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Definit Definitions ions M&M M&M Etiologies Etiologies Diagnos Dia gnosis is Evalua Evaluation tion Mana Management gement

Definit Definition of ion of FGR FGR • Failur ailure e to to ob obta tain in op optimal timal intr intrau aute terine rine growth wth • ACOG COG: : EF EFW W < 10% < 10%  Fetu etus s ma may be y be no norma mal bu but small t small  FGR FGR may may be pr be prese esent nt if if E EFW FW > 10% > 10% • SGA: SGA: Inf Infan ant < 10% t < 10%

Mor Morbid bidity ity & Mor & Morta tality lity of of FGR FGR M&M M&M  sh shar arpl ply as as BW BW  fr from om 10 10% % to to 1% 1% From Mann om Manning F ing FA A in in Resn esnik ik R. R. Intr Intrau aute terine rine Gr Growth wth Rest estriction riction. Obs Obste tet Gyne t Gyneco col l 20 2002 02;99:49 ;99:490-6. 6.

Risk Risks s of of FGR FGR in Ad in Adult ultho hood od Hyperten Hype tension sion Str Strok oke Cor Coron onar ary y he hear art di t disea sease se Dia Diabe betes tes DJP Ba DJP Barker er. Cli . Clin n Obs Obste tet Gyneco Gynecol 20 2006 06;49:27 ;49:270-83 83. .

Nor Normal mal Fet etal al Gr Growth wth • 15 15 wee eeks ks ’ GA: GA: 5 5 g/da g/day • 20 20 wee eek ’ s s GA: GA: 10 10 g/da g/day • 32 32-34 34 wee eeks ks ’ GA: GA: 30 30-35 35 g/da g/day

Parental Characteristics for FGR

Genetics of Genetics of Bir Birth W th Weight V eight Variance ariance ~20% ~20% of of tot total BW al BW va varia riation tion fr from om ge gene netic tic co cont ntribu ribution tion fr from mot om mothe her Ma Mate terna nal l ge gene nes s ha have e main main infl influe uenc nce e on on BW BW Pate terna nal l infl influe uenc nce e is is with Y with Y chr hromo omoso some me

Fetal Etiologies

Fetal Structural Anomalies Gastroschisis Congenital heart defects

FGR FGR + str + structur uctural def al defect ect FGR FGR in in midtrimester midtrimester ACO COG Pr Practice actice Bul Bullet letin. in. Number 134, M umber 134, May ay 2013 2013

Ge Gene netic tics s in V in Var arian iance ce of of B Bir irth th Weig eight ht Chr Chromo omoso somal mal abn bnor ormalities malities &/or &/or co cong ngen enital ital an anoma omali lies es: 20 20% % of of F FGR GR fet etus uses es Abn Abnor ormal mal ka karyot otyp ype e in 19% in 19% of of FGR FGR fet etus uses es* Abn Abnor ormal mal ka karyot otyp ype e in 40% in 40% with with an anoma omaly vs vs. . 2% with 2% with isola isolate ted d FGR FGR* Abn Abnor ormal mal ka karyot otyp ype e in 40% in 40% with with no normal mal or or  AFI vs. AFI vs. 8% with 8% with  or or abs bsen ent t AFI* AFI* *RJM *RJM Snij Snijde ders s et et al. al. Am Am J J Obs Obste tet Gyne t Gyneco col l 19 1993 93;168 ;168:547 :547-55. 55.

Con Confi fine ned d Place Placent ntal al Mos Mosaicism aicism Plac Placen enta tal l mo mosa saicism icism in in up up to to 25 25% % of of case ca ses s of of une unexp xplained lained FGR FGR L W L Wil ilkins kins-Hau aug et et al. Am al. Am J J Obs Obste tet Gyn Gynec ecol ol 19 1995 95;172 ;172:44 :44-50. 50.

Multiples!!! Multiples!!! Twins: wins: 25% 25% Triplets: riplets: 60% 60% Quads: Quads: 60% 60%

Maternal Factors

Smoking Smoking 3.5x 3.5x  of of SGA SGA inf infan ants ts Quit Quit < < 16 16 w wee eeks ks ’ GA: GA: BW BW simil similar ar to to no nons nsmok moker ers s th mo Qu Quit it by by 7 th mont nth: h: me mean an BW BW hig highe her th than an th thos ose e who ho smok smoked ed th throu ough ghou out

Substance Abuse Substance Abuse Fet etal al alc alcoh ohol ol sy synd ndrom ome: e: all all ha have e FG FGR Unkno Unk nown wn if if t thr hres esho hold ld li limit mit exist xists Her Heroin: oin: up up to to 50 50% Met Metha hado done ne: : up up to to 35 35% Cocaine Coc aine: : 30 30% % or or mor more

Ter eratogens togens Warf arfarin arin Ph Phen enyt ytoin oin, , tr trimet imetha hadio dione ne, , ph phen enob obar arbit bital al At Aten enolo olol

Congenital Congenital Inf Infections ections Acc Accou ount nts s for or 5 5-10 10% % of of F FGR GR Malaria most common world wide Rub ubella, ella, CMV CMV & var & varice icella lla Toxoplasmosis & sy syph phil ilis is Bac Bacte terial rial inf infec ection tions s no not dir t direc ect t ca caus use e of of F FGR GR

Malnutrit Malnutrition ion Poo oor r pr prege gest station tional al nu nutr trition: ition: BW BW  by by 40 400-60 600 0 g. g. In previou In pr vious s well ell no nour urishe ished d gravid; vid; BW BW  rd tr by by ~ 10% ~ 10% if if <150 <1500 0 kc kcal/day al/day in in 3 rd trimeste imester In absence of malnutrition, increased nutrient intake doesn’t improve outcomes

Ma Mate terna nal l Vas ascu cular lar Disea Disease se: : 25 25-30 30% % of of F FGR GR Con Condition ditions s th that af t affec ect micr t microc ocir ircu cula lation tion Mos Most t co common mmon ca caus use e of of FGR FGR in in no nona nano nomalou malous fet etus us Co Colla llage gen-va vasc scula ular r dise diseas ase Ren enal al dise diseas ase Hemoglobino Hemo lobinopa path thies ies Diabe Dia bete tes s with with micr microva vasc scular ular dise diseas ase Ant Antipho iphosp spho holi lipid pid sy synd ndrome ome (APS) (APS)

Hyper Hypertensiv tensive e Disor Disorder ders Chr Chronic hyper onic hypertens tension: ion: • Se Sever erity ity of of vas vascu cular lar da dama mage ge • Abs Absolut olute e le level el of of b blood lood pr pres essu sure Pr Preec eeclampsia lampsia • Abn Abnor ormal mal plac placen enta tation tion • Inc Incom omple plete te in inva vasion sion of of t trop opho hobla blast st

Placental Factors

Placental Placental Factor actors s in FG in FGR • Freq eque uent ntly y ha have e abn bnor ormal mal siz size e &/or &/or func function tion • Abr Abruption uption • Abno Abnormal cor mal cord insertion inser tion • Cir Circumvalla cumvallate te placenta place nta • Two v o vessel essel cor cord

Risk of recurrence for SGA birth: 20% Review for risk factors Modify those you can Serial ultrasounds

In Review: ➢ FGR: EFW < 10% for GA ➢ 20% of variance for fetal weight contributed by mother & 20% from fetus ➢ Environmental factors account for 60% of variance ➢ Abnormal placentation biggest cause of FGR

Problem Solving: Assess Risk Factors Social habits Weight gain Medications Optimize medical management Avoid aerobics

Clinical Clinical Dia Diagn gnos osis is of of FGR FGR Fundal height 24- 38 weeks’ GA Single Sing le fund fundal al mea measu sureme ement nt be betw twee een 32 32-34 34 wks wks. . GA: GA: ~ ~ 65 65-85 85% % se sens nsitiv itive e an and d 96 96% % sp spec ecif ific ic for or FGR FGR Comp Compromise omised d by by ma mate terna nal l bo body dy ha habitu bitus & fi & fibr broids oids Scr Scree eening ning on only; y; no not as t as gu guide ide for or mana manage gemen ment t whe hen n risk risk fac acto tors s or or susp su spicions icions for or FGR FGR pr pres esen ent

Ultr Ultras asou ound nd Eva Evalua luation tion for or FGR FGR 4 Sta 4 Stand ndar ard d Mea Measu sueme ement nts: s: 1. F 1. Femu emur r leng length th 2. BPD 2. BPD 3. HC 3. HC 4. A 4. AC Value alues a s app ppli lied ed to to for ormu mulas las to o to obta btain in EFW EFW

AC C vs. vs. EFW EFW • Nor Normal mal AC e C exclude ludes FGR s FGR Lo Lower sen er sensiti sitivity vity the then with with a f a false alse ne nega gativ tive r e rate te AC: C: 85 85% vs. % vs. 98 98% of of < <10 10% High Hi gher PP er PPV V tha than A n AC: C: • Su Suspe spect ct FGR if FGR if A AC < 10 C < 10% 51 51% vs. 3 % vs. 36% 6% • AC C < 2.5% < 2.5% c/w F c/w FGR GR AA AA Basc Bascha hat. Ob t. Obste stet Gyne t Gyneco col l Sur Surv v 20 2004 04;59:61 ;59:617-27. 27.

In Review: Serial fundal measurements only for screening If significant risk factors or suspicions for FGR: obtain sono Serial ultrasounds 3-4 weeks apart until delivery

Problem Solving: Evaluating for Diagnosis Sono with echo: Amniocentesis: Karyotype/microarray Anomalies? PCR for toxo & CMV Chromosomes? Lab work: Infections? Infections? Placenta? Preeclampsia? APS?