Fetal growth

restriction
Dr Smitha Sreenivas K
Additional Professor
OBG,GMC Kozhikode
FGR
• Estimated fetal weight (EFW) or abdominal circumference (AC)
<10th percentile for gestational age
• FGR occurs when the genetic growth potential is not achieved due to
an abnormality of any of factors like maternal, fetal, and/or placental

• 10 percent of pregnancies
• Major contributor to perinatal morbidity and mortality
• AGA
• Biometric parameters and/or EFW
between 10 and 90th percentile

• SGA
• EFW or AC <10th percentile
• No pathologic restriction of fetal growth
• not at increased risk of adverse perinatal
outcome

• LGA
• EFW or AC >90th percentile
• Severe FGR
• EFW or AC <3rd percentile for gestational age.
• Higher risk for perinatal morbidity and mortality
• Presence of umbilical artery Doppler abnormalities suggests that FGR
is severe (eg, pulsatility index >95th percentile, absent or reversed
end-diastolic flow)
Delphi Consensus Criteria for Fetal Growth Restriction and
Classification (In absence of congenital anomalies, based on
international Delphi consensus)
Identification of FGR:Why?
• Fetal surveillance can be initiated
• Birth timing optimized to decrease stillbirth (risk for stillbirth is
increased eightfold when FGR is not detected)

• Long-term impacts
• Neurodevelopmental delay in childhood
• Increased risks for cardiovascular disease, dyslipidemia, and diabetes
mellitus in adulthood(Barker’s hypothesis)
Etiology
• Placental
• Placental insufficiency is the most common risk factor for FGR.
• Velamentous cord insertion, circumvallate placenta, and single umbilical artery
• Maternal
• Maternal vascular disease (such as chronic hypertension), renal disease, diabetes, collagen
vascular disease, and antiphospholipid syndrome
• Tobacco and substance use, including cocaine, alcohol, and opioids, are modifiable risk factors.
• Medications-anti-seizure and chemotherapeutic medications and warfarin
• Fetal
• Fetuses with genetic abnormalities, syndromes, and congenital anomalies
• Fetal infection with malaria, cytomegalovirus, syphilis, rubella, varicella, and toxoplasmosis
Identify FGR
• Maternal history
• Medical and obstetric history
• Dating pregnancy :8-14 weeks –CRL most reliable
• >14 weeks ,CRL>84 mm –BPD,HC,AC,FL

• Fundal height measurement

• Beyond 24 weeks, the measurement in centimeters (+/- 3 cm)
approximates gestational age in weeks
• fundal height measurement >3 cm -potential marker for FGR
• sensitivity of fundal height to detect FGR ranges from 17 to 86 percent
Gravidogram
• Measure SFH every 2-4 weeks and
at every antenatal visit from 24
weeks onwards and plot it on
growth charts.
• The gravidogram is a simple and
inexpensive screening tool and as
useful as an ultrasound in
detection of intrauterine growth
restriction
• When SFH is less than 10th centile
or on clinical suspicion of slow or
static growth on serial SFH
measurements, perform
ultrasound to confirm FGR
Management of FGR
• Confirm the diagnosis
• Determine the probable cause
• Assess the severity
• Closely monitor fetal growth
• Monitor fetal well-being
• Determine the optimal time for and route of birth
DIAGNOSIS
• USG estimation of fetal weight (EFW) <10th percentile or fetal
abdominal circumference (AC) <10th percentile
• FGR is highly likely in nonanomalous fetuses with EFW or AC
<3rd percentile, regardless of gestational age
• When EFW or AC between the 3rd and 10th percentile, abnormal
Doppler parameters and decreasing growth trajectory of the EFW or
AC support the diagnosis of FGR
Determine the probable cause
• Maternal history and physical examination
• Fetal anatomic survey
• approximately 10 percent of FGR is associated with congenital anomalies
• omphalocele, gastroschisis, diaphragmatic hernia, skeletal dysplasia, some
congenital heart abnormalities, and rarely congenital portosystemic shunts
• Selective work-up for genetic abnormalities
• FGR before 32 weeks in the absence of an identifiable nongenetic cause of
the growth restriction.
• FGR with major fetal structural abnormalities or ultrasound markers
associated with an increased risk of aneuploidy, such as a thickened nuchal
fold.
• •FGR with polyhydramnios.
• •Ultrasound findings suggestive of a triploid pregnancy.
Genetic testing modalities include:
• •Cell-free DNA of maternal blood
• •Microarray or karyotype – Microarray or karyotype is performed on cells
in amniotic fluid obtained by amniocentesis.
• •Exome and whole genome
• Selective work-up for infection
• Sonographic markers of fetal infection (echogenicity and calcification of the
brain and/or liver, hydrops) or
• when a careful maternal history and physical examination suggest the
possibility of maternal infection and vertical transmission
Assess severity of FGR
Dopplers for uteroplacental insufficiency
• Uterine artery doppler:
• When uterine arteries fail to transform from high- to low-resistance
circulation due to inadequate trophoblastic invasion of the spiral arteries,
this is reflected as a persistence of high uterine artery mean pulsatility
index (PI) (above 95th percentile) and is associated with placental
insufficiency and maternal vascular malperfusion of the placenta.
• Umbilical artery doppler:
• An umbilical artery pulsatility index of more than 95th centile for that
gestation reflects a raised value.
• It indicates reduction in placental surface area available for gas and
nutrient exchange and placental vascular insufficiency.
• Increasing severity of placental vascular insufficiency results in absent end
diastolic flow (AEDF) or reverse end diastolic flow (REDF).
Doppler for fetal adaptation
• Middle cerebral artery doppler:
• Reduced puslatility index (less than 5th centile), reflects a hemodynamic response in the
fetus to hypoxemia which results in vasodilation and preferential shunting of blood flow
(brain-sparing effect).
• Ductus venosus doppler:
• Alterations in the ductus venosus flow velocity waveform, especially absent or reversed
awave, may be a consequence of increased intra-atrial pressure due to high cardiac
afterload and/or a direct effect of fetal acidemia on myocardial cell function.
• Cerebroplacental Doppler ratio (CPR) :
• CPR is ratio of middle cerebral artery pulsatility index divided by umbilical artery
pulsatility index.
• A low CPR indicates fetal blood flow redistribution (brain sparing) and is predictive of
adverse neonatal outcome.
Umbilical artery Doppler
• UA Doppler is the primary surveillance tool for monitoring
pregnancies with FGR
• UA diastolic flow normally increases with advancing
gestational age
• UA indices become abnormal when 30 percent of the
placental villous vasculature is damaged by embolization
• When 60 to 70 percent of the placental villous vasculature is
obliterated, flow in the UA can become absent or even
reversed at the end of the cardiac cycle
Middle cerebral artery pulsatility
index
• In uncomplicated pregnancies, vascular resistance of the fetal
brain changes with advancing gestation
• Middle cerebral artery (MCA) PI is low at early gestational ages
(<20 weeks), then gradually increases, before gradually
decreasing in the third trimester
• FGR experiencing progressive hypoxemia, cerebral blood flow
increases to compensate for the decrease in available oxygen
(brain-sparing effect) , which results in a reduction in MCA PI
• Subsequent normalization of the MCA PI may occur and is
considered an ominous sign because it indicates the loss of
brain-sparing
Ductus venosus Doppler
• Normal flow in the fetal ductus venous (DV) is forward and
uniform
• With progressively increasing UA resistance in FGR, fetal
cardiac performance becomes impaired and atrial pressure
increases, resulting in reduced diastolic flow in the DV a-
wave.
• With progression of the severity of FGR, and late in the
course of the disorder, the a-wave becomes absent or
reversed
• Absent or reversed DV a-wave is considered a sign of
impending acidemia and fetal demise.
Assess liquor volume
• Oligohydramnios
Monitor fetal growth
• Fetal weight
• Sonography every two to four weeks to assess the change in EFW
over time
• fall in the EFW percentile for gestational age is associated with
increased perinatal morbidity and mortality
• A normal growth velocity (ie, parallel to the growth curve of fetuses
with EFW or AC >10th percentile) predict a favorable outcome
Fetal surveillance
• Fetal movement count:
• simple, inexpensive and reasonable tool
• Reduced fetal movement (FM) is defined as less than 10 movements
in 2 hours during focused maternal counting on 'rest' in left lateral
position.
• as fetal hypoxia sets in, fetal activity is reduced-Indication for USG and
or NST
• Disadvantage -lack of objectivity, risks of false alarms or false
perception of movement despite fetal inactivity.
• Fetal heart rate monitoring:
• Fetal heart rate characteristics reflect fetal oxygenation, gestational age,
and maturational state of the nervous and cardiovascular systems.
• Studied on an antepartum cardiotocograph (CTG) or non-stress test (NST).
• A normal baseline heart rate (110-160 bpm) with periodic accelerations
(raise of 15 bpm above baseline lasting for 15s) defines a normal or
“reactive” CTG.
• an abnormal CTG has low specificity for predicting fetal hypoxia and further
tests will be needed to ascertain the exact fetal condition
• Computerised CTG (cCTG):
• Better than the traditional CTG in predicting fetal hypoxia.
• cCTG can look into “short term variability” (STV) of fetal heart rate
• Reduced STV correlates well with fetal hypoxia
• Availability of cCTG in India is extremely limited and non-
standardised.
• Fetal biophysical profile (BPP):
• Assess the possibility of fetal acidosis.
• Traditional BPP includes a 30 minute fetal ultrasound assessment of
movements, breathing movements, tone and amniotic fluid level.
• Negative predictive value for fetal death with one week of a normal BPP is
99%.
• Since the traditional BPP takes time, a modified BPP with a CTG and
amniotic fluid assessment has been suggested.
• If this this abnormal, a 30 minute BPP can be done.
• BPP is a more accurate predictor of fetal acid-base status at the time of
testing than CTG/NST.
• BPP can be used to clarify fetal acid base status when a nonreactive NST
• Fetal Dopplers:
• Important for monitoring pregnancies with FGR.
• Doppler studies of fetal vessels provide vital information about fetal
hemodynamics and can be correlated to fetal cardiovascular response
to the hypoxic/ metabolic changes happening in FGR.
• Cerebroplacental ratio
• The cerebroplacental ratio (CPR) is the MCA PI divided by UA PI
• The CPR reflects both the placental status and fetal response
• sensitive Doppler index for predicting perinatal outcome
• CPR <5th centile- predict adverse outcome
• Antenatal corticosteroids
• <34+0 weeks of gestation
• Magnesium sulfate for neuroprotection
• <32 weeks.
• a decrease in significant neurodevelopmental impairment and death
was observed
Maternal interventions
• No convincing evidence that any intervention improves fetal growth
and outcome in FGR.
• Bed rest-improves uterine perfusion-unproven benefit
• Maternal nutritional supplementation with high caloric and protein
diet
• oxygen therapy, and interventions to improve blood flow to the
placenta (eg, plasma volume expansion, bed rest in left lateral
position , low-dose aspirin, anticoagulation)
DELIVERY
• Timing and route of delivery based on a combination of factors
• umbilical artery (UA) Doppler findings
• biophysical profile (BPP) score
• nonstress test (NST)/cardiotocography (CTG) result
• gestational age
• fetal weight.

• Shared decision-making regarding pregnancy management

• 37+0 weeks - upper threshold for delivery of FGR pregnancies
• risk of stillbirth in pregnancies delivered after the 37 th week was twice
as high as that in those delivered in the 37th week
Reactive NST and BPP score 8/8, 10/10 or 8/10 with
normal amniotic fluid volume
• UA reversed diastolic flow
• – Deliver between 30+0 and 32+0 weeks of gestation or at diagnosis if
>32+0 weeks.
• •UA absent diastolic flow
• – Deliver between 33+0 and 34+0 weeks of gestation or at diagnosis if
>34+0 weeks.
• •UA pulsatility (PI >95th percentile)
• – Deliver at 37+0 weeks or at diagnosis if >37+0 weeks.
• UA PI normal (PI ≤95th percentile):
• -EFW <3rd percentile and no comorbidities
• – Deliver at 37+0 weeks or at diagnosis if >37+0 weeks.
• -EFW ≥3rd and <10th percentile and no comorbidities
• – Deliver between 38+0 and 39+0 weeks of gestation
• -FGR with oligohydramnios or comorbidities (eg, preeclampsia,
chronic hypertension) –
• Timing should be individualized
• delivered between 34+0 and 37+6 weeks of gestation.
Route of delivery
• Cesarean birth for standard obstetric indications
• REDF
• AEDF
Barcelona stage based management
Intrapartum management
• In the absence of contraindications, induction of labor is indicated
• During labor, continuous fetal heart rate monitoring is recommended

• Continuous fetal heart rate monitoring is indicated, given the

increased potential for fetal hypoxemia during labor.
Pediatric Outcome
• Short-term morbidity and mortality – • Long-term morbidity –
• Fetal demise, neonatal death, and • FGR may predispose to hypertension,
neonatal morbidity type-2 diabetes mellitus, coronary
• prognosis worsens with early-onset heart disease, and chronic kidney
FGR, increasing severity of FGR , and disease in adulthood
absent or reversed end-diastolic flow • partial resetting of fetal metabolic
on umbilical artery homeostasis and endocrine systems in
• neonatal morbidities response to in utero nutritional
deprivation.
• respiratory distress syndrome (34
percent
• retinopathy of prematurity (13
percent
• sepsis (30 percent).
Maternal outcome
• Risk for cardiovascular disease
• Coronary artery disease
• Myocardial infarction
• Coronary revascularization
• Peripheral arterial disease
• Transient ischemic attack
• Stroke
Risk reduction in subsequent
pregnancies
• Cessation of smoking and alcohol intake
• Chemoprophylaxis and mosquito avoidance in areas where malaria is
prevalent
• Balanced energy/protein supplementation in patients with significant
nutritional deficiencies
• Avoiding a short interpregnancy interval
• Low-dose aspirin is recommended for women at increased risk of pre-
eclampsia and FGR,150 mg starting at 12–16 weeks
TO CONCLUDE
• Estimated fetal weight (EFW) or abdominal circumference (AC)
<10th percentile for gestational age
• Confirm the diagnosis
• Determine the probable cause
• Assess the severity
• Closely monitor fetal growth
• Monitor fetal well-being
• Determine the optimal time for and route of birth
Thank you