Seminar Presentation on fetal growth restriction

Presenter: Dr Abdulaziz N .(Year II resident)
Moderator: Dr Jemal (Ass. Professor of gyneobs )
2/8/2024 Seminar presentation on FGR 1

Outline
 Objective
Introduction
Definition and pattern of FGR
Etiologies of FGR
Diagnostic Tools in FGR
Screening And prevention
Management of FGR
Selective FGR
References
2/8/2024 Seminar presentation on FGR

Objectives
To discuss on definition and Diagnosis FGR
To discuss on Etiologies and risk factors FGR
To discuss on methods of screening and prevention of FGR
To discuss current on recommendations on management of
FGR
To discuss on Diagnosis and management of selective FGR

Introduction
Fetal growth may be divided into three phases
phase of hyperplasia ( First 16 weeks )
Phase of cellular hyperplasia and hypertrophy ( 16-32
weeks)
Phase of cellular hypertrophy (After 32 weeks )
Eighty percent of fetal fat gain is accrued after 28 weeks’
gestation

Cont…
Fetal development is believed to be determined by
maternal provision of substrate and its placental
transfer, whereas fetal growth potential is governed by
the genome.
FGR is defined as the failure of the fetus to meet its
growth potential due to a pathological factor.

Cont…
FGR is the second leading cause of PNM (6-10x ) next to
prematurity
53% of preterm stillbirths and 26% of term stillbirths have
FGR.
The incidence of intrapartum asphyxia may be as high as
50%

Definition and pattern of FGR
From the 1960s, growth has been classified by the
absolute birth weight as ;
LBW; <2500 g
VLBW; < 1500 g
ELBW; <1000 g
macrosomia > 4000 g
subsequently, studies demonstrated only the comparison
actual birthweight with GA, associated with high risk.

Cont…
This resulted in the currently accepted classification of birth
weight as;
very small for gestational age (VSGA; <3rd percentile),
small for gestational age (SGA; <10th percentile),
 Average for gestational age (AGA; 10th to 90th percentile), or
 Large for gestational age (LGA; >90th percentile).

ETIOLOGIES AND RISK
FACTORS FGR
Maternal
Fetal
 Hypertensive Disease
 Pregestational diabetes
 Cyanotic cardiac disease
 Autoimmune disease
 Restrictive pulmonary disease
 High altitude
 Substance abuse
 Malabsorbative disease
 Malnutrition
 Multiple gestation
 Teratogenic exposure
 Fetal infection
 Genetic Disorders
 Structural abnormalities
placental
 Primary placental disease
 Placental abruption and ind
infarction
 Placenta previa
 Placental mosaicism

Diagnostic Tools in FGR
 Accurate gestational age assessment is critical for determining whether
birth weight is normal.
 Symphysis–fundal height
 A single SFH at 32-34ks has 65-85 %
sensitivity and 96% specificity
 The overall sensitivity of serial fundal height to detect FGR ranges
from 11 to 25 % .
 Detection rates are lower in obese women

Diagnostic Tools in FGR
Fetal Biometry
SEFW- most important calculated US variable
BPD-alone is a poor tool for the detection of FGR
HC
TCD
AC-single best measurement for the detection of FGR
HC/AC -70% to 85% FGRs detected
FL/AC ≥ 23.5 suggests FGR

Diagnostic Tools….
Fetal Anatomic Survey
Amniotic Fluid Assessment -Placental dysfunction and fetal
hypoxemia both may result in decreased perfusion of the fetal
kidneys.

Diagnostic Tools…
Doppler Velocimetry –
 serves as a diagnostic as well as a monitoring tool
 Arterial Doppler waveforms provide information on
downstream vascular resistance.
 S/D ratio, the resistance index, and the pulsatility index (PI) are
the three Doppler indices most widely used
 Venous Doppler parameter Provide assessment of cardiac
forward function

Umbilical Artery Flow-Velocity
Waveforms
►Normal
►Decreased EDF; Indices
become affected when 30% of
placental bed obliterated
►AEDF-when 50% of placental
bed obliterated
►REDF-when ≥70% of
placental bed obliterated

Cont…
Invasive Testing
maternal serology and/or viral polymerase chain reaction (PCR)
Invasive fetal testing can be performed to obtain amniotic fluid
and/or fetal blood for karyotyping or microarray analysis

Fetal Growth Restriction Dx
Various criteria has been used to define FGR. Included;
EFW below the 3rd, 5th, or 10th percentiles ;
Similar abdominal circumference (AC) percentiles;
A specified decline in the EFW percentile or AC percentile over
serial assessments; and
Various abnormal Doppler findings

Diagnosis
SMFM-ACOG-AIUM ISUOG
AC or EFW <10th centile
for GA
Early (<32 weeks) Late (≥32 weeks)
AC or EFW <3rd centile for
GA or UA-AEDF
or
AC or EFW <10th centile
Combined with one of the
following:
a) UtA PI >95th centile
b) UA-PI >95th centile
AC or EFW <3rd centile for
GA
or
Any two of the following:
a) AC or EFW <10th centile
for GA
b) AC/EFW crossing centiles
>2 quartiles on growth
centiles
c) CPR <5th centile or UA-PI
>95th centile

Cont..
SMFM criteria had higher sensitivity than the ISUOG criteria for
the prediction of neonatal SGA (54.7% vs 28.8%) but had a
higher false-positive rate (6.7% vs 1.6%).
The positive predictive value for the prediction of neonatal
morbidity was poor for both deﬁnitions (15.3% vs 25.5%)
SMFM criteria offers a more simple, straightforward and
pragmatic approach to the diagnosis of FGR, that also has
the ability to identify more at-risk pregnancies.

Cont…
Early Onset FGR Late Onset FGR
 <32 weeks
 prevalence of 0.5%_1%
 Strong association with PE
 Predictable natural course
 Main challenge is management
 ≥ 32 weeks
 5%_10%
 Less likely associated with PE
 Main challenge is diagnosis
 Natural course is less
predictable and there is a risk
of sudden decompensation And
stillbirth.

Which growth chart should should be
used
Growth references vs growth standards
Charts based on birth weight vs SFWE
Universal versus customized charts
Comparison of the 10th
percentile curves of common
growth charts.

Diagnostic Algorism

Screening And prevention
FGR as a disease entity fulfills several criteria that potentially
justify a screening program.
 Maternal History
poor pregnancy outcome (spontaneous abortions , neonatal
and intrauterine deaths)
 25 % risk of recurrence after 1 FGR.
 After 2 pregnancies the risk increased by 4 fold.

Maternal serum analytes
Serum estriol, human placental lactogen , hCG and MSAFP in
2nd Triminister .
Elevated MSAFP and hCG levels in the 2nd trimester are
considered markers of abnormal placentation.
Associated with increased risk of FGR
Single, unexplained elevated value of 2 to 2.5 MoM raises the
risk 5-fold to 10-fold.

Cont…
A decrease in PAPP-A or the PlGF shown the most consistent
predictive performance in 1st triminister.
They associated with early abnormalities in placental
angiogenesis and development
 A decrease in the PAPP-A to less than 0.8
MoM is a risk for subsequent placental dysfunction

Cont…
 Clinical Examination
After 20 weeks’ gestation, a lag of the SFH ≥4 cm
signifies FGR
Is the only screening tool recommended
 Maternal Doppler Velocimetry
Abnormal uterine artery flow-velocity waveforms
 Integrated Approach

prevention
Efforts to prevent FGR have been disappointing
Life style modification
Low-dose aspirin has been extensively evaluated as a possible
preventive agent for placental dysfunction.
Only starting aspirin before 16 weeks’ gestation derive a 50% to
60% reduction in the RR for development of preeclampsia or
FGR.

Cont…
Elimination of contributors such as stress, smoking, and alcohol
and drug use .
 Bed rest in the left lateral decubitus position to increase
placental blood flow.
Dietary supplementation may be helpful in those with poor
weight gain or low pre pregnancy weight

Cont…
Maternal hyper oxygenation
can raise the fetal cord blood pO2
fetal growth velocity was not improved
 Maternal hyper alimentation
Maternal volume expansion
Corticosteroids for enhancing lung maturation and preventing
IVH when delivery is anticipated before 34 weeks’ gestation

Risk Assessment and Screening for
FGR

Assessment of fetal well-being
The institution of antenatal surveillance is a critical component
in the management of the growth-restricted fetus.
The goal is to avoid stillbirth and optimize the timing of
delivery,
The likelihood of fetal acidemia and stillbirth is the strongest
fetal criterion for delivery.
Incontrast, gestational age–specific expectations for neonatal
complications and survival force conservative management.

Cont…
 Antenatal surveillance tests need to predict fetal acid-base
status, rate of anticipated progression, and the resulting risk
for deterioration and stillbirth.
The monitoring tools available to achieve this include NST ,
CST, BPP and Doppler studies.

Cont…
 Maternal Monitoring of Fetal Activity
Fetal activity charting in pregnancies complicated by FGR
predicts subsequent distress in labor.
 Fetal Heart Rate Analysis
Normal FHR characteristics are determined by gestational age,
maturational and functional status of central regulatory centers,
and oxygen tension

Cont…
Reactive NST indicates absence of fetal acidemia at the moment
of the FHR recording
Correlates highly with a fetus not in immediate danger of
intrauterine demise
Nonreactive NST results, on the other hand, are often falsely
positive and require further evaluation
The CST is an additional option for testing placental respiratory
reserve

Cont…
 Amniotic Fluid Volume
 Assessment of AFV provides an indirect measure of vascular
status
Interventions based on twice-weekly MBPP scores result in
similar perinatal outcomes as with weekly CST .
 Biophysical Parameters

Cont…
four components of the BPP are lost at different levels of
hypoxemia and acidemia .
Loss of heart rate reactivity along with the absence of fetal
breathing.
decreased fetal tone and movement in association with more
advanced acidemia , hypoxemia, and hypercapnia.

Cont…
 Doppler Ultrasound
Doppler parameters are influenced by several variables that
include vascular histology, tone, and fetal BP.

Early responses to placental insufficiency mild placental
vascular disease when UA EDV is still present ….Decrease in
CPR is compensatory.

Cont…
Late responses to placental insufficiency are observed when
loss or reversal of UA EDV occurred in parallel with venous
Doppler indices.
Fetal Doppler assessment based on the UA alone is no
longer appropriate, particularly in the setting of early-onset
FGR prior to 34 weeks.
The SMFM does not recommend Doppler assessment of
the MCA or ductus venosus (DV) in the clinical
management of FGR, which is a signiﬁcant difference
from the ISUOG guideline.

Anticipation of progression

Cont…
There is currently no treatment for FGR, and the management
and its outcomes relies on
 early diagnosis
 possible risk and etiologic identification
 optimal fetal surveillance
 timely delivery
 short term and long term complication prevention, identification
and intervention
 prevention
 Antenatally undetected SGA neonates had a 4-fold risk of
adverse outcome
It has been reported that a suboptimal antenatal management is
the most common finding in cases of unexplained stillborns

Timing and Mode of Delivery

Cont…
 The decision for delivery is a delicate balance between the risk of
prematurity and perinatal death
The timing of delivery in FGR is determined by
 a gestational age
 Severity of FGR
 Findings of fetal monitoring tests
 Maternal factors such as pre-eclampsia

 In SGA fetuses that remain undelivered after 38 weeks, the risk of
stillbirth doubles every week and reaches 60/10 000 for pregnancies
that continue beyond the due date.
 Steroid and magnesium sulfate adminstration protocol for preterm
FGR fetus is similar as non-IUGR .

Cont…
Risk of fetal death in
growth-restricted
fetuses with umbilical
and/or ductus venosus
absent or reversed end-
diastolic velocities
before 34 weeks of
gestation:

Cont…
 In IUGR with an UA Doppler S/D, RI or PI above than the 95th
percentile but without A/REDV or in the setting of severe FGR ,
delivery is recommended at 37 weeks of gestation
Delivery is recommended at 38–39 weeks in IUGR with an
EFW between 3rd and 10th percentile and normal UA Doppler
 Delivery is at 34 0/7–37 6/7 wks for IUGR with
oligohydramnios
 In the presence of AEDV, delivery is recommended at 33 0/7 to
34 0/7 wks
 In the presence of REDV, delivery is recommended at 30 0/7–
32 0/7 wks

Cont…
 FGR in itself is not an indication for cesarean section. However,
primary cesarean section may be considered in selected cases of
severe FGR where the likelihood of successful vaginal delivery is low.
 Mode of delivery depends on
 gestational age
 severity of FGR
 Doppler changes
 associated obstetric complications
 parity
 cervical Bishop score, and patient preference
 Cesarean delivery should be considered in pregnancies with FGR
complicated by A/REDV

Cont…
The optimal approach for cervical ripening in women
undergoing induction for FGR remains unclear
Cervical ripening using mechanical methods seem to be
associated with a lower rate of overall composite adverse
intrapartum outcome, cesarean section for non-reassuring
fetal heart tracing, uterine tachysystole and compared with
prostaglandins.
During labor, continuous FHR monitoring is recommended.
Delivery should take place at an institution with the
appropriate level of neonatal care for the gestational age.

Monitoring, Timing, and Mode of Delivery in cases with FGR

Delivery criteria for FGR

Outcomes
Short-Term Outcomes
MAS
Hypoglycemia
Hypocalcemia
Hyponatremia
Polycythemia or anemia,
Thrombocytopenia
Hypothermia
Perinatal death
Long-Term Outcomes
Lag in growth
Poor school performance
Metabolic syndrome
Obesity
Diabetes
Stroke
 Coronary artery disease

Fetal growth restriction in twin
gestations
Twin fetuses grow more slowly than singletons,
starting from 28–32 weeks.
At term, approximately 30%–50% of twins would be
identified as SGA.
The mechanisms underlying the relative smallness of
twins remain unclear

Cont…
Two different beliefs
Pathologic
 Failure of the uteroplacental circulation to meet the demands of
two fetuses
Physiologic
 Benign physiological adaptation of twins to the “crowded”
intrauterine environment in an effort to delay the onset of labor

Cont…
Growth abnormalities in twins manifest in 3 ways
Selective fetal growth restriction
Both twins small for GA
One twin significantly smaller (although neither is SGA )

Causes of Discordant growth
Dichorionic twins Monochorionic twins
 Different genetic growth
potential
 Suboptimal implantation site of
one
 Umbilical cord abnormalities
such as velamentous insertion,
marginal insertion, or vasa
previa
 Placental pathology
 Unequally shared placenta
 Placental anastomosis as in
TTTS leads to perfusion
imbalance.
 Discordance in structural
anomalies

Cont…
Twin gestations with discordant growth between two fetuses
that are appropriately grown for gestational age are not at
increased risk.
However, accumulated data suggest that weight discordancy
exceeding 25 to 30 percent most accurately predicts an adverse
perinatal outcome
Some diagnose sFGR when AC measurement difference
exceeds 20 mm or if fetal-growth discordance is >20 %

Cont…
In dichorionic twin FGR is generally managed as in
singleton.
Determination of Couse , serial ultrasound evaluation,
Ongoing evaluation of fetal well being…
And timed delivery based on combination of factors ( GA,
UA doppler , BPP , …

Selective FGR In MC twins
 Selective FGR is defined as growth restriction of one twin, with appropriate
growth in the co-twin .
 Diagnosed when EFW on a sonographic scan of the growth-restricted twin
falls below the 10th percentile, while the other twin is appropriate for GA
 Occurs in 10% to 15% of MCDA gestations
 Occurs earlier and has different course
 Umbilical artery (UA) Doppler findings cannot be interpreted in the same
way as in singleton or DC gestations
 sFGR can be seen more often in MCDA pregnancies than in MCMA
pregnancies

Classification
Type I; is characterized by positive diastolic flow
 Commonest form with incidence of 29–63.5%
 A smaller degree of weight discordance
 Relatively benign clinical course.
Type II; by persistently absent or REDF
 carries a high risk of deterioration and demise.
 incidence: 22.4–36.5% of the sFGR
Type III; by intermittently absent or REDF
 incidence is 48% of all sFGR cases
 lower risk of deterioration than type II.

Cont…

Cont…
 There is no evidence of optimal monitoring of MC twins with sFGR .
 Serial evaluation of fetal growth is performed every 3 weeks
 If sFGR is diagnosed, biweekly testing of fetal wellbeing, evaluation
of AFV , and UA Doppler are undertaken for type II and III
 Doppler studies in the smaller fetus may help guide management.

Cont…
Three management options are available for type II and III early-
onset sIUGR in a MC twin pregnancy:
Careful expectant management with an effort to maximize
outcome for both twins
Cord occlusion of the IUGR twin and
Laser photocoagulation for severe sFGR at early gestation and
where sFGR is combined with TTTS ( dichorionizing )

References
1. Williams OBSTETRICS 26TH EDITION, PP. 2116-2141
2. Gabbe: Obstetrics: Normal and Problem Pregnancies, 8th ed. PP. 555-582
3. ACOG Practice Bulletin , Fetal growth restriction, No. 204, 2023
4. The Investigation and Management of the Small–for–Gestational–Age Fetus. Green-
top Guideline No. 31,MAY 2022
5. Best practice advice for screening, diagnosis, and management of fetal growth
restriction.FIGO, 2021
6. Diagnosis and management of small-for-gestational-age fetus and fetal growth
restriction, ISUOG Practice Guidelines: 2020
7. The High-Risk Profile of Selective Growth Restriction in Monochorionic Twin
Pregnancies, Medicina , 2023
8. Early onset fetal growth restriction, Maternal Health, Neonatology, and Perinatology,
2017
9. Fetal Growth (Restricted), South Australian Perinatal Practice Guideline, 2023
10. Risk of fetal death in growth-restricted fetuses with umbilical and/or ductus venosus
absent or reversed end-diastolic velocities before 34 weeks of gestation: a systematic
review and meta-analysis.https://doi.org/10.1016/j.ajog.2017.11.566
11. Diagnosis and management of fetal growth restriction: the SMFM guideline and comparison
with the ISUOG guideline, Ultrasound Obstet Gynecol 2021; 57: 880–883

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