I I ha have e no no co confli nflict cts s of of i int - - PowerPoint PPT Presentation

I I ha have e no no co confli nflict cts s of

• f i

int nter eres est t to to disc disclose lose.

Definit Definitions ions Etiologies Etiologies M&M M&M Dia Diagnos gnosis is Evalua Evaluation tion Mana Management gement

Definit Definition of ion of FGR FGR

• Failur

ailure e to to ob

• bta

tain in

• p
• ptimal

timal intr intrau aute terine rine growth wth

• ACOG

COG: : EF EFW W < 10% < 10%

Fetu etus s ma may be y be no norma mal bu but small t small FGR FGR may may be pr be prese esent nt if if E EFW FW > 10% > 10%

• SGA:

SGA: Inf Infan ant < 10% t < 10%

Mor Morbid bidity ity & Mor & Morta tality lity of

• f FGR

FGR M&M M&M  sh shar arpl ply as as BW BW  fr from

• m

10 10% % to to 1% 1%

From Mann

• m Manning F

ing FA A in in Resn esnik ik R.

• R. Intr

Intrau aute terine rine Gr Growth wth Rest estriction riction. Obs Obste tet Gyne t Gyneco col l 20 2002 02;99:49 ;99:490-6. 6.

Risk Risks s of

• f FGR

FGR in Ad in Adult ultho hood

• d

Hype Hyperten tension sion Str Strok

• ke

Cor Coron

• nar

ary y he hear art di t disea sease se Dia Diabe betes tes

DJP Ba DJP Barker

• er. Cli

. Clin n Obs Obste tet Gyneco Gynecol 20 2006 06;49:27 ;49:270-83 83. .

Nor Normal mal Fet etal al Gr Growth wth

• 15

15 wee eeks ks’ GA: GA: 5 5 g/da g/day

• 20

20 wee eek’s s GA: GA: 10 10 g/da g/day

• 32

32-34 34 wee eeks ks’ GA: GA: 30 30-35 35 g/da g/day

Parental Characteristics for FGR

Genetics of Genetics of Bir Birth W th Weight V eight Variance ariance

~20% ~20% of

• f tot

total BW al BW va varia riation tion fr from

• m ge

gene netic tic co cont ntribu ribution tion fr from mot

• m mothe

her Ma Mate terna nal l ge gene nes s ha have e main main infl influe uenc nce e on

• n BW

BW Pate terna nal l infl influe uenc nce e is is with Y with Y chr hromo

• moso

some me

Fetal Etiologies

Fetal Structural Anomalies

Gastroschisis Congenital heart defects

FGR FGR + str + structur uctural def al defect ect FGR FGR in in midtrimester midtrimester

ACO COG Pr Practice actice Bul Bullet letin.

• in. Number 134, M

umber 134, May ay 2013 2013

Ge Gene netic tics s in V in Var arian iance ce of

• f B

Bir irth th Weig eight ht Chr Chromo

• moso

somal mal abn bnor

• rmalities

malities &/or &/or co cong ngen enital ital an anoma

• mali

lies es: 20 20% % of

• f F

FGR GR fet etus uses es Abn Abnor

• rmal

mal ka karyot

• typ

ype e in 19% in 19% of

• f FGR

FGR fet etus uses es* Abn Abnor

• rmal

mal ka karyot

• typ

ype e in 40% in 40% with with an anoma

• maly

vs vs. . 2% with 2% with isola isolate ted d FGR FGR* Abn Abnor

• rmal

mal ka karyot

• typ

ype e in 40% in 40% with with no normal mal

• r
• r  AFI vs.

AFI vs. 8% with 8% with  or

• r abs

bsen ent t AFI* AFI*

*RJM *RJM Snij Snijde ders s et et al.

• al. Am

Am J J Obs Obste tet Gyne t Gyneco col l 19 1993 93;168 ;168:547 :547-55. 55.

Con Confi fine ned d Place Placent ntal al Mos Mosaicism aicism Plac Placen enta tal l mo mosa saicism icism in in up up to to 25 25% % of

• f

ca case ses s of

• f une

unexp xplained lained FGR FGR

L W L Wil ilkins kins-Hau aug et et al. Am

• al. Am J

J Obs Obste tet Gyn Gynec ecol

• l 19

1995 95;172 ;172:44 :44-50. 50.

Multiples!!! Multiples!!!

Twins: wins: 25% 25% Triplets: riplets: 60% 60% Quads: Quads: 60% 60%

Maternal Factors

Smoking Smoking

3.5x 3.5x  of

• f SGA

SGA inf infan ants ts Quit Quit < < 16 16 w wee eeks ks’ GA: GA: BW BW simil similar ar to to no nons nsmok moker ers s Qu Quit it by by 7th

th mo

mont nth: h: me mean an BW BW hig highe her th than an th thos

• se

e who ho smok smoked ed th throu

• ugh

ghou

• ut

Fet etal al alc alcoh

• hol
• l sy

synd ndrom

• me:

e: all all ha have e FG FGR Unk Unkno nown wn if if t thr hres esho hold ld li limit mit exist xists Her Heroin:

• in: up

up to to 50 50% Met Metha hado done ne: : up up to to 35 35% Coc Cocaine aine: : 30 30% % or

• r mor

more

Substance Abuse Substance Abuse

Ter eratogens togens

Warf arfarin arin Ph Phen enyt ytoin

• in,

, tr trimet imetha hadio dione ne, , ph phen enob

• bar

arbit bital al At Aten enolo

• lol

Congenital Congenital Inf Infections ections

Acc Accou

• unt

nts s for

• r 5

5-10 10% % of

• f F

FGR GR Rub ubella, ella, CMV CMV & var & varice icella lla Toxoplasmosis & sy syph phil ilis is Bac Bacte terial rial inf infec ection tions s no not dir t direc ect t ca caus use e of

• f F

FGR GR Malaria most common world wide

Malnutrit Malnutrition ion

In pr In previou vious s well ell no nour urishe ished d gravid; vid; BW BW  by by ~ 10% ~ 10% if if <150 <1500 0 kc kcal/day al/day in in 3rd

rd tr

trimeste imester Poo

• or

r pr prege gest station tional al nu nutr trition: ition: BW BW  by by 40 400-60 600 0 g. g. In absence of malnutrition, increased nutrient intake doesn’t improve outcomes

Ma Mate terna nal l Vas ascu cular lar Disea Disease se: : 25 25-30 30% % of

• f F

FGR GR Con Condition ditions s th that af t affec ect micr t microc

• cir

ircu cula lation tion Mos Most t co common mmon ca caus use e of

• f FGR

FGR in in no nona nano nomalou malous fet etus us Ren enal al dise diseas ase Co Colla llage gen-va vasc scula ular r dise diseas ase Dia Diabe bete tes s with with micr microva vasc scular ular dise diseas ase Hemo Hemoglobino lobinopa path thies ies Ant Antipho iphosp spho holi lipid pid sy synd ndrome

• me (APS)

(APS)

Hyper Hypertensiv tensive e Disor Disorder ders

Chr Chronic hyper

• nic hypertens

tension: ion:

• Se

Sever erity ity of

• f vas

vascu cular lar da dama mage ge

• Abs

Absolut

• lute

e le level el of

• f b

blood lood pr pres essu sure

Pr Preec eeclampsia lampsia

• Abn

Abnor

• rmal

mal plac placen enta tation tion

• Inc

Incom

• mple

plete te in inva vasion sion of

• f t

trop

• pho

hobla blast st

Placental Factors

Placental Placental Factor actors s in FG in FGR

• Abr

Abruption uption

• Abno

Abnormal cor mal cord inser insertion tion

• Cir

Circumvalla cumvallate te place placenta nta

• Two v
• vessel

essel cor cord

• Freq

eque uent ntly y ha have e abn bnor

• rmal

mal siz size e &/or &/or func function tion

Risk of recurrence for SGA birth: 20% Review for risk factors Modify those you can Serial ultrasounds

In Review:

➢ FGR: EFW < 10% for GA ➢ 20% of variance for fetal weight contributed by mother & 20% from fetus ➢ Environmental factors account for 60% of variance ➢ Abnormal placentation biggest cause of FGR

Problem Solving: Assess Risk Factors Social habits Weight gain Medications Optimize medical management Avoid aerobics

Clinical Clinical Dia Diagn gnos

• sis

is of

• f FGR

FGR Sing Single le fund fundal al mea measu sureme ement nt be betw twee een 32 32-34 34 wks wks. . GA: GA: ~ ~ 65 65-85 85% % se sens nsitiv itive e an and d 96 96% % sp spec ecif ific ic for

• r FGR

FGR Scr Scree eening ning on

• nly;

y; no not as t as gu guide ide for

• r mana

manage gemen ment t whe hen n risk risk fac acto tors s or

• r

su susp spicions icions for

• r FGR

FGR pr pres esen ent Comp Compromise

• mised

d by by ma mate terna nal l bo body dy ha habitu bitus & fi & fibr broids

• ids

Fundal height 24-38 weeks’ GA

Ultr Ultras asou

• und

nd Eva Evalua luation tion for

• r FGR

FGR 4 Sta 4 Stand ndar ard d Mea Measu sueme ement nts: s:

• 1. F
• 1. Femu

emur r leng length th

• 2. BPD
• 2. BPD
• 3. HC
• 3. HC
• 4. A
• 4. AC

Value alues a s app ppli lied ed to to for

• rmu

mulas las to o to obta btain in EFW EFW

• Nor

Normal mal AC e C exclude ludes FGR s FGR with with a f a false alse ne nega gativ tive r e rate te

• f
• f <

<10 10%

• Su

Suspe spect ct FGR if FGR if A AC < 10 C < 10%

• AC

C < 2.5% < 2.5% c/w F c/w FGR GR

AC C vs.

• vs. EFW

EFW

Lo Lower sen er sensiti sitivity vity the then AC: C: 85 85% vs. % vs. 98 98% Hi High gher PP er PPV V tha than A n AC: C: 51 51% vs. 3 % vs. 36% 6%

AA AA Basc Bascha

• hat. Ob
• t. Obste

stet Gyne t Gyneco col l Sur Surv v 20 2004 04;59:61 ;59:617-27. 27.

In Review:

Serial fundal measurements only for screening If significant risk factors or suspicions for FGR:

• btain sono

Serial ultrasounds 3-4 weeks apart until delivery

Problem Solving: Evaluating for Diagnosis Sono with echo:

Anomalies? Chromosomes? Infections? Placenta?

Amniocentesis:

Karyotype/microarray PCR for toxo & CMV

Lab work:

Infections? Preeclampsia? APS?

ACO COG Pr Practice actice Bul Bullet letin.

• in. Number 134, M

umber 134, May ay 2013 2013

Nut Nutrition ritional al & dieta & dietary y su supp pplemen lements ts Bed Bed res est Asp Aspirin irin Trea eatme tment nt for

• r APS

APS

Ant Antep epar artu tum m Tes esting ting: : Bioph Biophys ysical ical Pr Profil

• file

e (BPP) (BPP) Dyn Dynamic amic co compo mpone nent nts: s:

• Br

Brea eathin thing

• Mo

Moveme ement nt

• Ton
• ne

Relia eliabili bility ty of

• f B

BPP: PP:

• Stil

Stillbir lbirth th rate: 0 te: 0.8/100 .8/1000

ACOG P COG Practice actice Bulletin.

• Bulletin. Antepar

Antepartum tum Fetal S etal Sur urveillan eillance ce No No. . 145 145,201 ,2014. 4.

Long Long-te term m co comp mpon

• nen

ent: t:

• Amniotic fluid po

Amniotic fluid pocket et

• f
• f >2

>2 cm cm.

Do Dopp ppler ler Ev Evalu aluatio tion n of

• f Plac

Placen enta tal l Fu Func nctio tion

• Nor

Normal plac mal placenta: lo enta: low r w resistance esistance

S/D S/D ratio: tio: n nor

• rmal values

mal values ar arou

• und

nd 3 or 3 or less less

Do Dopp ppler ler Ev Evalu aluatio tion n of

• f Plac

Placen enta tal l Fu Func nctio tion

• S/D

S/D ratio: tio:  after after 30% 30% of

• f v

vil illous lous dama damaged ged

• Abs

Absen ent t en end-dias diasto toli lic c fl flow (AEDF (AEDF)

• Whe

hen n >70% >70% plac placen enta tal l ar arte teries ries ob

• bli

lite terate ted: d:

• Rever

erse sed d en end-dia diast stolic

• lic flo

flow (REDF (REDF)

Ho How w to Decid to Decide W e When hen to Deliv to Deliver? er?

La Late te-Pr Preter eterm m & Ear & Early-Ter erm m Pr Pregnan gnancy

CY CY Sp Spron

• ng

g et et al.

• al. Obs

Obstet tet Gyne Gyneco col l 20 2011 11;118 ;118:323 :323-333. 333.

Unc Uncomp

• mpli

lica cate ted d & & no no con concu curren ent t fi find ndings ings in in a sing singleto leton: n: 38 38-39 39 wee eeks ks GA GA Co Conc ncur urren ent t co cond ndition itions s (oligo (oligo, a , abn bnor

• rma

mal Dop Doppler pler st stud udies, ies, ma mate terna nal l risk risk fac acto tors, s, co co-mor morbidity bidity): ): 34 34-37 37 wee eeks ks GA GA

FGR FGR < 34 W < 34 Weeks GA eeks GA

Statistics of Survival for FGR

Neo eona nata tal survival al >50 50% af afte ter 26 26 w wee eeks, 2 w 2 wee eeks late ter th than an normall mally grown wn neo eona nates tes Intac tact t survival al >50 50% af afte ter 28 28 wee eeks

AA Bascha hat t et al. Ob Obstet tet Gy Gynecol ecol 2007;109:25 07;109:253-61 61.

AA Bascha hat t et al. Ob Obstet tet Gy Gynecol ecol 2007;109:25 07;109:253-61. 61.

Statistics for Survival for FGR

Su Survival al incr creas eases es by 2% 2% per er day in ute tero, , until til at t lea east t 27 27 wee eeks GA & 60 600 g 0 g ar are ob e obtained tained

41 41 FGR FGR fet etus uses es: : 23 23.1 .1-32 32 wee eeks ks 94 94% % of

• f p

per erina inata tal l de death ths s de deli liver ered ed < 29 < 29 wks wks. No No su surviv vivor

• rs

s if if de deliv liver ered ed < 25 w < 25 wee eeks ks Eac Each h wee eek k of

• f pr

pregn gnan ancy y ga gained ined: de decr crea ease sed d 48 48% % in in pe perin rinata tal l mo morta tality lity

G Mari e G Mari et al t al. J Ul . J Ultr traso asoun und Med d Med 200 2007;26 7;26:555 :555-59. 59.

CC Lees es et al. Lancet ncet 2015; 15;385:2 385:2162 162-2172, 2172,

Tri rial al of Umb mbilical ilical and Fetal tal Flo low w in in Eur urope

• pe - TRUFFLE

UFFLE

50 503 3 wome men: n: FGR si singleton leton fet etus uses es: : 26 26-32 32 wee eeks s wi with th AC < C < 10 10% & EF EFW >50 500g 0g Abnormal normal umb mbilical lical ar arte tery ry Do Doppler pler wi with th a PI a PI >95 95% wi with th or wi with thout

• ut AED

EDF or RED EDF Normal mal DV w V wavef eform rm wi with th PI PI <95 95% Norma mal l STV on cardiog iograph phy afte ter 1 h hour ur tr tracing ng Mai ain outcome: tcome: co composi posite te of fet etal al or neo eona natal tal dea eath th an and sever ere e morbidi bidity ty

Pu Pulsa sati tilit ity y Inde dex= x= sy

syst stolic velocity ty-dia iast stolic

• lic velocity

ty mean velocity ty

CC Lees es et al. Lancet ncet 2015; 15;385:2 385:2162 162-2172, 2172,

Randomly domly Assigned signed in in 1:1:1 :1 Groups

• ups

Group up 1: 1: del eliver ered ed if cC cCTG ST STV if V if ST STV <3 V <3.5 5 ms <29 29 wee eeks s GA or <4 4 ms ms > 29 29 wee eeks G s GA Group up 2: 2: del eliver ered ed if DV P V PI >95 95% for GA Group up 3: 3: del eliver ered ed if DV h V had ad AED EDF or RED EDF

CC Lees es et al. Lancet ncet 2015; 15;385:2 385:2162 162-2172, 2172,

s

Safety ety Ne Net t De Deliv liveri eries es

All group

• ups had

ad UA Doppler ler & cC cCTG at t lea east t 1x 1x/w /wee eek Delivery: : cCTG STV < 2.6 ms at 2 t 260-28 286 wee eeks GA De Deliver ery; ; cC cCTG ST STV < 3 ms V < 3 ms a at t 29 290-32 320 wee eeks GA De Deliver ery: : spontane ntaneous

• us per

ersistent tent unpr provok

• ked

ed dec ecel eler erati tions

• ns occ

ccur ur on CT CTG

CC L Lees et t al. Lancet cet 2015;385:21 85:2162-217 2172. 2.

Pri rimary mary Ou Outco tcome me at 2 y year ears

No significant icant differ erence ence bet etween een survival al wi with thout

• ut

neu eurodis

• disabi

bili lity ty bet etween een th the e 3 g 3 group

• ups

Pr Primar ary outcome tcome is co compos posite ite of both th dea eath th an and neu eurodis

• disabil

bility ity Nons nsignif gnificant icant incr creas ease e in dea eath ths in Group up 3, 3,was as

• ffset

et by a a signif ificant cant red educt ction

• n in neu

eurodis

• disabi

bility ity in th the e surviving ing group

• up co

compa pared ed to to Group up 1 1 (p (p=.005) .005)

OR for St Stillbir irth: th: AED EDF Umb mbilical lical Artery tery Do Doppler pler

• J. Carad

adeux eux, , et al. Am J Obstet et Gynecol ecol 2018;2 8;218: 18:S774 774-S7 S782. 82.

OR for AED EDF: : 3. 3.59 59 (2 (2.29 29-5.62 5.62) Risk of dea eath th: : 6. 6.8% 8% (5 (59 of 9 of 86 863) 3) Risk for fet etal al dea eath th outw tweig eighed ed by risks of infan ant t mo mortality tality or se sever ere e mo morbidi bidity ty at 33 t 33-34 34 wee eeks GA

OR for St Stillbir irth: th: RED EDF Umbili lical cal Artery tery Do Dopple pler

• J. Carad

adeux eux, , et al. Am J Obstet et Gynecol ecol 2018;2 8;218: 18:S774 774-S7 S782. 82.

OR for RED EDF: : 7. 7.27 27 (4 (4.61 61-11.4 11.44) 4) Risk of dea eath th: : 19 19% (7 (72 of 2 of 37 376) 6) Risk for fet etal al dea eath th outw tweig eighed ed by risks of infan ant t mortali tality ty or sever ere mo e morbidi bidity ty at 3 t 30 w 0 wee eeks GA

Fetal tal Ductu ctus s Venosu nosus s (DV) V)

OR for sti tillbi birth th wi with th AED EDF or RED EDF in DV: 11 11.16 16 (6 (6.31 31-19.7 19.73) 3)

• J. Carad

adeux eux, , et al. Am J Obs bstet et Gynec ecol

• l 2018;

8;21 218: 8:S774 S774-S78 782.

Risk of dea eath th wi with th RED EDF in th the e DV: 46 46% (2 (21 of 1 of 46 46) This risk outw tweig eighed ed by prem ematurity turity risks at <28 28 wee eeks GA

• J. Carad

adeux eux, , et al. Am J Obstet et Gynecol ecol 2018;2 8;218: 18:S774 774-S7 S782 82.

With th AED EDF or RED EDF in umbi bilical ical ar arte tery ry, 25 25% had ad AED EDF or RED EDF in DV

Ob Obstet tet Gy Gyneco ecol 2019;133:15 19;133:151-55. 55.

• No. 764

Uncomp

• mpli

licated ted; ; no concur current ent findin dings gs: : 38 38 0/ 0/7-39 39 6/ 6/7 wk 7 wks. GA El Elevate ted S/ S/D r D rati tio wi with th dias asto toli lic c flow: w: Co Consi sider der at t 37 37 0/ 0/7 7 wee eeks or s or at t diagno nosi sis s if late ter AED EDF umbil ilical ical ar arte tery Do Doppl pler er: Co Consider der at t 34 34 0/ 0/7 w 7 wee eeks or at t diagnosi nosis if late ter RED EDF umbil ilical ical ar arte tery Do Doppl pler er: Co Consider der at t 32 32 0/ 0/7 w 7 wee eeks or at t diagnosi nosis if late ter

ACO COG TR TRUFFLE UFFLE

“…the role of these measure in clinical practice remains uncertain.”

ACOG OG Practice ctice Bulletin letin No. . 134, 4,Ma May y 2013 13

Antenatal corticosteroids < 37 weeks MgSO4 for neuroprotection < 32 weeks Tdap if indicated NICU notified and consulted