assessment fetal growth
DESCRIPTION
Antenatal diagnosis of fetal growth anomalies including biochemical and sonographic investigations, and subsequent management.TRANSCRIPT
Max MongelliWomen & Childrens’ Health
Nepean HospitalSydney, Australia
Assessment and Management of Abnormal Fetal Growth
Updated December 2014
Max Mongelli 2014
Max Mongelli 2009
Fields to be covered:Fields to be covered:
Prevention Screening Diagnosis Management Long term complications
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Prevention of IUGRPrevention of IUGR
Stop smoking Avoid D & A Aspirin if indicated Minimize risk of multiple pregnancy Minimize risk of infections ? Treat vit. D deficiency Pre-conceptional counselling
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NotNot effective in prevention: effective in prevention:
Bed rest Antihypertensive therapy Folic acid Long-chain PU fatty acids Beta-mimetics
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Prevention of MacrosomiaPrevention of Macrosomia
Normalise BMI prior to conception Early detection of GDM Good control of GDM Moderate exercise during
pregnancy
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Screening for Abnormal Screening for Abnormal Fetal GrowthFetal Growth
Fetal size estimation by palpation alone can be inaccurate
Better results by measuring the symphysis-fundus height (SFH)
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Technique of SFH Technique of SFH MeasurementMeasurement
Patient supine, bladder empty. Measuring tape should be blank on one side,
cm markings on other side. Blank side up. SFH measured in cm from top of uterine
fundus to the top of symphysis pubis. Measurement plotted on reference chart.
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Reference Charts for Antenatal Reference Charts for Antenatal Screening for Abnormal Fetal GrowthScreening for Abnormal Fetal Growth
Unadjusted, population based charts: inaccurate for many women
Individually adjusted charts: customised growth charts
Customised charts have lower false positive rates than unadjusted charts.
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Reference Charts for Antenatal Reference Charts for Antenatal Screening for Abnormal Fetal GrowthScreening for Abnormal Fetal Growth
Unadjusted, population based charts: inaccurate for many women
Individually adjusted charts: customised growth charts Customised charts have lower false positive rates than
unadjusted charts. Better correlation with perinatal outcomes
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Examples of Customized Growth Examples of Customized Growth Charts for Antenatal Screening Charts for Antenatal Screening
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Antenatal Diagnosis of Antenatal Diagnosis of SGA/IUGRSGA/IUGR
SFH measurements alone cannot confirm. Possibility of IUGR if there is a growth
deceleration pattern or a single small SFH measurement.
Ultrasound examination is indicated if there is clinical suspicion.
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Ultrasound Diagnosis of Ultrasound Diagnosis of SGA/IUGRSGA/IUGR
Fetal biometry: HC, BPD, FAC, FL Can be converted to an estimated fetal
weight (EFW) Amniotic fluid index (AFI) Doppler studies of umbilical arteries Screen for fetal anomalies (10% of IUGR) Cardiotocography (non-stress test)
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KaryotypeKaryotype
Fetal karyotype may be indicated if: IUGR is of early onset Severe (< 3rd pct) Associated with polyhydramnios Structural anomalies are present
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Doppler StudiesDoppler Studies
Examination of umbilical arteries and MCA Proven to reduce PNM by 30% Abnormal if absent or reversed diastolic flow If abnormal in ductus venosus, fetal risk is
very high
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Management of IUGR:Management of IUGR:InvestigationsInvestigations
FBC, EUC, LFT’s, urate LAC, antiphospholipid antibodies TORCH/viral studies Chromosome studies Tests for celiac disease if indicated
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Management of IUGR:Management of IUGR:Conservative or elective Conservative or elective
delivery?delivery?
Depends on severity of IUGR If close to term and fetus not
compromised, induction of labour If there are signs of fetal distress
cesarean section is indicated.
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Management of IUGR:Management of IUGR:ConservativeConservative
Twice weekly U/S for AFI/flows Daily CTG’s 2 -weekly EFW measurements Antenatal steroids Pregnancy should not extend beyond 37
weeks’ gestation
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Complications of IUGR:Complications of IUGR:Short termShort term
Hypoglycemia Hypothermia Hyperviscosity syndrome Impaired immune function RDS / NEC if preterm Birth asphyxia
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Complications of IUGR:Complications of IUGR:long termlong term
Cerebral palsy Small decrease in IQ Reduced scores for executive cognitive functions Risk related to severity of IUGR
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The Barker HypothesisThe Barker Hypothesis
IUGR fetuses compensate for adverse intrauterine environment by endocrine-metabolic reprogramming
In adult life this leads to increased risk of hypertension, hypercholesterolemia, IGT, IHD
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Management of Management of MacrosomiaMacrosomia
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Differential Diagnosis of Differential Diagnosis of High SFHHigh SFH
Macrosomia Polyhydramnios Multiple pregnancy Uterine fibroids Pelvic masses Maternal obesity
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Diagnosis of Diagnosis of LGA/MacrosomiaLGA/Macrosomia
Ultrasound biometry Conversion to an estimated fetal weight Some centres use FAC only Cut-off for LGA is EFW>90th pct Cut-off for macrosomia 4500 g or 5000 g
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Accuracy of UltrasoundAccuracy of Ultrasound
Less accurate for big babies Sensitivity ranges from 22% to 69% May not be more accurate than clinical
palpation alone
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Complications of MacrosomiaComplications of Macrosomia
Birth trauma Shoulder dystocia Erbs’ Palsy Birth asphyxia Neonatal hypoglycemia Neonatal jaundice Hypercalcemia, hypomagnesemia
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Shoulder dystociaShoulder dystocia
Variable incidence – 0.5% Difficult to predict – recurrence risk 10% More likely in macrosomia, GDM, post-
term, instrumental delivery, prolonged second stage
50% have no risk factors
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Complications of Macrosomia:Complications of Macrosomia:Long TermLong Term
In GDM offspring Neurodevelopmental delay Reduced head circumference at 3
years of age Greater risk of type 2 DM Obesity
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Management of Macrosomia:Management of Macrosomia:Vaginal Delivery or C/S ?Vaginal Delivery or C/S ?
Controversial issue Shoulder dystocia difficult to predict Some centres use 4500 g or 5000 g RCOG does not recommend C/S for
suspected macrosomia
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Management of Macrosomia:Management of Macrosomia:Induction of Labor ?Induction of Labor ?
Common request from patients No evidence that it reduces the risk of
shoulder dystocia May possibly increase the risk of
shoulder dystocia
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Postnatal Management of Postnatal Management of Unexpected/Undiagnosed IUGRUnexpected/Undiagnosed IUGR
Many cases of IUGR not diagnosed until after delivery
Confirmation with customised birth weight percentile
Maternal follow in clinic to exclude underlying medical conditions