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Fetal growth assessment

S U P E RV I S E D B Y D R . E L I A S E L - S U N A A PRESENTED BY : OSAMA ALHUMISI OMAR ABU KAUSH M O H A M M E D TA H A ABDULRAHMAN OMAR HASAN KULMIAH

Why do we study obstetrics !!!


To Decrease the maternal and perinatal morbidity and

mortality.

What are the objectives of this seminar !!!


To understand whats the normal pattern of fetal growth . To detect fetuses with abnormal growth

How to achieve these objectives


1. Early confirmation of dates.. 2. Detection of congenital malformations. 3. Detecting fetal hypoxia. 4. Detecting abnormal fetal growth

Fetal growth assessment

Optimal birth weight


In developed countries , the average birth weight is

3.5 Kg at the end of normal preganancy lasting of 40 weeks .


The average fetus gains approximately 25 g /day

between 32 weeks gestation and term

1/3 of the eventual birth is reached by 28 weeks ,

by 31 weeks , 2/3 by 34 weeks

Fetal growth and maturation


Determinants of fetal growth are multi-factorial :

Fetal factors Intrauterine enviroment Others

Hormones ; IGFs , thyroid , insulin Sex , (M>F); 60 grams

Metrnal : wt , height , age, parity Placental

Ethinc group Geographical area (altitude ) . Socioeconomic status , ( nutrition and smoking)

Methods of assessing Fetal Growth


History

Physical examination

Investigations

Accuracy of the date of the LMP:


1. The date of the LMP : sure or not, length, amount 2. 3. 4. 5.

of bleeding. Regularity of the last 3 cycles. Lactation in the last 3 months. Combined oral contraceptive pills use. Date of quickening: - primi-gravida feels it btw 18-20 weeks - multi-gravida feels it btw 16-18 weeks

Physical examination

General examination

Obstetric examination

Fundal height

Pelvic exam

Physical examination
Obtaining serial uterine

fundal height measurements. The Mcdonalds rule in pregnancy is a rough determination of fetal age in weeks compared to uterine/fundal size Less valid during the 3rd trimester

Physical examination
2. Evaluating the size of the uterus by pelvic examination in the first trimester and subsequent antenatal visits

Ultrasound

Uses of US in assessing fetal growth


1. 2. 3. 4. 5. 6. 7. 8.

Diagnosis and confirmation of viability in early pregnancy Determintion of gestational age and asessment of fetal size Intrauterine or Extrauterine (Ectopic) pregnancy. Multiple pregnancy Diagnosis of fetal abnormalities Placental localization Assessment of fetal well-being Measurment of cervical length

1. Diagnosis and confirmation of viability in early pregnancy


Detection of : Gestational sac (4-5 wks) Yolk sac (5 wks) Embryo (5-6 wks) Visible heart beat (6 wks).

2. Determination of gestational age and assessment of fetal size and growth


The sonographic parameters uesed to diagnose

IUGR : 1. Biparietal diameter 2. Head circumference 3. Abdominal circumference 4. Head to abdominal circumference ratio 5. Femoral length 6. Femoral length to abdominal circumference ratio 7. aminiotic fluid volum 8. Calculated fetal weight

2. Determination of gestational age and assessment of fetal size and growth


Up to 13 wks + 3 days : Crown-Rump Length (CRL) [ accuracy + \ - 5 days ] Most accurate from 16 to 24 wks : - Head circumference (HC) - Biparietal Diameter (BPD) [ accuracy + \ - 7 days] - Femur length (FL) Gestational age cannot be accurately calculated by US after 20 wks gestation because of the wider range of normal values of AC and HC around the mean . NOTE : The earlier the measurement is the more accurate.

Crown-Rump Length (CRL)

Bi-parietal Diameter (BPD)

Femur length (FL)


- Accurate only when the image shows two blunted ends of the femur.

Head circumference (HC)

Abdominal circumference (AC)

It is the most accurate single predictor of fetal weight.


Small abdominal circumference in comparison with normal head and femur length indicates asymmetrical growth restriction.

HC to AC Ratio, and the GA


In the latter part of pregnancy, Abdominal circumference (AC) and (HC) Allow assessment of the size and growth of the fetus and assist in Dx and management of fetal growth restriction HC:AC > 1 (HC is bigger) the GA < 35 wks.

HC:AC = 1 (Equal) the GA = 35 wks.


HC:AC < 1 (AC is bigger) the GA > 35 wks.

3. Multiple pregnancy

dichorionic and diamniotic monochorionic and monoamniotic

monochorionic and diamniotic conjoined (Siamese) twins

Small for gestational age


Small for gestational is defined as a fetal

birth weight below the 10th centile for the stated gestational age. The incidence of SGA fetuses is 5-10%.
Not always pathological

Why the fetus is small?

Intrauterine growth restriction


Definition :

a failure of the fetus to achieve its genetic growth potential.


So Not all IUGRs are below 10th centile, and not all those below

the 10th centile are IUGR.

As many as 70 percent of fetuses who are estimated to weigh

below the 10th percentile for gestational age are small simply due to constitutional factors

Significance
Major cause of neonatal morbidity and mortality.

Growth restricted fetuses are particularly prone to

problems such as meconium aspiration ,asphyxia ,polycythemia ,hypoglycemia and mental retardation . Significant cost in terms of facilities required to look after these infants . They are at grater risk for developing adult onset conditions such as hypertension ,diabetes and atherosclerosis .

CAUSES
Reduced fetal growth potential fetal

Reduced fetal growth support maternal, placental

Fetal factors
Chromosome defects ; trisomy 18 , triplooidy . Single gene defect ; seckles syndrome . Structural abnormalities ; renal agenesis

Infections ; CMV , toxoplasmosis

Maternal factors
Under-nutrition , e.g. poverty, eating disorder. Maternal hypoxia, e.g. altitude , CHD. Drugs , e.g. smoking , alcohol , cocaine .

Advanced diabetes Uterine malformation .

.. Typically asymmetrical IUGR

PLACENTAL FACTORS
Reduced uteroplacental perfusion e.g. inadequate trophoblast inavsion , antiphospholipid syndrome , DM, sickle-cell disease , multiple gestation

Reduced feto-placental perfusion e.g. single umbilical artery , twin-twin transfusion syndrome.

Infarction , abruption , placental tumors TTTS ,

velamentous cord insertion )

..Typically asymmetrical IUGR.

Classification of IUGR

Symmetrical (20-30%)
This is characterized by inadequate growth of the

head, body and extremities and occurs in 2030% of IUGR fetuses . Etiology is decreased growth potential :e.g aneuploidy ,early IU ,infection ,gross anatomical anomaly . Antepartum test usually normal .

Asymmetrical 70-80%
Asymmetric FGR is characterized by a relatively

greater decrease in abdominal size (eg, liver volume and subcutaneous fat tissue) than head circumference and is found in the remaining 70 to 80 percent of the FGR population. Asymmetric fetal growth is thought to result from the capacity of the fetus to adapt to a hostile environment by redistributing blood flow in favor of vital organs (eg, brain, heart, placenta) at the expense of non vital fetal organs (eg, abdominal viscera, lungs, skin, kidneys .

Asymmetrical IUGR
This illustrates asymmetrical IUGR in which the head and femur are growing normally but the abdomen is not growing properly. This results in an elevated head/abdomen ratio and an estimated fetal weight just above the 10th percentile

Diagnosis of IUGR
History Physical examination

Investigations

Growth restriction may go undiagnosed unless the obstetrician establishes the correct gestational age of the fetus , identifies high risk factors from obstetric database & serially assesses fetal growth by fundal height or US

History
Assure accurate dating. Current pregnancy history. Past obstetric history. Past medical history. Drug history. Family history. Socioeconomic history.

History of current pregnancy :


- Mothers age. - Exposure to X-Ray.

- Infections during pregnancy.


- Multiple pregnancy: lead to SGA due to inadequate

nutritional supply.
- Antenatal care and visits. - Supplements.

Past obs. History:


Previous deliveries of pre-term, low birth weight, complications, miscarriage or live and well babies.

Past medical history:


some diseases like sickle cell anemia, HTN, DM and antiphospholipid syndrome can lead to IUGR and SGA.

Drug history:
Immunosuppressive, anti convulsant agents , SLE drugs and drug abuse can lead to fetal growth retardation.

Family history:
- Inherited diseases, any congenital deformities.

Socioeconomic history :
- Malnutrition, smoking, alcohol drinking.

Chronic diseases:
- (DM, HTN, chronic RF)

Physical Examination
fundal height measurements :primary screening tool for

IUGR. If: - 3 cm variation ? Or, - the mother has a high risk condition a more thorough U/S assessment should be undertaken.
New promising charts

~Customized growth curves for ethnicity, parental size, and gender are in development so as to improve sensitivity and specificity of diagnosing IUGR. ~Study : using fundal height curves that customized for maternal weight, height, and ethnicity was able to increase the detection rate .

Ultrasound
Abdominal circumference is the single most effective

parameter for predicting fetal weight because its reduced in both symmetrical & Asymmetrical IUGR .

In the presence of normal head and femur measurements,

abdominal circumference (AC) measurements of less than 2 standard deviations below the mean appear to be a reasonable cutoff to consider a fetus asymmetric.

Asymmetrical growth restriction : BPD is normal in the 3rd

trimester , whereas ratio of HC/AC is abnormal .

Symmetrical growth restriction : HC/AC may be normal .

amniotic fluid volumes ( oligohydramnios increases

the risk of IUGR) .


Umbilical artery & fetal artery dopplar assessments :

increased resistance is associated with a greater risk of IUGR as pregnancy progresses.

Complications of IUGR

Antenatal

Intrapartum

Neonatal

Antenatal Complications
Metabolic changes in fetus (acidosis, hypoxia). Oligohydramnios (80%) Abnormal fetal heart patterns. Abnormal Doppler studies. Intra-uterine fetal death.

Intrapartum complications
Abnormal CTG. Meconium-stained liquor. Increased incidence of instrumental and caesarean

deliveries. Fetal death.

Neonatal complications Related to hypoxia and acidosis: Metabolic: Related to the etiology:
1. Meconium aspiration. 2. Persistent fetal circulation. 3. Hypoxic ischemic encephalopathy (HIE).

1. Hypoglycemia 2. Hypocalcaemia 3. Hypothermia 4. Hyperviscosity syndrome

1. Chromosomal abnormalities. 2. Congenital anomalies. 3. Fetal infection.

Possible long-term complications


Lower IQ Learning and behavioral problems. Neurological deficits(Cerebral palsy). Hypertension and Ischemic Heart Disease. diabetes and atherosclerosis Metabolic disorders(type 2 D.M.).

Management principles
Pre-pregnancy. Antepartum (during

pregnancy).
Labor & delivery.

Pre-pregnancy
Modify lifestyle habits. Balanced nutrition. Magnesium & Folate

supplements decrease rate of SGA. Quit smoking, alcohol, & drug abuse. Detect and treat medical disorders. Correction of anemia. Control any chronic illnesses (anti-phospholipids syndrome , sickle cell

disease, DM, HTN, thyroid dysfunction )

Antepartum
Regular antenatal care: assess Fetal heart beat and

fetal movement Serial fetal growth assessment. Fetal surveillance & serial US measurements at three weekly intervals are indicated Fetal weight every 2 weeks Serial fetal wellbeing assessment. 1-Biophysical profile 2-Computerized CTG 3-Umblical artery Doppler Bed rest to maximize uterine blood flow Betamethasone administration between GA 3035weeks.

Timing of delivery : to maximize gestation

without the fetus suffering any neurological abnormality, and increasing maturity as possible before delivery.
Mode of delivery.

Labor & Delivery


Time & Mode of delivery governed by: maternal age past obs. History gestational age fetal well being status of cervix availability of direct monitoring during labor. Ex: scalp PH sampling.

Cesarean delivery without a trial of labor:

1. in the presence of evidence of fetal distress 2. for traditional obstetrical indications for cesarean delivery
Induction of labor

continuous heart rate monitoring and scalp pH monitoring optimize success of vaginal delivery

Postpartum
The infant should be carefully

examined for any congenital anomalies and infections. Monitor blood glucose, hypoglycemia is a common finding. Hypothermia is not uncommon. optimized nutrition may help the baby to catch up height and weight

Prognosis
Main danger is neurological injury Some will suffer morbidity or die as a result

of prematurity.

But long-term prognosis is good with low

incidence of mental or physical handicap. below 50th centile .

Height and weight curves remains slightly

Infants with IUGR secondary to placental

insufficiency show catch up growth after delivery when feeding is optimized While IUGR related to chromosomal abnormality or congenital infection the development depend on abnormality present.

New researches suggest

a link between birth weight and increased incidence of HTN and diabetes in adults