks ≈34-35wk

20. Normal
Fetal
Growth
Fetus’s
Predetermined
growth potential
Healthy
Fetus
Healthy Mother
Healthy
Placenta

21. Aetiology/Risk Factors
Constitutionally
small babies
Maternal Fetal Placental
Parents genetically
small (dx of
exclusion)
Chronic
Malnutrition
Cyanotic heart
diseases
Renal disease
Sickle cell anemia
Congenital
anomalies
-Trisomies
Infections
-Rubella
-CMV
-Hepatitis A, B
-Listeria
-TB
-Syphilis
Inadequate
trophoblastic
invasion:
-hypertensive
diseases
-autoimmune
Placental infarction

22. Classification
IUGR
Symmetric
vs
Asymmetric
Early
Vs
Late

23. Parameter Early Late
GA <32wk >32wk
Solitary parameters AC & EFW< 3rd centile +
AEDFV in UA
EFW and AC <3rd centile
EFW or AC <10th centile < 10th centile OR crossing 2
centiles
Cerebroplacental ratio - < 5th centile
OR
Uterine artery PI > 95th centile -
Umbilical artery PI > 95th centile >95th centile

26. Results
1. Definitions: FGR -EFW < 10th centile-ALL
2. Prevention-Aspirin: No consensus.
• RCOG ≤16W
• ACOG-insufficient evidence,
• Canada ≥SGA risks
3. Prevention-Smoking cessation: 3-benefit any point, 1-no
role, 1 benefit in early pregnancy
4. Corticosteroids: <34w0d, RCOG=up to 35w6d
5. MgSo4 Neuroprotection: <30w to 32-33w (4/6)

27. Results cont’
6. UA Doppler: All recommend e.g. RCOG: 26-
28wk in at risk pts. ACOG-no criteria
7. SFH: Measure and plot. Dx SGA if SFH >3cm
less than GA
8. Routine T3 scans: No role in low risk

28. Delivery-Early onset IUGR <32wk
RCOG ACOG
Timing of delivery AEDV by 32wk
REDV by 32wk
AEDV ≥34wk
REDV ≥ 32wk
Indication for immediate
delivery
Abnormal computerised
CTG or Ductus venosus
doppler
Abnormal CTG, BPP, AFV
Mode of delivery CS- AEDV and REDV FGR alone not indication
for CS

29. Delivery-Late Onset IUGR ≥32wk
RCOG ACOG
Timing of birth
(Abnormal Doppler)
37wk if MCA PI <5TH centile
or abnormal UA doppler
Consider at >37wk when
REDF in UA
Timing of birth
(Normal Doppler)
>34wk, deliver if no growth
over 3wk.
May deliver 37wk with
senior obstetrician
involvement
38w0d-39w6d if only IUGR
Mode of delivery IOL if PEDF. Continuous
CTG
FGR alone not indication
for CS

30. Conclusions
• IUGR common complication, need to identify
• Knowledge of risk factors aids in having high
index of suspicion
• Fetal biometry charts crucial
• Still no worldwide consensus on IUGR
management
• Each unit to base management on own
evidence and availability of resources

31. References
1. HS Cronje, C. M. (2018). Clinical Obstetrics a South
African Perspective Pretoria: Van Schaik. McCowen,
L. M. (2018).
2. Evidence based guidelines for management of
suspected fetal growth restriction: comparision,
consensus and controversies. American Journal of
Obstetrics and Gynaecology, 855-868.