Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

General obstetrics > FGR/SGA > Flashcards

FGR/SGA Flashcards

1
Q

Definition of SGA and FGR.

A
  • Small for gestational age (SGA) Estimated fetal weight/birthweight less than 10th centile
  • Fetal Growth Restriction (FGR) A fetus that has not reached its growth potential, most commonly due to placental insufficiency. Absolute definition controversial.

• Severe FGR: Often SGA <3rd centile, features such as oligo/abnormal dopplers etc (oligohydramnios late sign of poor placental perfusion).

  • Early onset: <32 weeks gestation
  • Late onset: >32 weeks
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

When to suspect suboptimal fetal growth?

A
  • The abdominal circumference on the population (ASUM) scan chart is <5th centile
  • Discrepancy in HC and AC
  • AC is >5th but is crossing centiles by > 30th centile e.g. reduction from 50th centile to 20th centile
  • A change in AC of <5mm over 14 days
  • EFW on GROW is <10th
  • EFW on GROW is crossing centiles with > one third reduction in EFW percentile
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What information should be gained from women with suspected FGR?

A
  1. maternal characteristics and medical history (a history of a previous SGA or stillborn infant; maternal age >40; maternal or paternal history of being SGA at birth; smoking >10 cigarettes daily; using cocaine, and maternal diseases associated with increased risk (e.g. chronic hypertension, renal disease, diabetes with vascular disease, anti-phospholipid syndrome)
  2. previous obstetric history (3x increased risk)
  3. risk factors that may arise in pregnancy (low PAPP-A, heavy early pregnancy bleeding, fetal echogenic bowel, preeclampsia, severe pregnancy-induced hypertension, unexplained APH or abruption and low gestational weight gain)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Prevention

A

Start low dose aspirin (100-150mg) in those with risk factors for FGR if <16/40

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What factors indicate regular growth scans rather than relying on SFH?

A 
.Raised BMI
large fibroids
prev SGA
HTN disorder 
Multiple pregnancy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Suspicion FGR, which investigations?

A

PET screen including urine,
USS growth +/- dopplers,
CTG,
TORCH and karyotyping if early onset severe SGA (especially if uterine/umbilical dopplers normal),
Consider fetal abnormality/chromosomal causes also in early onset.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

How to manage babies once born if the have FGR/SGA?

A
  • Monitoring and maintenance of oxygenation, temperature and blood glucose levels.
  • Paired cord blood gases can be undertaken to assess acid base status at birth.
  • In the care of the preterm growth restricted neonate, consider specific issues relating to prematurity such as lung disease, increased risk of infection, neurological complications and necrotising enterocolitis.
  • Term babies at increased risk of hypothermia, hypoglycaemia and jaundice
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Advice for future pregnancies?

A

Adjust any modifiable risk factors (e.g. smoking), aspirin for future pregnancies, serial growth scans
Uterine artery doppler

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What does umbilical artery doppler measure?

A

Umbilical artery Doppler provides a measure of placental resistance.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What does MCA doppler measure?

A

MCA provides information about cerebral redistribution of blood flow, abnormal MCA is a response to hypoxia and means there is an increased proportion of flow to the brain- brain sparing.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What does DV doppler measure?

A

DV provides information about cardiac redistribution- abnormal DV associated with imminent fetal death.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Technique for UA doppler assessment?

A

• Free loop of cord (away from insertions)
• No fetal body, limb or breathing movements
• Identify UA with colour Doppler
• Measure FVW with pulsed Doppler
- set gate size to cover entire vessel
- Ideally display arterial and venous waveforms simultaneously
• Adjust Doppler gain, baseline, scale and sweep speed to produce a good quality FVW
• Analyse FVW to calculate S/D ratio or PI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Indications for measuring uterine artery doppler

A

• In women assessed to be at high risk of severe or early SGA
E.g:
- previous early SGA with delivery <34/40,
- antiphospholipid syndrome,
- severe chronic HTN,
- maternal renal disease
- an autoimmune condition)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Which gestation to perform uterine artery dopplers as screening?

A

20-24/40

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Significance of abnormal uterine artery doppler?

A

Those with very abnormal uterine artery dopplers have a 60% risk of developing SGA/PET that requires delivery <34/40.

Should have regular scans and maternal surveillance.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

List maternal medical conditions that predispose to SGA:

A
  • Hypertensive disease
  • Renal disease
  • Diabetes
  • Antiphospholipid syndrome
  • Maternal history of SGA
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

List current pregnancy complications/developments that predispose to SGA:

A
  • Preeclampsia
  • First trimester bleeding
  • Placenta abruption
  • APH
  • Gestational HTN
  • Teratogenic exposure
  • Low PAPP-A <0.4 MoM
  • Echogenic bowel
18
Q

List maternal risk factors that predispose to SGA:

A
  • Low BMI
  • High BMI
  • AMA
  • Nulliparity
  • Smoking
  • Substance abuse
  • IVF
  • Poor diet
  • Excessive exercise
  • Previous SGA
  • Previous stillbirth
  • Short interpregnancy interval
19
Q

If UAPI is abnormal in an SGA fetus but delivery is not indicated, how often should you repeat the UAPI?

A
  • Twice weekly if forward EDF.

- Daily if absent or reversed EDF.

20
Q

List the benefits of UAPI surveillance (4):

A
  • Reduction in perinatal deaths RR 0.71
  • Reduction in IOLs RR 0.89
  • Reduction in Caesarean section RR 0.90
  • Reduced use of antenatal resources (monitoring occasions, hospital admissions, inpatient stay).
21
Q

In an SGA fetus with normal UAPI, how often would you repeat the UAPI?

A
  • Every 14 days.
22
Q

When does RCOG recommend delivery of an SGA fetus with static growth over 3 weeks (UAPI normal or abnormal but with forward EDF)?

A

After 34 weeks.

23
Q

At what gestation should an SGA fetus with reversed EDF but normal DV doppler be delivered by?

A

30-32 weeks

24
Q

At what gestation should an SGA fetus with absent EDF but normal DV doppler by delivered by?

A

32-34 weeks

25
Q

At what gestation should an SGA fetus with absent or reversed EDF and reversed/absent A-wave on DV doppler be delivered by?

A

Between 26-32 weeks

26
Q

Briefly describe the DIGITAT Trial

A

Aim: To compare the effect of IOL with expectant monitoring for IUGR near term
Participants: singleton, > 36/40, suspected IUGR
Interventions: Randomised to IOL OR expectant management

Conclusion: IOL babies were delivered 10 days earlier and weight less, but NO important differences in adverse outcomes or CS rates

27
Q

Briefly describe the GRIT Trial

A

Aim: To compare the effect of delivery early with delaying birth for as long as possible
Inclusion: Fetal compromise, 24-36/40, UAPI recorded, clinical uncertainty about whether immediate delivery was indicated
Intervention: Randomised to Immediate delivery or Delayed deliver until the obstetrician was no longer uncertain

Results: No difference in mortality, or developmental quotient of survivors
Conclusion: Obstetricians are delivering sick preterm babies at about the correct moment to minimise mortality

28
Q

What is the relative risk of stillbirth in SGA?

A

4 fold

29
Q

What are the delphi criteria for FGR?

A
  • EFW ≤3rd centile
  • EFW ≤10th centile with UAPI >95th or uterine art ≥95th
  • EFW ≤10th centile with Slowing growth ≥50 centiles drop
  • Slowing growth ≥50 centiles drop with UAPI ≥95th
30
Q

Compare delphi criteria for FGR with traditional criteria of EFW ≤10th centile.

A

Delphi identifies fewer cases of SGA, but better predicts babies with adverse perinatal outcomes (NICU admission, cord pH < 7.10, 5-min Apgar score < 7, RDS, IVH, neonatal seizures or neonatal death.)

31
Q

What is the controversy in defining FGR?

A

SMFM definition:

  • FGR: EFW or AC <10th centile
  • SGA: newborn with BW <10th centile

ISUOG definition:
- SGA: EFW or AC <10th should be considered at risk of FGR
- Fetal size alone not sufficient for diagnosis of FGR unless
• EFW or AC <3rd (sole criteria), or
• In early onset FGR: <10th with either >95th
Uterine artery PI or Umbilical artery PI
• In late onset FGR: 2 out of 3 <10th ; >2 quartiles
slowing AC or EFW; CPR <5th or UA >95th

32
Q

What is the risk with livebirth population based growth charts and predicting SGA/FGR?

A

Livebirth (population) charts systematically under-diagnose fetal growth restriction prior to term.
This is because they are based on measurement of birthweights of babies born preterm, which is usually skewed due to many preterm (spontaneous or iatrogenic) being at risk for SGA/FGR. Thus <10th on these charts likely demonstrates an extreme (e.g. <3rd) of healthy ongoing pregnancies.

33
Q

What is the aim of WHO and intergrowth21 charts? What do they show?

A

‘To present the fetal growth charts for estimated fetal weight and fetal biometry for worldwide use’

  • They show optimal fetal growth at different gestations for different ethnicities
  • Significant contributors to variation in fetal growth:
    gender, parity, maternal height and weight and country
34
Q

What growth charts are most useful for predicting FGR and adverse outcomes?

A

Limited evidence suggests customised and WHO charts more sensitive than population based or intergrowth

35
Q

Aetiology and Ix of early onset FGR.

A 
Aetiology:
• Placental
• Infection
• Genetic
• Structural abnormality

SMFM 2020: Advice on early onset FGR Recommendations:

-Detailed US should be performed with early onset FGR • 20% associated with fetal or chromosomal abN
- Choromosomal microarray when unexplained isolated FGR diagnosed at <32 weeks
- Chromosomal microarray when FGR is detected and a fetal abnormality, polyhydramnios or both are present (any gestation)
- No Toxo, Rubella or Herpes serology unless other risk factors, but check CMV
• Suggest CMV PCR if doing an amniocentesis

36
Q

What are the chronic and acute markers of FGR and outcome in order of presence/acuity?

A

Chronic (weeks):

  • Abn uterine artery doppler
  • UAPI >95th
  • MCA or CPR <5th

Acute (7-10 days):

  • AEDF UAPI
  • REDF UAPI
  • DV >95th
  • absent/reversed DV a wave
    OR
  • Reduced STV CTG <3bpm
  • BPP ≤4
    OR
  • CTG decelerations
37
Q

Findings of the TRUFFLE Trial.

A

3 arm randomised clinical trial; n= 542;
• Inclusion: 26-32 weeks; <10th, plus abnormal umbilical artery doppler (UPI)
• Intervention: Trigger for delivery:
• reduced STV on CTG
• early DV changes (PI >95th)
• late DV changes (absent/ reversed a wave)

Primary Outcome: survival free of neuroimpairment at the age of 2 years

Safety net: CTG STV in DV group; spontaneous repeated decelerations in all groups; deteriorating maternal condition; REDF >30 weeks; AEDF >32 weeks
• Safety net triggered delivery commonly (38% overall; up to 52% in late DV group)

Findings: ‘The difference in the proportion of infants surviving without neuroimpairment was non significant at the primary endpoint… of survivors, delivery using late DV changes might improve developmental outcomes at 2 years of age’

38
Q

What are the delivery criteria for early onset FGR?

A

Delivery criteria - Fetal
- 24-25+6: individualise
- >26 weeks:
• spontaneous persistent unprovoked decels,
• altered BPP (≤ 4)
- 26-32 weeks: Reversed/ absent a wave DV or ↓STV

Delivery criteria - Maternal indication
• severe PET/ HELLP at any gestation or Obstetric emergency requiring delivery

39
Q

Sensitivity of SFH and USS biometry for detecting SGA.

A

SFH = 20%
biometry = 57%
(NB AC<10th and EFW<10th perform similarly as predictor)

40
Q

What is the utility of routine of 3rd trimester USS for predicting FGR and poor perinatal outcome?

A

Routine T3 ultrasound increases US diagnosis of SGA/ LGA/ AbN AFV
Increased chance of CTG and AFV/ Doppler assessment
No difference in rates of SGA at birth
No difference in perinatal death

41
Q

SMFM criteria for delivery for late FGR.

A

‘No consensus on the best approach to management…primarily due to paucity of RCTs and heterogeneity of study populations…’

Recommend delivery at 30-32W with FGR and REDF
Recommend delivery at 33-34W if FGR and AEDF
Recommend delivery at 37W if FGR (<10th) with abN UA PI or with EFW< 3rd
Recommend delivery at 38-9W if EFW 3-10th with N UA PI

Recommend Caesarean if AREDF

Suggest AGAINST the use of uterine, MCA or DV for ‘routine’ management of Late Onset FGR

=============================
Deliver at any gestational age for:
• Maternal indication
• Repeated unprovoked decelerations 
• BPP ≤ 4
• Reduced STV <3ms cCTG
(ISUOG)

General obstetrics (34 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions