small for gestational age management
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TRANSCRIPT
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Management of
Small For Gestational Age
RCOG,2013
Aboubakr Elnashar
Benha university Hospital, Egypt
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Definitions
Prevention
I. Screening
II.Diagnosis
III.Investigations
IV.Surveillance
V.Delivery
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Definitions SGA
EFW or AC <10th centile
EFW or AC <3rd centile: Severe
60%:
constitutionally small, with fetal growth appropriate
for maternal size and ethnicity.
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FGR
Pathological restriction of the genetic growth
potential.
±Manifest evidence of fetal compromise:
abnormal Doppler studies, reduced liquor volume.
Not synonymous with SGA.
Some, but not all, FGR are SGA
Higher in severe SGA
LBW
An infant with a birth weight < 2500 g.
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Population centiles:
Customised centiles:
Maternal: height, weight, parity and ethnic
group
Foetal: sex
better sensitivities for identifying FGR lower false-positive rates predictive of poor perinatal events (Grade B, RCOG 2013)
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Prevention
1. Smoking cessation
2. Antithrombotic agents
Promising in high risk women.
insufficient evidence, especially concerning
serious adverse effects, to recommend its use.
3. Antiplatelet agents
Effective in preventing SGA in women at high risk
of preeclampsia
At or before 16 w
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I. Screening 1. At booking for risk
factors
1 major risk factor:
serial US for
fetal size and
Um AD at 26-28 W
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Fetal echogenic bowel
:Serial US
fetal size and
Um A D at 26-28 W
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A low level (< 0.415 MoM) of the 1st trimester
marker PAPP–A should be considered a major
risk factor for SGA.
2nd trimester DS markers have limited
predictive accuracy for a SGA:
AFP: (> 2.5 MoM or < 0.25 MoM),
Elevated hCG (> 3.0 MoM) and
Inhibin A (≥ 2.0 MoM),
low unconjugated estriol (< 0.5 MoM) and the
combined triple test
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3 minor risk factors:
Ut A D at 20-24 W:
Abnormal [PI]
>95th centile:
Serial US for fetal size
and Um A D at 26-28 w
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Ut AD: Normal Ut AD:
Notch
Decreased diastolic flow
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2. At each ANV from 24 W:
Serial SFH: <10th centile or static:
US of fetal size & UmAD at 28 w.
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II. Diagnosis
AC or EFW < 10th centile
Reduced growth velocity:
AC or EFW at least 3 w apart
{minimize false–positive rates for diagnosing FGR}.
: serial assessment of fetal size and UA Doppler.
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Transverse abdominal Triad
Deep portion of portal vein
(J sign)
Spine
Stomach
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III. Investigations Severe SGA:
1. Detailed fetal anatomical survey and uterine
artery Doppler
2. Serological screening for CMV and toxoplasmosis
3. With structural anomalies: Karyotyping
High risk population:
Testing for syphilis and malaria .
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IV. Surveillance 1. Umbilical artery Doppler
Every 14 days.
More frequent: severe SGA
Twice weekly: abnormal U A D
(PI or RI > +2 SDs above mean for ges age) and
end–diastolic velocities present
Daily: absent/reversed end–diastolic
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Normal
Absent
Reversed
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2. MCA Doppler
In preterm SGA:
limited accuracy: should not be used
In term SGA:
Normal UA Doppler, an abnormal MCA Doppler
(PI < 5th centile) has moderate predictive value for
acidosis at birth: used to time delivery.
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IUGR Normal
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A: The normal middle cerebral artery
flow pattern has relatively
little diastolic flow
B: With elevation of placental blood
flow resistance the changes in the
middle cerebral artery waveform may
be subtle, although the
cerebroplacental ratio may become
abnormal.
C: With progressive placental
dysfunction there may be an increase
in the diastolic velocity, resulting in a
decrease in the Doppler index (Brain
sparing
D: With marked brain sparing, the
systolic down slope of the waveform
becomes smoother so that the
waveform almost resembles that of
the umbilical artery. The associated
rise in the mean velocity results in a
marked decline in the
Doppler index.
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3. Ductus venosus (DV) and umbilical vein (UV)
Doppler
Moderate predictive value: used in the preterm
SGA with abnormal UA Doppler and to time
delivery.
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In the ductus venosus blood flow is always antegrade throughout the cardiac
cycle under normal circumstances.
Pulsatility is less pronounced in waveform patterns obtained at the inlet (A)
versus the outlet (B). With impaired cardiac forward function there is a decline
in forward flow during atrial systole (C). If progressive atrial forward flow may be
lost (D) or reversed (E, F).
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4. CTG or
Amniotic fluid volume
not be used as the only form
Biophysical profile should not be used
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V. Delivery Corticosteroids
Single course
Between
Vaginal delivery: 24+0 and 35+6 w
CS: 24+0 and 38+6 w.
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Timing: Normal Um AD
-At 37 w
-At 34 W:
Static growth over 4 w
MCA PI < 5 centile
EDV present but PI or RI >2SD
-At 37 w
-At 34 W:
Static growth over 3 w
AREDV
-At 32 w
-Before 32w:
Abnormal DV Doppler
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Mode
AREDV:
CS
Normal UA Doppler or
Abnormal UA PI but end–diastolic velocities
present:
IOL +
continuous FHR monitoring
CS
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At booking: 1 major risk factor
or 3 minor risk factor
At each ANV: SFH <10 centile or
static
Reassess at 20 w
Abnormal D synd marker (minor)
F echogenic bowel (major)
Ut a Doppler at 20-24 w
3 minor R factors 1 major R factor
Normal Abnormal
Reassess F size and Um
A Doppler in 3rd T
Serial assessment of F size and um A
Doppler 26-28w
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Thank you