IN THE NAME OF GOD

SMALL FOR GESTATIONAL AGE

CASE 1

27years

G1

GA : 28w 2d (by sono 8w :28w 3d ) Fondal height : 24 cm

Sono 3 days ago

BPD :24W 3D AC : 22 W FL : 21 W AFI : NL Severe IUGR BPP: breath:0

AF:2 tone:2

Doppler : increased Umbilical artery RI

Diagnostic criteria

AC < 10% and EFW < 10% : SUSPECTED TO IUGR

AC < 10% and EFW > 10% : at risk to IUGR

27years ,G1 GA : 28w 2d (by sono 8w :28w 3d )

C.C : fundal height 24 cm سال قبل 10-بیمار مورد شناخته شده تاالسمی اینترمدیا که

اسپلنکتومی شده استهفته بعد از اسپلنکتومی دچار ترومبوفلبیت عروق کبدی می شود و 2-

ماه پس از ترخیص قرار میگیرد1تحت درمان با هپارین و وارفارین تا سال قبل تا کنون آسپیرین مصرف می کند10-از

سال پس از اسپلنکتومی کوله سیستکتومی می شود1 سال قبل تزریق خون نداشته 10-از

BD واحد 5000-از ابتدای بارداری تحت درمان با هپارین به صورت بوده است

ultrasonography

Gestational age BPD ,HC,AC,FL TCD EFW AFI Doppler sonography BPP

sonography : after 2days

BPD : 24W HC : 24W 2D AC : 24W 1D FL :23W 3D EFW : 539 g AFI : 10cm Umbilical artery : reversed EDV Ductus venosus : NL BPP : 10/10

symmetric IUGRAssociated conditions: - Genetic

- Congenital anomalies - Intrauterine infections - Substance abuse - Cigarette smoking - Therapeutic irradiation

management

Anomaly scan

Karyotyping identification : severe early onset IUGR , Symmetrical IUGR ,polyhydramnious ,stractural anomaly .

Echocardiography

Serology :CMV ,RUBELLA , VARICELLA

Algorithm IUGR

yesTORCH stigmata work-up? no yesDysmorphic features work-up? no

yesMaternal/placental explanation work-up?

no yes

Maternal drug use tox screenno

Unknown cause

Follow up

Growth curve (biometry)

Doppler

BPP

NST

Frequency of fetal surveillance Normal doppler & AFI : fortnightly umbilical artery end diastolic flow is

present : weekly Doppler BPP twice weekly Absent or reversed end diastolic flow in

the umbilical artery : hospital admission daily BPP and Doppler

BPP daily

FGR < 5 % Severe oligohydramnious Absent / reverse EDV Equivocal BPP ( 6/10 )

Sonography after than 18 days BPP : 26w 5d HC : 25w 6d AC : 24w 6d FL : 24w 2d EFW : 615 g AFI : 10 cm Umbilical artery reversed EDV DV : flow a wave decreased

GA : 30w 2d C/S Female : 630 gr

Indication of C/S

Fetal acidemia

Spontaneous late deceleration

Absent /reverse umbilical artery EDV

CASE 2 40y , G3L2(c/s) GA : 35w 1d but by sono 8 weeks : 33w 1d FH : 30 cm PMH : no problem OBH : neg US : BPD : 28w 3d HC : 28w 3dAC : 25wFL : 26wHL : 24w 5dEFW : 746gAFI : 5 cm doppler : NL

intervention

SGA 24+0 and 35+6 weeks before delivery : antenatal corticosteroids.

Magnesium : under 30 week. smoking cessation. Antithrombotic therapy appears to be a

promising therapy for preventing SGA in high risk women.However there is insufficient evidence, especially concerning serious adverse effects, to recommend

its use.

Sonography after than 16 days

BPD : 29W 3D AC : 26w FL : 26W 5D EFW : 767 g AFI : 2 cm BPP : 8/10 DOPPLER : NL

GA : 33w 1d GA : 35w 3d BPD : 28w 3d HC : 28w 3dAC : 25w (191 mm)FL : 26wHL : 24w 5dEFW : 746gAFI : 5 cm

BPD : 29W 3D HC : 28w 5d AC : 26w (200 mm) FL : 26W 5D

EFW : 767 g AFI : 2 cm

During 16 days : growth arrest .

GA 35w 3d : C/S

BW : 825 gr

Case 3 29y , G2ab1 GA : 30w 4d (by sono 13w : 30w 6d )

FH=26 cm PMH : NEG DH: heparin Sono : GA : 29 w 6 d BPD=27W 4D HC : 27W 6D AC : 25W 4D FL : 25W 4D EFW: 765 g AFI : 67 mm BPP : 10/10 DOPPLER : NL

Sono ( GA : 30w 4d) AFI < 5 cm BPP=6/8 (breath=0) RI MCA/ RI UMA=0.67/0.79 Hospitalization

Sono ( GA : 31 w 6d )

AFI < 5 cm

Doppler : absent EDV in umbilical artery

BPP=10/10

After than 15 days AFI =severe oligohydramnious

EFW= 997 gr BPP=8/8

حاملگی سن و 32در صورت 5هفته به روزشدید اکالمپسی پره دلیل به اوژانسی

شد انجام ترمیناسیون

Timing delivery

Abnormal DV(A/R a wave) or umbillical vein(pulsetile) with every GA .

Umbilical artery reverse EDV until 30-32 weeks

Umbilical artery absent EDV until 32-34 weeks

Umbilical artery high RI until 36- 37 weeks

Constitutional IUGR : 37-38 weeks

Indication delivery after than 34 weeks Maternal comorbidity arrest of growth Oligohydramnious A/R EDV umbilical artery MCA PI < 5% BPP < 4 Recurrent deceleration FHR

Recurrence risk in second pregnancy

First pregnancy AGA : 9% First pregnancy SGA : 29% First and second pregnancy SGA :

44%

Management of subsequent pregnancy cessation of smoking and alcohol

intake

balanced energy/protein supplementation

Avoiding a short or long interpregnancy interval

Screening option

Low risk : fundal height (exception large myoma ,BMI > 35)

High risk : ultrasonography

Biochemical : low PAPP-A , high AFP

Uterine artery doppler

MINOR RISK FACTORS

Maternal age > 35 yrs Nulliparity BMI <20 BMI 25-29.9 Smoker 1-10 per day Pregnancy interval < 6 mo Pregnancy interval >30 mo Paternal SGA

Major risk factors

Maternal age > 40 yrs Daily vigorous exercise Previous SGA baby Smoker >11 per day Previous stillbirth Maternal SGA Preeclampsia Maternal Medical disease Heavy bleeding similar to mense Echogenic bowel Low maternal weight Low PAPP-A

RCOG

"Advise women at high risk of pre-eclampsia to take 75 mg of aspirin* daily from 12 weeks until the birth of the baby. Women at high risk are those with any of the following:

• hypertensive disease during a previous pregnancy• chronic kidney disease• autoimmune disease such as systemic lupus erythematosis or antiphospholipid syndrome• type 1 or type 2 diabetes• chronic hypertension.

RCOG

Advise women with more than one moderate risk factor for pre-eclampsia to take 75 mg of aspirin* daily from 12 weeks until the birth of the baby. Factors indicating moderate risk are:

• first pregnancy• age 40 years or older• pregnancy interval of more than 10 years• body mass index (BMI) of 35 kg/m² or more at first visit• family history of pre-eclampsia• multiple pregnancy.