FETAL GROWTH ASSESSMENT

Obstetric Care
Objective
Decrease the maternal
and perinatal morbidity
and mortality

Fetal growth

The normal fetal growth pattern

Fetal growth is
dependent on genetic,
placental and
maternal factors.
Fetal growth
restriction is the
second leading cause
of perinatal morbidity
and mortality.

How to achieve these

objectives
1. Early confirmation of
dates
2. Detection of congenital
malformations
3. Detecting fetal hypoxia
4. Detecting abnormal
fetal growth
Small for gestational age
Small for gestational age is defined as a fetal birth
weight below the 10th centile for the stated
gestational age.
The incidence of SGA fetuses is 5-10%

1/3 of the eventual birth is reached by 28 weeks , by 31 weeks ,

2/3 by 34 weeks

Constitutionally Small Fetus

Unfortunately, it can be concluded that a fetus is
constitutionally small only after pathologic processes
have been excluded.
Therefore, identification of a constitutionally small infant
is usually made in retrospect, after the infant is born
Why is the fetus constitutionally small?
Determinants of fetal growth are multi-factorial :
1. Race
2. Geographical area
3. Sex (M>F)
4. Maternal age
5. Maternal weight and height
6. Socioeconomic status
Assesing fetal growth
1.History
2.Examination
1. Mothers age
General examination
2. Accuracy of
Obstetric examination
LMP date
Uterine fundal ht

Uterus size

3. Infections
during
pregnancy
4. Multiple
pregnancy
5. Antenatal care
and visits
6. Supplements
7. Past obs.
History
8. Past medical
history
9. Drug history
10.Family history
11.Socioeconomic
history

Assesing fetal growth

3.Investigation: U/S
Uses of US

Obtaining serial uterine fundal height

measurements.
The Mcdonalds rule in pregnancy is a
rough determination of fetal age in weeks

Evaluating the size of the uterus by pelvic

examination in the first trimester and subsequent
antenatal visits
Uterine size = Misleading in: Full bladder, obesity,
deep masses, uterine fibroids &multiple pregnancy

Diagnosis and Confirmation of Viability

Determination of GA and
assessment of fetal size
and growth

1. Diagnosis and
confirmation of viability in
early pregnancy
2. Determination of
gestational age and
assessment of fetal size
3. Intrauterine or Ectopic
pregnancy.
4. Multiple pregnancy
5. Diagnosis of fetal
abnormalities
6. Placental localization
7. Assessment of fetal wellbeing

Detection of :
Gestational sac (4-5 wks)
Yolk sac (5 wks)
Embryo (5-6 wks)
Visible heart beat (6 wks).

a.
b.
c.
d.
e.

Crown-Rump length
Biparietal diameter
Head circumference
Abdominal circumference
Femoral length

Up to 13 wks :
- Crown-Rump Length (CRL)
from 16 to 24 wks :
- Head circumference (HC)
- Biparietal Diameter (BPD)
- Femur length (FL)

a.Crown-Rump Length (CRL)

3.Investigation: U/S
b. Bi-parietal Diameter (BPD)

From Crown to Coccyx (Rump) (longitudinal axis).

Accurate up to 14 wks (1st TM).
It is the most accurate parameter.
Provides accuracy of +/- 5 days from the GA.

The transverse width of the head at its

widest (the distance between the
parietal bones eminence of the skull).
Accurate up to 16-24 wks.
Provides accuracy of +/- 7 days.
It is affected by the shape of the head.

Not affected by the shape of the head.

c.Head circumference (HC)

3.Investigation: U/S
d. Femur length (FL)

Better than BPD in accuracy and timing.

Accurate only when the image shows two blunted ends of
the femur.

e.Abdominal circumference (AC)

It is the most accurate single predictor of fetal weight.

IUGR

It is made at the widest points in the abdomen.

It is the most accurate single predictor of fetal weight.

IUGR and SGA

Incidence

Is ..
Failure of the fetus to
achieve its growth
potential
True or False?
All SGA infants are
IUGR
False
All IUGR infants are
SGA
False
Classification of IUGR
Symmetrical growth
restriction: fetus
whose entire body is
proportionally small.
Incidence : 20 %

Asymmetrical
growth restriction:
Decrease in
subcutaneous fat
and abdominal
circumference with
relative sparing of
head circumference
and femur length.
Incidence : 80 %

3 - 10 % of all pregnancies.
20 % of stillborns are growth retarded.
9 - 27 % have anatomic and/or genetic
abnormalities.
Perinatal mortality is 8 - 10 times higher for
these fetuses.

Maternal causes
Physiological
Pathological
Multiple
1. Decrease Uteroplacental
pregnancy
blood flow:
- Short stature
Pre eclampsia /
- Younger or
eclampsia
older age (<15
chronic renovascular
and >45)
disease
- Low
Chronic hypertension
socioeconomic
2. Maternal malnutrition
class
3. Maternal hypoxemia
- Primiparity
- Hemoglobinopathies
- Grand
- High altitudes
multiparity
4. Drugs
- Low
- Cigarettes, alcohol, heroin,
pregnancy
cocaine
weight
- Teratogens, antimetabolites
- Previous h/o
and therapeutic agents such as
preterm IUGR
trimethadione, warfarin,

baby

Fetal causes
Physiological

phenytoin
- Chronic illness ( DM, renal
failure, cyanotic heart disease
etc.)

Placental Causes
Pathological

- Genetic Factors:
- Race, ethnicity, nationality
- sex (male weigh 150 -200 gm more
female )
- parity (primiparous, weigh less than
subsequent siblings)

Genetic disorders (Achondroplasia,

Russell - silver syn.)
Chromosomal anomalies:
- Chromosomal deletions
- trisomies 13,18 & 21
Congenital malformations:
eg: Anencephaly, GI atresia, potters
syndrome, and pancreatic agenesis.
Fetal Cardiovascular anomalies
Congenital Infections:mainly TORCH
infections.
Inborn error of metabolism:
- Transient neonatal diabetes
- Galactosemia
- PKU

Diagnosis of IUGR
History
Physical examination
Investigations
U/S
Abdominal circumference is the single most effective
parameter for predicting fetal weight because its reduced
in both symmetrical & Asymmetrical IUGR .
In the presence of normal head and femur measurements,
abdominal circumference (AC) measurements of less than
2 standard deviations below the mean appear to be a
reasonable cut off to consider a fetus asymmetric.

o
o
o
o

Placental insufficiency ( most

imp in 3rd trimester)
Anatomic problems:
Multiple infarcts
Aberrant cord insertions
Umbilical vascular thrombosis &
hemangiomas
Premature placental separation
Small Placenta

Asymmetrical growth restriction: BPD is normal in the 3rd

trimester , whereas ratio of HC/AC is abnormal .
Symmetrical growth restriction : HC/AC may be normal .
amniotic fluid volumes ( oligohydramnios is associated
with IUGR) .
Umbilical artery & fetal artery dopplar assessments :
increased resistance is associated with a greater risk of
IUGR as pregnancy progresses.

Complications of IUGR
Antenatal
Complications
Metabolic changes
(acidosis,..).
Oligohydramnios
(80%)
Abnormal fetal heart
patterns.
Abnormal Doppler
studies.
Intra uterine fetal
death.
Management Principles
Pre-pregnancy
Modify lifestyle habits.
Detect and treat
medical disorders.

Intrapartum
complications:
Abnormal CTG.
Fetal death.
Meconium stained
liquor.
Increased incidence
of instrumental and
caesarean
deliveries.

Neonatal complications
1- related to hypoxia
and acidosis:
a- meconium
aspiration.
b- persistent fetal
circulation.
c- hypoxic
ischemic
encephalopathy

2- metabolic:
ahypoglycemia
bhypocalcaemia
chypothermia
dhyperviscocity
syndrome

During pregnancy (Ante-partum)

Time & Mode of delivery
Regular antenatal care.
governed by:
Serial fetal growth
maternal age
assessment.
Serial fetal wellbeing
past obs. History
gestational age
assessment
1-Biophysical profile
fetal well being
2-Computerized CTG
status of cervix
3-Umblical artery Doppler
availability of direct
Timing of delivery.
monitoring during labor.
Mode of delivery.
Ex: scalp PH sampling.

3- related to the etiology:

a- chromosomal abn.
b- infection.
c- congenital anomalies.

Mode of delivery
Cesarean delivery without a
trial of labor:
1. in the presence of evidence
of fetal distress
2. for traditional obstetrical
indications for cesarean
delivery
Induction of labor
continuous heart rate
monitoring and scalp pH
monitoring optimize success of
vaginal delivery