27years g1 ga : 28w 2d (by sono 8w :28w 3d ) fondal height : 24 cm
TRANSCRIPT
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IN THE NAME OF GOD
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SMALL FOR GESTATIONAL AGE
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CASE 1
27years
G1
GA : 28w 2d (by sono 8w :28w 3d ) Fondal height : 24 cm
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Sono 3 days ago
BPD :24W 3D AC : 22 W FL : 21 W AFI : NL Severe IUGR BPP: breath:0
AF:2 tone:2
Doppler : increased Umbilical artery RI
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Diagnostic criteria
AC < 10% and EFW < 10% : SUSPECTED TO IUGR
AC < 10% and EFW > 10% : at risk to IUGR
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27years ,G1 GA : 28w 2d (by sono 8w :28w 3d )
C.C : fundal height 24 cm سال قبل 10-بیمار مورد شناخته شده تاالسمی اینترمدیا که
اسپلنکتومی شده استهفته بعد از اسپلنکتومی دچار ترومبوفلبیت عروق کبدی می شود و 2-
ماه پس از ترخیص قرار میگیرد1تحت درمان با هپارین و وارفارین تا سال قبل تا کنون آسپیرین مصرف می کند10-از
سال پس از اسپلنکتومی کوله سیستکتومی می شود1 سال قبل تزریق خون نداشته 10-از
BD واحد 5000-از ابتدای بارداری تحت درمان با هپارین به صورت بوده است
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ultrasonography
Gestational age BPD ,HC,AC,FL TCD EFW AFI Doppler sonography BPP
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sonography : after 2days
BPD : 24W HC : 24W 2D AC : 24W 1D FL :23W 3D EFW : 539 g AFI : 10cm Umbilical artery : reversed EDV Ductus venosus : NL BPP : 10/10
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symmetric IUGRAssociated conditions:
- Genetic - Congenital anomalies - Intrauterine infections - Substance abuse - Cigarette smoking - Therapeutic irradiation
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management
Anomaly scan
Karyotyping identification : severe early onset IUGR , Symmetrical IUGR ,polyhydramnious ,stractural anomaly .
Echocardiography
Serology :CMV ,RUBELLA , VARICELLA
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Algorithm
IUGR
yesTORCH stigmata work-up? no yesDysmorphic features work-up? no
yesMaternal/placental explanation work-up?
no yes
Maternal drug use tox screenno
Unknown cause
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Follow up
Growth curve (biometry)
Doppler
BPP
NST
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Frequency of fetal surveillance Normal doppler & AFI : fortnightly umbilical artery end diastolic flow is
present : weekly Doppler BPP twice weekly Absent or reversed end diastolic flow in
the umbilical artery : hospital admission daily BPP and Doppler
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BPP daily
FGR < 5 % Severe oligohydramnious Absent / reverse EDV Equivocal BPP ( 6/10 )
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Sonography after than 18 days BPP : 26w 5d HC : 25w 6d AC : 24w 6d FL : 24w 2d EFW : 615 g AFI : 10 cm Umbilical artery reversed EDV DV : flow a wave decreased
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GA : 30w 2d C/S Female : 630 gr
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Indication of C/S
Fetal acidemia
Spontaneous late deceleration
Absent /reverse umbilical artery EDV
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CASE 2
40y , G3L2(c/s) GA : 35w 1d but by sono 8 weeks : 33w 1d FH : 30 cm PMH : no problem OBH : neg US : BPD : 28w 3d HC : 28w 3dAC : 25wFL : 26wHL : 24w 5dEFW : 746gAFI : 5 cm doppler : NL
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intervention
SGA 24+0 and 35+6 weeks before delivery : antenatal corticosteroids.
Magnesium : under 30 week. smoking cessation. Antithrombotic therapy appears to be a
promising therapy for preventing SGA in high risk women.However there is insufficient evidence, especially concerning serious adverse effects, to recommend
its use.
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Sonography after than 16 days
BPD : 29W 3D AC : 26w FL : 26W 5D EFW : 767 g AFI : 2 cm BPP : 8/10 DOPPLER : NL
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GA : 33w 1d GA : 35w 3d
BPD : 28w 3d
HC : 28w 3d
AC : 25w (191 mm)
FL : 26w
HL : 24w 5d
EFW : 746g
AFI : 5 cm
BPD : 29W 3D HC : 28w 5d AC : 26w (200 mm) FL : 26W 5D
EFW : 767 g AFI : 2 cm
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During 16 days : growth arrest .
GA 35w 3d : C/S
BW : 825 gr
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Case 3 29y , G2ab1 GA : 30w 4d (by sono 13w : 30w 6d )
FH=26 cm PMH : NEG DH: heparin Sono : GA : 29 w 6 d
BPD=27W 4D
HC : 27W 6D
AC : 25W 4D
FL : 25W 4D
EFW: 765 g
AFI : 67 mm
BPP : 10/10
DOPPLER : NL
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Sono ( GA : 30w 4d) AFI < 5 cm BPP=6/8 (breath=0) RI MCA/ RI UMA=0.67/0.79 Hospitalization
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Sono ( GA : 31 w 6d )
AFI < 5 cm
Doppler : absent EDV in umbilical artery
BPP=10/10
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After than 15 days AFI =severe oligohydramnious
EFW= 997 gr
BPP=8/8
حاملگی سن و 32در صورت 5هفته به روزشدید اکالمپسی پره دلیل به اوژانسی
شد انجام ترمیناسیون
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Timing delivery
Abnormal DV(A/R a wave) or umbillical vein(pulsetile) with every GA .
Umbilical artery reverse EDV until 30-32 weeks
Umbilical artery absent EDV until 32-34 weeks
Umbilical artery high RI until 36- 37 weeks
Constitutional IUGR : 37-38 weeks
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Indication delivery after than 34 weeks
Maternal comorbidity arrest of growth Oligohydramnious A/R EDV umbilical artery MCA PI < 5% BPP < 4 Recurrent deceleration FHR
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Recurrence risk in second pregnancy
First pregnancy AGA : 9% First pregnancy SGA : 29% First and second pregnancy SGA :
44%
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Management of subsequent pregnancy
cessation of smoking and alcohol intake
balanced energy/protein supplementation
Avoiding a short or long interpregnancy interval
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Screening option
Low risk : fundal height (exception large myoma ,BMI > 35)
High risk : ultrasonography
Biochemical : low PAPP-A , high AFP
Uterine artery doppler
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MINOR RISK FACTORS
Maternal age > 35 yrs Nulliparity BMI <20 BMI 25-29.9 Smoker 1-10 per day Pregnancy interval < 6 mo Pregnancy interval >30 mo Paternal SGA
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Major risk factors
Maternal age > 40 yrs Daily vigorous exercise Previous SGA baby Smoker >11 per day Previous stillbirth Maternal SGA Preeclampsia Maternal Medical disease Heavy bleeding similar to mense Echogenic bowel Low maternal weight Low PAPP-A
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RCOG
"Advise women at high risk of pre-eclampsia to take 75 mg of aspirin* daily from 12 weeks until the birth of the baby. Women at high risk are those with any of the following:
• hypertensive disease during a previous pregnancy• chronic kidney disease• autoimmune disease such as systemic lupus erythematosis or antiphospholipid syndrome• type 1 or type 2 diabetes• chronic hypertension.
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RCOG
Advise women with more than one moderate risk factor for pre-eclampsia to take 75 mg of aspirin* daily from 12 weeks until the birth of the baby. Factors indicating moderate risk are:
• first pregnancy• age 40 years or older• pregnancy interval of more than 10 years• body mass index (BMI) of 35 kg/m² or more at first visit• family history of pre-eclampsia• multiple pregnancy.