Small for gestational age

Dr.V.Ravimohan SpR

• • • • •

Definition Implications Causes Diagnosis management

Definition
SGA refers to a fetus that has failed to achieve a specific biometric or estimated weight threshold by a specific gestational age. 10 th centile Abdominal circumference Estimated fetal weight

One of most frequently sited suboptimal care is the failure
 to suspect growth restriction in a mother with a previous history  to detect  to act on  to monitor

Implications
• • • • • stillbirth birth hypoxia neonatal complications Neurodevelopment delay type 2 (non-insulin-dependent) diabetes and hypertension in adult life.

Small for gestational babies
Small for gestational babies

Fetal Fetal growthgrowth restriction restriction30% 30% constituninal small babies 70% constitutional

constitutional

constituninal small babies Fetal growth restriction

Fetal growth restrictio

70%

Ott Wj.The diagnosis of altered fetal growth.Obstet Gynecol Clin North Am 1988;15:237-63

SFH customised fundal chart ultrasound scan biometry(AC)

population sensitivity General 27% General High risk 48% 72.9–94.5%

specificity 88%

50.6–83.8%

Improving sensitivity…
– Use customised ultrasound charts(maternal weight, maternal height, ethnic group and parity) – Use growth velocity in addition to size

biometric tests
designed to predict size •abdominal palpation •symphyseal fundal height •ultrasound biometry •ultrasound estimated fetal weight

biophysical tests
fetal wellbeing •Doppler •Amniotic fluid index •CTG

diagnosis of SGA

more indicative of FGR than SGA

Management
• (I) aetiology(ex.chromosomal defects) • (ii)arrange surveillance • (iii) delivery» when? » how? » where?

Causes of Growth restriction

8%

6%

12%

Severe UP dysf uction Chrom osom abnorm al ality Structural m orm alf ation Congenital inf ection 54% m iscellaneous

20%

High risk pregnancy management options 2nd edition p300

Chromosomal abnormalities

10
th

th

Centile

7% 19%

5 Centile

Surveillance
• Umbilical artery doppler is the primary surveillance tool
– frequency of monitoring in SGA fetuses with normal Doppler need not generally be more than once every fortnight.

Doppler indices
S/D ratio Resistance index
Systolic peak velocity diastolic peak velocity
Systolic-end diastolic peak velocity systolic peak velocity

Pulsatility index

Systolic-end diastolic peak velocity Mean systolic velocity

Doppler

Absent/Reverse EDF

EDF present
Delay delivey till 37w*

>34 weeks deliver

<34 weeks (i)Admission (ii)Closed surveillance (iii)steroids

<34 weeks with RED/AED
• Daily CTG/Biophysical profile/Venous doppler • Consider delivery
» Pathological CTG » Biophysical score <4 » Reversal of doppler velocities in ductus venosus during atrial contraction or umbilical vein pulsations

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Survival by birth weight

Survival by gestation

Growth Restriction Intervention Trial (GRIT)
• Hypothesis:early delivery,to pre-empt intrauterine hypoxia,would alter brain development compared with delaying delivery for as long as possible ,to gain maturity.

588 babies (fetal compromise between 24-36 weeks)

Immediate delivery (296)

Delivery when obstetrician no longer uncertain (292)

D e a t h a n d s e v e r e d i s a b il i t y a t 2 y r s I m m e d ia t e d e liv e r y 5 5 ( 1 9 % ) D e la y e d d e liv e r y 4 4 ( 1 6 % )

OR 1.1(0.7-1.8)

Conclusion
• The present study should discourage doctors who deliver fetuses (<30 weeks) before at which they delivery can be delayed no longer.

Mode of delivery
Indications for LSCS (I)late decelerations in antenatal CTG (II)Reversed End diastolic flow (III)thick meconium during induction of labour

Clinical obstetrics and Gynaecology 40:4:1997;p822

Summary
• • • • • Definition Implications Causes Diagnosis management