Small for Gestational Age (SGA) Fetus

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Small for Gestational Age (SGA) Fetus Small for Gestational Age (SGA) Fetus. Diagnostic and Management Dilemmas. Dr. Dan Valsky Fetal Medicine Unit Department of Obstetrics and Gynecology Hadassah University Hospital - Mt. Scopus Jerusalem, Israel

SGA: Definition and Diagnosis Before the early 1960s, it was assumed that a newborn with a birth weight less than 2500 g was “premature.” Lubchenco recognized that there exists a cohort of newborns who do not achieve their growth potential, and that their failure to do so imparts a significant burden of increased perinatal mortality as well as short- and long-term childhood morbidity. Hansmann in 1973 incorporated the concept of evaluating fetal growth in reference to percentiles

Early IUGR: Definition and Diagnosis

הגדרה הערכת משקל עוברית מתחת לאחוזון 10. כל עובר בקטגוריה זו נכנס להגדרה של SGA (Small for Gestational Age) אבחון SGA מתחת ל-32 שבועות נקרא SGA מוקדם. אבחון SGA מעל 32 שבועות נקרא SGA מאוחר. p10 p50 IUGR+SGA NORMAL+IUGR

אבחנה קליניקה – מדידת המרחק בין החלק העליון של הסימפיזיס פוביס עד לפונדוס. לאור רגישות נמוכה של שיטה זו היא אינה מהווה כיום נדבך חשוב באבחנה של SGA אולטרה סאונד – הוא הכלי העיקרי באבחון. ההערכה כוללת : וידוא גיל ההריון. ביצוע ביומטריה עוברית וחישוב משקל העובר. קביעת אחוזון.

אבחנה: וידוא גיל ההריון אבחנה: וידוא גיל ההריון גיל ההריון נקבע על פי תאריך הוסת האחרונה במידה והוסתות סדירות ועל פי בדיקת אולטרה סאונד בשבועות מוקדמים כאשר הדיוק של מדידת האורך CRL של העובר הוא +/- 3 ימים. תיקון לגיל ההריון ייעשה אם בדיקת על-קול שבוצעה ב-13 השבועות הראשונים תגלה פער של יותר מ-6 ימים, או אם בדיקת על-קול שבוצעה בין השבועות 14-20 תגלה פער מעל 10 ימים. בשבועות מתקדמים יותר של ההריון, כאשר אין US מוקדם לתארוך מדויק, יש להשתמש במדידה של הצרבלום. קוטר הצרבלום (TCD) אינו מושפע כמעט מקצב גדילת העובר.

אבחנה: ביומטריה עוברית אבחנה: ביומטריה עוברית אפשר לחשב את משקל העובר על פי נוסחאות שונות הכוללות בתוכן את מדדי הראש, הבטן והפמור של העובר. HC & BPD AC FL + =EFW

אבחנה: קביעת אחוזון משקל העובר יתורגם לאחוזון על פי טבלה המייצגת גדילת עוברים בקרב האוכלוסיה הנבדקת. p10 p50 IUGR+SGA NORMAL+IUGR

+ =EFW SGA: Definition and Diagnosis IUGR+SGA NORMAL+IUGR HC & BPD AC FL + =EFW p10 p50 IUGR+SGA NORMAL+IUGR

Integrated Definition Early IUGR: Definition and Diagnosis Population references: They provide birthweigh pecentile at each gestational week, but infants born preterm are more likely to be IUGRs. Prospective studies: They don’t give a longitudunal growth pattern and dont assess individual growth parameters Retrospective ultrasound based: They have a selection bias, eg, why some women receive US examination at non routine week? The individualized approach: Incorporate information about fetal growth potential based on maternal and fetal parameters ( race, BMI, sex, parity…) So as fetal weight is not good enough for IUGR definition’ some other parameters should be used. Fetal well being parameters are nor enough sensitive ( AF, NST, BPP) But some Doppler parameters are good. As fetal weight alone cannot predict accurately perinatal mortality and morbidity it shoul be integrated with other parameters of fetal or placental health. Zhang J, Kramer M, AJOG, 2010

Abnormal Fetus SGA Constitutional IUGR SGA: Definition and Diagnosis Fetal Abnormalities Aneploidy Malformations Infections Multiple Gestations Maternal Diseases Vascular/renal Thrombophilias Drugs Extreme undernutrition Placental Abnormalities Chorioangioma Confined placental mosaisism Chronic placental abruption Idiopathic Placental Insufficiency

בירור : גורמים עובריים שלילת מומים אנטומיים ביצוע אקו לב עוברי הערכת שליה וחבל טבור יעוץ גנטי שלילת סימני זיהום תוך רחמי בדיקת זרימות (דופלר)

15% 85% Abnormal Fetus SGA Constitutional IUGR Early IUGR: Definition and Diagnosis Abnormal Fetus IUGR SGA Constitutional 15% 85% Fetal Abnormalities Aneploidy Malformations Infections Multiple Gestations Maternal Diseases Vascular/renal Thrombophilias Drugs Extreme undernutrition Placental Abnormalities Chorioangioma Confined placental mosaisism Chronic placental abruption Idiopathic Placental Insufficiency The differenciation between SGA and IUGR is ABNORMAL Doppler ( UA)

Placental compromise

Depending on the maternal history and ultrasound findings, further diagnostic evaluation may require any or all of the following: ● Fetal karyotyping. ● Maternal serum studies for evidence of seroconversion when there is suspicion of viral infection, with specific amniotic fluid viral DNA testing when indicated. ● Careful observation for early detection of preeclampsia. ● Evaluation of the congenital and acquired thrombophylic disorders, particularly if a previous pregnancy was complicated by early and severe preeclampsia.

MANAGEMENT Risk factors assessment and modification Interval growth evaluation NST BPP Doppler studies

Types of Doppler Pulse Doppler Color Doppler Power Doppler

Doppler systolic-diastolic waveform indices of blood flow velocity. S/D Ratio (S-D)/S - resistance index (RI) (S-D)/mean – pulsatility index (PI)

Umbilical Artery 21

Umbilical Artery

Early IUGR: Definition and Diagnosis Umbilical artery UA Doppler indices correlate with fetal levels of glucose, AA,blood gases, and could be a surrogate measurement of placental function * UA is a risk discriminator tool in the management of SGA fetuses** Increased UA impedance (AREDF) is associated with an increased risk for perinatal mortality, morbidity and long term abnormal neurodevelopment*** The use of UA Doppler associated with 30% reduction in perinatal mortality and improvement of number of perinatal outcomes **** To give an example of Umbilical art flow, normal and abnormal. So explain PI, to tell how the measurement should be done ** those studies show that the outcome of small fetuses with normal UA is the same like AGA. So it rised a question if these fetuses should be monitored at all. In this aspect UA is discriminatory, as shows us, who are at risk for adverse outcome ( abnormal UA) and who are not ( normal UA ) *** It does not mean that each fetus with such pattern should be delivered, as there is onothe rmore important factors which should be considered ( as gestational age, by being more strong, or DV , by being more specific ) **** it was based on the data from several studies included 7000 fetuses * Karsdorp, Eur J Obstet Gynecol Reprod Biol, 1994, Nicolaides, BMJ,1998 ** Ott WJ, JUM, 2000, Bashat AA, AJOG, 2000 *** Cosmi E, Obstet Gynecol, 2005, Valcamonico, AJOG, 1994 **** Nelson JP, Cochrane Database, 2000

Early IUGR: Definition and Diagnosis 85-90% 10-15% PEG

Middle Cerebral Artery (MCA)

Ductus venosus (DV)

Placental Resistance Early IUGR: Doppler Assessment Subclinical placental disease Compensated hypoxia Decompensated hypoxia (acidosis) Fetal death

Placental Resistance Early IUGR: Doppler Assessment Subclinical placental disease Compensated hypoxia Decompensated hypoxia (acidosis) Fetal death

Placental Resistance Early IUGR: Doppler Assessment Subclinical placental disease Compensated hypoxia Decompensated hypoxia (acidosis) Fetal death When 30% of placenta ill- UAPI wil increase Brain redistribution Fetal developmant- delay in achievement of develpmental milestones: - increased HR - lower variability - delayed reactivity 29

Placental Resistance Early IUGR: Doppler Assessment Subclinical placental disease Compensated hypoxia Decompensated hypoxia (acidosis) Fetal death When villous oblitaration is more than 50% of placental area First clinical sign is AEDF in UA Risk of acidemia increases 2 Doppler parameters should be mentioned here as they are critical for severity assessment at this stage ant as we will see for prognosis: - DV - Aoi 30

Placental compromise

Placental Resistance Early IUGR: Intervention threshold C B A Subclinical placental disease Compensated hypoxia Decompensated hypoxia (acidosis) Fetal death Where shoul be the intervention threshold be? A - Risk of fetal death vs severe prematurity B - Less risk of death, less decompensative hypoxia period but still prematurity C- No risk of death, theoretically small risk of neurological influence, but highr risk of prematurity, so could be appropriate policy from some week of pregnancy, where the risk of prematurity complications is small How this cut off should be defined ( DV?? Which changes, BPP, which changes ??) 32

Placental Resistance Early IUGR: Intervention threshold >32w 28-32w Abnormal BPP >32w 28-32w <28w Subclinical placental disease Compensated hypoxia Decompensated hypoxia (acidosis) Fetal death In BCN – before 28 weeks of gestation, according to the literature ( Bashat) when the most important factor is GA, only severe DV changes are considered abnormal – Reversed a wave - 28-32 week when the risk of prematurity is less- absent A vawe will be considered as abnormality of DV, which nessesitates delivery - after 32 week – when the risk of prematuruty is low, any abnormality of DV, for example elevated PI, will be considered as a reason for delivery. BPP lost in sequential manner, which is determined by differemt sensitivity on pH Loss of reactivity, breathing movement, gross movement, tone. AF in mostly dependent on cardiac function and not a part of neural system deterioration. 33