6.2 - Fetal Growth Restriction - exam Flashcards
1
Q
Fetal Macrosomia definition
A
- 4000 - 4500 grams
-
causes
- Maternal factors
- history of macrocosmic pregnancy
- Pregnancy weight gain
- Parity
- Glucose intolerance
- gestational diabetes
- pre gestational diabetes
- Fetal Factors
- Male
- beckwith wireman syndrome
- Significance
- Maternal
- PPH
- Vaginal Lacerations
- C-section if EFW is >5000 or >4500 for a gestational diabetes
- Fetal
- Shoulder Dystocia
- Clavicular fracture
- lower Apgar score
- obesity later in life
- Maternal
- Maternal factors
2
Q
Diagnosis of macroscomia
A
- fundal height
- clinical palpation of estimate weight
- U/S - estimated fetal weight is ruling out macrosmia
*
3
Q
Management of macrosomia
A
- Induction not required
4
Q
Intra uterine growth restriction
A
< than 10% centile
5
Q
Significance of IUGR
A
- Try to identify infants who are:
- short term morbidity and mortality:
- May potentially lack adequate reserve
- long term morbidity and mortality:
- Predict long term health risks:
- cardiovascular disease
- insulin resistance
- obesity
- Predict long term health risks:
- smaller the fetus the greater the risk
- short term morbidity and mortality:
6
Q
Early onset IUGR V Late IUGR
A
- Early onset IUGR
- Fetal growth: cellular hyperplasia
- can lead to irreversible decrease organ size and function
- Maternal factors
- infection (rubella, varicella, CMV
- Smoking
- multiple pregnancies
- chronic maternal disease
- Maternal factors
- Late onset IUGR
- Fetal growth: cellular hypertrophy
- more amenable to restoration of fetal size with adequate nutrition
- factors
- uteroplacental insufficiency
- factors
7
Q
Diagnosis of IUGR
A
- Fundal height measurement
- clinical palpation of estimate fetal weight
- estimated fetal weight
- doppler velocity of fetal vessels
8
Q
Uterine Artery systolic diastolic (S/D)
A
- fetal placental circulation
- placental resistance increases
- diastolic flow decrease
- there is a increase in the S/D ratio
- Absent/reversed end diastolic flow
- worse perinatal outcomes
- delivery is necessary
- MCA doppler
- when is there is a decrease in placental perfusion
- there is an increase of MCA doppler flow
9
Q
Management of IUGR
A
- Deliver the healthiest possible infant at the optimal time
- fetal surveillance
- timing of delivery
- delivery should occur when the fetal death is greater the neonatal death
10
Q
Normal singleton fetal growth
A
- is approximately
- 5 grams/ day at 14 -15 weeks of gestation
- 10 grams/day at 20 weeks of gestation
- 30 - 35 grams/day at 32 - 34 weeks of gestation
- after 34 weeks gestation the growth rate decreases
11
Q
Definition of normal fetal growth
A
- expression of the genetic potential growth in a way that is neither constrained nor promoted by internal or external factors
12
Q
Definition of Small for gestational age (SGA)
A
- Birthweight below the 10th centime of weight for gestation
- this does not necessarily indicate fetal growth restriction
- majority of foetuses with a birthweight below the 10th centime for gestational age are constitutionally small
13
Q
Fetal growth restriction (FGR)
A
- FGR is defined antenatally by an estimated weight or serial antenatal u/s evidence of growth restriction or growth arrest
- birthweight is below the 10 th percentile
14
Q
Related birthweight definitions
A
- Low birthweight <2500 grams
- Very low birthweight <1500 grams
- Extremely low birthweight <1000 grams
- Low birthweight can be due to preterm birth, constitutionally small infants or growth restricted infants
15
Q
Common factors associated with low weight for gestation include
A
- Race
- Maternal size
- Female infant (as opposed to male infant)
- Nulliparity (as opposed to 2nd or 3rd infants)
- History of a baby of low weight for gestation age
- Matrilineal tendency
16
Q
Common Lateral factors associated with fetal growth restriction include
A
- Multiple pregnancy
- smoking, alcohol, amphetamines, cocaine/crack
- social disadvantage/ DV
- preeclampsia
- previous stillbirth
- Obesity
- Chronic hypertension, especially if associated with atherosclerosis
- connective tissue disorder
- acquired or genetic thrombophilias
- diabetes - especially the white classes indicating diabetic vasculopathy
- cardiac disorders - primary cyanotic cardiac disease
- hypotension < 60mmhg diastolic
- respiratory disease - severe asthma
- anaemia
- renal disease
- Drugs (anticancer agents, narcotics
- poor nutrition
17
Q
Fetal factors
A
- fetal infection
- malformation
- chromosomal defects
18
Q
Placental factors
A
- abruption placentae
- placenta praevia
- Thrombosis, infarction (fibrin deposition)
- Choroamnionitis
- Placental cysts - Chorioangioma
- Decreased uteroplacental blood flow
19
Q
Uterine factors
A
- Fibromyoma (large submucosal fibroids)
- Morpholoigic abnormalities - especially uterine septum
20
Q
Midwifery pregnancy counselling
A
- Behavioral modifications
- inform women that smoking has been associated with low birthweight, preterm birth and perinatal death
- Encourage/offer enrolment in smoking cessation programs to reduce/stop smoking
21
Q
Midwives education around nutrition
A
- severe dietary restriction is related to decreased birthweight
- under-nutrition may be recognised by a low fasting glucose or low maternal weight for height
- low fasting glucose has also been associated in low birthweight in austrlai
- encourage a well balanced diet
- nutritional advice is moderately effective in increasing protein and energy intake of pregnant women
22
Q
Clinical assessments
A
- Fetal biometry and doppler flow
-
Abdo examination
- the predictive value of adobo palp is measuring the SFH as a primary surveillance method for estimating fetal growth in the third trimester is limited
- SFH measure must betaken form the top of the funds to the fixed point of the upper edge of the pubic symphsis. Measure along the fetal axis using a non-elastic tape measure
- serial measurement of fundal height and plotting on a growth chart is a useful screening toll and is recommended
-
Pregnancy unsuitable for primary surveillance by SFH:
- Fibroids
- high maternal body mass index
- high risk pregnancy eg: previous IUGR
-
Referral for further investigations if
- the first fundal height measurement is below the 10th centile
- Consecutive measurements suggest static or slow growth.
-
Customised fundal height charts
- routine use of the customised growth chart is still being evaluated
- Calculation of customised centimes (fundal height and ultrasound growth) requires computer software.
- customised SFH chart is adjusted for sex as well as maternal characteristics such as height, weight, parity and ethnic origin
- Pathological factors known to affect birth weight and growth such as smoking, hypertension, diabetes and preterm delivery are excluded
23
Q
Clinical assessments continue
A
-
Ultrasound
- routine dating and morphology scans at 18-20 weeks
- all growth restricted fetuses require careful assessment for malformations
- serial measurements of abdominal circumference and estimated fetal weight are useful to identify restricted fetal growth
- serial relationship between the head circumference and abdominal circumference as well as amniotic fluid index are useful indicators for growth pattern
- fetal structural abnormalities with normal liquor volume and normal uterine or umbilical artery dopplers may also be associated with chromosomal defects
