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Fetal growth restriction

This guide provides an overview of fetal growth restriction (FGR), defining its risk factors, screening methods, diagnosing techniques, and management strategies. Key take-home points highlight the importance of ultrasound screening for at-risk pregnancies between 16-24 weeks and fundal height checks post-20 weeks to identify discrepancies. FGR is characterized by growth below the 3rd percentile. Essential aspects of diagnosis include assessing ultrasound measurements and recognizing red flags for intervention. Proper management decisions can help mitigate risks to fetal well-being and neonatal outcomes.

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Fetal growth restriction

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  1. Fetal growth restriction Joseph Breuner, MD 8-08-05

  2. Objectives • Define risk factors • Define screening • Define diagnosis • Define management

  3. Take-home points • Risk factors: if positive, obtain ultrasound for growth 16-24 wks • if negative, use fundal height to screen

  4. Take-home points • Screening: use fundal height > 2cm discordant from GA after 20 wks or =2cm discordant from GA on serial visits • Either + risk factor or fundal height discrepancy =ultrasound • both fh and us most accurate 18-34 wks

  5. Take-home points • Define fetal growth restriction as <3rd%ile • follow 3-6th%ile carefully

  6. Take-home points • Red flags: • oligo: AFI < 5 deliver • systolic/diast ratio >95th %ile deliver • asymmetry--HC/AC >95%. Lower threshold for delivery, track other parameters closely

  7. Risk Factors • Fetal: • birth defect history (genetic syndromes, anomalies, karyotype abnormalities) • multiple gestation • uteroplacental insufficiency

  8. Risk factors • Maternal disease • starvation • hypoxemia due to heart/lung disease • antiphospholipid Ab syndrome • renal disease, chronic htn • pre-eclampsia

  9. Risk factors • Maternal exposure • infections prior to 20 wks: rubella, toxoplasmosis, cmv, vzv, malaria • substance abuse: smoking, alcohol, drug use • meds: coumadin, anticonvulsants, antineoplastic agents, folic acid antagonists

  10. Risk Factors • Maternal demographics • high altitude • race • extremes reproductive age • nullip or grand multip • prior FGR neonate (29 vs 9%) • prepreg wt <10%ile or no wt gain

  11. Risk Factors • Conspicuous by their absence: • maternal wt gain 10-24 lbs

  12. Screening • Order • basic ultrasound from hospital or swedish nuc med/ultrasound, because umbilical artery measurements are useful by themselves • anatomic survey comes with this scan, is useful to dx ‘birth defects’ group

  13. Diagnosis • Ultrasound: EFW based on AC, BPD and FL is best single measure to dx FGR and has • sensitivity 90% • specificity 85% • PPV 80% • NPV 90%

  14. Diagnosis • Understand three different entities present as small baby: • constitutionally small fetus • fetus with structural/chromosomal abn, fetal infection • uteroplacental insuffiency

  15. diagnosis • 3 phases of growth • cellular hyperplasia up to 16 wks • cellular hyperplasia and hypertrophy 16 to 32 wks • cellular hypertrophy 32 wks to term

  16. diagnosis • Use 3 features to dx among 3 different entities • symmetric vs. asymmetric • AFI • umbilical artery velocimetry (S/D ratio)

  17. diagnosis • Symmetric vs. asymmetric • symmetric growth restricted babies are small from the beginning, all measurements are equally small and grow on their own curve, hence title • includes constitutional and ‘birth-defect’ • 20-30% of growth restricted fetuses

  18. diagnosis • Asymmetric: relatively greater decrease in abdominal size than head circumference • results from redistribution of blood flow to vital organs in UPI • 70-80% of growth-restricted fetuses

  19. Diagnosis • Ultrasound: use AC, along with HC/AC and FL/AC ratios to dx asymmetric FGR • HC/AC ratio decreases linearly so is expressed in terms of SD above the mean. 2 SD >mean for GA is abnormal • FL/AC ratio is independent of GA after 20wks. > 23.5 % is abnormal

  20. Diagnosis • Systolic/diastolic ratio of umbilical artery flow is abnormal if > 95%ile for GA or absent/reversed in > 18-20 wk fetus • for diagnosing FGR, in comparison to US, • less sensitive (55 vs. 76%) • more specific (92 vs 80%) • higher PPV (73 vs 58%)

  21. Management • Mortality rises quickly with SGA

  22. management • Severe FGR=delivery > 32-34 weeks, • weigh fetal mortality vs neonatal morbidity at earlier GA

  23. Management • FGR <6 but >3rd %ile • if constitutional, follow to term • if ‘birth defect’ manage per the dx • if asymmetric, weigh fetal well-being vs neonatal morbidity

  24. Management • FGR <6 but >3rd %ile • Growth scans every 2-4 weeks • Be aggressive re UAV • BPP/AFI q wk in some ‘birth defects’ group and all uteroplacental insufficiency • increase BPP/AFI to daily if abnl but delivery risk > in utero risk

  25. Take-home points • Risk factors: if positive, obtain ultrasound for growth 16-24 wks • if negative, use fundal height to screen

  26. Take-home points • Screening: use fundal height > 2cm discordant from GA after 20 wks or =2cm discordant from GA on serial visits • Either + risk factor or fundal height discrepancy =ultrasound • both fh and us most accurate 18-34 wks

  27. Take-home points • Define fetal growth restriction as <3rd%ile • follow 3-6th%ile carefully

  28. Take-home points • Red flags: • oligo: AFI < 5 deliver • systolic/diast ratio >95th %ile deliver • asymmetry--HC/AC >95%. Lower threshold for delivery, track other parameters closely

  29. references • Williams chapter 29 2002 (pocket pc memo avail) • Up to date march 2005

  30. Case #1 • 26 yo G3P1SAB1 has normal prenatal course. No FH birth defects. You obtain clinic US for gender at 22 wks and they measure size =20 wks +/- 2 wks. FH are normal. • What do you do?

  31. Case #1 • You decide to obtain a hospital ultrasound 4 wks later, now 26 wks by LMP • shows EFW 15 %ile for LMP • GA is 24 wks +/-2 wks by biometry • umbilical artery S/D ratio is 1.4 • what’s your dx? • What do you do?

  32. Case #1 • More results from same US • no anatomic defects • HC %ile close to AC % ile, HC/AC and FL/AC ratios are normal • NOW what do you do?

  33. Case #1 • 2nd scan 4wks later at 30 wks LMP: • EFW 7%ile for LMP • symmetric • normal UAV • what do you do?

  34. Case #2 • 22 yo G1P1 smoker has hx IVDU and remote hx hypertension • 2nd prenatal visit is 28 wks • insists she knows when she got pregnant • what do you do?

  35. Case #2 • Maternal tox screen negative • Basic US shows EFW 6%ile for LMP GA • what else do you want to know about US?

  36. Case #2 • Anatomic survey intact • AC 4 %ile • HC/AC ratio 1.6 standard deviations above mean • UAV: S/D ratio 1.8, normal for this GA • Dx: ?

  37. Case #2 • Management?

  38. Case #2 • Follow up scan at 31 wks • EFW 4%ile • AC2%ile • HC/AC >2 SD • FL/AC 28% • S/D ratio 2.8, abnl is 3 for this GA • management?

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