Fetal growth restriction

FETAL GROWTH RESTRICTION..

What the evidence says?!

Dr. Kirtan VyasM. S. (Ob/Gy)

Assistant Professor,P.D.U. Medical College, Rajkot

Gujarat Uni. First-Gold medallistGujarat Public Service Commission(GPSC) firstFellow in Gynec Endoscopy(Mumbai)Fellow in Ultrasonography(FOGSI)Publications in various International Journals Presented Scientific Papers and Chaired Sessions at State and National conferencesFaculty at State and National ConferencesLocal Joint Secretary of SOGOG-Gujarat State Org of Ob Gy 2015 Organizing Secretary for the First Rajkot Obstetrics and Gynec Society Annual Conference 2015 and Committee Member at State and National conferencesOrganizing secretary for the West Zone Yuva Fogsi 2016, RajkotFaculty at FOGSI-JOGI PICSEP Scientific Program 2016 at RajkotPresently an Assistant Professor at P.D. U. Medical College, Rajkot

Dr. Kirtan VyasM.S.(Ob/Gy)

Dr. Kirtan Vyas # 9825407702

• The major concern in IUGR is not the small size of the fetus, but the possibility of life threatening fetal compromise

• Timely identification is difficult but crucial

for proper management and a favorable neonatal outcome as it is the second leading cause of perinatal mortality after prematurity


Baffles the researchers in the most controversial way

Extensively studied, still confusing!!


To compare and contrast the used terminology and definitions

To evaluate screening approaches

To critically review proposed management

Surveillance regimens

Recommendations for timing and mode of delivery

Risk of Recurrence, preventative strategies

Postnatal management Dr. Kirtan Vyas # 9825407702

DEFINITION

• IUGR: A condition where the fetus fails to achieve its genetic growth potential and consequently is at risk of increased perinatal morbidity & mortality

• SGA: Infant with weight < 10th percentile of those born at the same gestational age or > 2 SDs below mean for Gestational Age


Easiest way to think about these terms are

• IUGR: is a term used by Obstetrician to describe a pattern of growth over a period of time

• SGA: is a term used by Pediatrician to describe a single point on a growth curve


V/S

• Preterm gestation and small• Term gestation and small• Healthy but small – Constitutionally small• Pathologically small – IUGR


• Thus 2 essential components for IUGR are

– Birth weight <10th percentile – Pathologic process that inhibits normal growth potential

(intrinsic) 30 %• And the 2 essential components for SGA are

– Birth weight <10th percentile – Absence of pathologic process 70 %


• In 2013, 3 major obstetric colleges in the UK, Canada, and the USA have published their clinical recommendations for pregnancies with FGR

RCOG February 2013

SGA

ACOG May 2013 FGR SOGC August

2013IUGR


• All guidelines use a different terminology

• All do agree that an EFW < 10th centile for gestation should be used to alert clinicians to small fetal size


INCIDENCE• 3 - 5% of all pregnancies

• 20 % of still borns are growth restricted

• 1/3 of infants with BW < 2750 gms are growth restricted and not premature

• Only 20-30% of growth restricted fetuses are small due to pathological restriction of growth

• Perinatal mortality is 8 - 10 times higher for these fetuses *Peleg D et alDr. Kirtan Vyas # 9825407702

NORMAL INTRAUTERINE GROWTH PATTERN

• Stage I (Hyperplasia) - 4 to 20 weeks - Rapid mitosis - Increase of DNA content

• Stage II (Hyperplasia & Hypertrophy) - 20 to 28 weeks - Declining mitosis - Increase in cell size


NORMAL INTRAUTERINE GROWTH PATTERN

• Stage III ( Hypertrophy)

- 28 to 40 weeks - Rapid increase in cell size - Rapid accumulation of fat, muscle and

connective tissue

95% of fetal weight gain occurs during last 20 weeks of gestations


• 15 weeks = 5 grams/day• 20 weeks = 10 grams/day• 30 weeks = 25 grams/day• 35 weeks = 35 grams/day• 40 weeks = 15 grams/day

• May vary by race, gender, multiple gestation

MATERNAL PLACENTAL FETAL

Chronic diseaseCyanotic heart disease DM (class F or above)

Chronic respiratory diseaseChronic hypertension Chronic renal disease

General Malnutrition

Malabsorption syndrome High attitude

Constitutionally small mother

Substances abuse SmokingAlcohol

Other disorders Severe anemia

Hemoglobinopathies Antiphospholipid

antibody syndromeRecurrent APH

Abnormal placentation

Abruptio

Infarction

Circumvallate Placenta

Chorioangioma

Placenta accreta

Placenta previa

ChromosomalTrisomy 13,Triploidy 21

Turner syndrome Structural abnormality Congenital Heart disease

NTD Collagen and musculoskeletal.

Fetal infection CMV

Rubella Herpes

Toxoplasmosis Teratogens

Anti-convulsant Anticoagulant

AlcoholNarcotic

Multiple gestation (10 times more common)


Dr. Kirtan Vyas 98254 07702

RELATIVE FREQUENCY OF DIFFERENT ETIOLOGIES

• Placental insufficiency -80%• Tobacco /Smoking -5%• Fetal Chromosomal -5%• Fetal Infections -1-2%

CLASSIFICATION• Based on evaluation & USG examination small fetuses are divided

into two categories

Healthy SGA or True IUGR orConstitutionally small Pathologically growth restricted

TYPE –I TYPE –IISymmetrical IUGR Asymmetrical IUGRIntrinsic IUGR Extrinsic IUGR

*Campbell S and Thomas ADr. Kirtan Vyas # 9825407702

FETAL GROWTH - A COMPLEX PHENOMENON

• Besides these there occurs a delicate interplay between fetal adaptation to the maternal metabolism by modulating placental function

• This means that an adequate maternal nutritional status does not ensure adequate supply to the fetus, it requires a normal placental function also


FGR is a pathologic process associated with additional features • abnormal placental morphology • oligohydramnios or

• abnormal uteroplacental or fetoplacental doppler


PRIOR H/O IUGR HAS 4FOLD INCREASE INCIDENCE

• Lagging fundal measurement of 3cms with the estimated gestational age

• Poor maternal weight gain of <5 kg by 24 wks or 8 kg by 32 wks (for women with BMI<30)

• EFW <10 percentile• HC/ AC ratio>1 • AFI ≤ 5 • Grade 3 placenta before 34 wks • Decrease DFMC


EFFECTS OF IUGR• The study by Bernstein et al (2000) done on

20,000 neonates born IUGR without major anomaly described the following RR


Death 2.77

RDS 1.19

IVH 1.13Intravascular hemorrhage 1.27

NEC 1.27

LONG TERM MORBIDITIES Cerebral palsy (Goldenberg RL et al. 1998)

Hypertension (Hannsens M et al 1996),

Dyslipidemia (Gogate S. 2001)

Diabetes Melitus (Mukhopadhyay S et al 2001)

Breast cancer (LeMarchand L et al 1998)

Prostate cancer (Ekbom A et al 1996)

Mental health problems, academic impairment and poorer general health


IUGR SCREENING• Whom to screen?

• Ideally Symphysis Fundal Height (SFH) performed regularly for all pregnancies

• SFH in cms = weeks of gestation

• High risk cases will need ultrasound for growth, liquor volume, umbilical artery Doppler and Biophysical Profile

• Umbilical Artery Doppler is the best test!Dr. Kirtan Vyas # 9825407702

There are FOUR TESTING MODALITIES which are helpful

• Daily fetal movement count (DFMC)• Non-Stress Test (NST)• Amniotic Fluid Index (AFI)• Doppler of the Umbilical Artery • Biophysical Profile (BPP)

Combination of tests are better than an isolated test


DIAGNOSIS

CLINICAL BIOPHYSICAL BIOCHEMICAL Ultrasonography MSAFP & hCG in 2nd trimester Erythropoietin level in cord blood is high in IUGR


DIAGNOSIS - CLINICALLY

Maternal weight gain Stationary or falling during second half of

pregnancy

Palpation of uterus SFH-Normally increases by 1 cm per week

between 14 and 32 wks - A lag in fundal height of 4 wks s/o moderate IUGR and over 6 wks s/o severe IUGR Abdominal girth – stationary or decreasing Liquor volume - less


BIOCHEMICAL MARKERS IN IUGR

ERYTHROPOIETIN (EPO)

An elevated HCG and amniotic fluid EPO has been found which supports the concept of early damage of placenta

sufficient to cause erythroblastic response (Seppo Heinonen et al 1999)

High levels of EPO were also found in hypoxic and growth restricted neonates (Ostlund E at al 2000)

PAPPA A positive co-relation of PAPPA with femur length and

abdominal circumference in second trimester (Leung TY et al 2006)


SERIAL ULTRASOUND BIOMETRY AND DOPPLER STUDIES FORM THE MAINSTAY OF DIAGNOSIS

• The greater the risk of IUGR based on clinical findings, the greater is the positive predictive value of USG

• It must be borne in mind that each measurement has an error potential of about 1 week up to 20 weeks gestation, 2 weeks from 20-36 weeks and 3 weeks thereafter Dr. Kirtan Vyas # 9825407702

USGAbdominal circumference (AC)

• The most sensitive indicator • Sensitivity is 95% if it measures below 2.5th

percentile• HC/AC ratio drops almost linearly from 1.2

to 1.0 between 20-36 weeks normally• It is elevated in asymmetric IUGR and is

normal in symmetric IUGR• FL/AC ratio elevated to >2.4 in IUGR


• Remember that we shall not switch to color doppler directly when patient is referred for color doppler

• First go for biometry & precisely define type of growth retardation by plotting the finding in growth charts, assess fetus for malformation. Assess Amniotic fluid & biophysical activity & then switch on the color doppler


IMPORTANCE OFCOLOUR DOPPLER

THE ACCURACY OF DOPPLER VELOCIMETRY

IN CONJUNCTION WITH 2D ULTRASOUND AND

COLOR FLOW MAPPING IS NOW REGARDED AS

AN INDISPENSABLE COMPONENT OF A

PREGNANCY SONOGRAM


PERSPECTIVE OF COLOUR DOPPLER

• EXCLUDE FETAL ANOMALIES

• EVALUATE FETAL SIZE

• QUANTIFY LIQUOR AMNII

• ASSESS PLACENTA, CORD &

CERVIX


Quantitative analysis

Doppler indices


DOPPLER VESSELS TO BE STUDIED

• MATERNAL SIDEUterine artery

• PLACENTAL SIDEUmbilical artery

• FETAL SIDE

Arterial: MCA, renal and othersVenous: ductus, hepatic, umbilicalFetal echocardiography


UTERO PLACENTAL CIRCULATION

Conversion of spiral artery into utero placental vessel

Brosens et alDr. Kirtan Vyas # 9825407702

UTERINE ARTERYNormal impedance to flow the uterine arteries in 1º trimester

Normal impedance to flow the uterine arteries in early 2ºtrimester

Normal impedance to flow the uterine arteries in late 2º and 3º trimester

UTERO PLACENTAL CIRCULATIONDr. Kirtan Vyas #

9825407702


UTERINE ARTERY FACTS

• More accurate for screening in high risk- early onset cases

• At a place, where UtA crosses the EIA• B/L notch or U/L notch on the side of

placenta is significant• Best GA is 22-24 weeks• High negative predictive value

• Progressive rise in the end-diastolic velocity • Decrease in the pulsatility index

ADVANCING GESTATION

UMBILICAL ARTERY

UMBILICAL ARTERY FLOW

• Whether at fetal end, placental end or in between – no difference

S/D ratio : 2-3 in 2nd & 3rd trimester

PI : 1.5 – 2.0 in 2nd trimester1.0 – 1.5 in 3rd trimester

RI : decreases with gest. In late 2nd and 3rd it is around 0.5


UMBILICAL ARTERY FLOW- WHAT DOES IT TELL US ??

First sign of hypoxia & growth retardation


NORMAL UMBILICAL ARTERY1º trimester Absent Diastolic Flow

early 2ºtrimester Low Diastolic Flow

late 2º and 3º trimester Resistance further reduce, more diastolic flow

UMBILICAL ARTERY - ABNORMAL

Umbilical arteries- normal

Umbilical arteries- high pulsatility index

Umbilical arteries- Absent end diastolic velocity- very high pulsatility index.- pulsation in the umbilical vein

Umbilical arteriesreversal of end diastolic


UMBILICAL ARTERY & CTG• Umbilical artery 90% more sensitive to

CTG• Interval between absence of end

diastolic flow & onset of late deceleration was 3-12 days

Bekedam DJ et al. Early Hum Dev 1990;24:79–89 High ResistanceDr. Kirtan Vyas # 9825407702

MIDDLE CEREBRAL ARTERIES

Reflects : cerebral flow

End points : rising PI after a nadir– More than 1.45 before term– Fall down to 1– If less than 1- peak of redistribution

MCA• 22-28 weeks- no EDF in MCA

• 28w to term- some EDF seen- normal

• Increased EDF ( low PI) suggests ‘brain sparing’ redistribution in IUGR

• Worsening hypoxia- fetal acidemia- paradoxical rise in resistance (high PI)

• CPR increases – this is indicative of IUGR

MANNING’S BPP• NST• FBM• FM• FT• AFI

• Maximum score 10 - Minimum 0

• Oligohydramnios indicates abnormal BPP regardless of the total score of others

MANAGEMENT• Depends on the severity of growth restriction and how

early the problem began in pregnancy

• Earlier the onset, more severe is the IUGR and greater the risk to fetus

• Management is based on the followingo Prevention o Diagnosis of IUGRo Antenatal vigilance. Treatment of the cause, if found to be

present.o Delivery o Neonatal managementDr. Kirtan Vyas # 9825407702

MATERNAL BED REST

• This is the initial approach for the treatment of IUGR

• Adequate bed rest in left lateral position results in increased blood flow to the uterus & placenta

ASPIRIN THERAPY

• The use of aspirin to treat foetus with IUGR is still controversial

• If aspirin is used, it may be advantageous if given to patients before 20 weeks of gestation It is minimal to limited benefit if given at the time of diagnosis• (third trimester)

• However it is beneficial in cases with

– history of thrombotic disease– hypertension– pre-eclampsia

• The Maternal-Fetal Medicine Network randomized 3135 women to receive 60mg/d aspirin or placebo and found no significant difference in incidence of IUGR


HYPEROXYGENATION

• Fetal oxygenation is crucial for fetal growth

• A positive response to maternal oxygen therapy found by decreased resistance in placental circulation is marker of good prognosis and lack of response is an indication of poor outcome

(Bilardo et al 1991)


OTHERS….o Other forms of treatment that have been

studied are maternal hyperalimantation by aminoacids, nutritional supplementation, zinc supplementation, fish oil and hormones

o Maternal volume expansion may be helpful in improving placental perfusion

o Limited studies are available regarding the use of these modalities in the treatment of IUGR


JUDGE OPTIMUM TIME OF DELIVERY

Risk of PREMATURITYDifficult extra uterine existence

Risk of IUD hostile intra uterine environment


MANAGEMENT ACCORDING TO GESTATIONAL AGE

Less than 24 weeks of gestational age• Antenatal surveillance with Umbilical & Ductus

venous doppler study is reliable

٠ If UmA diastolic flow +nt ٠ If UmA –RDF٠ DV – Uninterrupted ٠ DV– Interrupted forward flow forward flow Fetal Acidosis& Hypoxia

Expectant Management Imminent Fetal Death

Termination

26 to 34 weeks gestational age• Antenatal surveillance with NST and Umbilical

A, Middle cerebral A, Ductus venous doppler

1. NST-REACTIVE UmA Doppler-Reassuring Repeat in 1wk UmA Doppler-Non reassuring Ductus venous Doppler Reassuring--Repeat 1wk Non reassuring—Deliver


2. NST-NON REACTIVE UmA Doppler—follow as above Or Biophysical profile ≥8 UmA doppler ≤4 Deliver 6 Repeat in 6-24hrs wait till ≥36wks

Deliver

34 TO 37 WEEKS GESTATIONAL AGE

Antenatal surveillance with FHR monitoring by • NST AND COLOR DOPPLER VELOCIMERY.1. Both the tests reassuring Repeat in 1 week Test for lung maturity Immature Mature

Repeat in 1 wk Deliver

2.Either test non reassuring Deliver

MODE OF DELIVERY• Labour is a stressful process for the fetus

• Every contraction reduces oxygenation, though briefly and it recovers

• Prolonged difficult labors should be avoided!

• Continuous fetal monitoring is a MUST!

• Elective LSCS for severe IUGR, abnormal presentation, oligohydramnios, abnormal CTG/ NST


AMNIOINFUSION• Amnioinfusion refers to the instillation of fluid

into the amniotic cavity

• This procedure is typically performed during labor through an intrauterine pressure catheter introduced transcervically after rupture of the fetal membranes

• Alternatively, fluid can be infused through a needle transabdominally, the reverse process of amniocentesis


Randomised trial of Amnioinfusion during labour with meconium stained amniotic fluid

(BJOG Jan 2002)

• Conclusion- Amnioinfusion in an under resourced labour ward decreases caesarean section rates and fetal morbidity


CONCLUSION• Currently USG measurements are used to confirm small fetal size,

whereas, BPP is used to assess fetal function. Based on BPP one can consider the safety of continuing pregnancy. Unequivocal cessation of ultrasound growth would also constitute fetal grounds for delivery

• Risk of elective delivery after 37 weeks is very small, suspicion of fetal compromise from any abnormal fetal welfare study may precipitate decision for undertaking prompt delivery

• LSCS is used increasingly for the compromised fetus because of high risk of fetal distress in labour

• However, in the Indian setup, facilities for NICU are not uniformly available. Hence, the decision for time and mode of delivery needs to be individualized as the management of such a neonate is a real challenge. If possible, the mother should be transferred to a center with a well-equipped neonatal care unit to minimize the risks involved in transfer of the newborn baby


IUGR• Heads are

disproportionately large for their trunks and extremities

• Facial appearance has been likened to that of a “wizened old man”

• Long nails

• Scaphoid abdomen

IUGR

“ I AM A FETUS IN THE WOMB I FEAR IT MAY BECOME MY TOMB

IF ONLY I COULD GIVE A SHOUTTO MAKE MY DOCTOR GET ME

OUT!”

UNKNOWN MEDICAL STUDENT

DUBLIN, UK 1982

THANK YOU

Health & Medicine

Fetal growth restriction