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Definitions Definitions Etiologies Etiologies M&M M&M Dia Diagnosis gnosis Evalua Evaluation tion Mana Management gement

Definition of Definition of FGR FGR

• Failur

ailure e to to ob

• bta

tain in

• p
• ptimal

timal intr intrau aute terine rine growth wth

• ACOG:

COG: EFW EFW < 10% < 10%

Fetu etus s may may be be no normal mal bu but sma t small ll 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 Morbidity bidity & Mor & Morta tali lity ty 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 Man m Manning ing F 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 2002;99 ;99:49 :490-6. 6.

Risk Risks s of

• f FGR

FGR in Ad in Adult ultho hood

• d

Hype Hyperten tension sion Hype Hypercho holester lesterolemia

• lemia

Cor Coron

• nar

ary y he hear art dise t diseas ase Di Diabe betes tes

DJ DJ Ba Barker r et al. t al. Lancet t 1986;1:10 ;1:1077-1081. 1081.

Nor Normal mal Fet etal al Gr Growth wth

• 15

15 wee eeks ks’ GA: GA: 5 5 g/d g/day ay

• 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/day g/day

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 ntrib ribut ution ion fr from

• m mot

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 Ma Mate terna nal l ge geno noty typic pic diso disorde ders

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 & & multif multifac acto torial rial 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* Ab Abno norma mal l ka karyot

• typ

ype e in 40 in 40% % with with an anom

• mal

aly 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 absen

bsent t AF* AF*

*RJ *RJM M Snijde Snijders s et al. t al. Am Am J Ob Obste stet Gyn t Gynecol l 1993;16 ;168:54 :547-55. 55.

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

ACO COG G Pr Prac acti tice ce Bull Bulletin.

• etin. Number 134

Number 134, , May May 20 2013 13

Uterine En Uterine Envir vironment:

• nment: 60%

60% Variance ariance

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 & var CMV & varicella icella 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

Smoking Smoking

3.5 3.5x x  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 Quit Quit by by 7th

th mon

month th: : mea mean n BW BW high higher er th than an th thos

• se

e who ho smok smoked ed th throu

• ugh

ghou

• ut

Fet etal al alco alcoho hol l sy synd ndrome

• me:

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

Substanc Substance e Abuse Abuse

Ter eratoge togens ns

War arfar arin in Phe Pheny nyto toin, in, tr trimeth imethad adione ione, , ph phen enob

• bar

arbita bital At Aten enolol

• lol

Malnu Malnutritio trition

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

rd tr

trimest imester er Poor

• or pr

pregest gestational tional nutr nutrition: ition: BW BW  by by 40 400-60 600 0 g. g.

Ma Mate terna nal l Vas ascu cular lar Dise Diseas ase: e: 25 25-30 30% % of

• f F

FGR GR Co Cond ndition itions s th that a t affec ect micr t microc

• cir

ircu cula latio tion Ren enal al dise diseas ase Colla Collage gen-va vasc scular ular dise diseas ase Dia Diabe bete tes s with with micr microva vasc scula ular r dise diseas ase Hemo Hemoglobino lobinopa path thies ies An Antip tipho hosp spho holipid lipid sy synd ndrom

• me

e (APS (APS)

Hyper Hypertensiv tensive e Disor Disorder ders

Chr Chronic

• nic hyper

hypertension: tension:

• 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

• Inco

Incomplet mplete e in inva vasion sion of

• f t

trop

• pho

hoblas blast

Abn Abnor

• rmal

mal Place Placent ntation tion in in Pr Pree eeclamps lampsia ia

• Ab

Abno norma mal in inva vasion sion of

• f

tr trop

• pho

hoblas blast

• Res

esults ults in in failur ailure to e to su sufficient ficiently remo emode del sp spir iral al ar arte teries ries

• High

High- res esista istanc nce ves esse sels ls

Placental Placental Factor actors s in FG in FGR

• Abr

Abruption uption

• Abnor

Abnormal mal cor cord inser insertion tion

• Cir

Circumvalla cumvallate te placen placenta ta

• Two v
• vessel

essel cor cord

• Freq

eque uent ntly y ha have e abn bnor

• rma

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

Con Confi fine ned d Place Placent ntal al Mos Mosaicism aicism Place Placent ntal al mos mosaicism aicism 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 g et et al. Am

• al. Am J

J Obs Obste tet Gyne t Gyneco col l 19 1995 95;172 ;172:44 :44-50. 50.

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

Multiples!!! Multiples!!!

Twins: wins: 25 25% Triplet riplets: s: 60 60% Qua Quads ds: : 60 60%

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

Norma mal A l AC e C exclud ludes es FGR FGR wi with th 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% c/w < 2.5% c/w F 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

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 G Pr Prac acti tice ce Bull Bulletin.

• etin. Number 134

Number 134, , May May 20 2013 13

Nut Nutrition ritional al & dieta & dietary y su supp pplemen lements ts Bed Bed res est As Aspir pirin in 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) Dy Dyna namic mic co compo mpone nent nts: s:

• Br

Brea eathing 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 Pr COG Practice actice Bullet Bulletin.

• in. Ant

Antepar epartum tum Fetal Sur etal Surveillance eillance No No. . 145,2014. 145,2014.

Long Long-te term m co compo mpone nent nt:

• Amniotic fluid po

Amniotic fluid pocket et

• f
• f >

>2 2 cm. cm.

Dop Doppler pler Eva Evalua luation tion of

• f Placen

Placenta tal l Fu Func nction tion

• Nor

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

S/D S/D ratio: n tio: nor

• rma

mal l va value lues ar s arou

• und

nd 3 o 3 or le r less ss

Dop Doppler pler Eva Evalua luation tion of

• f Placen

Placenta tal l Fu Func nction tion

• S/D

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

• f v

vil illous lous da dama mage ged

• Abs

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

• 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)

ACOG Practice Bulletin Fetal Growth Restriction

• No. 134; May, 2013.

AEDF or REDF: associated with an increased frequency of perinatal mortality

When hen to D to Deliv eliver? er?

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

CY CY Sp Spron

• ng

g et et al. Obs

• al. Obstet

tet Gyn Gynec ecol 20

• l 2011

11;11 ;118:3 8:323 23-333. 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 weeks eeks GA GA Con Concu curren ent t co cond nditions itions (oli (oligo go, , abn bnor

• rmal

mal Do Dopp ppler ler st stud udies, ies, ma mate terna nal l risk risk fac acto tors, s, co co-mor morbidity bidity): ): 34 34-37 37 weeks eeks GA GA

FGR FGR < 34 W < 34 Weeks GA eeks GA

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 deliv deliver 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 Ma G Mari e ri et al. J t al. J Ul Ultr tras asou

• und

nd Med Med 20 2007 07;26 ;26:55 :555-59. 59.

rowth estriction ntervetion rial

RCT CT of

• f 54

548 p 8 pts ts. . (58 (588 inf 8 infan ants ts) ) be betw twee een 24 24-36 weeks’ GA Unc Uncer erta tain in if if immedia immediate te de deli liver ery y indica indicate ted Immedia Immediate te de deli liver ery y v. . de defer er deliv deliver ery

BJOG 2 BJOG 200 003;1 3;110 10:27 :27-32 32

Median delay: 4 days No significant difference in deaths prior to discharge

BJOG BJOG 20 2003 03;110 ;110:27 :27-32 32

No significant difference between groups at 6-12 yrs f/u for cognitive or behavioral scores

DM Walker et al. AJOG 20211;204:34.e1-9.

Antenatal corticosteroids < 37 weeks MgSO4 for neuroprotection < 32 weeks Tdap if indicated