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© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7
FETAL GROWTH RESTRICTIONNATHAN BLUE, MD
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DISCLOSURES
1. No financial disclosures2. I do research in FGR
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OBJECTIVES
Review…1. screening2. definitions & diagnostic criteria3. when / how to start a workup4. management
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• Sept 1944 – May 1945• 1800 500 kcal/day
@ n a t e y b l u e Portrait FRM et al. Econ Hum Biol 2017Lumey LH, van Poppel FWA. 2013
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HISTORY
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Prenatal
Preeclampsia
Fetal growthrestriction
Stillbirth
Postnatal
NICU
Seizures
Cerebral palsy
Death
Adulthood
Heart disease
Stroke
Death
Ananth et al. AJOG 2006Jarvis et al. Lancet. 2003.McIntire et al. NEJM 1999.
Crispi et al. Circulation 2010.Levine et al. Pediatrics 2015.Crispi et al. AJOG 2018Kalousek DK. J Med Gen. 1996
DUTCH HUNGER WINTER
• Lifelong sequelae:– Glucose intolerance,
coronary heart disease, kidney disease
– Cognitive aging– All-cause mortality
• DOHaD: Developmental Origins of Health and Disease
Roseboom et al. Early Hum Dev. 2006de Rooji et al, Proc Natl Acad Sci 2010Ekamper and Lumey, Social Science & Medicine. 2014
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OBJECTIVES
Review…1. screening2. definitions & diagnostic criteria3. when / how to start a workup4. management
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SCREENING
Who needs ultrasound?- Not everyone!- can’t do/interpret
fundal height- FH off by +/- 3cm- Risk factors!
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Henrichs et al. BMJ 2019.Skrastad et al. Acta Obstet Gynecol Scand 2013.
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OBJECTIVES
Review…1. screening2. definitions & diagnostic criteria3. when / how to start a workup4. management
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DEFINING CONCEPTS
• Small for gestational age (SGA): size <10th
percentile. – Maybe normal, maybe not
• Fetal growth restriction (FGR): Inability to achieve growth potential – Not normal
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FGR IN PRACTICAL TERMS
• ACOG: EFW <10th percentile• RCOG: EFW or AC <10th percentile• SOGC: EFW or AC <10th percentile• ISUOG:
– EFW/AC <3rd or – EFW <10th and evidence of compromise
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ACOG Practice Bulletin no. 204RCOG Green top guideline No. 31SOGC Clinical Practice guideline No. 295ISUOG Practice Guideline: ultrasound assessment of fetal biometry and growth. 2019
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DEFINING FGR – ITS COMPLICATED
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Brenner AJOG 1976Williams Obstet Gynecol 1982Hadlock Radiology 1991 11
N DesignDerived using… Maternal population
Brenner – 1976 30,772 Retrospective BW, PG abortions Cleveland, OH: white, black
Williams – 1982 2,265,478 Retrospective BWs CA; mixed; included stillbirths
Hadlock – 1991 392 Prospective EFWs Houston, TX; white, middle-class
NICHD – 2015 2335 Prospective EFWs- normals U.S. – 12 centers
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Salomon et al. Ultrasound Obstet Gynecol 2007. 12
SalomonN=18,959
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DEFINING FGR – ITS COMPLICATED
• US report:
– EFW: 25th percentile (Brenner)• BPD: 5th
• HC: 5th
• AC: 5th
• FL: 5th
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Hadlock
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• Hadlock vs NICHD, N=1,514• EFW within 30d of delivery• Outcomes:
– Prediction of neonatal morbidity and SGA
– Rates of FGR using each standard
– Birthweight percentile prediction
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Blue et al. Obstet Gynecol 2018. 15
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DEFINING FGR – ITS COMPLICATED
Fetus is small – 3 possibilities:
- Constitutionally small- FGR in evolution – no compromise- FGR with compromise
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OBJECTIVES
Review…1. screening2. definitions & diagnostic criteria3. when / how to start the workup4. management
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DEFINING FGR
How can I tell?• Isolated EFW or AC <10th check again
• Other findings MFM– Severe (EFW/AC <3rd)– Early (<24 weeks)– Dopplers– Ultrasound findings: anomaly, infection,
aneuploidy
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ETIOLOGIES
• Maternal conditions• Placental
insufficiency• Fetal• Trans-placental
infection (TORCHES)
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THE WORKUP
• Maternal conditions• Placental
insufficiency• Infection• Fetal
– anomalies– syndrome
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H&P
DopplersGrowth trajectorySurveillance
TORCHES
Ultrasound (anatomy)Genetic testing
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DEFINING FGR
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Red flag?
Workup!
yes
Repeat US in 3-4w
no
MFM
Constitutionally small
Stable
EFW/AC <10th
Not reassuring
Red flags:- EFW/AC <3%- Early onset- Abnormal US- Abnormal Dopplers
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OBJECTIVES
Review…1. screening2. definitions & diagnostic criteria3. when / how to start a workup4. management
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OBJECTIVES
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Start NST/BPP 2x/wk at “viability”
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IT’S OKAY BECAUSE….NOTHING MATTERS
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IT’S OKAY BECAUSE….NOTHING MATTERS
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Boers et al. BMJ 201025
Immediate group: 17 (5.3%)Delayed group: 20 (6.1%)
Diff -0.8% (-4.3% to 2.8%)
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OBJECTIVES
We reviewed:1. screening2. definitions & diagnostic criteria3. When /how to work it up4. management
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Indication driven!EFW or AC <10th
When: Red flags!How: TORCHES
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THE END
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