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fetal growth Flashcards

1
Q

when is fetal growth assessed

A

after 24 weeks of gestation

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2
Q

what are the two clinical examination medthods used in assessing fetal growth

A
  • Abdominal palpation of fundal height
  • Symphysis-fundal height measurement using a measuring tape

US

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3
Q 
at 
12
36-38
40
weeks what is the position of the fundus
A

12 weeks - fundus just above pubic bone

36-38 weeks - fundus usually right up under sternum

40 weeks - fundus drops below 38 week level as presenting part drops down into pelvis

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4
Q

how is fetal growth assessed in US

A
  • Head circumference (and Biparietal diameter)
  • Abdominal Circumference
  • Femur length
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5
Q

what does small for dates or large dates imply

A

describe the position of fetal measurements on a gestational population centile chart.

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6
Q

define small for dates/SGA

A

describes anthropometric variables below the 10th population centile for gestational age

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7
Q

define large for dates/LGA

A

describes anthropometric variables above the 95th population centile for gestational age

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8
Q

causes for SGA

A

intrauterine hypoxia, acidaemia, prematurity (often iatrogenic) and neonatal complications

placental insufficiency include low pre-pregnancy weight, substance abuse, autoimmune disease, renal disease, diabetes and chronic hypertension.

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9
Q

what is a growth restricted fetus

A

A growth restricted fetus is one that has failed to reach its genetic growth potential

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10
Q

RFs for FGR

A

age
high or low BMI

Previous FGR
Hypertension

Smoking
Alcohol
Substance abuse

Recurrent fetal loss
Previous unexplained SB
Haemoglobinopathies

Domestic Violence
Raised AFP

Antiphospholipid syndrome

Prescription and OTC Drugs

Infection

Collagen vascular disease
High altitude

Placental pathology (praevia, cirumvallata

Renal disease

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11
Q

If a small baby is referred what do u do

A
  1. Is the fetus really small (confirm diagnosis)
  2. Why is the fetus small (establish cause)
  3. How to monitor pregnancy with a small fetus (make management plan)
  4. Timing and mode of delivery (weigh up risks and benefits)
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12
Q

how to diagnose small baby

A

measure using US scan

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13
Q

what is

Normal small
Abnormal small
Infected small 
Starved small
Wrong small
A

Normal Small
Constitutionally small, healthy baby

Abnormal Small
Chromosomal abnormalities, syndromes, congenital malformations

Infected Small
Infection during pregnancy (commonly CMV)

Starved Small
‘Placental FGR’ - placental growth restricted
due to 
- poor placentation
- smoking
- maternal disease affecting placenta
- multiple pregnancy etc

Wrong Small
Incorrect Dates or measurements

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14
Q

what does Adequate trans-placental transfer depends on

A
  1. Uteroplacental blood flow (from the uterine artery to the placenta
  2. Villous structure at the interface of maternal and fetal blood
  3. Fetoplacental blood flow (from the umbilical arteries to the placenta
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15
Q

how to measure successful trophoblast invasion

A

assessed with a uterine artery Doppler

at 20 weeks gestation

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16
Q

what additional sonographic measures will help differentiate SFD from FGR

A
  • Centile position
  • Symmetry
  • Liquor volume
  • UMA Doppler
  • Growth velocity
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17
Q

DD for SGA

A

healthy small baby
aneuploidy/infection
placental IUGR

18
Q

how will

1) growth symmetry and velocity
2) amniotic fluid
3) fetal well being

in healthy small baby be

A

1) normal velocity, symmetrical growth
2) normal
3) normal UMA doppler

19
Q

how will

1) growth symmetry and velocity
2) amniotic fluid
3) fetal well being

in aneuploidy/infection

A

1) markedly small, velocity may be reduced, symmetrical (??) growth
2) variable, usually normal or increase
3) normal UMA doppler

20
Q

how will

1) growth symmetry and velocity
2) amniotic fluid
3) fetal well being

in placental IUGR

A

1) often asymmetrical velocity may be reduced
2) may be reduced
3) evidence of high resistance UMA flow BPP score decreases

21
Q

what maternal monitoring is done in SGA babies

A

1) Assess for any modifiable factors (smoking) bring it up in every clinic
2) Assess for presence of maternal disease
3) Continue monitoring for pre-eclampsia, with blood pressure and urine checks, in regular intervals

22
Q

what fetal surveillance is done in SGA babies

A

1) Serial growth measurements (every 2-4 weeks)

2) Fetal wellbeing surveillance 
Maternal perception of fetal movements
Fetal Doppler
Amniotic volume measurements
Biophysical profile
23
Q

As resistance increases in the umbilical artery what will u see in UMA

A

1) decreased end-diastolic velocity
2) absent end-diastolic velocity
3) reversed end-diastolic velocity

24
Q

what is uterine arteries doppler

A
  • Dopplers illustrate successful remodelling and conversion into high flow, low pressure vessels
  • Useful for screening, where notching identifies high risk patients
  • NOT USEFUL FOR SURVEILLANCE- performed as a screening test at 20 weeks
25
Q

what i UMA umbilical artery

A
  • End-diastolic flow velocity (continuous, absent, reversed) reflects increases in placental resistance
  • Essential in surveillance of the growth restricted fetus

USEFUL FOR SURVEILLANCE

26
Q

what is MCA

A
  • Represents downstream resistance in cerebral microcirculation
  • MCA resistance is normally high throughout gestation, with increasing flow in the third trimester
  • Increased diastolic flow signifies onset of circulatory changes in response to placental disease
  • Also useful at later gestation, where placental changes in FGR may be functional rather than structural and MCA compensatory flow may be present with near normal UMA Doppler

USEFUL FOR SURVEILLANCE

27
Q

what is venous dopplers

A
  • Candidate vessels include IVC, UVC, and hepatic veins, but evidence still poor.
  • The ductus venosus is probably the vein of choice
  • Waveform deterioration precedes, and strongly predicts, changes in BPS requiring delivery

USEFUL FOR SURVEILLANCE

28
Q

when to deliver baby according to AREDF

A
  • When umbilical artery Doppler is normal, delay delivery until at least 37 weeks (in the presence of satisfactory additional assessment)
  • With AREDF consider delivery if gestation >34/40 even in the presence of normal additional assessment
  • With AREDF, deliver before 34/40 if CTG abnormal, BPP abnormal, or other Doppler parameters are abnormal (MCA, umbilical vein)
  • Mode of delivery will depend on gestation, presentation, fetal condition and maternal factors
29
Q

risks of a fetal growth restricted baby

A
  • Odds ratio for perinatal death 2.5
  • Increased need for resuscitation
  • Hypothermia & Hypoglycaemia
  • RDS & NEC
  • Neurodevelopmental disability
  • Cerebral palsy
  • Adult disease
30
Q

what are the other causes for an increased symphysis fundal height in a singleton pregnancy

A
  • Uterine fibroids
  • Pelvic mass pushing up the uterus
  • Polyhydramnios
  • Maternal obesity
31
Q

maternal factors that cause large for dates baby

A
  • Diabetes
  • Obesity
  • Increased maternal age
  • Multiparity
  • Large stature
32
Q

possible causes of a large baby

A
  • Constitutional
  • Male gender
  • Postmaturity
  • Genetic disorders (Beckwith Wiedeman)
33
Q

maternal Risks of having a macrosomic baby

A
  • Prolonged labour
  • Operative delivery
  • Postpartum haemorrhage
  • Genital tract trauma
34
Q

fetal RFs of having a macrsomic baby

A
  • Birth injury
  • Perinatal asphyxia from difficult delivery
  • Shoulder dystocia/Erb’s palsy
  • Hypoglycaemia
  • Childhood obesity
  • Metabolic syndrome
35
Q

what to do w a chunky baby

A
  • Exclude maternal diabetes
  • In the absence of polyhydramnios, treat pregnancy as normal
  • There is NO benefit of induction of labour or Caesarean section in the absence of maternal diabetes
    If maternal diabetes is present in addition to macrosomia, offer Caesarean section
  • Early recourse to intervention where there is delay in labour
  • Anticipate shoulder dystocia
  • Monitor for hypoglycaemia in the neonatal period
36
Q

what can reduced fetal movements mean

A

fetal distress, as a method of fetal compensation to reduce oxygen consumption as a response to chronic hypoxia in utero. This is concerning, as it reflects risk of stillbirth and fetal growth restriction.

37
Q

when is the first onset of recognised fetal movements

A

quickening - 18-20 weeks and icnrease until 32 weeks gestation where the movements plateau

multiparous women from 16-18 weeks

38
Q

RFs/reasons for reduced fetal movements

A

Posture
- There can be positional changes in fetal movement awareness, generally being more prominent during lying down and less when sitting and standing

Distraction
- Awareness of fetal movements can be distractable, and if a woman is busy or concentrating on something else, these can be less prominent

Placental position
- Patient with anterior placentas prior to 28 weeks gestation may have lesser awareness of fetal movements

Medication
- Both alcohol and sedative medications like opiates or benzodiazepines can temporarily cause reduced fetal movements

Fetal position
- Anterior fetal position means movements are less noticeable

Body habitus
- Obese patients are less likely to feel prominent fetal movements

Amniotic fluid volume
- Both oligohydramnios and polyhydramnios can cause reduction in fetal movements

Fetal size
- Up to 29% of women presenting with RFM have a SGA fetus

39
Q

if RFM past 28 weeks gestation

A

1) handheld doppler - confirm fetal heartbeat
1a) if no fetal heartbeat - immediate US
2) if fetal heartbeat present - CTG should be used for at least 20 minutes to monitor fetal heart rate which can assist in excluding fetal compromise.

If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used.
Ultrasound assessment should
- abdominal circumference or
- estimated fetal weight (to exclude SGA),
- and amniotic fluid volume measurement

40
Q

if RFM between 24-28w, below 24w

A
  • If between 24 and 28 weeks gestation, a handheld Doppler should be used to confirm presence of fetal heartbeat.
  • If below 24 weeks gestation, and fetal movements have previously been felt, a handheld Doppler should be used.
  • If fetal movements have not yet been felt by 24 weeks, onward referral should be made to a maternal fetal medicine unit.
41
Q

At which week should you refer to an obstetrician for lack of fetal movements?

A

24 weeks refer to maternal fetal medicine unit

repro (28 decks)

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