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Definitions Definitions M&M M&M Etiologies Etiologies Dia Diagnosis gnosis Evalua Evaluation tion Mana Management gement

Definition of Definition of FGR FGR • Failur ailure e to to ob obta tain in op optimal timal intr intrau aute terine rine growth wth • ACOG: COG: EFW EFW < 10% < 10%  Fetu etus s may may be be no normal mal bu but sma t small ll  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 Morbidity bidity & Mor & Morta tali lity ty 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 Man m Manning ing F 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 2002;99 ;99:49 :490-6. 6.

Risk Risks s of of FGR FGR in Ad in Adult ultho hood od Hype Hyperten tension sion Hype Hypercho holester lesterolemia olemia Coron Cor onar ary y he hear art dise t diseas ase Di Diabe betes tes DJ DJ Ba Barker r et al. t al. Lancet t 1986;1:10 ;1:1077-1081. 1081.

Nor Normal mal Fet etal al Gr Growth wth • 15 15 wee eeks ks ’ GA: GA: 5 5 g/d g/day ay • 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/day g/day

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 ntrib ribut ution ion fr from om mot 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 Ma Mate terna nal l ge geno noty typic pic diso disorde ders

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 & & multif multifac acto torial rial 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* Ab Abno norma mal l ka karyot otyp ype e in 40 in 40% % with with an anom omal aly 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 absen bsent t AF* AF* *RJ *RJM M Snijde Snijders s et al. t al. Am Am J Ob Obste stet Gyn t Gynecol l 1993;16 ;168:54 :547-55. 55.

FGR FGR + str + structur uctural def al defect ect FGR FGR in midtrimester in midtrimester ACO COG G Pr Prac acti tice ce Bull Bulletin. etin. Number 134 Number 134, , May May 20 2013 13

Uterine En Uterine Envir vironment: onment: 60% 60% Variance ariance

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 & var CMV & varicella icella 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

Smoking Smoking 3.5 3.5x x  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 mon Quit Quit by by 7 th month th: : mea mean n BW BW high higher er th than an th thos ose e who ho smok smoked ed th throu ough ghou out

Substanc Substance e Abuse Abuse Fet etal al alco alcoho hol l sy synd ndrome ome: : all all ha have e FGR FGR Unk Unkno nown wn if if t thr hres esho hold ld li limit mit exist xists He Heroin oin: : up up to to 50 50% Met Metha hado done ne: : up up to to 35 35% Coc Cocaine aine: : 30 30% % or or mor more

Ter eratoge togens ns War arfar arin in Phe Pheny nyto toin, in, tr trimeth imethad adione ione, , ph phen enob obar arbita bital At Aten enolol olol

Malnu Malnutritio trition Poor oor pr pregest gestational tional nutr nutrition: ition: BW  by BW by 40 400-60 600 0 g. g. In pr In previou vious s well ell no nour urishe ished d gravid; vid; BW BW  rd tr by ~ 10% by ~ 10% if if <1500 <1500 kcal/day kcal/day in in 3 rd trimest imester er

Ma Mate terna nal l Vas ascu cular lar Dise Diseas ase: e: 25 25-30 30% % of of F FGR GR Co Cond ndition itions s th that a t affec ect micr t microc ocir ircu cula latio tion Colla Collage gen-va vasc scular ular 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 scula ular r dise diseas ase An Antip tipho hosp spho holipid lipid sy synd ndrom ome e (APS (APS)

Hyper Hypertensiv tensive e Disor Disorder ders Chr Chronic onic hyper hypertension: tension: • 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 • Inco Incomplet mplete e in inva vasion sion of of t trop opho hoblas blast

Abn Abnor ormal mal Place Placent ntation tion in in Pr Pree eeclamps lampsia ia • Ab Abno norma mal in inva vasion sion of of tr trop opho hoblas blast • Res esults ults in in failur ailure to e to su sufficient ficiently remo emode del sp spir iral al ar arte teries ries • High High- res esista istanc nce ves esse sels ls

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

Con Confi fine ned d Place Placent ntal al Mos Mosaicism aicism Place Placent ntal al mos mosaicism aicism in in up up to to 25 25% % of of ca case ses s of of une unexp xplained lained FGR FGR L W L Wil ilkins kins-Hau aug g et et al. Am al. Am J J Obs Obste tet Gyne t Gyneco col l 19 1995 95;172 ;172:44 :44-50. 50.

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

Multiples!!! Multiples!!! Twins: wins: 25 25% Triplet riplets: s: 60 60% Qua Quads ds: : 60 60%

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 Norma mal A l AC e C exclud ludes es FGR FGR Lower sen Lo er sensiti sitivity vity the then wi with th 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% c/w < 2.5% c/w F 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

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