A lady presents with complaints of inappropriate increase in abdominal size according to gestation. She is at 30 weeks of gestation according to her last menstrual periods. On ultrasound, symphysis-fundal height corresponds to 25 weeks, and amniotic fluid index is 10 weeks. SUB-QUESTIONS What is the diagnosis? What is the management?
Reading File
Finding Sources
Finding Sources
Searching PubMed
"fetal growth restriction" AND management
Searching the Web
SMFM fetal growth restriction diagnosis management umbilical artery Doppler delivery timing consult series 52
Reading File
Finding Sources
Finding Sources
Reading File
Reading File
Reading Web Page
https://www.contemporaryobgyn.net/view/summary-of-society-fo…
Reading File
Diagnosis
This is suspected fetal growth restriction (FGR), previously termed intrauterine growth restriction (IUGR).
- At 30 weeks by reliable LMP, symphysis-fundal height of 25 weeks indicates a significant growth lag.
- Ultrasound must confirm by estimating fetal weight (EFW) and abdominal circumference. FGR is generally diagnosed when EFW or abdominal circumference is below the 10th centile for gestational age.
- At 30 weeks, this is early-onset FGR.
- An AFI of 10 cm is normal and does not represent oligohydramnios. Oligohydramnios is usually AFI ≤5 cm or single deepest pocket <2 cm.
First exclude wrong dates, especially if there was no early dating scan. The pattern of fetal biometric measurements distinguishes:
- Symmetrical FGR: head and abdomen both proportionately small, suggesting early fetal causes such as chromosomal abnormality, congenital infection, or malformation.
- Asymmetrical FGR: abdominal circumference disproportionately reduced with relative head sparing, more often due to placental insufficiency, maternal hypertension, or preeclampsia.
Management at 30 weeks
Refer/manage in a high-risk obstetric unit with neonatal intensive-care support.
1. Confirm and assess severity
- Review dating criteria and first-trimester ultrasound, if available.
- Detailed ultrasound:
- EFW and centile
- Abdominal circumference
- Interval growth, preferably repeated after about 2 weeks
- Amniotic-fluid volume
- Placenta, cord insertion, and fetal structural survey
- Umbilical artery Doppler is the key investigation for placental insufficiency and risk stratification.
- Consider middle cerebral artery Doppler and ductus venosus Doppler in severe early FGR or abnormal umbilical artery Doppler.
- Assess fetal well-being with NST/CTG and/or biophysical profile.
Umbilical artery Doppler is the main surveillance tool in FGR because worsening resistance, absent end-diastolic flow, and reversed end-diastolic flow progressively indicate higher fetal risk. Creasy & Resnik's Maternal-Fetal Medicine, pp. 1041-42.
2. Evaluate cause and maternal condition
- Check blood pressure and symptoms/signs of preeclampsia.
- Urine protein assessment, CBC with platelet count, liver enzymes, renal function as clinically indicated.
- Review maternal disorders: chronic hypertension, renal disease, diabetes with vasculopathy, autoimmune disease, thrombophilia where clinically indicated, smoking/substance use, malnutrition.
- In early-onset unexplained FGR, especially with anomalies or symmetrical restriction, offer genetic counseling and diagnostic testing such as amniocentesis with chromosomal microarray.
- Do not routinely order a TORCH screen for isolated FGR. CMV PCR may be considered if amniocentesis is performed for unexplained FGR. Creasy & Resnik's Maternal-Fetal Medicine, p. 1040.
3. Surveillance
The frequency depends on Doppler and fetal testing:
| Finding | Usual surveillance |
|---|---|
| Normal umbilical artery Doppler | CTG/NST at least weekly, Doppler every 1-2 weeks initially, serial growth every 2-4 weeks |
| Raised umbilical artery resistance/decreased diastolic flow or EFW <3rd centile | Weekly Doppler and at least weekly CTG/NST |
| Absent end-diastolic flow (AEDF) | Admit or very close specialist monitoring; umbilical artery Doppler 2-3 times/week and frequent CTG |
| Reversed end-diastolic flow (REDF) | Hospitalize; CTG 1-2 times daily, corticosteroids, and prepare for delivery |
Management aims to balance prematurity against intrauterine hypoxia/stillbirth using serial biometry, Doppler, amniotic fluid, and CTG/BPP. Creasy & Resnik's Maternal-Fetal Medicine, p. 1041. Current SMFM guidance summary similarly recommends serial umbilical artery Doppler after FGR is diagnosed.
4. Measures if preterm delivery is likely
At 30 weeks:
- Give a course of antenatal corticosteroids if delivery is anticipated within 7 days.
- Give magnesium sulfate for fetal neuroprotection if delivery before 32 weeks is likely.
- Arrange delivery where appropriate neonatal care is available.
5. Timing and mode of delivery
Deliver earlier for:
- Nonreassuring CTG/BPP
- Severe oligohydramnios
- Deteriorating maternal preeclampsia or other maternal indication
- Progressive Doppler deterioration
- AEDF or REDF
Common Doppler-based delivery targets:
- Normal umbilical artery Doppler, EFW 3rd-10th centile: 38-39 weeks.
- Severe FGR, EFW <3rd centile, or decreased diastolic flow without AEDF/REDF: 37 weeks.
- AEDF: 33-34 weeks, or earlier if fetal testing becomes nonreassuring.
- REDF: 30-32 weeks after corticosteroids, or immediately if fetal/maternal status requires.
For AEDF/REDF, caesarean delivery is usually preferred because the fetus may not tolerate labor. Delivery timing must be individualized by fetal surveillance, Doppler pattern, maternal condition, and neonatal capability.
In best brief important way only
Diagnosis:
Fetal growth restriction (FGR/IUGR) at 30 weeks gestation.
Fetal growth restriction (FGR/IUGR) at 30 weeks gestation.
- SFH corresponds to 25 weeks.
- AFI = 10 cm is normal.
Management:
- Confirm dates and perform detailed ultrasound for EFW, abdominal circumference, anomalies, and growth pattern.
- Do umbilical artery Doppler and fetal surveillance with NST/CTG ± biophysical profile.
- Assess mother for preeclampsia/placental insufficiency: BP, urine protein, CBC, liver and renal tests.
- Serial monitoring: fetal growth every 2 weeks; CTG and Doppler frequency according to severity.
- If delivery may occur before 34 weeks, give antenatal corticosteroids; give magnesium sulfate if delivery before 32 weeks is likely.
- Deliver early for abnormal fetal testing, worsening Doppler, absent/reversed end-diastolic flow, or maternal deterioration.
- Caesarean is preferred in severe FGR with absent/reversed end-diastolic flow.
This is a shared conversation. Sign in to Orris to start your own chat.