Fgr case discussion

FETAL GROWTH RESTRICTION DISCUSSION

Prof.Pushpalatha

ETIOLOGY OF FGR…….

Maternal

Hypertensive disorders

Diabetic vasculopathy

CRF

Collagen vascular disease

Thrombophilia

Fetal

Aneuploidy

Viral infections

Heart Disease

Placental

Placental abnormalities

Thrombosis

Chorioangioma

Placental Dysfunctio

n

CHROMOSOMAL ABNORMALITIES…..

Edward’s

Patau’s

Down’s

DIAGNOSIS……….?

Clinical

examination

Ultrasoun

d

CLINICAL EXAMINATION

SFHSensitivi

ty 60-85%

PPV 20-80%

ULTRASOUND BIOMETRY…… A C

Highest sensitivity

Highest NPV

Serial measureme

nt

Smallest measureme

nt

FETAL DOPPLER….UMBLICAL ARTERY

FETAL DOPPLER….

Reduced diastolic flow-30 % villi

affected

Absent/reversal-70% affected

Reduces fetal death by 29%

Intervention based on fetal

doppler

MCA

MCA

Hypoxia – Cerebral Vasodilation

Brain Sparing / Cephalisation flow liver & kidneys, “Hind limb reflex” Oligohydramnios

MCA

Does not predict more than umb A alone

-ve predictive value

Worsening of hypoxia – normalisation of previously abn MCA doppler

MCA – PSV remains abnormal as fetus decompensates

VENOUS DOPPLER

Ductus Venosus•Forward flow throughout cardiac cycle

•Reflects cardiac function

DUCTUS VENOSUS

VENOUS DOPPLER

Reversed ‘a’ wave backflow in venous circulation leads to pulsations in umbilical vein & reversed flow in IVC - foetal right heart faliure.

Associated with metabolic acidosis

Venous doppler evaluation most beneficial in early onset IUGR

DOPPLER INDICES < PNM

Doppler Parameter

Increased UA resistance

Absent UA EDF

Decreased MCA

Reversed UA EDF

IAUV Pulsations

Abnormal DV a-wave

Perinatal Mortality

5.6%

11-13%

21%

20-24%

35%

30-38%

ANTEPARTUM SURVEILLANCE EARLY

N umblical

art

Uterine art.

notching Elevated doppler index

Brain sparing

N MCA

N DV

N UV

DOPPLER

FHR –delayed maturationAFV – no changesBPS – delayed maturation of behavioural states

ANTEPARTUM SURVEILLANCE LATEUmb art. AREDFDV

elevated index

Loss of variability

Umb V- pulsatile flow

Absent/reversed a

wave

Late decelerat

ion

oligohydramnios

anhydramnios

Declining activity

Loss of tone

Loss of movement

Loss of breathing

DOPPLER

AFV

FHR

BPS

MANAGEMENT

Rest stress, quit smoking

Low dose aspirin

Antenatal corticosteroids – word of caution

Doppler waveform abn precede abn in BPP & NST by several weeks

MANAGEMENT

Most mature foetus

HIE / PM

BALANCE

MANAGEMENT

Abn UA waveforms

Late decelaration• Lagtime is more

in Preterm• Less in term

GRIT TRIAL

500 Women• Randomized• A / R EDF in UA• Immediate Vs Delayed

Delivery

Outcome• No difference in perinatal

mortality• At 2 years no difference

in neurological outcome > 31 wks

GRIT TRIAL

< 31 wks immediate delivery in disability(14% vs 5 %)

GA is the greatest determinant of intact survival

Awaiting TRUFFLE study results

ALGORITHM

DECREASED EDF

NST Bi weekly

BPP weekly

UA doppler weekly

Fetal growth every 3 weeks

AREDFHospitalisation

Frequent / continuous fetal monitoring

Steroids

MCA doppler weekly

DV doppler every 3-4 days

BPP daily

FGR > 24 wks

UMBLICAL ART

DOPPLER

MODE OF DELIVERY

UA EDF normal OCT successful induction of labour

A / RED EDF ----- LSCS

SCREENING

Ultrasound

Uterine artery

notching

Biochemical

analytesAFP

Beta HCG

PlGF

SCREENING UTERINE ARTERY

THANK YOU….