1. FETAL GROWTH RESTRICTION for MBBS students

2. Definition Fetuses that have failed to achieve their growth potential because of inadequate oxygen and nutritional supply

3. FGR is divided into two groups Type 1: Fetus is symmetrically small Type2:Fetal growth is asymmetrical. Abdomen is small as compared to the head

4. Gestational AgeApproximate Weight 105 22500 301500 403400 Approximate Weight of Normal Fetus

6. Factors Affecting Fetal Growth And Size Physiological a.Genetic b.Fetal Sex c.Parental Height and Weight d.Maternal Age e.Birth Order Socioeconomic Status

7. Causes of FGR Chromosomal Abnormalities Infection Structural malformations Primary Fetal

8. Maternal Causes of FGR Chronic Illnesses., APAS,HTN,chronic renal,cardiac diseases etc Infections. Endocrine disorders e.g. diabetic nephropathy, hyperthyroidism. Malnutrition. anorexia nervosa and bulimia Smoking,alcoholism Drug Abuse. Cocaine, amphetamines, betal chewing Therapeutic drugs like B-blockers,Phenytoin

9. Placental causes Placento fetal causes placental mosaicism failure of second wave of invasion ( pre-eclampsia) fibroids Fetoplacental causes defective angiogenesis single umbilical artery

10. Hazards of FGR IUD,15 fold increased risk Intrapartum hypoxia Neonatal Complications Respiratory distress syndrome Meconium aspiration syndrome Post asphyxial seizures Hypoglycemia, hypocalcemia DIC,Polycythemia Necrotizing enterocolitis Renal complications

11. Long term complications Impaired neurodevelopment Diabetes mellitus Hypertension Cardiovascular disease Obesity

12. Management

13. Prediction of FGR History to find risk factors Low S.E.C Family h/o FGR. BMI < 19 Smoking Poor pregnancy weight gain Medical complications Obstetric complications

14. Maternal serum screening If level of AFP is 2.5 or > of the median risk of FGR is 5-10 times more USG markers Abnormal uterine artery Doppler velocimetry Echogenic fetal bowel

15. Screening & diagnosis Clininical assessment F undal Height Measurement Ultrasound assessment fetal biometry HC,AC,HC/AC ratio AC,Femur ratio, EFW Liquor volume Umbilical artery Doppler studies

21. DIAGNOSIS Fetal AC < 5 th centile Fetal growth velocity < 1.5 S.D in 2 wks AFI < 5 Abnormal umbilical artery Doppler waveform

22. Management Find the cause Chromosome analysis MSAFP Screening for TORCH Anticardiolipin antibodies, lupus anticoagulant Anomaly scan

23. Management Bed Rest Frequent AN Checkup Nutritional Supplements Beta Adrenergic Drugs Fetal Monitoring

24. Assessment of Fetal Growth Serial measurement of: mother’s weight fundal height fetal biometry

25. Assessment of fetal well-being Fetal movement record NST, CST BPS Doppler studies

26. Management Options Depends on Fetal Size Liquor Volume Umbilical artery doppler

27. SGA With all Indices Normal If > 37 wks Deliver

28. SGA and all indices are normal < 37 weeks No risk factors 1.Steroids if < 34 wks 2. Monitor fortnightly by: Fetal biometry UADW Liquor assessment

29. If Reduced EDF Admit the patient Steroids CTG & BPS daily Doppler twice weekly Growth scan after one week 40 % Humidified Oxygen

30. If absent or reversed end diastolic flow Admit Plan Delivery

31. Mode of delivery Depends on : Gestational age Presence of acidaemia Bishop score

32. Indications of an elective CS 1.Any obstetric indication like CPD, APH,PIH etc. 2.Low BPS,abnormal CTG 3.Poor Bishop Score

33. Induction of Labour  At > 37 wks of gestation  In a well equipped hospital  Short trial of labour  Continuous intrapartum fetal monitoring  Early amniotomy to detect the presence of meconium stained liquor and apply scalp electrode for internal CTG.

34. Cont. Narcotic analgesics to be avoided Epidural analgesia is safe but maternal hypotension and hypovolaemia should be avoided. Senior paediatrician should be in the L.R to do proper resuscitation so that meconium aspiration is avoided.

35. Immediate neonatal period First 72 hours are very critical.

36. Prevention TOP AID Avoidance of maternal hyperthermia at time of NT closure Avoidance of contact with infected individuals. Girls immunized against Rubella,Cytomegalovirus. Women seronegative for toxoplasmosis should avoid contact with animals Alcohol, cigarette smoking avoided Treatment of medical problems