2024 31 SGA & FGR Flashcards
When should women be assessed for FGR risk factors?
Booking, by 14/40
Update with midtrimester scan
What steps can be taken to reduce FGR caused by smoking?
CO testing
Trained tobacco dependence team
What reduces the rate of SGA & FGR in women at risk of placental dysfunction?
Aspirin 12/40-36/40
What is the pathway for women at high risk of fetal growth disorders?
- Uterine artery Dopplers 18-23+6
- If normal, serial scans from 32/40
- If normal but SGA, serial scans from 26-28/40
- If abnormal, serial scans from 28/40
- If abnormal & SGA, FMU
What is the pathway for women at low risk of fetal growth disorders?
SFH at every CMW appt from 24/40
What is the pathway for women at moderate risk of fetal growth disorders?
- Serial growth scans from 32/40
- 4-weekly scan intervals until birth
Which model should be used for calculating EFW?
Hadlock 3-parameter model
How should fetuses identified as SGA be monitored?
Ultrasound biometry every 2 weeks
Umbilical artery Doppler as primary surveillance tool, at least every 2 weeks
In SGA with EFW 3rd-10th centile, what birth plans should be made?
- Don’t deliver before 39/40 unless maternal or fetal concerns
- Consider from 39/40
- Recommend birth by 39+6
In early FGR, prior to 32/40, what is the management?
- Tertiary level care
- Fetal biometry every 2 weeks
- Fetal wellbeing including cCTG &/or ductus venosus
How should late FGR be managed?
Birth 37-37+6
How are SGA & FGR defined?
SGA: < 10th centile
FGR: < 3rd centile or SGA with Doppler abnormalities
Early up to 31+6, late from 32/40
What is the definition of static growth?
No forward growth velocity
In EFW or AC
Measured at least 14 days apart
What are the potential reasons for a small fetus?
- Constitutionally small
- Non-placenta-mediated:
* structural anomaly
* chromosomal anomaly
* inborn errors of metabolism
* fetal infection - Placenta-mediated:
* placental dysfunction
What maternal factors can affect placental transfer of nutrients?
- Low pre-pregnancy weight
- Undernutrition
- Substance misuse
- Severe anaemia
- Medical conditions (separate card)
What maternal medical conditions can affect placental implantation & vasculature?
- Pre-eclampsia
- Autoimmune disease
- Thrombophilias
- Renal disease
- Diabetes
- Cardiac disease
- Essential hypertension
What is the pathology in early vs late FGR?
Early:
Significant abnormal placentation
Increased hypoxia & cardiovascular adaptations
Often coexists with mat med
Late:
Milder deficit, but harder to detect so significant proportion of adverse outcomes
For which women is SFH inappropriate, and how is this managed?
- BMI > 35
- Fibroids
—> serial scans from 32/40 - Congenital uterine anomalies
—> serial scans from 28/40
What are the moderate risk factors for FGR?
- Previous SGA
- Previous stillbirth (normal growth)
- Current smoker
- Drug misuse
- Age ≥ 40
- BMI < 18.5
- Gastric bypass surgery
- Previous PTB or 2nd trim MC
What are the maternal medicine high risk factors for FGR?
- CKD
- HTN
- Autoimmune disease
- Complex cardiac disease
What are the obstetric history high risk factors for FGR?
- Previous FGR
- HTN in previous pregnancy
- Previous SGA stillbirth
What are the current pregnancy high risk factors for FGR?
- PAPP-A < 5th centile
- Inhibin A > 2 MoM (2nd trim)
- AFP > 2 MoM (2nd trim)
- Echogenic bowel
- Significant bleeding
- EFW < 10th centile
- Single umbilical artery
What is the pathway if early FGR is identified?
- Fortnightly EFW
- Weekly UA Dopplers
- If AREDF, twice weekly cCTG +/- DV
- Deliver if DV a-wave absent or STV reduced
- Deliver by 32/40 if REDF
- Deliver by 34/40 if AEDF
In FGR with AREDF, what STV indicates delivery at different gestations?
26-28+6: <2.6ms
29-31+6: <3.0ms
32-33+6: <3.5ms
34-36+6: <4.5ms
What is the pathway for FGR at 32-36+6?
- Fortnightly EFW
- Weekly UA Dopplers
- If PI > 95th centile, twice weekly cCTG
- Deliver if DV a-wave absent, reduced STV, deliver by 36-36+6 if PI > 95th
What is the pathway for FGR from 37/40 onwards?
- Fortnightly EFW
- Weekly UA Dopplers
- Deliver if AC/EFW < 3rd centile by 37+6, signs of cerebral redistribution, Doppler abnormalities
How should fetuses with FGR be prepared for birth?
- Steroids for 24-34+6, ideally 48 hours before birth
- Magnesium sulphate for 24-29+6 (consider to 33+6 as FGR may require neuroprotection for longer)
In what FGR circumstances is CS recommended?
- Abnormal cCTG STV
- DV alteration
- Absent or reversed end diastolic flow velocities
- Ideally after steroids & MgSO4
