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OBSTETRIC PATHOLOGY > FETAL GROWTH ASSESSMENT > Flashcards

FETAL GROWTH ASSESSMENT Flashcards

1
Q

Intrauterine Growth Restriction (IUGR)

A

• IUGR best described as decreased rate of fetal growth
• Complicates 3% to 7% of all pregnancies
• Is commonly defined as fetal weight at or below 10% for given gestational age

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2
Q

Significant Maternal Factors for
JUGR

A

Significant Maternal Factors for
JUGR
• Previous history of fetus with IUGR
• Significant maternal hypertension
• History of tobacco use
• Presence of uterine anomaly
• Significant placental hemorrhage
• Placental insufficiency

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3
Q

• DO NOT confuse IUG with term small for gestational age (SGA).

A

• SGA describes fetus with weight below 10th percentile without reference to cause.

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4
Q

IUGR

A

• Basic classifications of IUGR: symmetric and asymmetric

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5
Q

IUGR SYMMETRIC

A

• Symmetric IUGR is usually the result of first trimester insult, such as chromosomal abnormality or infection

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6
Q

Symmetrical IUGR

A

• Results in fetus proportionately small throughout pregnancy
• Approximately 20% to 30% of all IUGR cases symmetric

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7
Q

Asymmetric IUGR

A

• Asymmetric IUGR begins late in second or third trimester and usually results from placental insufficiency.
• Fetus usually shows head sparing at expense of abdominal and soft tissue growth.
• Early diagnosis of IUGR and close fetal monitoring
(BPP, Doppler, fetal growth evaluation) of significant help in managing pregnancy suspected of IUGR.

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8
Q

• Clinical signs of IUGR:

• Key IUGR sonographic markers:

A

decreased fundal height and fetal motion

• Key IUGR sonographic markers: grade 3 placenta before

36 weeks or decreased placental thickness
• Carefully evaluate placenta and fetal anatomy.
• Assess umbilical artery Doppler for increased resistance to flow.

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9
Q

PLACENTAL GRADING

A

GRADE 0 1-2-3

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10
Q

Multiple Parameters for IUGR

A

•BPD: imaged in transverse plane
* BPD can be misleading in cases associated with unusual head shapes
• Used alone, poor indicator of IUGR
• HC-to-AC ratio: high false-positive rate for use in screening general population

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11
Q

Multiple Parameters for IUGR

A

FL-to-Ac ratio has poor positive predictive value.
• AC single most sensitive indicator of IUGR
AC: measure at level of portal-umbilical venous complex
• FL: may decrease in size with symmetric IUGR

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12
Q

single most sensitive indicator of IUGR

A

AC single most sensitive indicator of IUGR
AC: measure at level of portal-umbilical venous complex

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13
Q

Estimated Fetal Weight

A

• Most reliable estimated fetal weight (EFW)
formulas incorporate several fetal parameters, such as BPD, HC, AC, and FL.

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14
Q

Estimated Fetal Weight

A

• Important because overall reduction in size and mass of parameters naturally gives below-normal
EFW

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15
Q

EFW ABNORMAL

A

• EFW below 10th percentile considered by most to be IUGR

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16
Q

Points to Remember for IUGR

A

• Oligohydramnios occurs if fetal urine output reduced.
• Polyhydramnios develops if fetus cannot swallow.
• Amniotic fluid pocket <1 to 2 cm may represent
IUGR.
• Not all oligohydramnios associated with IUGR

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17
Q

Biophysical Profile

A

• Five biophysical parameters were assessed individually and in combination.
• Each individual test had high false-positive rate that was greatly reduced when all five variables were combined.

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18
Q

Biophysical Profile

A

Parameters
1. Cardiac nonstress test (NST)
2. Observation of fetal breathing movements (FBM)
3. Gross fetal bOdy movements (FM)
4. Fetal tone (FT)
5. Amniotic fluid volume (AFV)

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19
Q

Biophysical Profile

A

Biophysical Profile
• BPP has specified time limit (30 minutes) to observe parameters.
• Each variable arbitrarily assigned score of 2 when normal and 0 when abnormal.
• BPP score of 8 to 10 considered normal.
• Core of 4 to 6 has no immediate significance.
• Score of 0 to 2 indicates either immediate delivery or extending test to 120 minutes.

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20
Q

Fetal Breathing Movements

A

• Alternative area to watch for breathing is fetal kidney movement in longitudinal plane.
• 2 points given if one episode of breathing lasting 30 seconds within 30-minute period noted by practitioner.
• If absent, no points given
• Fetal central nervous system initiates and regulates frequency of fetal breathing movements; patterns vary with sleep-wake,cycles.

21
Q

Gross body movement:

A

• Gross body movement: at least three discrete body or limb movements in 30 minutes, unprovoked; to score 2 point
Fewer than three movements scores 0 points.

22
Q

Fetal tone:

A

Fetal tone: active extension and flexion of one
Fetal tone is characterized by the presence of at least one episode of extension and immediate return to flexion of an extremity or the spine. This view of the upper extremity is shown in flexion.
One active extension and flexion of an open and closed hand is a good example of positive fetal tone. This image shows the hand wide open, with all fingers and thumb extended.
24

23
Q

Amniotic

A

• Amniotic fluid index (AFI): one pocket of amniotic fluid at least 2 cm in two perpendicular planes or
AFI total fluid measures of 5 to 22 cm

24
Q

Fetal heart rate (FHR

A

• Fetal heart rate (FHR): also known as nonstress test
(NST).
At least two episodes of fetal heart rate changes of 15 bpm and at least 15 seconds duration in 20-minute period

25
Q

Stress test

A

• Stress test (ST) done using Doppler to record fetal heart rate and its reactivity to the stress of uterine contraction

26
Q

Nonstress Test

A

• Time expended for this portion of examination is (NST)usually 40 minutes.
• Fetal motion detected as rapid rise on recording of uterine activity or patient noting fetal movements.

27
Q

Nonstress Test

A

Following conditions indicate reactive, or normal,
NST and score of 2 points:
• Two fetal heart rate accelerations of 15 bpm or more
• Accelerations lasting at least 15 seconds
• Gross fetal movements noted over 20 minutes without late decelerations

28
Q

NONSTRESS TEST

A

In the nonstress test, the heart rate of the fetus that is not acidotic or neurologically depressed will temporarily accelerate with fetal movement.

Loss of reactivity is commonly associated with a fetal sleep cycle but may result from any cause of central nervous system depression, including fetal acidosis.

Heart rate reactivity is believed to be a good indicator of normal fetal autonomic function.

29
Q

a good indicator of normal fetal autonomic function.

A

Heart rate reactivity is believed to be

30
Q

Non stress test

A

The nonstress test of the neurologically healthy preterm fetus is frequently nonreactive-from 24 to 28 weeks of gestation, up to 50 percent of nonstress tests may not be reactive, and from 28 to 32 weeks of gestation, 15 percent of nonstress tests are not reactive.

31
Q

Most commonly, the nonstress test is considered reactive, or normal,

A

Most commonly, the nonstress test is considered reactive, or normal, if there are two or more fetal heart rate accelerations within a 20-minute period, with or without fetal movement discernible by the woman, according to ACOG.

32
Q

The nonreactive stress test lacks

A

The nonreactive stress test lacks sufficient fetal heart rate accelerations over a 40-minute period.

33
Q

The contraction stress test is based on the response of the fetal heart rate to uterine contractions.

A

It is believed that fetal oxygenation will be transiently worsened by uterine contractions.
In the fetus with suboptimal oxygenation, the resulting intermittent worsening in oxygenation will, in turn, lead to the fetal heart rate pattern of late decelerations.

34
Q
A

• fetal tone center develops at 7.5 to 8.5 weeks.
• fetal movement center develops at 9 weeks
• regular diaphragmatic motion develops by 20 to 21 weeks.
• Heart rate reactivity is the last to occur; it appears by the late second to early third trimester.

35
Q

Centers that develop later are more sensitive to acute hypoxia.

A

Cessation of FM and eventually loss of FT will occur with progressively more profound hypoxemia.
Loss of cardiac reactivity and suppression of fetal breathing movements will occur with relatively mild hypoxia.

36
Q

DOPPLER MESURMENT ANOTHER PARAMETER TO CHECK IUGR
WITH BIOPHISICAL PROFILE

A

Increased vascular resistance is reflected by an increased
S/D ratio or pulsatility index.
Some authors consider an $/D ratio of more than 3.0 in the umbilical artery after 30 weeks to be abnormal, and it is demonstrated by increased resistance in the fetal circulation.
The maternal uterine artery S/D ratio should be below 2.6.
A ratio above 2.6 suggests increased vascular resistance and indicates a decreased maternal blood supply to the uterus.

37
Q

Abnormal ratio in umbilical artery

A

Umbilical artery Doppler waveform demonstrating increased vascular resistance (less diastolic
154 flow) in the fetal umbilical circulation.
The systolic to diastolic

-60
(S/D) Tatio is 3.8. Some
40
authors consider an S/D ratio of more than 3.0 after
30 weeks of gestation to be
abnormal.

38
Q

Abnormal wave form

A

Umbilical artery waveform with absent end-diastolic velocity (AEDV).
The S/D ratio cannot be measured in these cases because of the missing diastolic flow. The patient should be followed closely because AEDV has been associated with adverse perinatal outcome.

39
Q

Abnormal wave form

A

This umbilical Doppler waveform is the most severe Doppler finding and has been associated with adverse fetal outcomes.

This finding is called complete reversal of end-diastolic velocity.
Note how the diastolic flow dips
below the baseline. These
results should be reported
immediately to the patient’s physician

40
Q

Umbilical Vein Doppler

A

• Pulsatile flow in early pregnancy
• Becomes non-pulsatile by the beginning of second trimester
• The presence of pulsatility from second trimester onwards can indicate severe pathological state
- Ominous sign of severely compromised fetus

41
Q

Umbilical Vein Doppler pulsatilla

A

IUGR

42
Q

MACrosomia

A

• Is classically defined as birth weight of 4000 g or greater or above 90th percentile for estimated gestational age
• With respect to delivery, any fetus too large for pelvis through which it must pass is macrosomic.

43
Q

Macrosomia

A

• Is common result of poorly controlled maternal diabetes mellitus
• In addition to adipose tissue, the liver, heart, and adrenal glands are disproportionately increased in size, which can be reflected by an increased AC.

44
Q

• Malformation syndromes in which fetal increase in size, with or without organomegaly:

A

• Malformation syndromes in which fetal increase in size, with or without organomegaly:
• Beckwith-Wiedemann syndrome
• Marshall-Smith syndrome
• Sotos’ syndrome
• Weavers syndrome S.

45
Q

Macrosomia and IUGR AC

A

A, Transverse section through a macrosomic fetal abdomen. Note the fat rind (calipers) encircling the entire abdomen compared with
(B) a severely intrauterine growth-restricted fetus, whose growth is 8 weeks behind. The fetal skin is sonolucent and difficult to differentiate from other surrounding organs.

46
Q

Three types of mechanical macrosomia identified

A

• Three types of mechanical macrosomia identified
Fetuses generally large
• Fetuses generally large but with especially large shoulders
• Fetuses with normal trunk but large head

47
Q

Two terms relating to macrosomic

A

• Two terms relating to macrosomic fetuses are mechanical macrosomia and metabolic macrosomia.

48
Q

Macrosomia
Three types of mechanical macrosomia identified reason

A

• First type can result from genetic factors, prolonged pregnancy, or multiparity.
• Second type found in diabetic pregnancy.
• Third type can be caused by genetic constitution or pathologic process, such as hydrocephalus.

49
Q

Other Methods for Detecting
Macrosomia

A

• Placentas can become significantly large and thick because not immune to growth-enhancing effects of fetal insulin.
• Placental thickness >5 cm considered thick when measurement taken at right angles to its long axis.

OBSTETRIC PATHOLOGY (7 decks)

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