APPROACH TO A

PATIENT WITH FGR

Presented By: Mentor:
Devesh Rajoriya (665) Dr Vinita Singh
Dharavath Bharath (666) PG Student:
Harikrishnan T (669) Dr Priyanka
FETAL GROWTH RESTRICTION

 INTRA UTERINE GROWTH RESTRICTION

 SMALL FOR GESTETIONAL AGE
 FETAL GROWTH RESTRICTION
DEFENITION
Intrauterine growth retardation (IUGR)
or fetal growth restriction (FGR)
occurs when the unborn baby is at or
below the 10th weight percentile for
his or her age ( in weeks) .
SGA VS FGR

 FGR is a pathological condition in which a fetus has not

achieved its genetic growth potential regardless of fetal
size.
 FGR and SGA are not synonymous
 Fetus need not be small to be growth restricted.
 Majority of FGR fetuses are SGA; but 50-70% of SGA
fetuses have grown appropriately but are constitutionally
small.
CLASSIFICATION
 Based on Estimated fetal weight
1. Mild : around 10th percentile
2. Moderate : EFW between 3-10th percentile
3. Severe : EFW less than 3rd percentile

 Based on Abdominal circumference

1. On USG < 10th percentile is called IUGR/FGR
AETIOLOGY
Maternal Causes

 Obstetric causes
 Medical causes: 1) cardio-vascular – pre eclampsia , hypertension ,
cyanotic heart disease 2) chronic kidney disease 3) chronic infections
 Teratogenic exposure to the mother
 Low BMI or poor weight during pregnancy
 Malnutrition during pregnancy
 Greater the maternal age
 High altitude
 Short inter pregnancy gap
Fetal causes
 Fetal intra-uterine infections
 Congenital anomalies
 Genetic or chromosomal anomalies : 1) trisomy – 18( Edwards synd)
2) Trisomy – 21 ( down’s synd)
 Multifetal pregnancy
 Placental or umbilical chord defect
Placental Factors

 Utero-placental insufficiency resulting from :

1) improper or inadequate trophoblastic invasion and
placentation in the first trimester
2) lateral insertion of placenta
3) reduced maternal blood flow to the placental bed
 APLA (Anti phospholipid antibodies) syndrome
 Placental chord anomalies :
1) Single uterine artery
2) Velamentous insertion of placenta
3) circumvallate placenta
TYPES OF FGR
Symmetrical
 This means that the head, body, and limbs are all affected, resulting in a
uniformly smaller size for the entire fetus.
 All the organs are effected proportionally
 Less common – 20 to 30% of cases
 Early onset - 32 weeks
 Due to decreased nutritional supply
 Mainly due to fetal causes
TYPES OF FGR
Asymmetrical
 some parts of the fetus, usually the head and brain, may maintain relatively
normal growth while other parts, such as the abdomen and body, experience
restricted growth
 Most common
 Late onset - >32 weeks
 Mainly due to maternal or placental causes
 Head circumference is preserved and weight is compromised to a greater
extend
 Brain sparing effect : This means that the brain receives a relatively higher
proportion of available nutrients and oxygen compared to other parts of the
body. The body redirects resources to ensure that the brain, a vital organ,
continues to develop properly.
DIAGNOSIS OF FGR
 Important points in history:

1. Maternal age >/= 35 years

2. Nulliparity
3. BMI
4. Maternal substance exposure ( cigarettes, cocaine)
5. In vitro fertilization
6. Daily vigorous exercise
7. Low fruit intake pre pregnancy

8. Maternal medical history: SGA in mother, HTN, DM, renal disease,

APLA
9. Paternal medical history: SGA in father
 Important points in history (contd..):

10.Previous pregnancy:
 Previous SGA newborn
 Previous stillbirth
 Previous pre eclampsia
 Interpregnancy interval ( <6 months/ > 60 months)

11.Current pregnancy:
 Threatened miscarriage ( heavy bleeding)
 Pregnancy induced hypertension, preeclampsia
 Low weight gain
DIAGNOSIS OF FGR
 Clinical Assessment:
Healthcare providers take into account various factors from the mother's medical history,
including pre-existing conditions, medications, and lifestyle habits. Maternal factors like
smoking, drug use, and certain chronic medical conditions can contribute to FGR. Physical
examinations, including measurements of the mother's abdomen and weight gain, are also
considered.
 Ultrasound Evaluations:
Ultrasound is a primary tool for diagnosing FGR and assessing fetal growth. Specific
ultrasound measurements are used to estimate fetal size and growth potential. These include:
1. Crown-Rump Length (CRL): Early in pregnancy, CRL is measured to estimate gestational
age and assess fetal size.
2. Biparietal Diameter (BPD): This measurement helps estimate the fetal head size, which
is a key indicator of growth.
3. Abdominal Circumference (AC): The measurement of the fetal abdomen can help
assess the size of the abdominal organs and overall growth.
4. Femur Length (FL): The length of the fetal thigh bone provides information about
skeletal growth.
5. Estimated Fetal Weight (EFW): Calculated using various measurements, EFW helps
assess whether the fetus is growing as expected.
DIAGNOSIS OF FGR
 Doppler Ultrasound Studies: As mentioned earlier, Doppler ultrasound
studies of the umbilical artery can provide information about blood flow
patterns between the placenta and the fetus. Abnormalities in blood flow
can indicate placental insufficiency and potential FGR.

 Serial Measurements: Regular ultrasound measurements taken over

multiple visits allow healthcare providers to track fetal growth over time. A
lack of appropriate growth or deviations from the expected growth curve
can be concerning for FGR.

 Biophysical Profile (BPP): A biophysical profile is a comprehensive

assessment that combines fetal heart rate monitoring (non stress test) with
ultrasound evaluations of various parameters, including fetal breathing
movements, fetal movements, amniotic fluid volume, and fetal tone. The
BPP helps evaluate overall fetal well-being and can detect signs of FGR.
COMPLICATIONS

 During Pregnancy:  After Birth:

1. Preterm Birth 1. Low Birth Weight
2. Hypoxia and Acidosis 2. Respiratory Distress Syndrome
3. Meconium Aspiration Syndrome 3. Hypoglycemia
4. Placental Abruption 4. Temperature Instability
5. Preeclampsia 5. Feeding Difficulties
6. Reduced Amniotic Fluid 6. Neurodevelopmental Issues.
7. Organ Dysfunction
8. Increased Neonatal Morbidity and
Mortality
MANAGEMENT
Management:
Based on Uterine Artery Doppler Finding's
If Uterine Artery with IF uterine artery is with
If Uterine Artery Absent end Diastolic Flow Reverse End Diastolic Flow
Doppler is Normal (ADEF) (REDF)
thenDoppler
• Do Uterine Artery • Patient is to be Hospitalized • Patient is to be Hospitalized
Weekly • Corticosteroid's are to be • Corticosteroid's are to be
• DO NST /BPS - Weekly given for fetal lung Maturity given for fetal lung Maturity.
• Fetal Growth Assessment -3 • Mgso4 Should be given for • Mgso4 Should be given for
Weekly Neuro protection Neuro protection
• NST to be done 1-2 times/ • NST to be done 1-2 times/
• If EFW is between Day Day
• 3-9 th Percentile then Delivery • Uterine Artery Doppler 2-3 • Uterine Artery Doppler should
at 38-39 Weeks by Normal times / Weekly be done Daily.
Vaginal Delivery • Delivery to be done at 33-34 • Ductus Venosus Doppler can
• If EFW is < 3rd weeks be done.
• Percentile then Delivery by 37 • C section is Preferred
weeks. • Delivery at 30-32 weeks of
• Vaginal Delivery is preferred if gestation.
aminotic fluid is less C -
Section
ANTENATAL SURVEILLANCE
 Frequency of monitoring
1. Fetal monitoring by USG: for every 3 week
2. Weekly evaluation of Amniotic fluid
3. Weekly monitoring of umbilical artery Doppler
4. Fetal surveillance by NST/ Biophysical profile
ANTENATAL SURVEILLANCE
 Types of Monitoring :
1. Ultrasound Monitoring: Ultrasound scans are a primary tool for assessing fetal growth,
measuring key parameters (head circumference, abdominal circumference, femur length), and
evaluating amniotic fluid levels.
2. Doppler Flow Studies: Doppler ultrasound assesses blood flow in various fetal and placental
vessels. It helps identify signs of placental insufficiency, compromised blood flow, and
potential distress in the fetus.
3. Non stress Tests (NSTs): NSTs involve monitoring the fetal heart rate in response to fetal
movements. If the heart rate accelerates with fetal movement, it's considered a reassuring
sign of fetal well-being.
4. Biophysical Profiles (BPPs): A BPP combines NST results with ultrasound evaluations of fetal
movements, breathing, muscle tone, amniotic fluid volume, and sometimes the fetal heart
rate pattern. Each parameter is scored, and the total score indicates fetal well-being.
5. Cervical Length Measurement: If preterm birth risk is a concern due to IUGR, cervical length
measurements may be taken using ultrasound to assess the risk of preterm labor.
6. Maternal Blood Tests: Blood tests, such as those for gestational diabetes and preeclampsia,
are routinely performed during antenatal care to monitor maternal health and detect any
complications that could affect the pregnancy.
PREVENTION AND PUBLIC HEALTH STRATEGIES
 Preventing and addressing Fetal Growth Restriction (FGR) requires a
combination of public health strategies and individual interventions to
improve maternal health, fetal well-being, and overall pregnancy outcomes.
Here are some key prevention and public health strategies against FGR:
 Preconception Health:
1. Encourage women of reproductive age to maintain a healthy lifestyle, including a
balanced diet, regular exercise, and maintaining a healthy weight.
2. Address and manage pre-existing medical conditions such as diabetes,
hypertension, and thyroid disorders before pregnancy.
 Nutrition and Diet:
1. Promote nutrition education for women during pregnancy, emphasizing the
importance of consuming a variety of nutrient-rich foods to support fetal growth
and development.
2. Encourage adequate caloric intake, especially for undernourished populations.
PREVENTION AND PUBLIC HEALTH STRATEGIES

 Healthcare Access and Education:

1. Ensure that pregnant individuals have access to quality prenatal care, which
includes regular check-ups, screenings, and early detection of any potential
issues.
2. Provide education to pregnant individuals about the risks of smoking, alcohol
consumption, and drug use during pregnancy.
 Screening and Monitoring:
 Implement routine ultrasound screenings to monitor fetal growth and detect FGR
at an early stage.
 Use Doppler ultrasound to assess blood flow and placental function, identifying
signs of placental insufficiency that can lead to FGR.

 Antiplatelet agents:
 Antiplatelet agents like aspirin started before 16 weeks of pregnancy has
found to reduce the incidence of both preeclampsia and SGA
PREVENTION AND PUBLIC HEALTH STRATEGIES

 Management of Chronic Conditions.

 Tobacco and Substance Use Cessation:
 Promote Adequate Weight Gain:
 Support Mental Health.
 Genetic Counseling
 Public Health Awareness Campaigns
 Access to Adequate Prenatal Care
 Health Equity and Socioeconomic Factors
 Research and Data Collection
THANK YOU