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fetal growth restriction updated ppt 2.pptx
- 1. Diagnosis and Managementof Small- for-Gestational-Age Fetus and Fetal Growth Restriction (FGR) Presented by Dr. Riyam Kaur Under the guidance of - Dr. Vettri Vignesh Assistant Professor
- 2. INTRODUCTION • Fetal growthrestriction (FGR) and small- for-gestational-age (SGA) are major causes of perinatal morbidity and mortality. • Accurate diagnosis allows improved monitoring and timing of delivery. • Fetal growth depends on maternal, placental, and fetal factors.
- 3. Terminologies – SGA,AGA & FGR SGA – Small for Gestational Age: • EFW or AC <10th percentile • One that has not acheived its growth potential AGA – Appropriate for Gestational Age: • EFW/AC > 10 th percentile. FGR – Fetal Growth Restriction: • Pathologic restriction of growth potential irrespective of absolute size • Often defined as EFW or AC <5th percentile • Doppler abnormalities typically present
- 4. Epidemiology and Importance Affects5–10% of pregnancies- • Associated with stillbirth, hypoxia, and neurodevelopmental delay. • Overall, growth-restricted fetuses have a higher rate of conditions associated with prematurity, experience worse neurodevelopmental outcome and are at increased risk of non- communicable diseases in adulthood, such as hypertension, metabolic syndrome, insulin resistance, Type-2 diabetes mellitus, stroke. .
- 5. Etiology of FGR Maternal: Hypertension, preeclampsia, malnutrition, smoking. Placental: Infarction, abruption, insufficiency. Fetal: Chromosomal abnormalities, infections (TORCH).
- 6. Doppler Indices –PI, RI, S/D PI (Pulsatility Index): • (Peak systolic – End-diastolic) / Mean velocity Sensitive marker of placental resistance RI (Resistance Index): • (Systolic – Diastolic) / Systolic S/D Ratio: • Systolic velocity / Diastolic velocity Increases when placental resistance rises
- 7. Cerebroplacental Ratio (CPR) How to Calculate CPR: • CPR = MCA PI / UA PI Interpretation: • Low CPR indicates redistribution & fetal hypoxia • CPR <5th percentile = abnormal Clinical Use: • Helps identify late-onset FGR • •Guides timing of delivery
- 8. Pathophysiology Placental insufficiency •leads to decreased uteroplacental flow and decreased oxygen and nutrient delivery Fetal hypoxia • Chronic low oxygen leads to redistrubution of blood flow • Brain sparing - increased flow to brain , heart and adrenals • Oxidative stress damages placental villi and worsens placental function
- 9. Doppler Studies Umbilical artery(UA): Increased PI → placental resistance. • Middle cerebral artery (MCA): Decreased PI → brain sparing. • Ductus venosus (DV): Reversed a-wave → severe hypoxia.
- 10. Terminologies – Symmetricvs Asymmetric FGR Symmetric FGR: • Proportionate reduction in AC, HC, FL • Early pregnancy insult (chromosomal, infection) Asymmetric FGR: • AC reduced more than HC (HC/AC ratio ↑) • Late placental insufficiency • Brain-sparing present
- 11. Diagnosis of Early-OnsetFGR (<32 Weeks) Ultrasound: • EFW or AC <3rd–5th percentile • Falling growth centiles • ↓ AFI / oligohydramnios Doppler Abnormalities: • UA: ↑PI, absent/reversed EDF • MCA: ↓PI (brain-sparing) • •DV: ↑PI or reversed a-wave
- 12. Type of FGRSolitary Criterion Contributory Criteria (≥2 required) Early-Onset FGR (<32 weeks, no congenital anomalies) • AC or EFW <3rd percentile OR • UA AEDF (absent end- diastolic flow) • AC or EFW <10th percentile • UtA-PI >95th percentile and/or UA-PI >95th percentile • Growth crossing >2 quartiles Late-Onset FGR (≥32 weeks, no congenital anomalies) • AC or EFW <3rd percentile • AC or EFW <10th percentile • AC/EFW drop >2 quartiles • CPR <5th percentile or UA-PI >95th percentile
- 13. Severity Stage (Primary)Factors (Secondary) Factors Stage I – Mild Placental Insufficiency • Mild placental insufficiency • UA ↑PI • Normal MCA & DV • Mild maternal anemia • Low maternal weight gain Stage II – Severe Placental Insufficiency • UA high resistance / absent EDF • Early MCA redistribution • Maternal malnutrition • Low BMI • Smoking/alcohol Stage III – Pre-acidosis • UA reversed EDF ± • DV early abnormal PI • High-altitude hypoxia • Short inter-pregnancy interval Stage IV – High Risk of Acidosis • DV reversed a-wave • Severe placental vascular disease • Socioeconomic stress • Moderate maternal illness
- 15. Biophysical Profile &CTG • BPP assesses fetal tone, movement, breathing, and amniotic fluid. • BPP score can predict both fetal pH and outcome • CTG evaluates fetal heart rate variability.
- 16. Demand–Supply Situation inFGR Normal Demand & Normal Supply: • Normal fetal oxygenation & growth Low Demand State: • Fetus reduces metabolism to survive hypoxia Growth slows (adaptive response) Low Supply State: • Placental insufficiency → decreased oxygen/nutrient delivery • Primary mechanism behind FGR
- 17. Early-Onset FGR Management •Intensive Doppler surveillance. • Antenatal corticosteroids < 34 weeks. • Magnesium sulfate for neuroprotection < 32 weeks.
- 18. Gestational Age SurveillanceDelivery Criteria 24–28 weeks • UA Doppler 2–3×/week • MCA + DV weekly • Daily CTG if abnormal • Steroids + MgSO₄ • DV reversed a-wave • Persistent late decelerations 28–30 weeks • UA/MCA q2–3 days • DV weekly • Growth every 1–2 weeks • UA reversed EDF • DV abnormal/high PI • Abnormal CTG/BPP 30–32 weeks • UA q2–3 days • MCA + CPR weekly • DV weekly • Absent EDF (>30 wks) • Reversed EDF • Rising DV PI
- 19. Late-Onset FGR Management LateFGR is characterized by milder and more aspecific placental lesions Category Findings Management / Monitoring Timing of Delivery Umbilical Artery Doppler Normal / PI>95th 1–2 wk or weekly Doppler 38–39 wk / 37 wk CPR / MCA CPR<5th, MCA PI<5th Increase surveillance 37 wk CTG Normal/Abnormal Dopplers Weekly / twice weekly — Growth Scan — Every 2 weeks —
- 20. TRUFFLE Protocol Overview •Combines DV Doppler and computerized CTG for delivery timing. • Delivery recommended for reversed UA flow after 30 weeks.
- 21. Timing of Delivery •Based on gestation, Doppler findings, and fetal well-being. • Early FGR: delivery when DV abnormal or reversed flow. • Late FGR: induction at 37–38 weeks if CPR abnormal.
- 22. Mode of Delivery •Early FGR: often cesarean due to compromised fetus. • Late FGR: trial of labor possible with close monitoring.
- 23. Surveillance Frequency • NormalDopplers: every 2 weeks. • Abnormal Dopplers: every 2–3 days. • Hospital admission for reversed flow or abnormal CTG.
- 24. Adjunctive Therapies • Low-doseaspirin for prevention. • Oxygen therapy not recommended. • Nutritional supplements show limited benefit.
- 25. Prognosis • Dependent ongestational age at onset and severity. • Early detection and optimal timing improve survival.
- 26. Postnatal Outcomes • •FGR infants at risk for hypoglycemia, hypothermia, and growth delay. • • Long-term risk: metabolic and cardiovascular diseases.
- 27. Follow-Up • Pediatric growthand neurodevelopmental monitoring. • Parental counseling regarding long-term risks.
- 28. SUMMARY • FGR ≠SGA — pathologic vs physiologic smallness. • Doppler is cornerstone of diagnosis. • Early vs late FGR differ in etiology and management. • Individualized delivery timing is crucial.
- 29. References • Lees CC,Stampalija T, Baschat AA, et al. • Diagnosis and Management of Small-for- Gestational-Age Fetus and Fetal Growth Restriction. • Ultrasound Obstet Gynecol 2020; 56: 298– 312.
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