FETAL GROWTH RESTRICTION

for MBBS students

Definition

Fetuses that have failed to achieve their growth potential because of inadequate oxygen and nutritional supply

FGR is divided into two groups

• Type 1: Fetus is symmetrically small

• Type2:Fetal growth is asymmetrical.

Abdomen is small as compared to the head

Gestational Age Approximate Weight

10 5

22 500

30 1500

40 3400

Approximate Weight of Normal Fetus

Factors Affecting Fetal Growth And Size

• Physiologicala. Genetic

b. Fetal Sex

c. Parental Height and Weight

d. Maternal Age

e. Birth Order

• Socioeconomic Status

Causes of FGR

• Chromosomal Abnormalities• Infection • Structural malformations

Primary Fetal

Maternal Causes of FGR

• Chronic Illnesses ., APAS,HTN,chronic renal,cardiac diseases etc

• Infections . • Endocrine disorders e.g. diabetic nephropathy,

hyperthyroidism.• Malnutrition . anorexia nervosa and bulimia• Smoking,alcoholism• Drug Abuse . Cocaine, amphetamines, betal chewing• Therapeutic drugs like B-blockers,Phenytoin

Placental causes

• Placento fetal causes

placental mosaicism

failure of second wave of invasion

( pre-eclampsia)

fibroids• Fetoplacental causes

defective angiogenesis

single umbilical artery

Hazards of FGR

• IUD,15 fold increased risk• Intrapartum hypoxia • Neonatal Complications

• Respiratory distress syndrome • Meconium aspiration syndrome • Post asphyxial seizures •Hypoglycemia, hypocalcemia• DIC ,Polycythemia• Necrotizing enterocolitis• Renal complications

Long term complications

• Impaired neurodevelopment

• Diabetes mellitus

• Hypertension

• Cardiovascular disease

• Obesity

Management

Prediction of FGR

History

to find risk factors

• Low S.E.C

• Family h/o FGR.

• BMI < 19

•Smoking

• Poor pregnancy weight gain

• Medical complications

• Obstetric complications

• Maternal serum screening If level of AFP is 2.5 or > of the median risk

of FGR is 5-10 times more

• USG markers Abnormal uterine artery Doppler

velocimetry

Echogenic fetal bowel

Screening & diagnosis

• Clininical assessment Fundal Height Measurement

• Ultrasound assessmentfetal biometry HC,AC,HC/AC ratio

AC ,Femur ratio, EFW• Liquor volume• Umbilical artery Doppler studies

DIAGNOSIS

• Fetal AC < 5th centile

• Fetal growth velocity < 1.5 S.D in 2 wks

• AFI < 5

• Abnormal umbilical artery Doppler waveform

Management

Find the cause• Chromosome analysis• MSAFP• Screening for TORCH• Anticardiolipin antibodies, lupus

anticoagulant• Anomaly scan

Management

• Bed Rest

• Frequent AN Checkup

• Nutritional Supplements

• Beta Adrenergic Drugs

• Fetal Monitoring

Assessment of Fetal Growth

Serial measurement of:

• mother’s weight

• fundal height

• fetal biometry

Assessment of fetal well-being

• Fetal movement record• NST, CST• BPS• Doppler studies

Management Options Depends on

• Fetal Size

• Liquor Volume

• Umbilical artery doppler

SGA With all Indices Normal

If > 37 wks Deliver

SGA and all indices are normal < 37 weeks

No risk factors

1. Steroids if < 34 wks

2. Monitor fortnightly by:

• Fetal biometry

• UADW

• Liquor assessment

If Reduced EDF

• Admit the patient

• Steroids

• CTG & BPS daily

• Doppler twice weekly

• Growth scan after one week

• 40 % Humidified Oxygen

If absent or reversed end diastolic flow

• Admit

• Plan Delivery

Mode of delivery

Depends on :

• Gestational age

• Presence of acidaemia

• Bishop score

Indications of an elective CS

1. Any obstetric indication like CPD, APH,PIH etc.

2. Low BPS,abnormal CTG

3. Poor Bishop Score

Induction of Labour

At > 37 wks of gestation In a well equipped hospital Short trial of labour Continuous intrapartum fetal monitoring Early amniotomy to detect the presence of

meconium stained liquor and apply scalp electrode for internal CTG .

Cont.

• Narcotic analgesics to be avoided

• Epidural analgesia is safe but maternal hypotension and hypovolaemia should be avoided .

• Senior paediatrician should be in the L.R to do proper resuscitation so that meconium aspiration is avoided.

Immediate neonatal period

First 72 hours are very critical.

Prevention

• TOP• AID• Avoidance of maternal hyperthermia at time of NT closure• Avoidance of contact with infected individuals.• Girls immunized against Rubella,Cytomegalovirus.• Women seronegative for toxoplasmosis should

avoid contact with animals• Alcohol, cigarette smoking avoided• Treatment of medical problems