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Management of small for gestational age fetus

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Update on management of small for gestational age fetus.

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Management of small for gestational age fetus

  1. 1. Updates of the Management of Small–for–Gestational–Age Fetus & Doppler Studies Dhammike Silva
  2. 2. objectives  Definitions  Risk factors at booking  Uterine artery Doppler  Umbilical artery Doppler  Dutus venosus doppler  MCA Doppler  Concept of Cerebro-placental ratio  Timing of delivery  Practical demonstration
  3. 3. Definitions…  SGA  Estimated fetal weight (EFW) or abdominal circumference (AC) less than the 10th centile  Severe SGA < than 3rd centile.  FGR is not synonymous to SGA  pathological restriction of the genetic growth potential
  4. 4. Plotting on charts???  Customized Vs Population charts  Customized = adjusting for maternal height, weight, parity, ethnicity, and other physiological variables.  Better identification of SGA  No randomized controlled trial evidence comparing population to customized
  5. 5. 2500 g
  6. 6. Serial Vs Single… 2500 g Serial in 3/52 apart
  7. 7. Risk factors… Major risk factor (OR > 2.0)  Age > 40 yrs  Previous SGA  Previous Still births  Maternal and paternal SGA  Chronic HT, preeclampsia  DM with vasculopathy  Cocaine, heavy smoking Should offer serial ultrasound measurement of EFW & UA PI since 26–28 weeks
  8. 8. ASPRE Trial… “meta-analysis reported that the administration of low- dose aspirin in high-risk pregnancies is associated with a decrease in the rate of PE by approximately 10% (Askie et al, 2007) “ NNT was 9 (95% CI 5.0–17.0)
  9. 9. Risk factors… Minor risk factor (OR < 2.0)  age > 35  BMI <20 or > 30  Hx of preeclampsia  Placental abruption If 3 or more- Should offer Ut Artery Doppler at 20-24 weeks
  10. 10. Incresed resistant of Ut artery Due to multiple risk factors for poor placentation Decresed diastolic flow
  11. 11. Pulsatility index… PI = Peak systolic velocity – Peak diastolic velocity Mean velocity Decreased diastolic flow Incresed PI
  12. 12. Uterine Artery Doppler…  Why in minor risk factors only ???  In high risk populations - moderate predictive value  low risk populations, High LR+ than high risk populations  abnormal result - Serial assessment of fetal size and umbilical artery Doppler from 26–28 weeks  normal result - may still be value in a single assessment of fetal size and umbilical artery Doppler Then WHY ???
  13. 13. Place for SFH… Serial measurement with plotting From 24 weeks onwards Improves prediction of a SGA neonate <10th centile or serial measurements of static growth , crossing centiles - referrer for ultrasound
  14. 14. Uterine artery Doppler… Foetus retain blood in circulation Poor placentation and poor blood flow to foetus Increased resistance of uterine artery Decreased diastolic flow
  15. 15. Pulsatility index… PI = Peak systolic velocity – Peak diastolic velocity Mean velocity Decreased diastolic flow Incresed PI
  16. 16. UA Doppler…  Normal flow indices  repeat every 14 days.  More frequent Doppler if severely SGA fetus.  Abnormal doppler flow indices (UA PI > +2 SDs above mean for gestational age)  delivery is not indicated  End–diastolic velocities present  twice weekly  Absent/reversed end–diastolic frequencies  daily
  17. 17. How to messure UA Doppler…  Free loop  Away from placenta and abdominal insertion  Vessel 2-4 mm diameter  Angle between vessel & US beam - 0 degree  If twins closer to abdomen
  18. 18. Absent Vs Reversed…
  19. 19. Pathophysiology of pulsatile venous flow… UA resistence futher increase foetal heart adapts to increase pressure in venous system Pulsatility appears in UV
  20. 20. Ductus venosus Doppler…  This triphasic waveform  S wave: fetal ventricular systolic contraction - highest peak  D wave: fetal early ventricular diastole - second highest peak  A wave (or rather trough): fetal atrial contraction - lowest point in the wave , still being in the forward direction S D A
  21. 21. DV Doppler, redused A wave and appearing pulsatility…
  22. 22. Ductus venosus Doppler… Absent or reversed Diastolic flow of UA doesn’t mean need delivery DV has moderate predictive value for acidaemia and adverse outcome used to time delivery
  23. 23. How to messure DV Doppler… right ventral mid-sagittal view of the fetal trunk color flow mapping demonstrate the umbilical vein, ductus venosus and fetal heart insonationa angle should be 30°
  24. 24. Early Vs. Late FGR… UA Doppler with timing of delivery with DV – if diagnosed < 34 weeks Why UA Doppler may fail to diagnose FGR after 34 weeks ???
  25. 25. Why UA Doppler may fail to diagnose FGR after 34 weeks ???  UA Doppler normal in late FGR  Even few hours before IUD Why???  Large placenta after 34  >50% of placenta should be malfunction to UA Doppler to become abnormal  Unlikely to occur
  26. 26. Middle Cerebral Artery Doppler… Smart foetus increase blood flow to Brain and adrenals shutting down others In normal state small systolic flow enough to maintain cerebral perfusion Decrease resistance of MCA Increase Diastolic flow
  27. 27. Pulsatility index… PI = Peak systolic velocity – Peak diastolic velocity Mean velocity Increased diastolic flow Decreased PI
  28. 28. Middle Cerebral Artery Doppler…
  29. 29. Cerebro-placental ratio… CPR= MCA PI UA PI In late FGR MCA PI decreases – CPR also decrease
  30. 30. Plotting of MCA PI or CPR
  31. 31. Timing of Delivery… Early FGR with Umbilical artery AREDV prior to 32 weeks  Abnormal DV Doppler  Appearance of UV pulsations  Provided fetus viable and completed steroids Place fpr computerized CTG Interpretation - based on short term fetal heart rate variation (CTG STV )  Fetal heart rate (FHR) variation is the most useful predictor of fetal wellbeing in SGA fetuses Late FGR  If MCA Doppler or CPR is abnormal, delivery should be recommended no later than 37 weeks.
  32. 32. Trial Randomizing Umbilical & Foatal FLow in Europe… TRUFFLE Study 2015  Compare Early ductus changes, late ductus changes and computarized CTG guided delivery Vs. 2 year neurodevelopment outcome of babies “ deferring delivery until the DV a wave has disappeared ( until delivery is mandated earlier by the CTG safety net criteria) compared to delivery based only on CTG STV changes possibly results in a small excess of antenatal deaths, but also in significantly improved survival without impairment at 2 years age corrected for prematurity “
  33. 33. Audit of adherence…  Risk assessment at booking Take histories,may ask, but no major vs. minor risk classification and planning Doppler studies  20-24 wk – Ut Artery Doppler in minor risk  Serial USS and plotting in charts of EFW and AC  Plotting UA Doppler in population charts  If AREDF using DV Doppler studies to time delivery  Using MCA PI and CPR in late FGR with plotting for timing
  34. 34. Thank you…

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