Fetal Growth

Restriction

FGR
Woman’s Hospital School of
Medicine Zhejing University
He jin
 Definition of FGR
• Growth at the 10th or less percentile
for weight of all fetuses at that
gestational age or>37W<2500g
• A condition in which a fetus is unable
to achieve its genetically determined
potential size
 FGR
• FGR perinatal mortality rate was 4-6
times normal fetus.

• About 22% of children with

congenital malformation is
accompanied by growth restriction.
 small for gestational
age ， SGA
• Structure was normal
• no malnutrition
• no adverse perinatal outcomes
• Relating maternal race, parity,
weight, height
 Causes of FGR
• Maternal causes include the
following:
• Chronic hypertension
• Pregnancy-associated hypertension
• Cyanotic heart disease
• Class F or higher diabetes
• Hemoglobinopathies
• Autoimmune disease
 Causes of FGR
• Maternal causes include the
following:
• Protein-calorie malnutrition
• Smoking
• Substance abuse
• Uterine malformations
• Thrombophilias
• Prolonged high-altitude exposure
 Causes of FGR
• Fetal causes include the following:
• Race
• sex
• Twin-to-twin transfusion syndrome
• Multiple gestations
• Trisomy 21/18/13
• virus infection
• Fetal alcohol syndrome
 Causes of FGR
• Placental or umbilical cord causes
include the following:
• Placental abnormalities
• Chronic abruption
• Placenta previa
• Abnormal cord insertion
• Cord anomalies
 Categories
• According to fetal growth characteristics,
weight and cause
• 1. Endogenous symmetry
• also known as early onset FGR, Rare
• harmful factors acting on the zygote or
early pregnancy
• Reason:
– chromosomal abnormalities
– intrauterine infection
– environmentally harmful substances
 Categories
• 2.Exogenous unsymmetry
• harmful factors acting on second and
third trimester
• most of them because the low
placental function
• PIH, GDM, placenta lesions
• 3. Exogenous symmetry
– One and two types mixed
 Diagnosis

• 1. History:

• Note : there is any risk factors for

FGR during this pregnancy

• Asked: appearance of FGR history

 Diagnosis
• 2. Signs and symptoms:
• Continuous determination:
– fundal height, abdominal circumference
and maternal weight to determine fetal
growth.
• fundal height
– significantly less than the corresponding
gestational age
– most obvious and most easily
identifiable signs
 Diagnosis
• Amniotic fluid volumes
• Amniotic fluid index (AFI)
– < 5 cm :the rate of FGR was 19%
– > 5 cm :9%
• Aaximum vertical pocket (MVP) values
• >2 cm : 5%
• < 2 cm : 20%
• <1 cm :39%
 Diagnosis
• Uterine artery Doppler measurement
– contribute to the identification of fetuses at
risk of FGR
• Umbilical artery Doppler measurement
– absent end-diastolic velocity
– reversed end-diastolic velocity
– corroborates the diagnosis of FGR
• Middle cerebral artery Doppler
– MCA-PSV (peak systolic velocity) is a better
predictor of FGR-associated perinatal mortality
than any other single measurement
 Diagnosis and
Surveillance
• Venous Doppler waveforms
– fetal cardiovascular and respiratory
responses
• Three-dimensional ultrasonography
– a 10th percentile femur/ humerus
volume threshold
 Therapeutic options
• No effective treatments are known
• First
– behavioral strategies to quit smoking result in
FGR
• Second
– balanced nutritional supplements
– magnesium and folate supplementation
• Third
– if malaria is the etiologic agent
– maternal treatment of malaria can increase
fetal growth
 Treatment
• Once FGR has been detected---
surveillance plan
• Maximizes gestational age
• Deliver the most mature fetus in the
best physiological condition possible
• while minimizing the risks of
neonatal morbidity and mortality
• while minimizing the risk to the
mother
 Treatment
• 1. general treatment
(1) to correct bad habits
(2) bed rest
(3) increased oxygen concentration

• 2. positive treatment of various

complications
 Treatment
• 3. intrauterine treatment
• (1) improve uteroplacental blood
supply
• (2) zinc, iron, calcium, vitamin E and
folic acid, amino acid compound
• (3) oral low-dose aspirin inhibits the
synthesis of thromboxane A2
 3. intrauterine treatment
• (4) low molecular weight heparin and
low-dose aspirin may improve the
outcome of FGR
– but not yet widely used clinically
– requires further clinical trials
• (5) the FGR fetus is expected to give
birth before 34 weeks
– should promote fetal lung maturity
 4 obstetric management
• (1) chromosomal abnormalities or severe
congenital malformations
– should early termination of pregnancy.
• (2) Placental function is poor
• but the treatment is effective

• continue to term
– intensive care
– should not exceed the expected date of
delivery
 intensive care
• A weekly nonstress test (NST)
• AFV determination
• Biophysical profiles
• Doppler assessments
• Severe FGR before 32 weeks'
– a poor prognosis
– therapy must be highly individualized
 4. obstetric management
• (3) termination of pregnancy:
– > 34 weeks ,a general treatment is poor
– fetal distress, or stop the growth of the fetus
more than 3 weeks
– pregnancy complications aggravate
– < 34 weeks, has been applied to promote fetal
lung maturity
• (4) the mode of delivery :
– fetal malformations
– maternal complications of the severity
– to evaluate fetal condition
Fetal Macrosomia
FMS
 Definition of FMS
• Defined in several different ways:
• Birth weight of 4000-4500 g (8 lb 13
oz to 9 lb 15 oz)
• Greater than 90% for gestational age
• Increased dystocia, perinatal
mortality
• Affects 7-15% of all pregnancies
 Influencing factors
• Gestational diabetes mellitus(GDM)
– class A, B, and C ， 26%
• Genetics
• Racial
• Ethnic
• Duration of gestation
• Neonatal sex
• Other: nutrition, parity, polyhydramnios
 Diagnosis
• Measure birth weight after delivery
– Only
– retrospective
• Perinatal diagnosis difficult
– often inaccurate
– no risk factors can predict it accurately
enough to be used clinically
– most FMS do not have identifiable risk
factors
 Diagnosis
2
• BMI ≥ 30 kg/m 、体重增加过多
• Fundal height measurements: 3-4
cm larger than the gestational age in
the third trimester
– inaccurate
– are influenced by maternal size, the
amount of amniotic fluid, the status of
the bladder, pelvic masses (eg,
fibroids), fetal position
 Diagnosis
• B ultrasound
• Biparietal diameter>10
• femur length>8
• chest circumference/ shoulder
diameter ： rule out shoulder
dystocia
• abdominal circumference>33 ， >35
• FSTT >2
 FMS on neonates injury
• Neonatal morbidity
• Neonatal birth trauma
• Intrauterine death (GDM infants)
• NICU admissions
– ≥4500 g vs ≤4000 g (9.3% vs 2.7%).
• Shoulder dystocia was 10 times
higher
– ≥4500 g vs ≤4000 g (4.1% vs 0.4%).
 FMS on mothers injury
• Birth canal lacerations
– Perineal
– Vaginal
– cervical
• Cesarean delivery
• Postpartum hemorrhage (PPH)
• Infection
 gestation period treatment
• Screening GDM
• Weight Control
• The recommendations for weight gain
– the Institute of Medicine (IOM): guidelines
published in 1990
• The suggested weight gain
• normal BMI : 11.2–15.9 kg (25–35 lb)
• overweight : 6.8 –11.2 kg (15–25 lb)
• obese : 6.8 kg (15 lb)
 Treatment during delivery
• Can not simply decide to do
Cesarean delivery ： Consider
Multiple Factors
• Cesarean delivery ： >4000-4500
• Vaginal delivery
– Strengthen the observation of labor
– Shoulder dystocia
– Birth canal injury
 Neonatal treatment
• Fetal macrosomia
• Prevention of low blood sugar
– early inleakage
• Aggressive treatment of
hyperbilirubinemia
– Blu-ray treatment
• Neonatal hypocalcemia
– Calcium
Shoulder Dystocia

SD
 Definition of SD
• An uncommon obstetric
complication of cephalic vaginal
deliveries
• The fetal shoulders do not deliver
after the head has emerged from
the mother’s introitus
• one or both shoulders become
impacted against the bones of the
pelvis
• Emergency in intrapartum
 Antepartum risk factors
• Listed below in order of importance:
• History of SD in a prior vaginal delivery
• Fetal macrosomia
– having a disproportionately large body
compared to head
• Diabetes/impaired glucose tolerance
• Excessive weight gain (>35 lb)
• Obesity
• Postterm pregnancy
• 胎儿异常
 Intrapartum risk factors
• Precipitous second stage (<20 min)
• Operative vaginal delivery (vacuum, forceps, or
both)
• Prolonged second stage
• Without regional anesthesia
– >2 h for nulliparous patients
– > 1h for multiparous patients
• With regional anesthesia
– >3 h for nulliparous patient
– >2 h for others
• Induction of labor for impending macrosomia
 Diagnosis
• More than customary traction
needed to deliver the fetal
trunk
• The need to perform ancillary
maneuvers to complete
delivery

• A minority of SD deliveries
• The turtle sign
• The fetal head retracts against
the perineum after it delivers
 Treatment
• An obstetric emergency
• SD can result in significant fetal and
maternal harm if not resolved in a
competent and expedient manner
• A 6-minute head-to-body interval has
been demonstrated to be safe
• Beyond that time, there is increased risk
– neonatal depression, acidosis, asphyxia,
central nervous system damage, or even death
 Table 1 SD maneuvers
Fetal Maneuvers Maternal Maneuvers
Rubin maneuver McRoberts maneuver
Jacquemier maneuver Suprapubic pressure
(posterior arm delivery)
Woods screw maneuver Gaskin maneuver
(all-fours)
Zavanelli maneuver Sims maneuver
(cephalic replacement) (lateral decubitus)
Cleidotomy Ramp maneuver
Shute forceps maneuver Symphysiotomy
McRoberts maneuver
Suprapubic pressure
Rubin maneuver

posterior arm delivery

Fetal Death
 Definition of Fetal Death
• A death that occurs after 20 weeks
constitute a fetal demise or stillbirth.
• Many states use a fetal weight of 350 g or
more to define a fetal demise

• Although this definition of fetal death is the

most frequently used in medical literature
• it is by no means the only definition in use.
 Causes of Fetal Death
• The etiology of FD is unknown in 25-60%
of all cases
• 1. fetal hypoxia
– The most common reason, about 50%

• maternal factors
• fetal factors
• Placenta
• abnormal cord
 Causes of Fetal Death
• Maternal ：
– Small artery insufficiency of blood
– Lack of red cells carrying oxygen deficiency
– hemorrhagic disease
– Uterine factor
– GDM, ICP
• Fetal ：
– Severe dysfunction of the cardiovascular
system
– Fetal malformations
 Causes of Fetal Death
• Placental pathology
– One prospective study: 64.9%
– higher rates of FD secondary to placental
pathology
– disfunction
– structural abnomalities
– abruption
– infection
• umbilical core abnormality
– Present ， procidentia ， clasp ， to tie a knot
 Causes of Fetal Death
• 2. Genetic mutations and chromosomal
aberrations
• Parents suffering from genetic diseases
• during pregnancy
– use of teratogenic drugs
– exposure to radiation
– chemical poisons
• Embryonic genes and chromosome
aberration
• Fetal malformations, miscarriage or death
 Diagnosis of Fetal Death
• History and physical examination
– limited value
• Death must be confirmed by
ultrasonographic
– visualization of the fetal heart
– the absence of cardiac activity
• In fact, the following description is rarely
– Macerated fetus
– fetus compressus
– fetus papyraceus
Management of Fetal Death
• Once the diagnosis has been
confirmed ， the patient should be
informed of her condition
• Often, allowing the mother to see the
lack of cardiac activity helps her to
accept the diagnosis.
• Immediate treatment
– Method of least damage to the mother
– Labor induction
Management of Fetal Death
• Medicine intra-amniotic injection
• Preinduction cervical ripening followed by
intravenous oxytocin
• Mifepristone and prostaglandin induction
of labor

• Patients with a history of a prior cesarean

delivery should be treated cautiously
– the risk of uterine rupture
Management of Fetal Death
• When a dead fetus has been in utero for
3-4 weeks
– Fibrinogen, blood plate levels may drop
– leading to a coagulopathy
– heparin therapy
– Rarely: because of earlier recognition and
induction

• In some cases of twin pregnancies

– induction after the death of a twin may be
delayed
– to allow the viable twin to mature
Thanks four your
listening