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FETAL GROTH RESTRICTION 2. .pptx

Fetal growth restriction

Education◦
FETAL GROWTH RESTRICTION 1 Seminar Department of DNB-OBG DISTRICT HOSPITAL - BALLARI
FETAL GROWTH RESTRICTION FGR Presenters- Dr Ayyanna Dr Nagaveni Moderator-Dr Sri Laxmi Guide-Dr Suyajna Joshi D 2
Chiefari E, Arcidiacono B, Foti D, Brunetti A. Gestational diabetes mellitus: an updated overview. J Endocrinol Investig. 2017;40:899– 909. Introduction: ►The major concern in FGR is not the small size of the fetus, but the possibility of life threatening fetal compromise. ►Timely identification is difficult but crucial for proper management and a favorable neonatal outcome as it is the second leading cause of perinatal mortality after prematurity 3
ARIAS HIGH RISK PREGNANCY EDITION 5 CHAPTER NO 5 Definition ►FGR: A pathological condition where the fetus fails to achieve its genetic growth potential ►SGA: Infant with weight < 10th percentile of those born at the same gestational age or > 2 SDs below mean for Gestational Age 4
►SGA – EFW/ AC< 10 TH CENTILE ►SEVERE SGA- EFW/AC < 3RD CENTILE ►FGR -SGA + DOPLER CHANGES
INCIDENCE ► 3-5% of all pregnancies ► 20% of still borns are growth restricted ► 1/3 of infants with BW < 2750 gms are growth restricted and not premature
►And the 2 essential components for SGA are ►Birth weight <10th percentile ►Absence of pathologic process 70% ►In 2013, 3 major obstetric colleges in the UK, Canada, and the USA have published their clinical recommendations for pregnancies with FGR 8
►All guidelines use a different terminology ►All do agree that an EFW < 10th centile for gestation should be used to alert clinicians to small fetal size 9
RISK FACTORS MINOR RISK FACTORS • Maternal age >/=35 years • Nulliparity • BMI<20kg/m • BMI 25-29.9kg/m • Smoker 1-10/day • Mild PIH • Low fruit intake prior pregnancy • Pregnancy interval <6 month or > 30 month • Paternal SGA ARIAS HIGH RISK PREGNANCY EDITION 5 CHAPTER NO 5
► MAJOR RISK FACTOR • MATERNAL AGE >40YEAR • SMOKER >/= 11/DAY • COCAINE • DAILY EXERCISE • PREVIOUS SGA/ MATERNAL SGA • PREVIOUS STILL BIRTH • MATERNAL SGA • DIABETES ANDVASCULAR DISEASE • RENAL IMPAIRMENT • CHRONIC HYPERTENSION • APLA • HEAVY BLEEDING IN 1ST TRIMESTER /APH • SEVERE PE/PRE ECLAMPISA • LOW MATERNALWEIGHT GAIN
ARIAS HIGH RISK PREGNANCY EDITION 5 CHAPTER NO 5 CAUSES OF SMALLNESS 1. ERROR IN PREGNANCY DATING 2. SGA- CONSTITUENTLY SMALL 3. SGA-FETAL DISEASE/ANAMALY/INFECTION 4. SGA – PLACENTAL INSUFFICIENCY 1 2
PARAMETER CONSTITUTIO NLY SMALL FETAL ANAMOLY [TRISOMY 18] FETAL INFECTION [TORCH] PLACENTAL INSUFFICIENCY TIME OF GROWTH RETARDATION 2ND TRIMESTER EARLY 2ND TRIMESTER SINCE INFECTION 2ND TRIMESTER SYMMETRY SYMMETRIC FGR SYMMETRIC / ASSYMETRIC FGR ASSYMETRIC FGR ASSYMETRIC FGR PLACENTAL HARMONE [MAINLY PAPP-A] DECREASED/ NORMAL INCREASED NORMAL DECREASED GROWTHVELOCITY NORMAL DECREASED DECELARTION OF VELOCITY DECELARTION OF VELOCITY ARIAS HIGH RISK PREGNANCY EDITION 5 CHAPTER NO 5
Normal intrauterine growth pattern
►Stage I (Hyperplasia) ►4 to 20 weeks ►Rapid mitosis ►Increase of DNA content ►Stage II (Hyperplasia & Hypertrophy) ►20 to 28 weeks ►Declining mitosis ►Increase in cell size
►Stage III (Hypertrophy) ►28 to 40 weeks ►Rapid increase in cell size ►Rapid accumulation of fat, muscle and connective tissue ►95% of fetal weight gain occurs during last 20 weeks of gestations ►15 weeks = 5 grams/day ►20 weeks= 10 grams/day
►30 weeks= 25 grams/day ►35 weeks= 35 grams/day ►40 weeks = 15 grams/day ►May vary by race, gender, multiple gestation RELATIVE FREQUENCY OF DIFFERENT ETIOLOGIES ►Placental insufficiency-80% ►Tobacco/Smoking-5% ►Fetal Chromosomal-5% ►Fetal Infections-1-2%
CLASSIFICATION ►Based on evaluation & USG examination small fetuses are divided into two categories
FETAL GROWTH - A COMPLEX PHENOMΕΝΟΝ ►Besides these there occurs a delicate interplay between fetal adaptation to the maternal metabolism by modulating placental function ►This means that an adequate maternal nutritional status does not ensure adequate supply to the fetus, it requires a normal placental function also FGR is a pathologic process associated with additional features ►Abnormal placental morphology
►Oligohydramnios or ►Abnormal uteroplacental or fetoplacental doppler 20
PRIOR H/O IUGR HAS 4FOLD INCREASE INCIDENCE ►Lagging fundal measurement of 3cms with the estimated gestational age ►Poor maternal weight gain of <5 kg by 24 wks or 8 kg by 32 wks (for women with BMI<30) ►EFW <10 percentile ►HC/AC ratio>1 ►AFI≤5 ►Grade 3 placenta before 34 wks ► Decrease DFMC 21
EFFECTS OF IUGR 22
►The study by Bernstein et al (2000) done on 20,000 neonates born IUGR without major anomaly described the following RR
LONG TERM MORBIDITIES ➤ Cerebral palsy (Goldenberg RL et al. 1998) ➤ Hypertension (Hannsens M et al 1996) ➤ Dyslipidemia (Gogate S. 2001) ➤ Diabetes Melitus (Mukhopadhyay S et al 2001) ➤ Breast cancer (LeMarchand L et al 1998) ➤ Prostate cancer (Ekbom A et al 1996)
►Mental health problems, academic impairment and poorer general health FGR SCREENING ►Whom to screen? ►Ideally Symphysis Fundal Height (SFH) performed regularly for all pregnancies ►SFH in cms = weeks of gestation ►High risk cases will need ultrasound for growth, liquor volume, umbilical artery Doppler and Biophysical Profile ►Umbilical Artery Doppler is the best test!
There are FOUR TESTING MODALITIES which are helpful ►Daily fetal movement count (DFMC) ►Non-Stress Test (NST) ►Amniotic Fluid Index (AFI) ►Doppler of the Umbilical Artery ►Biophysical Profile (BPP) ⮚ Combination of tests are better than an isolated test
DIAGNOSIS 27
DIAGNOSIS A] CLINICAL Maternal weight gain ►Stationary or falling during second half of pregnancy Palpation of uterus ►SFH-Normally increases by 1 cm per week between 14 and 32 wks SFH less than 2-3 cm suspect fgr ►A lag in fundal height of 4 wks s/o moderate IUGR and over 6 wks s/o severe IUGR ►Abdominal girth - stationary or decreasing ►Liquor volume - less
B] BIOCHEMICAL ERYTHROPΟΙΕΤΙΝ (ΕΡΟ) ►An elevated HCG and amniotic fluid EPO has been found which supports the concept of early damage of placenta sufficient to cause erythroblastic response (Seppo Heinonen et al 1999) ►High levels of EPO were also found in hypoxic and growth restricted neonates (Ostlund E at al 2000) PAPPA ►A positive co-relation of PAPPA with femur length and abdominal circumference in second trimester
C] ULTRASOUND ►The greater the risk of IUGR based on clinical findings, the greater is the positive predictive value of USG ►It must be borne in mind that each measurement has an error potential of about 1 week up to 20 weeks gestation, 2 weeks from 20-36 weeks and 3 weeks thereafter
FETAL BIOMETRY 1.Abdominal circumference (AC) ► The most sensitive indicator ► Sensitivity is 95% if it measures below 2.5th percentile 2. HC/AC ratio ► Usefull in differentiating early and late onset fgr ► It is elevated in asymmetric IUGR and is normal in symmetric IUGR ► Normally >1= <32 week 1=32-34 week <1=>34 week
3. FEMUR LENGTH ► RELATIVELY SPARED IN LATE ONSET FGR ► NORMAL VALUE- 22 ► FGR- >23.5 4. AMNIOTIC FLUID ► SINGLE VERTICAL POCKET -<2 CM ► AFI<5 CM 5. PONDERAL INDEX[efw/crl3] ► LESS THAN 10th percentile suggestive of fgr
►Remember that we shall not switch to color doppler directly when patient is referred for color Doppler ►First go for biometry & precisely define type of growth retardation by plotting the finding in growth charts, assess fetus for malformation. Assess Amniotic fluid & biophysical activity & then switch on the color doppler
IMPORTANCE OF COLOUR DOPPLER The accuracy of doppler velocimetry in conjunction with 2d ultrasound and color flow mapping is now regarded as an indispensable component of a pregnancy sonogram
DOPPLER VESSELS TO BE STUDIED ►MATERNAL SIDE Uterine artery ►PLACENTAL SIDE Umbilical artery ►FETAL SIDE ►Arterial: MCA, renal and others ►Venous: ductus, hepatic, umbilical Fetal echocardiography
UTERO PLACENTAL CIRCULATION Conversion of spiral artery into utero placental vessel
UTERINE ARTERY • Normal impedance to flow the uterine arteries in 1° trimester • Normal impedance to flow the uterine arteries in early 2°trimester • Normal impedance to flow the uterine arteries in late 2° and 3º trimester
UTERINE ARTERY FACTS ► More accurate for screening in high risk- early onset cases( 2nd trimester) ► At a place, where UtA crosses the EIA ► B/L notch or U/L notch on the side of placenta is significant ► Best GA is 22-24 weeks ► High negative predictive value
UMBILICAL ARTERY ► It represent placental function and indicate degree of placental insufficiancy ADVANCING GESTATION ►Progressive rise in the end-diastolic velocity ►Decrease in the pulsatility index
UMBILICAL ARTERY FLOW ►S/D ratio : 2-3 in 2nd and 3rd trimester ►PI : 1.5 – 2.0 in 2nd trimester 1.0 – 1.5 in 3rd trimester ►RI : Decrease with gest. In late 2nd and 3rd it is around 0.5 ►Whether at fetal end, placental end or in between – no difference
First sign of hypoxia & growth retardation UMBILICAL ARTERY FLOW – what does it tell us ??
NORMAL UMBILICAL ARTERY ►1º trimester Absent Diastolic Flow ►Early2°trimester Low Diastolic Flow ►Late 2º and 3° trimester Resistance further reduce, more diastolic flow
UMBILICAL ARTERY – ABNORMAL Umbilical arteries ►normal Umbilical arteries ►High pulsatility index Umbilical arteries ►Absent end diastolic velocity ►Very high pulsatility index ►Pulsation in the umbilical vein Umbilical arteries ►Reversal of end diastolic
UMBILICAL ARTERY & CTG ►Umbilical artery 90% more sensitive to CTG ►Interval between absence of end diastolic flow & onset of late deceleration was 3-12 days High resistance
Reflects : Cerebral flow End points : rising PI after a nadir • More than 1.45 before term • Fall down to 1 • If less than 1- peak of redistribution MIDDLE CEREBRAL ARTERIES
MIDDLE CEREBRAL ARTERY ►22-28 weeks- no EDF in MCA ►It represent fetal response to placental dysfunction ►28w to term- some EDF seen- normal ►Increased EDF (low PI) suggests 'brain sparing' redistribution in IUGR ►Worsening hypoxia- fetal acidemia- paradoxical rise in resistance (high PI) ►CPR increases - this is indicative of IUGR
EARLY ONSET FGR LATE ONSET FGR ► ALREADY ABNORMAL BECAUSE OF WORSENING PLACENTAL CIRCULATION ► Predective capacity of adverse neonatal outcome like neonatal metabolic acidosis
MANNING’S BPP
FREQUENCY OF FETAL SURVILLANCE
Management
Uncomplicated fgr < 37 week 1 Rest 2 High protein diet 3 Avoidance of smoking and alcohol 4 Pharmacological intervention -low dose aspirin
5 . Assesment of foetal well being a] Long term [valid for 2 week] -Ua doppler -Placental morphology -Fetal biometry b]Medium term[valid for 1 week ] -Umbilical artery doppler -Afi c]Short term [valid for 3-4 days ] -Nst - Bpp
STAGES OF IUGR
MODE OF DELIVERY ►Labour is a stressful process for the fetus ►Every contraction reduces oxygenation, though briefly and it recovers ►Prolonged difficult labors should be avoided! ►Continuous fetal monitoring is a MUST! ►Elective LSCS for severe IUGR, abnormal presentation, oligohydramnios, abnormal CTG/ NST
AMNIOINFUSION ►Amnioinfusion refers to the instillation of fluid into the amniotic cavity ►This procedure is typically performed during labor through an intrauterine pressure catheter introduced transcervically after rupture of the fetal membranes ►Alternatively, fluid can be infused through a needle transabdominally, the reverse process of amniocentesis
TAKE AWAY POINTS ►Currently USG measurements are used to confirm small fetal size, whereas, BPP is used to assess fetal function. ►Based on BPP one can consider the safety of continuing pregnancy. ►Unequivocal cessation of ultrasound growth would also constitute fetal grounds for delivery. ►Risk of elective delivery after 37 weeks is very small, suspicion of fetal compromise from any abnormal fetal welfare study may precipitate decision for undertaking prompt delivery
►LSCS is used increasingly for the compromised fetus because of high risk of fetal distress in labor. ►However, in the Indian setup, facilities for NICU are not uniformly available. Hence, the decision for time and mode of delivery needs to be individualized as the management of such a neonate is a real challenge. ►If possible, the mother should be transferred to a center with a well-equipped neonatal care unit to minimize the risks involved in transfer of the newborn baby
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