monitoring fetal growth

7/29/2019 monitoring fetal growth

1/81

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


2/81

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

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interpretation and use of the material lies with the reader. In no event shall the Pan American

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2 Monitoring Fetal Growth

Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR

TABLE OF CONTENTSPag

INTRODUCTION 4

FACTORS AFFECTING INTRAUTERINE GROWTH

PHYSIOPATHOGENESIS OF INTRAUTERINE GROWTH RESTRICTION

DIAGNOSIS

t $BMDVMBUJPOPGHFTUBUJPOBMBHF

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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EXERCISES USING THE PERINATAL COMPUTING SYSTEM FOR THE

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3Monitoring Fetal Growth


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BIBLIOGRAPHY


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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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Figure 2 Standards developed by CLAP/WR for neonatal weight bygestational age


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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:

a) Preconception risk factors,

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4. Pregnancy-induced hypertension / preeclampsia-eclampsia

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c) Environmental and behavioral risk factors

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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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the duration of pregnancy and properly evaluate fetal growth, we will

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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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An alternative method used is the clinical estimation of gestational age

E\WKHSK\VLFDOH[DPLQDWLRQRIWKHIXQGDOKHLJKW+RZHYHUWKHUHLVDOVRHYLGHQFHWKDWWKLVWHFKQRORJ\KDVOLWWOHYDOXH8VHGLQLVRODWLRQ

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18/81



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EHFRPHVYLVLEOHWKHSDUDPHWHUXVHGWRHVWLPDWHJHVWDWLRQDODJHLVWKHcrown-to-rump length, which has a linear relationship with gestational

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WKH)HPXU/HQJWK)/

105

9

13

17

21

25

29

33

37

41

16 22 28 34 40 46 52 58 6470 76 82 88 94 100 mm

Weeks

Femur

D.BP.

L.CN P95P50P5

P95

P50

P5

P95

P50

P5

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)


19/81



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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20/81



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

P25

P10

Figure 5. Maternal weight gain in Kg by gestational age. Longitudinal

prospective study N = 1023 weight measurements. (22)

P90P50

P10

35

33

3129

27

2523

21

19

1715

13

11

9

7

13 15 17 19 21 23 25 27 29 31 33 35 37 39 sem.

cm

Fun

dalheight

Figure 6. Fundal height in cm by gestational age. Longitudinal prospectivestudy. N = 1074 measurements. (23)


21/81



Exercise 3

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GDWDOLVWHGEHORZ0DWHUQDOXVXDOZHLJKW.J

Week Weight gainMaternalweight (kg.)

162427

3234

58.761.562.5

63.063.5


22/81



Table II - Maternal weight by height by gestational age (p10-p90). (22)


23/81



-RLQWKHSRLQWVWKDW\RXKDYHIRXQGLQJXUHDQGREWDLQWKHPDWHUQDOZHLJKW

gain curve for that case.

You will see that the curve of the case studied crosses it and falls under percentile

ZKLFKVXJJHVWVWKDWZHDUHIDFLQJDQ,8*5

Exercise 4

/RFDWHLQJXUHWKHIXQGDOKHLJKWYDOXHVIRUHDFKRIWKHJHVWDWLRQDODJHVEHORZ

Week Fundal height (cm)

16

24

273234

14

21

232425

-RLQWKHSRLQWVWKDW\RXKDYHIRXQGLQJXUHDQG\RXZLOOREWDLQWKHFRXUVH

of the fundal height of this case.


24/81



Exercise 5

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Maternal

height(cm.)

Maternal

Weight(kg.)

Is maternal weight forheight by gestational

age appropriate?

Gest.

age(wk.)

ABCDE

Yes No

53

58

46

55

67

154

160

150

156

162

27

20

18

31

36

If you answered that ladies A, C, and D do not have an appropriate weightIRU WKHLU JHVWDWLRQDO DJH DQG KHLJKW FRQWUDU\ WR ODGLHV % DQG ( \RX KDYH

XQGHUVWRRGWKHXVHRIWKHFKDUWFRUUHFWO\,IQRWUHDGIURPSDJHRQZDUG

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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WKHGLDJQRVLV7DEOH,,,$GGHGWRWKLVDGYDQWDJHWKURXJKDQXPEHURIIHWDODQWKURSRPHWULFPHDVXUHPHQWVLWSHUPLWVWRHVWDEOLVKWKHW\SHRIUHVWULFWLRQ

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25/81



7KH PHDVXUHV WKXV REWDLQHG DUHFRPSDUHG ZLWK WKH QRUPDO SDWWHUQV LQ WKLV

FDVH XVLQJ WKH JURZWK FXUYHV DFFRUGLQJ WR JHVWDWLRQDO DJHGLVWDQFH FXUYH

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PDQDJHPHQW RI LQWUDXWHULQH JURZWK UHVWULFWLRQ 7KH VHULDO PHDVXUHPHQWV

RI DEGRPLQDO FLUFXPIHUHQFH DQG IHWDO ZHLJKW HVWLPDWLRQ DUH EHWWHU WKDQ WKH

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DJUHDWHUSURSRUWLRQRILQFRUUHFWGLDJQRVHVIDOVHSRVLWLYHV

370

350

330

310

290

270

250

230

210

190

170

150

130

110

90

70

14 16 18 20 22 24 26 28 30 32 34 36 38 40

Headcircumference

mm

P95

P50P5

Weeks of amenorrhea

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)


26/81



mm.390

370

350

330

310

290

270

250

230210

190

170

150

130

110

90

70

15 17 19 21 23 25 27 29 31 33 35 37 39

Weeks of amenorrhea

Abdominalcircumference

P50

P5

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)


27/81



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


39/81



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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SUHYLRXVYDOXHDVVKRZQE\WKHXOWUDVRXQGZLWKLQDGD\WHUPWKDWLVSHUIHFW

- you have understood the pathophysiology of fetal growth correctly. Otherwise,UHUHDGSDJHVWRDQGUHYLVLWWKHDOJRULWKPRQSDJH

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value:

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40/81



DIFFERENTIAL DIAGNOSIS BETWEEN SYMMETRIC IUGRAND ERROR IN THE ESTIMATION OF GESTATIONAL AGEBY LMP

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LWRIWHQOHDGVWRLWLVLPSRUWDQWWRQRWHWKHGLIIHUHQWLDOGLDJQRVLVEHWZHHQsymmetric growth restriction and an error in the estimation of gestational

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circumference

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the growth rate

x 7KHJURZWKUDWHFXUYHVEDVHGRQDSUHYLRXVYDOXHRI'%3IHWDO

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an appropriate growth. Conversely, if the increase is less than

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distance curves and growth rates.


41/81



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


42/81



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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General population14% SGA

N = 100No SGA

86SGA14 TestTest +

Test +Test-

- -

True

11

False

23+ +

True

63

False

3

True

10

False

0+ +

True

23

False

1

- -

-

Prevalence 31%

3466

24 10

Antenatal lowrisk control

Interventionis lost

Intervention

P.

de

detectin

Fundal

height

< P10

and/or

Weight gain

< P25

Referral forSpecial exploration

P.c

onfirmatin

Ultrasound

Fetalabdominal

circumf < P5

3335 weeks37

Aprox. }

Figure 12 - Application of different tests to diagnose intrauterine growthUHVWULFWLRQ7KHUVWVWHSVFUHHQLQJVHOHFWHGRISUHJQDQWZRPHQ:KHQ

WKHVHXQGHUJRDFRQUPDWLRQWHVWWKHUHDO,8*5FDQEHGHWHFWHG


43/81



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Table V - Diagnosis of IUGR using risk factors, fundal height and

maternal weight gain as a screening procedure, and

XOWUDVRXQGDVDFRQUPDWLRQSURFHGXUHLQDSRSXODWLRQwith a 14% prevalence of IUGR

NO

0 11

89

100

86

86

Yes

Yes 11

3

14

NO

DIAGNO

SIS

IUGR

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{


44/81



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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45/81



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.

Uzan et al.

Sibai et al.

CLASP

Common

Odds ratio

4/41

4/30

2/34

19/156

69/1505

37/4810

473/6604

(8.3)(1985)

(1985)

(1985)

(1985)

(1985)

(1985)

(1985)

0.08

0.09

0.03

0.05

0.18

0.56

0.79

0.71

0.24

0.37

0.11

0.26

0.37

0.78

0.92

0.81

10.01 100.1

0.77

1.41

0.36

1.29

0.73

1.08

1.06

0.92

(19)

(13.3)

(5.9)

(12)

(4.6)

(7.7)

(7.1)

13/48

9/23

16/27

6/31

20/73

88/1519

401/4821

553/6542

(28.8)

(39)

(59.2)

(19.4)

(27)

(5.8)

(8.3)

(8.5)

B) Childbirth

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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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If one has special resources to monitor fetal health, in addition to

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In preterm pregnancies, if the assessment of fetal vitality shows a fetusin good conditions and the ultrasound shows that the fetus is growing,

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pregnancy. If the fetal lung has not synthesized surfactant, its synthesis

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increased fetal mortality. Conversely, the interruption of pregnancy doesnot worsen the neonatal prognosis.

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15 17 19 21 23 25 27 29 31 33 35 37 39 41

Weeks of amenorrhea

Area ofa la rm

Zone w i t hh igh deathodds

Figure 14-Normal pattern of fetal abdominal circumference growth

with alarm zone and zone of high probability of death.


48/81



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ultrasound assessments evaluating the fetal measurements and functional

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Serial ultrasound studies are an essential tool for monitoring fetal well-

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the contrary, it recovers its growth pace and exceeds the lowest level in the

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termination of pregnancy.

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this compensatory mechanism is missing, or when the resistance of the

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49/81



7KH XWHURSODFHQWDO DUWHULHV DUTXDWH DUWHULHV RI WKH XWHUXV VKRZ DQLQFUHDVHGUHVLVWDQFHWREORRGRZPDLQO\ZKHQWKHFDXVHRIWKHUHVWULFWLRQis a vascular disease in the mother.

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C) During labor

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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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Exercise 10

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value is consistent with the earlier ultrasound.


50/81



%DVHGRQWKLVLQIRUPDWLRQ\RXUGLDJQRVLVZRXOGEH

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 (


51/81



7KH IHWXV KDV EHHQ FRQUPHG DQ DV\PPHWULF ,8*5 :KDW PRQLWRULQJ

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

If your answer was to monitor with eco Doppler and ultrasound your choiceZDV FRUUHFW EHFDXVH WKH XOWUDVRXQG ZLOO DOORZ \RX WR DVVHVV ZKHWKHU WKH

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52/81



EXERCISES USING THE PERINATAL COMPUTINGSYSTEM FOR THE ASSESSMENT AND MONITORING OFFETAL GROWTH

7KH FRPSXWHU VRIWZDUH LQWKH 3HULQDWDO ,QIRUPDWLRQ 6\VWHP 6,3 RIIHUVseveral options to assess and monitor fetal growth.

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Weight by gestational age

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program Distribution of a variable we put Gestational age at birth asD GLVWULEXWLRQ YDULDEOH LQGHSHQGHQWDQG birth weightDVDVWXG\YDULDEOHGHSHQGHQW

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In the previous window, as we position ourselves at each gestational age,

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5000

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Amenorrhea in weeks

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Newborns weight in grams

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for this new target population, we have

Weeks p10 p90

Newborns birth weight in grams


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59/81



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studied. Count how many small for gestational age (SGA)QHZERUQVDUHLGHQWLHGLIWKHFXWWLQJSRLQWXVHGLVWKHWKSHUFHQWLOHRIELUWKZHLJKW

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Amenorrhea in weeks

Gram

s


61/81




62/81



History of LBW

Smoking habit


63/81



Preclampsia

Multiple pregnancy


64/81



Fill in the chart below with the data included in the table

Damage: SGAProportionexposed

(frequency %)Risk Factors RR

PAR%

History of LBW

95% Confidenceinterval

Smoking habit

Pre-eclampsia

Multiple pregnancy

Analyze the picture

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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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First trimester


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Second trimester


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Third trimester


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Fourth trimester


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Trimester ENM rate %o SGA %

1234

LBW % VLBW %

Tendenciaenadisminuirenelao

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o

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YES NO

ENM rate %SGA %LBW

VLBW%

Tendency to be reducedduring the year


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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

Grams

G

rams

Weeks of amenorrhea

Weeks of amenorrhea


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Both patterns are the samePercentile 10 is higher in the selected populationPercentile 90 is higher in the selected population

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The population of Institution A

Population selected from Institution B


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Yes

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Exercise B - 2QHE\RQHGLVWULEXWLRQRIWKHZHLJKWVRIWKHQHZERUQVDFFRUGLQJ WR WKH VWDQGDUGV XVHG E\ LQVWLWXWLRQV $ DQG % DQG WKRVHGHYHORSHGE\&/$3:5

Institution A

Grams

Weeks of amenorrhea

Grams

Weeks of amenorrhea


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Institution B

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following as a reference:

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Grams

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Grams

Weeks of amenorrhea


75/81




76/81



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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presenting with decreased fetal movements in late pregnancy. Acta

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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

monitoring fetal growth

Documents