FGR

Definition: Fetus whose growth velocity slows down or stops completely because of inadequate oxygenation or nutrition supply or utilization
Not all FGR are SGA or all SGA are FGR Fetus with FGR with adequate birth weight more about 5th centile (abd. Circumference) will not suffer from neonatal complications


SGA can be categorized according to the etiology into: Normal SGA: No structural anomalies, normal liquor, normal Doppler study of umbilical artery & normal growth velocity. Abnormal SGA: those with structural or genetic abnormalities FGR: those with impaired placental function identified by abnormal UADW & reduced growth velocity. SGA is divided into symmetrical or unsymmetrical according to Biometrial measurement

AETIOLOGY

MATERNAL FACTORSNutrition: BMI<19 starvationSmoking: 460 gm lighter than fetus with nonsmoker womanAlcohol and drug abuseMaternal therapeutic drugs e.g. B blockers esp. Atenolol in 2nd Trim. Anticonvulsant esp hydrantionsMaternal disCardiorespiratory compromise˃ hypoxemia> ↓ fetal growthSickle cell dis, Collagen vascular dis.Antiphospholipid antibodies →↓placental perfusionMaternal DM ( retinopathy & nephropathy)Maternal chronic hypertension esp if associated with renal impairmentAbnormalities in the uterus

2. FETAL FACTORS Fetal abnormalities Chromosomal Structural Cardiac dis Gastroschisis Infection Variciella CMV Rubella Syphilis Toxop Malaria


3. PLACENTAL FACTORSPlacental mosaicisim –16,22 chromPE -- ↓ blood supply to placental bed

PREDICTION

1. HISTORY BMI<19 Smoking Past history of FGR Congenital uterine abnormalities Big fibroid Old mother>40 nullip PE Retro placental. hemorrhage in 2nd & 3rd Trim


2.MATERNAL SERUM SCREENING : 2nd TimAlfa Feto Protien(AFP) – esp if ↓ E3Human Placental LactogenhCG

3. ULTRASOUND MARKERS Abnormal uterine artery Doppler --- absent End Diastolic Flow or notching of wave form Bright or echogenic fetal bowl in 2nd Trim is associated with increase FGR

CLINICAL ASSESSMENT:

Weight gain in pregnancyFundal heightClinical weight estimation of the fetus – liquor amount estimation U/S assessment Biometrial measurement of the fetus – abdominal circumference is the most accurate prediction of fetal weightBiparietal & FL One exam does not differentiate between SGA from FGR , so serial estimation 4wk interval

Liquor volume due to decrease renal perfusion – the degree of liquor decrement correlate well with degree of hypoxia as reflected by pO2 at cordocentesisUmbilical art Doppler velocity study --- reduced flow – absent End Diastolic Flow –reversed EDF

MANAGEMENT:

PROPHYLAXIS Small dose aspirin Protein energy Stop smoking Anti malaria Stop medications



MONOTORINGMonitoring of normal SGA – UADW better than bio physical profile & liquorCTG – Unclear role – every 2 wkMonitoring of GRF if diagnosis > 34wk → deliveryif diagnosis < 3wk → steroid

if RDEF → deliveryif AEDF → controversyMCA→ ↑ flow → adaptive mechanismAEDF→ fetal demise( 2 days to wk)

LABOR<37wk → C/S because at high risk of hypoxia & academiaIf normal UAD→>37wk→ induction – continuous CTG, fetal scalp monitoring