SGA

Question 1

A 30-year-old presents at 32 weeks with US finding of the foetus being less than 10% of predicted weight. What are the causes and what is the likely management?

2020 stem: 34/40 G1P0, fundal height on 30 weeks was 28cm, now 29cm at 34 weeks. How would you manage the patient?”

Answer 1

Impression
Given findings, this likely represents a small for gestational age foetus (meets the definition which is <10% of growth percentiles on US), for which there are a number of potential causes. Important to rule out physiological vs pathological causes. concerned about IUGR, where the baby doesn’t reach it genetic growth potential due to pathological causes.

physiological
- small mother, asian descent, incorrect dating,
pathological:
- foetal factors (type 1 - symmetrical): chromosomal abnormalities, twin pregnancy, infection
- maternal/placental factors (type 2 - asymmetrical): placental insufficiency, malnutrition, eclampsia,

Question 2

SGA - History

Answer 2

History

• obstetric hx: ask about dating scans and other scans (would want to check reports), LMP, gravity, parity, previous pregnancies, any issues with current pregnancy
• maternal: diet, nutrition, medications, SLE/APLS/other autoimmune, assistive reproductive technologies
• REDS: HTN, fevers, visual change, swelling,
• Foetal: reduced fetal movement
• PMHx/PSHx
• Medications (Warfarin, steroids, anticonvulsants)
• Substances

Question 3

SGA - Examination

Answer 3

Examination

• general appearance + vitals (facial oedema for eclampsia)
• anthropometric measurements (height, weight, ask about family members - screening for constitutionally small
• antenatal assessment: fundal height, fetal dopplers, abdo palp + fetal lie

Signs of eclampsia
- neuro examiantion: clonus, brisk reflexes, deficits
- resp: APO
facial oedema

Question 4

SGA - Investigations

Answer 4

Investigations
screen for causes according to clinical suspicion based on findings of history and examination:

Fetal:

• TORCH serolog + malaria, syphillis screening
• amniocentesis for genetic testing (chromosomal abnormalities, etc)

Maternal

• bedside: UA (proteinuria in pre-eclampsia),
• imaging: serial ultrasound for amniotic fluid volume, umbilical artery dopplers (reduced/reversed end diastolic flow is indication for delivery), placental assessment, fetal biometry
• CTG monitoring

Question 5

SGA - Management

Answer 5

Management
Goal of management is to balance the risks of fetal compromise due to IUGR vs risks of prematurity, aim to continue gestation for as long as possible before delivery, can manage expectantly based on foetal growth progress.

Patient will likely require referral to Materno-fetal medicine unit (MFMU), and may also require/benefit from counselling/psychology services referral if necessary.

Maternal

• increased monitoring interval for complications (including eclampsia), more regular US scans and clinic review, in conjunction with MFMU
• optimise risk factors: smoking cessation, nutrition
• medical management: HTN, infection, GDM/DM other chronic diseases
• LDA start 12-16 weeks if past history of IUGR or eclampsia
• consider early delivery by induction of labour/Caesarean section depending on risk profiles. Goal of course is to delay delivery as long as possible for max foetal maturation - balance risks of
• administer corticosteroids if <34 weeks gestation