Assessment and Management of Abnormal

Fetal Growth

Max Mongelli
Women & Childrens’ Health
Nepean Hospital
Sydney, Australia

Updated December 2009

Max Mongelli 2009

Fields to be covered:

Prevention

Screening

Diagnosis

Management

Long term complications

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Prevention of IUGR

Stop smoking

Avoid D & A

Aspirin if indicated

Minimize risk of multiple pregnancy

Minimize risk of infections

Treat thrombophilias

Pre-conceptional counselling

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Not effective in prevention:

Bed rest

Antihypertensive therapy

Folic acid

Long-chain PU fatty acids

Beta-mimetics

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Prevention of Macrosomia

Normalise BMI prior to conception

Early detection of GDM

Good control of GDM

? Moderate exercise during
pregnancy

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 Screening for Abnormal
Fetal Growth

 Fetal size estimation by palpation alone

can be inaccurate
 Better results by measuring the symphysis-
fundus height (SFH)

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 Technique of SFH
Measurement
 Patient supine, bladder empty.
 Measuring tape should be blank on one side,
cm markings on other side. Blank side up.
 SFH measured in cm from top of uterine
fundus to the top of symphysis pubis.
 Measurement plotted on reference chart.

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 Reference Charts for Antenatal
Screening for Abnormal Fetal Growth

 Unadjusted, population based charts:

inaccurate for many women
 Individually adjusted charts: customised
growth charts
 Customised charts have lower false positive
rates than unadjusted charts.

Max Mongelli 2009

 Reference Charts for Antenatal
Screening for Abnormal Fetal Growth

 Unadjusted, population based charts: inaccurate for

many women
 Individually adjusted charts: customised growth charts
 Customised charts have lower false positive rates than
unadjusted charts.
 Better correlation with perinatal outcomes

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Examples of Customized Growth
Charts for Antenatal Screening

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X
x

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 Antenatal Diagnosis of
SGA/IUGR
 SFH measurements alone cannot confirm.
 Possibility of IUGR if there is a growth
deceleration pattern or a single small SFH
measurement.
 Ultrasound examination is indicated if there
is clinical suspicion.

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 Ultrasound Diagnosis of
SGA/IUGR
 Fetal biometry: HC, BPD, FAC, FL
 Can be converted to an estimated fetal
weight (EFW)
 Amniotic fluid index (AFI)
 Doppler studies of umbilical arteries
 Screen for fetal anomalies (10% of IUGR)
 Cardiotocography (non-stress test)
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 Karyotype
Fetal karyotype may be indicated if:
 IUGR is of early onset
 Severe (< 3rd pct)
 Associated with polyhydramnios
 Structural anomalies are present

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 Doppler Studies
 Examination of umbilical arteries and MCA
 Proven to reduce PNM by 30%
 Abnormal if absent or reversed diastolic flow
 If abnormal in ductus venosus, fetal risk is
very high

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 Management of IUGR:
Investigations

 FBC, EUC, LFT’s, urate

 LAC, antiphospholipid antibodies
 TORCH/viral studies
 Chromosome studies
 Tests for celiac disease if indicated

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 Management of IUGR:
Conservative or elective
delivery?

 Depends on severity of IUGR

 If close to term and fetus not
compromised, induction of labour
 If there are signs of fetal distress
cesarean section is indicated.

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 Management of IUGR:
Conservative

 Twice weekly U/S for AFI/flows

 Daily CTG’s
 2 -weekly EFW measurements
 Antenatal steroids
 Pregnancy should not extend beyond
40 weeks’ gestation
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 Complications of IUGR:
Short term

 Hypoglycemia
 Hypothermia
 Hyperviscosity syndrome
 Impaired immune function
 RDS / NEC if preterm
 Birth asphyxia
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 Complications of IUGR:
long term

 Cerebral palsy
 Small decrease in IQ
 Reduced scores for executive cognitive
functions
 Risk related to severity of IUGR

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 The Barker Hypothesis

 IUGR fetuses compensate for adverse

intrauterine environment by endocrine-
metabolic reprogramming
 In adult life this leads to increased risk of
hypertension, hypercholesterolemia, IGT,
IHD

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Management of
Macrosomia

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Differential Diagnosis of
High SFH
 Macrosomia
 Polyhydramnios
 Multiple pregnancy
 Uterine fibroids
 Pelvic masses
 Maternal obesity

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 Diagnosis of
LGA/Macrosomia

 Ultrasound biometry
 Conversion to an estimated fetal weight
 Some centres use FAC only
 Cut-off for LGA is EFW>90th pct
 Cut-off for macrosomia 4500 g or 5000 g

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 Accuracy of Ultrasound

 Less accurate for big babies

 Sensitivity ranges from 22% to 69%
 May not be more accurate than clinical
palpation alone

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Complications of Macrosomia
 Birth trauma
 Shoulder dystocia
 Erbs’ Palsy
 Birth asphyxia
 Neonatal hypoglycemia
 Neonatal jaundice
 Hypercalcemia, hypomagnesemia

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 Shoulder dystocia

 Variable incidence – 0.5%

 Difficult to predict – recurrence risk 10%
 More likely in macrosomia, GDM, post-
term, instrumental delivery, prolonged
second stage
 50% have no risk factors

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Complications of Macrosomia:
Long Term

 In GDM offspring
 Neurodevelopmental delay
 Reduced head circumference at 3
years of age
 Greater risk of type 2 DM
 Obesity

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Management of Macrosomia:
Vaginal Delivery or C/S ?
 Controversial issue
 Shoulder dystocia difficult to predict
 Some centres use 4500 g or 5000 g
 RCOG does not recommend C/S for
suspected macrosomia

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Management of Macrosomia:
Induction of Labor ?
 Common request from patients
 No evidence that it reduces the risk of
shoulder dystocia
 May possibly increase the risk of
shoulder dystocia

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 Postnatal Management of
Unexpected/Undiagnosed IUGR

 Many cases of IUGR not diagnosed

until after delivery
 Confirmation with customised birth
weight percentile
 Maternal follow in clinic to exclude
underlying medical conditions

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