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FETAL GROWTH RESTRICTION
for MBBS students
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Definition
Fetuses that have failed to achieve their growth potential because of inadequate oxygen and nutritional supply
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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
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Gestational Age Approximate Weight
10 5
22 500
30 1500
40 3400
Approximate Weight of Normal Fetus
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Factors Affecting Fetal Growth And Size
• Physiologicala. Genetic
b. Fetal Sex
c. Parental Height and Weight
d. Maternal Age
e. Birth Order
• Socioeconomic Status
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Causes of FGR
• Chromosomal Abnormalities• Infection • Structural malformations
Primary Fetal
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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
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Placental causes
• Placento fetal causes
placental mosaicism
failure of second wave of invasion
( pre-eclampsia)
fibroids• Fetoplacental causes
defective angiogenesis
single umbilical artery
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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
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Long term complications
• Impaired neurodevelopment
• Diabetes mellitus
• Hypertension
• Cardiovascular disease
• Obesity
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Management
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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
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• 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
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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
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DIAGNOSIS
• Fetal AC < 5th centile
• Fetal growth velocity < 1.5 S.D in 2 wks
• AFI < 5
• Abnormal umbilical artery Doppler waveform
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Management
Find the cause• Chromosome analysis• MSAFP• Screening for TORCH• Anticardiolipin antibodies, lupus
anticoagulant• Anomaly scan
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Management
• Bed Rest
• Frequent AN Checkup
• Nutritional Supplements
• Beta Adrenergic Drugs
• Fetal Monitoring
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Assessment of Fetal Growth
Serial measurement of:
• mother’s weight
• fundal height
• fetal biometry
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Assessment of fetal well-being
• Fetal movement record• NST, CST• BPS• Doppler studies
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Management Options Depends on
• Fetal Size
• Liquor Volume
• Umbilical artery doppler
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SGA With all Indices Normal
If > 37 wks Deliver
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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
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If Reduced EDF
• Admit the patient
• Steroids
• CTG & BPS daily
• Doppler twice weekly
• Growth scan after one week
• 40 % Humidified Oxygen
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If absent or reversed end diastolic flow
• Admit
• Plan Delivery
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Mode of delivery
Depends on :
• Gestational age
• Presence of acidaemia
• Bishop score
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Indications of an elective CS
1. Any obstetric indication like CPD, APH,PIH etc.
2. Low BPS,abnormal CTG
3. Poor Bishop Score
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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 .
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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.
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Immediate neonatal period
First 72 hours are very critical.
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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