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    RCF ObG Project

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    James Martinez Medina
    The guidance from ACOG/SMFM on fetal growth restriction (FGR) was updated. While there is no consensus on defining or managing FGR, it is associated with adverse outcomes, so timely diagnosis and management is key. Ultrasound and fundal height checks are important diagnostics. Early delivery and expectant management have similar outcomes, so birth plans should be discussed.

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    RCF ObG Project

    Uploaded by

    James Martinez Medina
    30 views5 pages
    The guidance from ACOG/SMFM on fetal growth restriction (FGR) was updated. While there is no consensus on defining or managing FGR, it is associated with adverse outcomes, so timely diagnosis and management is key. Ultrasound and fundal height checks are important diagnostics. Early delivery and expectant management have similar outcomes, so birth plans should be discussed.

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    The guidance from ACOG/SMFM on fetal growth restriction (FGR) was updated. While there is no consensus on defining or managing FGR, it is associated with adverse outcomes, so timely diagnosis and management is key. Ultrasound and fundal height checks are important diagnostics. Early delivery and expectant management have similar outcomes, so birth plans should be discussed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    30 views5 pages

    RCF ObG Project

    Uploaded by

    James Martinez Medina
    The guidance from ACOG/SMFM on fetal growth restriction (FGR) was updated. While there is no consensus on defining or managing FGR, it is associated with adverse outcomes, so timely diagnosis and management is key. Ultrasound and fundal height checks are important diagnostics. Early delivery and expectant management have similar outcomes, so birth plans should be discussed.

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    of 5

    Fetal Growth Restriction: Definition, Evaluation and

    Management

    SUMMARY:

    ACOG / SMFM released a guidance update on fetal growth restriction (FGR). While there is currently no

    clear consensus on the definition, evaluation, and management, FGR is associated with adverse

    perinatal outcomes. Therefore, timely diagnosis and management is key to optimizing long term benefit.

    Ultrasound and fundal height measurement are important physical exam diagnostic maneuvers. Early

    delivery and expectant management have similar outcomes thus creating deliberate birth plans should be

    discussed.

    Key Terms and Definitions

    FGR: EFW or AC <10th percentile for gestational age


    Symmetric: Global growth restriction | Early insult

    Asymmetric: Head-sparing with generally better outcomes

    Small for gestational age (SGA): Newborn birthweight <10th percentile for gestational age

    Risk Factors

    Maternal Disease

    Hypertensive disorders
    Chronic hypertension

    Gestational hypertension and preeclampsia

    Kidney disease

    Endocrine
    Pregestational diabetes mellitus
    Autoimmune
    SLE

    Antiphospholipid syndrome

    Congenital heart disease (see ‘Learn More – Primary Sources’ for additional information)
    Highest risk: Cyanotic heart disease | Reduced cardiac output

    Note: Nutrition, oxygenation, and cardiovascular adaptation to pregnancy (placental perfusion) are

    underlying maternal factor mechanisms that impact fetal growth

    Fetal Factors

    Multiple gestation

    Teratogenic exposures
    Medications (e.g. fetal hydantoin syndrome)

    Substance abuse (modifiable risk) including alcohol, cocaine and smoking

    Intrauterine infections (e.g., CMV, rubella, syphilis)

    Genetics:
    Aneuploidy: Trisomy 13 and trisomy 18 commonly associated with FGR

    Single gene disorders

    Multifactorial: Congenital malformations (heart disease, gastroschisis)

    Placental Anomalies

    Abruption | Infarction | Circumvallate shape | Hemangioma | Chorioangioma

    Umbilical cord anomalies


    Velamentous or marginal insertion

    Single umbilical artery

    Note: Placental implantation abnormalities (e.g. placental accreta spectrum, previa) not associated with

    FGR

    Evaluation and Screening Methods

    Fundal height measurements


    Begin at 24 weeks gestation

    Perform at each prenatal visit


    3 cm discrepancy "proposed for identifying a fetus that may be growth restricted"

    Limitations
    Maternal obesity | Fibroids | Multiple gestation

    Ultrasound
    Preferred method of evaluation

    Measurements include
    BPD

    HC

    AC

    FL

    UA Doppler velocimetry
    Reduces perinatal death when added to antepartum testing

    Absent or reversed end-diastolic flow increases risk for perinatal mortality

    Evaluation of the fetal ductus venosus has not been shown to improve perinatal outcomes
    (TRUFFLE study)

    Note: No current evidenced based screening methods or preventative measures such as bed rest have

    demonstrated improved perinatal outcomes

    KEY POINTS:
    Management

    Address modifiable risk factors, for example


    Screen for fetal alcohol exposure

    Discuss and encourage reduction in smoking and/or smoking cessation


    Smoking is associated with 3.5 increased risk of SGA newborns

    Genetic counseling
    FGR alone may be associated with genetic syndromes and aneuploidy

    Combined FGR and fetal structural abnormalizes increase aneuploidy risk and warrants genetic
    counseling referral

    Depending on clinical scenario


    Serial ultrasounds q3-4 weeks for growth and AFV

    Do not measure fetal growth more often than every 2 weeks (measurements will be within error of
    the test)

    Fetal assessment (NSTs or BPPs): “…should not begin before a gestational age when delivery
    would be considered for perinatal benefit”

    Mode of delivery
    Reserve cesarean section for obstetric/neonatal indications

    Cesarean section and is not indicated for FGR in isolation

    Timing of Delivery

    Normal UA Doppler and EFW 3 to 10th percentile: 38w0d to 39w0d

    EFW <3rd percentile (severe FGR): 37w0d

    Decreased UA flow without absent end diastolic flow: 37w0d to 37w6d

    Absent end diastolic flow: 33w0d to 34w0d

    Reversed end diastolic flow: 30w0d to 32w0d

    With oligohydramnios or concurrent conditions (e.g., preeclampsia, chronic hypertension): 34w0d to 37w6d

    Note: If delivery planned <34 weeks, deliver at center with a NICU and consult MFM

    When to Give Antepartum Corticosteroids

    < 33w6d (anticipated delivery)

    34w0d-36w6d (late preterm) if risk


    No previous corticosteroids

    Anticipate delivery within 7 days

    Note: “Consider” magnesium sulfate (neuroprotection) if delivery <32w0d

    Future Pregnancies

    Counsel regarding 20% recurrence risk

    Review history to identify modifiable factors and/or treat maternal disease

    In subsequent pregnancies

    …it may be reasonable to perform serial ultrasonography for growth assessment, although

    the optimal surveillance regimen has not been determined.


    Maternal history of a prior SGA newborn with normal fetal growth in the current pregnancy is

    not an indication for antenatal fetal heart rate testing, biophysical profile testing, or umbilical

    artery Doppler velocimetry

    Note: There is insufficient evidence to routinely administer aspirin to prevent SGA in this population

    Learn More – Primary Sources

    ACOG Practice Bulletin 227: Fetal Growth Restriction

    Effect of Maternal Heart Disease on Fetal Growth

    Locate a Maternal Fetal Medicine Specialist

    Maternal Fetal Medicine Specialist Locator-SMFM

    https://www.obgproject.com/2019/03/06/fetal-growth-restriction-definition-evaluation-and-management/

    Downloaded on Sep 14, 2021


    © The ObG Project 2021

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