Growth Restriction

Question 1

Match the following with the dates:

Extremely preterm
Very preterm
Moderate to late preterm

28 to < 32 weeks
< 28 weeks
32 to 37 weeks

Answer 1

Extremely preterm = < 28 weeks
Very preterm = 28 to < 32 weeks
Moderate to late preterm = 32 to 37 weeks

Question 2

What is defined as a very low birth weight?

1 - <500g
2 - <1000g
3 - <1500g
4 - <2000g

Answer 2

2 - <1000g

Very low birth weight = <1500g
Low birth weight = < 2500g

Question 3

Foetal growth restriction (FGR) is the failure of the foetus to achieve its predetermined growth potential. What is the primary reason for this?

1 - congenital defects
2 - placenta dysfunction
3 - trauma
4 - infection

Answer 3

2 - placenta dysfunction

Question 4

What is small for gestational age (SGA)?

Answer 4

• term used to describe a baby who is smaller than the usual amount for the number of weeks of pregnancy
• BUT not foetal growth restriction

Question 5

Small for gestational age (SGA) is a term used to describe a baby who is smaller than the usual amount for the number of weeks of pregnancy, generally those in the <10 centile (NOT foetal growth restrction). What are the 2 methods commonly used to assess if the baby is SGA?

1 - serum levels of foetal HMB
2 - estimated foetal weight
3 - abdominal circumference
4 - bilirubin levels

Answer 5

2 - estimated foetal weight
3 - abdominal circumference

Question 6

Foetal growth restriction (FGR) is the failure of the foetus to achieve its predetermined growth potential, which is primarily caused by placenta dysfunction. What are the 2 types of FGR?

1 - symmetrical
2 - asymmetrical
3 - age based FGR
4 - geneder based FGR

Answer 6

1 - symmetrical
2 - asymmetrical

Question 7

Foetal growth restriction (FGR) is the failure of the foetus to achieve its predetermined growth potential, which is primarily caused by placenta dysfunction. There are 2 types of FGR, symmetrical and asymmetrical. What is symmetrical and asymmetrical FGR?

Answer 7

• symmetrical = small head and small abdomen (BUT everything is symmetrical)
• asymmetrical = normal head and small abdomen (NOT symmetrical)

Question 8

Which of the following measurews is NOT typically used to measure foetal growth restriction (FGR)?

1 - size
2 - growth
3 - type
4 - gender

Answer 8

4 - gender

Question 9

Assessing the size of the baby in pregnancy is crucial to assess if the baby has a small gestational age (SGA). What is the definition from the WHO on if a baby is SGA?

1 - <500 grams or 0.5kg at birth
2 - <1000 grams or 2.0kg at birth
3 - <2500 grams or 2.5kg at birth
4 - <5000 grams or 6.0kg at birth

Answer 9

3 - <2500 grams or 2.5kg at birth

Question 10

When assessing the growth of a foetus during pregnancy, why is it important to perform multiple observations?

Answer 10

• a dynamic and changing process

Question 11

Foetal growth restriction (FGR) is the failure of the foetus to achieve its predetermined growth potential, which is primarily caused by placenta dysfunction. There are 2 types of FGR, symmetrical and asymmetrical:

• symmetrical = small head and small abdomen (BUT everything is symmetrical)
• asymmetrical = normal head and small abdomen (NOT symmetrical)

Which of the following is NOT a common causes for symmetrical FGR?

1 - congenital/chromosomal abnormalities
2 - intrauterine infections
3 - pre-eclampsia
4 - environmental factors

Answer 11

3 - pre-eclampsia

Question 12

Foetal growth restriction (FGR) is the failure of the foetus to achieve its predetermined growth potential, which is primarily caused by placenta dysfunction. There are 2 types of FGR, symmetrical and asymmetrical:

• symmetrical = small head and small abdomen (BUT everything is symmetrical)
• asymmetrical = normal head and small abdomen (NOT symmetrical)

What is the most common causes for asymmetrical FGR?

1 - congenital/chromosomal abnormalities
2 - intrauterine infections
3 - pathology associated with pregnancy (delayed onset)
4 - environmental factors

Answer 12

3 - pathology associated with pregnancy (delayed onset)

• pre-eclampsia (high BP and coagulation issues), essential hypertension

Question 13

Which of the following is NOT a risk factor associated with an increased risk of small gestational age?

1 - asian/Indian ethnicity
2 - multiple pregnancy
3 - low BMI and maternal weight gain
4 - nulliparity (1st pregnancy)
5 - daily vigorous exercise
6 - maternal exposure to caffeine
7 - one baby at one time

Answer 13

2 - multiple pregnancy

Question 14

A woman attends her GP for pre-conception counselling because the first child was born small for gestational age (SGA). What intervention is significant in reducing risk of SGA foetus in those with risk factors?

1 - Progesterone supplement
2 - Dietary modification
3 - Calcium supplements
4 - Smoking cessation
5 - Anti platelets

Answer 14

4 - Smoking cessation

Question 15

In non-pregnant women there are a number of different blood vessels that supply the uterus. However, once the placenta has formed, angiogenesis begins and 3 types of arteries develop within the placenta. Which of the following is NOT one of these 3 blood vessels called?

1 - hairline arteries
2 - arcuate arteries
3 - uterine arteries
4 - spiral arteries

Answer 15

1 - hairline arteries

• uterine arteries = uterine
• spiral arteries = endometrium (generally lost during periods)

Question 16

What cell that is derived from the blastocyst forms the placenta?

1 - trophoblasts
2 - oocyte
3 - blastocyts
4 - cytotrophoblast

Answer 16

Question 17

What is the most common finding in stillborn babies?

1 - congenital abnormalities
2 - foetal growth restriction
3 - pre-eclampsia
4 - pregnancy of unknown origin

Answer 17

2 - foetal growth restriction

Question 18

If a baby is born and has foetal growth restrictions what are some of the acute conditions they may develop?

1 - necrotising enterocolitis
2 - hypoxic brain injury
3 - respiratory support
4 - chronic lung disease
5- retinopathy
6 - all of the above

Answer 18

6 - all of the above

Question 19

If a baby is born and has foetal growth restrictions what are some of the chronic conditions they may develop?

1 - metabolic electrolyte imbalance
2 - failure to thrive
3 - learning difficulties
4 - short stature
5 - cerebral palsy
6 - mental handicap
7 - all of the above

Answer 19

7 - all of the above

Question 20

What is the gold standard for antenatal care that is used to identify foetal growth restriction?

1 - alpha-fetoprotein
2 - abdominal palpatation
3 - human chorionic gonadotrophin
4 - serial ultrasound with doppler scans

Answer 20

4 - serial ultrasound with doppler scans

Abdominal palpatation has a sensitivity of 30%, so not great as can be difficult in late pregnancy

Question 21

A measurement from the symphysis to the fundus, provides fundal height with abdominal girth. What are the detection rates for this in detecting foetal growth restriction?

1 - 20-80% detection rate
2 - 1-2% detection rate
3 - 100% detection rate
4 - not used anymore

Answer 21

1 - 20-80% detection rate
- does not improve perinatal outcome

Question 22

When assessing foetal well being, in addition to imaging modalities, we can determine the foetus biophysical profile. Which of the following measurements are included in this profile?

1- cardiotocography (HR and uterine contractions)
2 - respiratory rate
3 - foetal body movements (ultrasound)
4 - liquor volume (amniotic fluid volume)
5 - foetal growth
6 - foetal breathing movements (ultrasound)

Answer 22

2 - respiratory rate

Question 23

In a normal pregnancy, does the blood flowing from the mother through the umbilical cord blood vessels (umbiliical artery and vein) have any resistance?

Answer 23

• no

- placenta acts as a sponge, from there it delivers oxygenated blood to the foetus

Question 24

What is placenta infarction?

1 - rupture of placenta
2 - infection of placenta
3 - interruption of blood supply to a part of the placenta
4 - all of the above

Answer 24

3 - interruption of blood supply to a part of the placenta

• normally in the umbilical artery
• lack of blood causes hypoxia and ischaemia
• cells of the placenta can die

Question 25

In a pregnancy where there is placenta infarction, which is interruption of blood supply to a part of the placenta, causing its cells to die, is there a resistance to blood flow to the foetus?

Answer 25

- Yes - placenta acts as a wall - blood is unable to reach the foetus and reflects back along the umbilical artery

Question 26

What method can be used to detect blood flow velocity in foetal and placenta vessels? 1 - Ultrasound doppler 2 - CT scan 3 - X-ray 4 - MRI

Answer 26

1 - Ultrasound doppler Reduced end diastolic flow suggests placenta has high resistance and is failing and baby may be at risk of hypoxia

Question 27

Does the growth chart show foetal growth restriction or small gestational age?

Answer 27

- small gestational age - plot is consistent and does not move between deciles

Question 28

Does the growth chart show foetal restriction growth or small gestational age?

Answer 28

- foetal growth restriction - Serial ultrasound scans provide this information - begins in 9th percentile, but drop between deciles

Question 29

In the growth chart below, we can see that the top figure demonstrates a small gestational baby and the bottom chart shows a foetal growth restriction. Of the 2 which baby may need to be delivered prematurely?

Answer 29

- foetal growth restriction - the placenta may be failing the baby is malnourished and/or hypoxic

Question 30

In asymmetrical foetal growth restriction there is generally a larger head and/or organs compared to the abdomen, as seen in the image below. Typically caused by pathology associated with pregnancy (delayed onset), such as pre-eclampsia (high BP and coagulation issues), essential hypertension. Why do some organs develop more than others? 1 - some organs develop quicker 2 - some organs dont need as much oxygen 3 - preferantial direction of oxygen 4 - all of the above

Answer 30

3 - preferantial direction of oxygen - the body adapts to lack of nutrient and hypoxia - for example the brain sparing effect as the foetus redistributes blood to the more critical tissues (liver, kidneys etc...)

Question 31

In the brain sparing effect that we observe in the asymmetrical foetal growth restriction, is the head circumference (HC) or abdomen circumference (AC) normally bigger?

Answer 31

- normally head is bigger - AC < HC

Question 32

What is Pregnancy Associated Plasma Protein-A (PAPP-A)? 1 - hormone secreted by ovaries to help pregnancy 2 - a hormone that made by the placenta (afterbirth) in pregnancy 3 - hormome secreted by hypothalamus to help with milk production 4 - hormone secreted by baby to stimulate increased insulin sensitivity

Answer 32

2 - a hormone that made by the placenta (afterbirth) in pregnancy - secreted by the placenta to maintain placenta development

Question 33

Pregnancy Associated Plasma Protein-A (PAPP-A) is a hormone that made by the placenta (afterbirth) in pregnancy secreted by the placenta to maintain placenta development. Do low levels of this indicate foetal growth restriction or small gestational age?

Answer 33

- foetal growth restriction

Question 34

What is the Barkers hypothesis?

Answer 34

- adverse nutrition in early life including foetal growth restriction can increase risk of metabolic syndrome (obesity, diabetes, insulin insensitivity, hypertension, hyperlipidemia, coronary heart disease)

Question 35

If a baby is detected as having an abnormal blood flow to the placenta using ultrasound doppler, what gestation should they be delivered? 1 - <28 weeks 2 - <32 weeks 3 - <36 weeks 4 - <40 weeks

Answer 35

2 <32 weeks - better to be in NICU than in a uterus with restricted blood flow to the placenta

Question 36

You are counselling a 16 week gestation primiparous woman regarding her results which suggest a low PAPP-A level. Which is the only form of surveillance that, when used alone, has been shown to reduce perinatal morbidity and mortality in a high-risk population? 1 - Foetal movement monitoring 2 - USS assessment of liquor volume 3 - CTG cardiotocography 4 - Biophysical profile scoring 5 - Umbilical artery doppler

Answer 36

5 - Umbilical artery doppler