monitoring fetal growth
TRANSCRIPT
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MONITORING
FETAL
GROWTH
Self - Inst ru cti on
Manual
2011
Fescina RH
De Mucio B
Mart nez G
Alem n A
Sosa C
Main ero L
Rubi no M
Scient if i c Publicat ion CLAP/WR 1586 .02
2 nd ed i t ion
Lat in Am er ican Center for Per inatology
Women & Reproduct ive Healt h - CLAP/WR
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MonitoringFetal
Growth
Self-Instruction
Manual 2nd editionFescina RHDe Mucio BMartnez GAlemn ASosa C
Mainero LRubino M
Latin American Center for PerinatologyWomen and Reproductive Health CLAP/WR
Familiy and Community Health
Pan American Health Organization / World Health Organization
www.clap.ops-oms.orghttp://new.paho.org/Clap
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2 Monitoring Fetal Growth
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TABLE OF CONTENTSPag
INTRODUCTION 4
FACTORS AFFECTING INTRAUTERINE GROWTH
PHYSIOPATHOGENESIS OF INTRAUTERINE GROWTH RESTRICTION
DIAGNOSIS
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DIAGNOSIS OF IUGR WITH KNOWN OR ESTIMATED GESTATIONAL AGE
DIAGNOSIS OF IUGR WHEN THE GESTATIONAL AGE IS EITHERUNRELIABLE OR UNKNOWN IN PREGNANT WOMEN CAPTURED LATEFOR CONTROL
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DIFFERENTIAL DIAGNOSIS BETWEEN A FETUS WITH APPROPRIATEGROWTH AND IUGR WITH UNCERTAIN LMP AND LATE CAPTURE
DIFFERENTIAL DIAGNOSIS BETWEEN SYMMETRIC IUGR AND ERROR INTHE ESTIMATION OF GESTATIONAL AGE BY LMP
PROPOSALS FOR THE SOUND USE OF THE FETAL GROWTHSURVEILLANCE METHODS
OBSTETRIC MANAGEMENT OF INTRAUTERINE GROWTHRESTRICTION
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BIBLIOGRAPHY
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Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR
MONITORING FETAL GROWTH
SELF-INSTRUCTION MANUAL
INTRODUCTION
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uneventful cell division and growth, yielding a full-term term infant with full
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For practical clinical purposes, a fetus is considered to have an intrauterine
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In a strict sense, it is important to consider that:
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a normal child with a low growth potential.
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Exercise 1
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Exercise 2
Let us review the concepts of SGA and LBW. Try to locate the 4values listed below in Figure 1.
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the population, as to warrant changing the reference standards.
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FACTORS AFFECTING INTRAUTERINE GROWTH
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differentiation, and it leads to the development of organs and tissues in
charge of complex and interrelated functions.
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at which they are detected:
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4. Pregnancy-induced hypertension / preeclampsia-eclampsia
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c) Environmental and behavioral risk factors
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2. Heavy alcohol consumption
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PHYSIOPATHOGENESIS OF INTRAUTERINE GROWTH
RESTRICTION
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In the latter, the asymmetric growth is due to insults that appear in the third
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the various tissues, i.e., tissues present their hyperplasia at different times of
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so-called critical period.
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Figure 3 Critical periods of the different tissues and perinatal outcomesdepending on the time of occurrence and the duration of thenoxa
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DIAGNOSIS
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of technological complexity, and that are generally found in specializedfacilities.
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monitoring of fetal growth for the entire population of pregnant women,
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of resources.
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diagnosis, and thus decide what level of complexity is appropriate forthat delivery.
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For this reason, instead of a scoring system, we recommend using a list
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time the pregnant woman is captured for antenatal care.
Table 1- Risk factors in a Latin American population (Brazil,Argentina and Uruguay)
Risk Factor Frequency inpopulation %
RelativeRisk
95% Confidenceinterval
History of SGASmoking habit (10 o +)Multiple pregnancyPregnancy-induced hypertensionPreeclampsiaHemorrhage 2nd trimesterWeight gain < 8 kg.Oligoamnios
1426174
0.5160.5
1.51.63
1.42.11.62.12.9
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as an approximation to the time of ovulation and therefore, the time
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in addition, this date also coincides with the clinical examination of the
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Central value andconfidence limitsfor estimatinggestational agebased on theultrasound
measurements of:
Femur lengthBiparietal D.Ceph.-Buttocks length
Figure 4. Estimation of gestational age based on the fetal anthropometricmeasurements using two-dimensional ultrasound. (21)
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DIAGNOSIS OF IUGR WITH KNOWN OR ESTIMATEDGESTATIONAL AGE
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with decreased fetal movements, oligohydramnios, low maternal weight
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relation to the duration of pregnancy.
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Although there is no compelling evidence regarding the use of fundal
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with the measurement of the fundal height, the diagnosis should always
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Maternal
weight
gain
Kg.15
13
16 20 24 28 32 36 40
11
9
7
5
3
10
Weeks of amenorrhea
P90
P75
P50
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P10
Figure 5. Maternal weight gain in Kg by gestational age. Longitudinal
prospective study N = 1023 weight measurements. (22)
P90P50
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3129
27
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19
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dalheight
Figure 6. Fundal height in cm by gestational age. Longitudinal prospectivestudy. N = 1074 measurements. (23)
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Exercise 3
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162427
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Table II - Maternal weight by height by gestational age (p10-p90). (22)
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-RLQWKHSRLQWVWKDW\RXKDYHIRXQGLQJXUHDQGREWDLQWKHPDWHUQDOZHLJKW
gain curve for that case.
You will see that the curve of the case studied crosses it and falls under percentile
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of the fundal height of this case.
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Exercise 5
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Maternal
height(cm.)
Maternal
Weight(kg.)
Is maternal weight forheight by gestational
age appropriate?
Gest.
age(wk.)
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KNOWN AND RELIABLE GESTATIONAL AGE
Serial measurements
Confirmation ultrasound
using GA-dependent
growth indicators
Appropriate fetal growth- low
risk antenatal control
D i a g n o s i s o f I U G R
Ruled out
See algorithm for the differential diagnosis betweensymmetric and asymmetric IUGR and management
Confirmed
Estimation ofGestational age by
ultrasound
Ultrasound after the3rd trimester usingGA independent
growth factors
Fundal heightMothers weightEstimation of volume amniotic fluidInvestigate risk factors
Values < lower limitOligohydramniosPresence of risk factors
Distance curve of fetalabdominal circumference andhead circumference bygestational age
By Crown-to-rump length8-13 weeksBy BPD after 12 weeksBy Femur length after13 weeks
Early captureBefore 20 weeks
.
Abd. CircFemur length
Growth rate based on previousvalue of fetal abdominalcircumference
Ratio =
Clinical
testing
Complementar
y
met
hods
Yes
Yes
No
Yes No
No
Figure 7. Algorithm for the diagnosis of IUGR
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Headcircumference
mm
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P50P5
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Figure 8 - The fetal head circumference measurements in thesymmetric growth restriction (---) fall early (24 weeks) belownormal limits (percentile 5), while in the asymmetric restriction(.....) measurements usually remain within normal limits. (15)
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mm.390
370
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230210
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Abdominalcircumference
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Figure 9 - The fetal abdominal circumference falls below the normalrange (percentile 5) around 32 weeks in the types of restrictions, sothis measure is the most sensitive indicator. In the case of symmetricrestrictions (---), its fall occurs later than the asymmetric restrictionsof the head circumference (24 weeks) (.....). (15)
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Table III-Effectiveness of fundal height, maternal weightgain, fetal abdominal circumference, fetal headcircumference, BPD and oligoamnios measured byultrasonography to predict SGA (24)
Measured Variable 4.25Normal fetal AC
Normal fetal femur length
Example = = 4.55300 mm
66 mm
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Symmetric. IUGR = = > 4.25Low fetal abdominal circumference
Low fetal femur length
Example = = 4.81
260 mm
54 mm
What test would you order to establish the differential diagnosisbetween a fetus with a normal growth and an asymmetric IUGR,
two situations that require a radically different management?
Measure the FAC/FL ratio
Measure the increase of the FAC based on its previous value
Measure the Head Circumference
Measure the BPD
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value:
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DIFFERENTIAL DIAGNOSIS BETWEEN SYMMETRIC IUGRAND ERROR IN THE ESTIMATION OF GESTATIONAL AGEBY LMP
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circumference
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the growth rate
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an appropriate growth. Conversely, if the increase is less than
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distance curves and growth rates.
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Table IV-Behavior of fetal growth when there is an error in theestimation of gestational age by LMP and asymmetricand symmetric growth restriction
CURVES
At a distance Growth rate based on a previous value
BPDHead circumferenceFemur length
AC
NormalNormal
Normal Decreased
DecreasedDecreased
B.P.DHead circ.Femur length
AC
Error in theestimation ofgestational age
Lower thannormal and tendingto converge
Lower than normal and diverging
Asymmetric IUGR
Symmetric IUGR
Within normalrangesmay occur late
Lower than normaland diverging
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PROPOSALS FOR THE SOUND USE OF THE FETALGROWTH SURVEILLANCE METHODS
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weight gain at each antenatal care visit.
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Table V - Diagnosis of IUGR using risk factors, fundal height and
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OBSTETRIC MANAGEMENT OF INTRAUTERINE GROWTH
RESTRICTION
A) Antenatal management
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others.
In the case of hypertensive women, the administration of low doses of
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of prostacyclin, with a predominance of the latter over the former, thus
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Table VI - Table VI: Prevention of the birth of small for gestationalage infants with low-dose aspirin. The common oddsratio (summary measurement of the results of the 7VWXGLHVVKRZVWKH VLJQLFDQWSURWHFWLYHHIIHFWRI LWVadministration. This protective effect of aspirin wouldreduce the SGA likelihood by 20% (between 10% and
30%)Therapy (%) (%) Odds ratio (95% confidence internval)Contr.
4/48Beaufils et al.
Wallenburg et al.
Wallenburg et al.
Schiff et al.
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Common
Odds ratio
4/41
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473/6604
(8.3)(1985)
(1985)
(1985)
(1985)
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0.08
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401/4821
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(28.8)
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death according to the different gestational ages.
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determine the gestational age at which you decide to interrupt pregnancy.
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pregnancy. If the fetal lung has not synthesized surfactant, its synthesis
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the contrary, it recovers its growth pace and exceeds the lowest level in the
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this compensatory mechanism is missing, or when the resistance of the
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In cases where the plan is to have a vaginal delivery, one must considerthat these fetuses show a high incidence of acute fetal distress, especiallyWKHDV\PPHWULFW\SHRI,8*5VRLWLVUHFRPPHQGHGWRHQVXUHDVWULFWclinical monitoring of the fetal heart rate and uterine contractions during
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value is consistent with the earlier ultrasound.
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Symmetric IUGR
Your diagnosis is:
Asymmetric IUGR
Fetus with a normal growth
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35 week fetus; GA based on the previous ultrasound
Abdominal circumference 280 mm (
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strategy would you suggest?
The fetus has been confirmed an asymmetric IUGR.What monitoring strategy would you suggest?
Monitoring with biophysical profile of the fetus
Monitoring only with fetal eco Doppler
Monitoring only with fetal eco Doppler ultrasound
Monitoring with measurement of the fundal height
Monitoring only with obstetric ultrasound
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EXERCISES USING THE PERINATAL COMPUTINGSYSTEM FOR THE ASSESSMENT AND MONITORING OFFETAL GROWTH
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program Distribution of a variable and place the Gestational ageat birthDVDYDULDEOHIRUGLVWULEXWLRQDQG birth weight as a studyYDULDEOH
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for this new target population, we have
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Listing of medical recordshistorias
B-7KH6,3VRIWZDUHOHWV\RXOLVWDVHWRIPHGLFDOUHFRUGVWKDWPHHWcertain conditions. In each list, the software displays a document that
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History of LBW
Smoking habit
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Preclampsia
Multiple pregnancy
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Fill in the chart below with the data included in the table
Damage: SGAProportionexposed
(frequency %)Risk Factors RR
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95% Confidenceinterval
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Basic statistics
D-7KHKey Indicators Report program provides the main indicatorsof perinatal care and gives a clear overview of some characteristics of thepopulation served and the outcomes of the care provided.
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Third trimester
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Fourth trimester
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Trimester ENM rate %o SGA %
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Answers to the exercises using the perinatal informationsystem for the assessment and monitoring of fetal growth
Exercise A - Weight percentiles of Institution A
Weight percentiles at Institution B
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Weeks of amenorrhea
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The population of Institution A
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Bibliography
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investigation and management of the small-for-gestational-age
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a gestational age estimation method. Paediatr Perinat Epidemiol
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7/29/2019 monitoring fetal growth
81/81
www.clap.ops-oms.org
Monitoring
Fetal
Growth
Self - InstructionManual
oring
Fe
talGrow
th
Se
lf-
Ins
truc
tion
Manu
al2n
d.
edition
CLAP/WR-
PAHO/WHO
ISBN 978-92-75-132 28-9
http://perinatal.bvsalud.org/
2nd edition