FGR fetal growth restriction SGA diagnosis management guidelines 2024 ISUOG ACOG

https://www.isuog.org/static/b2aa3fb4-031e-4d84-b7246d613a46…

mkdir -p /home/daytona/workspace/fgr-seminar && ls /home/daytona/workspace/fgr-s…

~/fgr-seminar/build_fgr.js

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pres.author = "OBG Seminar";

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// =========================================================
// SLIDES START
// =========================================================

// SLIDE 1: TITLE SLIDE
titleSlide(
  "Fetal Growth Restriction",
  "SGA vs FGR | Pathophysiology | Diagnosis | Surveillance | Management | Delivery Timing",
  "OBG Postgraduate Seminar"
);

// SLIDE 2: OUTLINE
contentSlide("Seminar Outline", [
  "1.  Introduction & Epidemiology",
  "2.  Definitions — SGA vs FGR: Why It Matters",
  "3.  Pathophysiology & Etiology",
  "4.  Classification — Symmetric vs Asymmetric; Early vs Late FGR",
  "5.  Risk Factors & Screening",
  "6.  Diagnosis — Biometry, Growth Curves, Doppler Indices",
  "7.  Antenatal Surveillance Protocols",
  "8.  Management Principles & Prevention",
  "9.  Timing & Mode of Delivery — Evidence-Based Approach",
  "10. Neonatal Outcomes & Long-term Sequelae",
  "11. Case Discussion",
  "12. Key Takeaways & References",
], { fontSize: 17 });

// SECTION 1
sectionDivider(1, "Introduction & Epidemiology");

// SLIDE 3
definitionSlide(
  "Why Does FGR Matter?",
  "FGR contributes to up to 30% of stillbirths and is a major driver of perinatal morbidity worldwide.",
  [
    "Global incidence: ~10% of all pregnancies (varies by definition used)",
    "Accounts for ~50% of unexplained stillbirths when Doppler abnormalities are present",
    "FGR fetuses have higher rates of prematurity-associated conditions",
    "Increased neonatal ICU admissions, neurodevelopmental impairment, and long-term adult disease (Barker hypothesis)",
    "Up to 20% of early-onset FGR is associated with chromosomal/structural anomalies (Creasy & Resnik, 2023)",
    "Prenatal recognition is the single most important modifiable factor in preventing FGR-related stillbirth",
  ]
);

// SECTION 2
sectionDivider(2, "Definitions — SGA vs FGR");

// SLIDE 4: SGA Definition
definitionSlide(
  "Small for Gestational Age (SGA) — Definition",
  "SGA: Estimated fetal weight (EFW) OR abdominal circumference (AC) BELOW the 10th percentile for gestational age.",
  [
    "Most are constitutionally small, otherwise healthy fetuses — not pathologically restricted",
    "Not synonymous with FGR, though often used interchangeably in older literature",
    "Severe SGA: EFW/AC below the 3rd percentile — higher risk of adverse outcome regardless of Doppler",
    "Population-based reference: Hadlock formula (most widely used in USA); INTERGROWTH-21st (international)",
    "~70% of SGA fetuses are constitutionally small (ISUOG 2020)",
  ]
);

// SLIDE 5: FGR Definition
definitionSlide(
  "Fetal Growth Restriction (FGR) — Definition",
  "FGR: A fetus that fails to achieve its genetically predetermined growth potential — NOT merely small, but PATHOLOGICALLY restricted.",
  [
    "Delphi Consensus (Gordijn et al, 2016) — most accepted international definition — endorsed by ISUOG, FIGO, RCOG, SOGC",
    "FGR = SGA + at least ONE of: abnormal uterine artery PI (>95th %ile), abnormal umbilical artery PI (>95th %ile), or CPR <5th %ile",
    "OR: EFW <3rd percentile alone (severe FGR) in a euploid, non-anomalous fetus",
    "OR: ≥50 centile drop in EFW/AC trajectory on serial scans",
    "SMFM 2020 / ACOG definition: simply EFW or AC <10th %ile (does NOT distinguish SGA from FGR — simpler but less precise)",
    "Key insight: FGR implies PLACENTAL DYSFUNCTION; SGA alone does not",
  ]
);

// SLIDE 6: SGA vs FGR comparison table
tableSlide(
  "SGA vs FGR — At a Glance",
  ["Feature", "SGA", "FGR"],
  [
    ["Definition", "EFW / AC <10th centile", "EFW <10th centile + Doppler/trajectory evidence of placental insufficiency"],
    ["Pathology", "Constitutional / genetic", "Placental dysfunction"],
    ["Doppler", "Normal", "Abnormal UA, UtA, CPR, MCA, or DV"],
    ["Biophysical", "Normal BPP, AFI", "May have oligohydramnios, low BPP"],
    ["Perinatal risk", "Low if Doppler normal", "High — stillbirth, NICU, NDD"],
    ["Management", "Standard surveillance", "Intensive Doppler, timed delivery"],
    ["Recurrence risk", "Low", "10–25% (higher with preeclampsia)"],
  ]
);

// SECTION 3
sectionDivider(3, "Pathophysiology & Etiology");

// SLIDE 7: Pathophysiology
contentSlide("Pathophysiology of FGR", [
  "CORE MECHANISM: Placental insufficiency → uteroplacental underperfusion → chronic fetal hypoxia + nutrient deprivation",
  "",
  "Early (< 32 wks): Failure of trophoblastic invasion of spiral arteries → high resistance placental circulation → reduced oxygen/nutrient delivery",
  "Late (≥ 32 wks): Placental aging, infarction, or functional impairment with initially preserved fetal compensation",
  "",
  "Fetal compensatory responses:",
  "  → Brain sparing (MCA vasodilation, redistribution of cardiac output to brain, adrenals, heart)",
  "  → Reduced fetal breathing, movements, tone (to decrease oxygen consumption)",
  "  → Oliguria → oligohydramnios",
  "  → Ductus venosus shunting (late sign — cardiac compromise)",
  "  → Progressive acidemia → fetal death if undelivered",
], { fontSize: 15 });

// SLIDE 8: Etiology (two columns)
twoColSlide(
  "Etiology of FGR",
  "FETAL Causes (~25%)",
  [
    "Chromosomal abnormalities (trisomy 18, 21, triploidy)",
    "Structural malformations",
    "Fetal infections: TORCH — CMV, toxoplasma, rubella, syphilis",
    "Genetic syndromes (Silver-Russell, etc.)",
    "Multiple gestation (TTTS, selective FGR)",
    "Confined placental mosaicism",
  ],
  "MATERNAL / PLACENTAL Causes (~75%)",
  [
    "Placental: Abnormal trophoblast invasion, placenta previa, circumvallate placenta, chorangioma, infarction",
    "Hypertensive disorders: Pre-eclampsia (#1 cause of early-onset FGR)",
    "Diabetes with vasculopathy, APS, SLE, renal disease",
    "Thrombophilia (acquired > hereditary)",
    "Malnutrition, severe anaemia",
    "Smoking, alcohol, illicit drugs (cocaine, heroin)",
    "Extremes of maternal age, short inter-pregnancy interval",
  ]
);

// SECTION 4
sectionDivider(4, "Classification");

// SLIDE 9: Symmetric vs Asymmetric
twoColSlide(
  "Classification 1 — Symmetric vs Asymmetric FGR",
  "SYMMETRIC FGR (~20–30%)",
  [
    "All measurements proportionally reduced (BPD, HC, AC, FL all small)",
    "Early onset — cell division phase affected",
    "Causes: chromosomal, genetic, structural, TORCH infections",
    "Head circumference equally affected",
    "Poorer prognosis (intrinsic insult)",
    "HC:AC ratio NORMAL",
  ],
  "ASYMMETRIC FGR (~70–80%)",
  [
    "AC reduced, HC and FL relatively spared (brain sparing)",
    "Late onset — placental insufficiency in growth phase",
    "Causes: pre-eclampsia, maternal vascular disease, idiopathic",
    "HC:AC ratio INCREASED (>1.0 after 36 wks)",
    "Hepatic glycogen depletion → reduced liver size → reduced AC",
    "Doppler changes — UA PI elevated early",
  ]
);

// SLIDE 10: Early vs Late FGR table
tableSlide(
  "Classification 2 — Early vs Late FGR (Clinically Most Useful)",
  ["Feature", "Early FGR (< 32 weeks)", "Late FGR (≥ 32 weeks)"],
  [
    ["Incidence", "~20–30% of all FGR", "~70–80% of all FGR"],
    ["Doppler pattern", "Severe UA changes, brain sparing common, DV abnormal late", "UA may be normal; MCA/CPR most useful marker"],
    ["Associated conditions", "Pre-eclampsia, APS, severe SGA", "Idiopathic, mild PE, constitutional"],
    ["Progression", "Stepwise, predictable deterioration", "Subtle; may deteriorate suddenly"],
    ["Stillbirth risk", "High — close monitoring mandatory", "Lower but not negligible"],
    ["Delivery timing", "34–37 weeks (individualized)", "37–39 weeks typically"],
    ["Primary Doppler tool", "UA + DV + STV (short-term variability)", "CPR (cerebro-placental ratio), MCA-PI"],
  ]
);

// SECTION 5
sectionDivider(5, "Risk Factors & First Trimester Screening");

// SLIDE 11: Risk factors
twoColSlide(
  "Risk Factors for FGR",
  "Major Risk Factors (OR > 2.0)",
  [
    "Previous SGA/FGR baby (strongest predictor — OR ~4–8)",
    "Chronic hypertension / Pre-existing renal disease",
    "Preeclampsia in current pregnancy",
    "Antiphospholipid syndrome",
    "Diabetes mellitus with vasculopathy",
    "Systemic lupus erythematosus",
    "Multiple pregnancy with TTTS",
    "Heavy smoking (>10 cigarettes/day)",
    "Uterine abnormality (fibroids, septum)",
  ],
  "Moderate Risk Factors (OR 1.5–2.0)",
  [
    "Primiparity",
    "Age > 40 years",
    "Low BMI (< 18.5 kg/m²) or high BMI (> 35)",
    "Short interpregnancy interval (< 6 months)",
    "IVF / ART pregnancies",
    "Thrombophilia (hereditary — factor V Leiden, MTHFR)",
    "Thyroid disease (uncontrolled)",
    "Substance use (cocaine, alcohol, opioids)",
    "Low socioeconomic status",
  ]
);

// SLIDE 12: First trimester screening
contentSlide("First Trimester Screening for FGR (11–14 Weeks)", [
  "Combined screening model (FMF Algorithm — Poon et al) — sensitivity 75–80% for early-onset FGR at 10% FPR:",
  "  → Mean uterine artery PI (UtA-PI)",
  "  → Mean arterial pressure (MAP)",
  "  → Serum PlGF (placental growth factor) — low in FGR",
  "  → Serum PAPP-A (low PAPP-A → 2–4× increased FGR risk)",
  "  → Uterine notching (bilateral > unilateral)",
  "",
  "ASPIRIN PROPHYLAXIS — Gold Standard Prevention:",
  "  → Low-dose aspirin 150 mg/day from 11–14 weeks until 36 weeks",
  "  → Reduces early-onset pre-eclampsia by 62% (ASPRE trial) → reduces FGR",
  "  → NICE / ISUOG / FIGO: recommended if ≥1 high-risk or ≥2 moderate-risk factors",
  "",
  "Cervical length measurement: short cervix increases risk via preterm delivery + FGR overlap",
], { fontSize: 15 });

// SECTION 6
sectionDivider(6, "Diagnosis & Biometry");

// SLIDE 13: Ultrasound biometry
contentSlide("Ultrasound Biometry for FGR Diagnosis", [
  "Four standard measurements: BPD, HC, AC, FL — combined into EFW (Hadlock formula most widely used)",
  "",
  "ABDOMINAL CIRCUMFERENCE (AC):",
  "  → MOST SENSITIVE single measurement for FGR — decreases EARLIEST in asymmetric FGR",
  "  → Normal AC virtually excludes significant FGR",
  "  → Hepatic glycogen depletion and ↓subcutaneous fat → reduced AC",
  "",
  "HEAD CIRCUMFERENCE (HC):",
  "  → Spared in asymmetric FGR ('brain sparing effect')",
  "  → HC:AC ratio increased in asymmetric FGR (normal < 1.0 after 36 wks)",
  "",
  "FEMUR LENGTH (FL) + BPD: reduced in symmetric FGR",
  "Transcerebellar diameter: gestational age estimation — spared even in FGR ('cerebellar sparing')",
  "",
  "Serial growth scans: minimum 2–3 weeks interval (shorter intervals unreliable due to measurement error)",
], { fontSize: 15 });

// SLIDE 14: Growth curves
contentSlide("Growth References & EFW Calculation", [
  "HADLOCK FORMULA (USA gold standard): uses HC + AC + FL — produces EFW in grams",
  "INTERGROWTH-21st charts: international; based on optimal-outcome populations from 8 countries",
  "NICHD curves: US-specific, ethnicity-adjusted",
  "WHO Multicentre Growth Reference: similar to INTERGROWTH",
  "",
  "Customized growth charts (Gardosi/GROW):",
  "  → Adjust for maternal height, weight, parity, ethnicity, gestational age",
  "  → Better at identifying 'small but normal' vs truly growth-restricted",
  "  → Not universally adopted — requires local software",
  "",
  "Key thresholds:",
  "  → <10th centile → SGA (investigate further with Doppler)",
  "  → <3rd centile → Severe SGA / FGR regardless of Doppler",
  "  → ≥50 centile drop in EFW trajectory → FGR even if absolute EFW >10th centile",
  "",
  "Interval growth: <5th centile fall over 2–3 weeks is clinically significant",
], { fontSize: 14 });

// SECTION 7
sectionDivider(7, "Doppler Surveillance — The Cornerstone");

// SLIDE 15: Doppler overview
contentSlide("Doppler Velocimetry — Overview", [
  "Doppler assessment is the CORNERSTONE of FGR surveillance — Grade A recommendation (ISUOG, RCOG, FIGO)",
  "",
  "VESSELS ASSESSED:",
  "  1. Uterine artery (UtA) — screens for placental dysfunction; elevated PI = impaired invasion",
  "  2. Umbilical artery (UA) — reflects placental vascular resistance; most important for early FGR",
  "  3. Middle cerebral artery (MCA) — reflects brain vasodilation / brain sparing",
  "  4. Cerebro-placental ratio (CPR) = MCA-PI / UA-PI — best single marker for late FGR",
  "  5. Ductus venosus (DV) — reflects right heart pressure; LATE, pre-terminal marker",
  "  6. Umbilical vein (UV) — pulsatility = very late sign of cardiac compromise",
  "",
  "Sequence of deterioration: UA↑ → MCA↓ (brain sparing) → CPR↓ → UA AEDV → UA REDV → DV a-wave absent/reversed → death",
], { fontSize: 15 });

// SLIDE 16: Doppler progression table
tableSlide(
  "Doppler Progression in FGR — Sequence of Deterioration",
  ["Stage", "Doppler Finding", "Clinical Significance", "Action"],
  [
    ["Stage 1", "UA PI > 95th centile", "Increased placental resistance", "Serial Doppler q1–2 weeks; growth scan"],
    ["Stage 2", "MCA PI < 5th centile / CPR < 5th centile", "Cerebral blood flow redistribution (brain sparing)", "Weekly Doppler; consider delivery ≥34 wks if late FGR"],
    ["Stage 3", "UA Absent End-Diastolic Flow (AEDV)", "Severe placental insufficiency", "Doppler q2–3 days; steroids if <34 wks; plan delivery"],
    ["Stage 4", "UA Reversed End-Diastolic Flow (REDV)", "Impending fetal compromise", "Admit; steroids; MgSO4 if <32 wks; delivery soon"],
    ["Stage 5", "DV a-wave absent / reversed; UV pulsatility", "Right heart failure; pre-terminal", "IMMEDIATE delivery (regardless of GA if viable)"],
  ]
);

// SLIDE 17: MCA and CPR
twoColSlide(
  "MCA Doppler & Cerebro-Placental Ratio (CPR)",
  "Middle Cerebral Artery (MCA)",
  [
    "Vasodilation = brain sparing → ↓ MCA-PI (<5th centile)",
    "Best vessel to assess cerebral redistribution",
    "Probe placement: axial view at level of sphenoid wings, sample at origin from ICA (near circle of Willis)",
    "MCA-PI < 5th centile for GA = abnormal",
    "Isolated low MCA in late FGR — associated with NDD, operative delivery for fetal distress",
    "Less useful in early FGR (DV more important then)",
  ],
  "Cerebro-Placental Ratio (CPR)",
  [
    "CPR = MCA-PI / UA-PI (normal > 1.0, threshold <5th centile)",
    "BEST single Doppler marker for LATE FGR (≥32 wks)",
    "Identifies compromise even when UA alone is normal",
    "Low CPR → 2–4× increased risk of stillbirth, emergency CS, low APGAR",
    "PORTO trial (2015): CPR <5th centile best predictor of adverse outcome in late SGA",
    "Low CPR indicates delivery should be planned ~38 weeks",
  ]
);

// SLIDE 18: Ductus venosus
contentSlide("Ductus Venosus (DV) — The Pre-Terminal Marker", [
  "Located: between umbilical vein and inferior vena cava — isthmus shunting oxygenated blood to foramen ovale",
  "",
  "Normal DV waveform: triphasic — S wave (systole) > D wave (diastole) > a wave (atrial contraction) — ALL above baseline",
  "",
  "ABNORMAL DV findings (in order of severity):",
  "  1. DV-PI > 95th centile — elevated resistance, early RV dysfunction",
  "  2. Absent a-wave — atrial contraction unable to push blood forward",
  "  3. Reversed a-wave (PIV 'crow's foot') — MOST SEVERE — right heart failure, imminent decompensation",
  "",
  "Clinical significance:",
  "  → DV reversed a-wave: stillbirth risk 40–50% within 1 week if undelivered",
  "  → TRUFFLE trial: DV a-wave at/below baseline = trigger for delivery even at 26–30 weeks",
  "  → Used alongside STV (short-term variability on CTG) in TRUFFLE protocol",
  "",
  "Pitfall: DV assessment requires high skill; angle dependency; false positives in fetal breathing",
], { fontSize: 14 });

// SECTION 8
sectionDivider(8, "Antenatal Surveillance Protocols");

// SLIDE 19: Surveillance protocol early FGR
contentSlide("Surveillance Protocol — EARLY FGR (< 32 Weeks)", [
  "DIAGNOSIS: Confirm GA (1st trimester dating mandatory), fetal anatomy scan, karyotype/microarray if severe or associated anomalies",
  "",
  "INVESTIGATIONS:",
  "  → Maternal: BP, urinalysis, thrombophilia screen, TORCH serology, APS antibodies, blood glucose, TFTs",
  "  → Fetal: Amniocentesis/CVS for chromosomal analysis if EFW <3rd centile + structural anomaly",
  "",
  "MONITORING SCHEDULE (adapt to severity):",
  "  → UA Doppler: every 1–2 weeks (weekly if UA PI > 95th centile)",
  "  → UA AEDV: every 2–3 days",
  "  → UA REDV: DAILY; admit; plan delivery",
  "  → DV + MCA + CPR: alongside UA",
  "  → CTG / STV: start at 28–30 weeks (or earlier if UA AEDV/REDV)",
  "  → Growth scan: every 2 weeks",
  "  → Liquor volume (AFI / maximum vertical pocket) at each visit",
  "",
  "ANTENATAL CORTICOSTEROIDS: Betamethasone 12mg IM q24h × 2 doses if delivery anticipated <34 weeks",
  "MAGNESIUM SULFATE: Give if delivery <32 weeks for fetal neuroprotection (MgSO4 4g IV loading)",
], { fontSize: 13 });

// SLIDE 20: Surveillance protocol late FGR
contentSlide("Surveillance Protocol — LATE FGR (≥ 32 Weeks)", [
  "LATE FGR more common (~70–80% of all FGR), often subtle, harder to identify",
  "",
  "Triggers for investigation: AC/EFW crosses 2 centile lines, growth velocity fall, oligohydramnios, reduced movements",
  "",
  "MONITORING SCHEDULE (ISUOG 2020 / RCOG 2024):",
  "  → Fortnightly growth scans (EFW + AC every 2 weeks)",
  "  → Weekly Doppler: UA-PI, MCA-PI, CPR, umbilical coiling ratio (UCR)",
  "  → No need to repeat UtA-PI after initial diagnosis (usually unchanged)",
  "  → CTG: start at 34 weeks or earlier if growth concern",
  "  → Liquor assessment at each Doppler visit",
  "",
  "Decision thresholds for late FGR:",
  "  → UA PI > 95th centile + EFW <10th: deliver ≥36–37 weeks",
  "  → CPR < 5th centile or MCA-PI < 5th centile: deliver ≥38 weeks (not beyond 38+6)",
  "  → Oligohydramnios (MVP < 2 cm): expedite delivery",
  "  → Normal Doppler SGA: deliver at 38–39 weeks (no later than 39+0 per ISUOG)",
], { fontSize: 14 });

// SLIDE 21: ISUOG delivery timing flowchart (text-based)
contentSlide("ISUOG 2020 — Delivery Timing Flowchart (Early FGR)", [
  "≥ 34+0 wks: Deliver if UA AEDV or REDF; STV <4.5 ms; abnormal BPP (≤4); maternal indication",
  "",
  "32+0 – 33+6 wks: Deliver if UA REDF; STV <3.5 ms; DV a-wave at/below baseline",
  "",
  "29+0 – 31+6 wks: Deliver if UA REDF; STV <3.0 ms; DV a-wave at/below baseline",
  "",
  "26+0 – 28+6 wks: Deliver if DV a-wave at/below baseline; STV <2.6 ms — consider after steroid course",
  "",
  "24+0 – 25+6 wks: Personalized management — viability counseling; involve neonatology; parental preferences",
  "",
  "ALL CASES:",
  "  → Antenatal steroids if delivery <34 weeks",
  "  → MgSO4 for neuroprotection if delivery <32 weeks",
  "  → Neonatal team briefing pre-delivery",
  "  → TRUFFLE trial protocol: DV-based delivery timing reduced perinatal mortality + NDD",
], { fontSize: 14 });

// SECTION 9
sectionDivider(9, "Management — Prevention & Intrapartum");

// SLIDE 22: Prevention
contentSlide("Prevention of FGR", [
  "1. LOW-DOSE ASPIRIN — Level A Evidence",
  "  → 150 mg/day started 11–14 weeks, taken at bedtime",
  "  → Reduces early-onset pre-eclampsia by 62% (ASPRE trial, Rolnik et al, NEJM 2017) → reduces associated FGR",
  "  → Who: ≥1 high-risk factor OR ≥2 moderate risk factors (NICE, ISUOG, FIGO, WHO)",
  "",
  "2. SMOKING CESSATION — population-attributable risk ~15–25% of SGA",
  "  → Nicotine replacement therapy safe in pregnancy",
  "",
  "3. TREATMENT OF UNDERLYING CONDITIONS:",
  "  → Optimize hypertension (aim BP 135/85)",
  "  → Anticoagulation for APS (LMWH + aspirin) — prevents recurrent FGR in APS",
  "  → Thyroid hormone replacement if hypothyroid",
  "",
  "4. NOT RECOMMENDED (no evidence):",
  "  → Low-molecular-weight heparin for isolated FGR (SMFM 2020 — Grade 1B)",
  "  → Sildenafil — STRIDER trial STOPPED early due to neonatal pulmonary hypertension deaths",
  "  → Bed rest / activity restriction — not beneficial (SMFM 2020)",
  "  → Oxygen therapy, nutrient supplementation beyond standard vitamins",
], { fontSize: 13 });

// SLIDE 23: Intrapartum management
contentSlide("Intrapartum Management of FGR", [
  "MODE OF DELIVERY:",
  "  → Vaginal delivery preferred if UA AEDV/normal and stable Doppler at/after 34 weeks",
  "  → Caesarean section recommended for:",
  "     • UA REDF at any gestation",
  "     • DV a-wave reversed",
  "     • Abnormal CTG unresponsive to intrauterine resuscitation",
  "     • Standard obstetric indications (malpresentation, etc.)",
  "",
  "INTRAPARTUM MONITORING:",
  "  → Continuous electronic fetal monitoring (CTG) throughout labor — MANDATORY in all FGR",
  "  → Low threshold for FBS (fetal blood sampling) if late decelerations persist",
  "  → Avoid amniotomy unless necessary — compromised cord may not tolerate",
  "  → Avoid prolonged oxytocin augmentation in severe FGR",
  "",
  "ADDITIONAL MEASURES:",
  "  → Left lateral tilt / position change for cord compression patterns",
  "  → IV fluids if maternal hypotension (e.g., post-epidural)",
  "  → Neonatologist / NICU team present at delivery",
  "  → Delayed cord clamping (≥60 sec) where possible — increases Hb and iron stores",
], { fontSize: 14 });

// SECTION 10
sectionDivider(10, "Neonatal Outcomes & Long-term Consequences");

// SLIDE 24: Neonatal complications
twoColSlide(
  "Neonatal Complications of FGR",
  "IMMEDIATE NEONATAL PERIOD",
  [
    "Birth asphyxia / low APGAR scores",
    "Meconium aspiration syndrome",
    "Hypothermia (reduced subcutaneous fat)",
    "Hypoglycaemia (depleted glycogen stores)",
    "Polycythaemia (chronic hypoxia → ↑EPO → ↑RBC production)",
    "Thrombocytopenia",
    "Necrotizing enterocolitis (NEC) — especially preterm FGR",
    "Respiratory distress syndrome (if preterm)",
    "Persistent pulmonary hypertension",
    "Sepsis — impaired immunologic function",
  ],
  "LONG-TERM (Barker Hypothesis / DOHaD)",
  [
    "Neurodevelopmental impairment: cognitive delay, cerebral palsy",
    "Hearing loss, visual impairment",
    "Hypertension in adult life",
    "Insulin resistance / Type 2 diabetes",
    "Metabolic syndrome, central obesity",
    "Coronary artery disease, stroke",
    "Chronic kidney disease",
    "Osteoporosis",
    "'Thrifty phenotype' — epigenetic programming during fetal life",
    "Psychological: ADHD, behavioral problems",
  ]
);

// SLIDE 25: Barker hypothesis
definitionSlide(
  "The Barker Hypothesis (DOHaD — Developmental Origins of Health and Disease)",
  "\"The nutritional conditions prevailing in early life permanently programme the body's physiology and metabolism, predisposing individuals to chronic disease decades later.\" — Barker, 1992",
  [
    "Fetal undernutrition → epigenetic changes → altered gene expression in metabolic organs",
    "Key organs permanently affected: pancreatic β-cells, hepatocytes, nephrons, vascular endothelium",
    "Catch-up growth (rapid postnatal weight gain) amplifies metabolic risk",
    "Clinical implication: FGR babies need long-term follow-up well beyond neonatal period",
    "Barker's original 'Hertfordshire cohort' data — seminal evidence for this concept",
    "DOHaD now a major global research priority — intergenerational cycle of disease",
  ]
);

// SLIDE 26: Specific Doppler vs outcomes (evidence summary)
contentSlide("Evidence Summary — Doppler-Guided Management", [
  "PORTO TRIAL (Unterscheider et al, 2014):",
  "  → 1,116 SGA fetuses; CPR <5th centile best predictor of adverse perinatal outcome (OR 3.91)",
  "",
  "TRUFFLE TRIAL (Lees et al, NEJM 2015):",
  "  → RCT: DV-guided delivery (a-wave at baseline) vs CTG-STV-guided delivery in early FGR",
  "  → DV-based delivery REDUCED severe neurodevelopmental disability at 2 years WITHOUT increasing mortality",
  "  → Key: delay delivery using DV monitoring rather than CTG short-term variability alone",
  "",
  "DIGITAT TRIAL (Boers et al, BMJ 2010):",
  "  → Term SGA (≥36 wks): induction of labour vs expectant management",
  "  → No difference in adverse outcomes; induction acceptable and avoids further deterioration",
  "",
  "STRIDER TRIAL (sildenafil for severe early FGR):",
  "  → STOPPED early — increase in neonatal pulmonary hypertension in treated group",
  "  → Sildenafil is NOW CONTRAINDICATED in FGR (SMFM 2020, Grade 1B)",
  "",
  "ASPRE Trial (Rolnik, 2017, NEJM): Aspirin 150mg from 11–14 wks reduces early PE by 62%",
], { fontSize: 14 });

// SECTION 11
sectionDivider(11, "Practical Case Discussion");

// SLIDE 27: Case 1
contentSlide("Case 1 — Early Onset FGR at 28 Weeks", [
  "Mrs. A, G2P1, 28 weeks | Previous FGR baby | BP 150/95 mmHg | Proteinuria 2+",
  "Scan: EFW 700g (<3rd centile) | AC <3rd centile | UtA-PI bilateral >95th centile | UA-PI >95th centile | MCA-PI 5th centile | DV normal",
  "AFI reduced (7 cm)",
  "",
  "DIAGNOSIS: Early-onset FGR (pre-eclampsia with FGR) — Stage 1–2 Doppler changes",
  "",
  "MANAGEMENT:",
  "  → Admit for BP management (labetalol / nifedipine) — target <135/85",
  "  → Antenatal corticosteroids: Betamethasone 12mg IM × 2 doses now",
  "  → MgSO4 — not yet (delivery not imminent), but prepare orders",
  "  → Doppler twice weekly (UA + DV + MCA)",
  "  → Daily CTG once >28 weeks",
  "  → Growth scan every 2 weeks",
  "  → Neonatology counseling and NICU notification",
  "  → Delivery plan: If UA REDF or DV a-wave reversal → deliver. Otherwise aim for ≥30 weeks",
  "  → Amniocentesis offered — chromosomal anomaly in 20% of severe early FGR",
], { fontSize: 13 });

// SLIDE 28: Case 2
contentSlide("Case 2 — Late SGA with Abnormal CPR at 36 Weeks", [
  "Mrs. B, G1P0, 36 weeks | No known risk factors | Routine scan found EFW 9th centile",
  "Serial scans: EFW dropped from 25th → 9th centile over 4 weeks",
  "Doppler: UA-PI normal (50th centile) | MCA-PI 4th centile | CPR 0.8 (<5th centile) | DV normal",
  "AFI 8 cm | BPP 8/8",
  "",
  "DIAGNOSIS: Late FGR (SGA + centile drop ≥50 + CPR <5th centile)",
  "",
  "MANAGEMENT:",
  "  → Classify as Late FGR — NOT just SGA",
  "  → Weekly Doppler (CPR, UA, MCA) + fortnightly growth scans",
  "  → CTG now and at each visit",
  "  → Low-dose aspirin has not been started (missed opportunity — teaching point!)",
  "  → Plan delivery at 37–38 weeks",
  "  → Given GA 36 weeks: consider delivery NOW vs wait",
  "  → RCOG/ISUOG: deliver at 37+0 if UA-PI >95th (here UA normal but CPR abnormal)",
  "  → Consensus: deliver at 37–38 weeks latest; ensure continuous CTG in labour",
], { fontSize: 13 });

// SLIDE 29: case 3 — acute deterioration
alertSlide(
  "CASE 3 — ACUTE DETERIORATION: What Would You Do?",
  [
    "Mrs. C, G3P2, 30 weeks, known early FGR | On previous review: UA PI 95th centile, DV normal",
    "TODAY: Reduced fetal movements × 2 days | UA REDF on Doppler | DV a-wave REVERSED | CTG: baseline bradycardia with shallow decelerations",
    "ACTION: EMERGENCY CAESAREAN SECTION — Do NOT delay. Give MgSO4 4g IV over 20 min for neuroprotection. Alert NICU. Inform blood bank. Give steroids if not already given.",
  ]
);

// SECTION 12
sectionDivider(12, "Key Takeaways");

// SLIDE 30: Key messages
contentSlide("Key Clinical Takeaways", [
  "1. FGR ≠ SGA — FGR = SGA + evidence of placental dysfunction (Doppler/trajectory); most SGA are constitutionally small",
  "2. AC is the FIRST biometric parameter to fall in asymmetric FGR; serial AC is your best friend",
  "3. Doppler is the cornerstone of surveillance — sequence: UA → MCA/CPR → DV → urgent delivery",
  "4. UA REDF = emergency: admit, steroids, MgSO4, plan immediate delivery",
  "5. DV a-wave reversal = deliver immediately (regardless of GA if viable)",
  "6. CPR <5th centile is the best marker for late FGR — do not rely on UA alone after 32 weeks",
  "7. Aspirin 150 mg from 11–14 weeks is the most effective prevention for early-onset FGR/PE",
  "8. Sildenafil is CONTRAINDICATED — STRIDER trial showed harm",
  "9. Antenatal steroids <34 weeks + MgSO4 <32 weeks — never forget in preterm FGR",
  "10. Long-term follow-up matters: Barker hypothesis — FGR babies are at lifetime risk of metabolic disease",
], { fontSize: 16 });

// SLIDE 31: Guidelines summary table
tableSlide(
  "Guideline Recommendations at a Glance",
  ["Guideline", "FGR Definition", "Key Doppler Trigger", "Delivery Trigger"],
  [
    ["ISUOG 2020", "Delphi criteria (EFW <10th + Doppler/trajectory)", "UA-PI >95th, CPR <5th", "DV a-wave reversed or STV-based protocol"],
    ["RCOG 2024", "Delphi criteria", "UA-PI, MCA-PI, CPR", "Individualized; AEDV: consider <37 wks; REDF: deliver"],
    ["SMFM 2020", "EFW or AC <10th centile", "UA-PI change pattern", "AEDV/REDF + steroids/MgSO4 trigger"],
    ["FIGO 2021", "Delphi criteria", "Multi-vessel Doppler at diagnosis", "Individualized per Doppler staging"],
    ["SOGC 2023", "Delphi criteria", "UA + DV", "UA-AEDV + DV/MCA abnormal → delivery"],
  ]
);

// SLIDE 32: Remember points (callout style)
contentSlide("EXAM-READY MNEMONICS & HIGH-YIELD FACTS", [
  "CAUSES of FGR — '3 Ps':",
  "  → Placental (pre-eclampsia, infarction, abnormal insertion)",
  "  → Pregnancy factors (multiple gestation, TORCH, chromosomal)",
  "  → Patient factors (smoking, malnutrition, drugs, systemic disease)",
  "",
  "DOPPLER SEQUENCE — 'UA → MCA → CPR → DV → DELIVER'",
  "",
  "HIGH-YIELD FACTS:",
  "  → EFW <3rd centile = FGR regardless of Doppler (severe SGA)",
  "  → Cerebellar diameter is SPARED in FGR (useful for GA dating in late presentation)",
  "  → TRUFFLE: DV-guided delivery reduces NDD without increasing mortality",
  "  → ASPRE: Aspirin from 11 wks reduces early PE by 62%",
  "  → Sildenafil = CONTRAINDICATED (STRIDER trial)",
  "  → MgSO4 = neuroprotection + prevents eclampsia (dual purpose < 32 wks)",
  "  → Continuous CTG in ALL FGR labours — MANDATORY",
], { fontSize: 15 });

// SLIDE 33: References
contentSlide("References", [
  "1. Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice, 8th ed. Chapter 44 (FGR), pp.1033–1064",
  "2. ISUOG Practice Guidelines: Diagnosis and management of SGA fetus and FGR. Ultrasound Obstet Gynecol 2020;56:298–312",
  "3. RCOG Green-top Guideline No.31: SGA Fetus and Growth Restricted Fetus (2024 update)",
  "4. SMFM Consult Series #52: Diagnosis and Management of FGR (2020, reaffirmed 2024)",
  "5. Lees C et al (TRUFFLE Group). 2-year neurodevelopmental and intermediate perinatal outcomes in infants with very preterm fetal growth restriction. Lancet 2015;385:2162–2172",
  "6. Rolnik DL et al (ASPRE Trial). Aspirin vs placebo in pregnancies at high risk for preterm pre-eclampsia. NEJM 2017;377:613–622",
  "7. Gordijn SJ et al. Consensus definition of fetal growth restriction (Delphi procedure). Ultrasound Obstet Gynecol 2016;48:333–339",
  "8. Unterscheider J et al (PORTO Trial). Optimizing the definition of intrauterine growth restriction. Am J Obstet Gynecol 2013;208:290.e1–6",
  "9. FIGO Working Group on Fetal Growth Restriction: Best practice recommendations. Int J Gynaecol Obstet 2021;152:s1–s76",
  "10. Barker DJP. Fetal origins of coronary heart disease. BMJ 1995;311:171",
], { fontSize: 14 });

// SLIDE 34: Thank you / Discussion slide
const endSlide = pres.addSlide();
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endSlide.addShape(pres.ShapeType.rect, { x: 0, y: H - 0.12, w: W, h: 0.12, fill: { color: ACCENT1 }, line: { color: ACCENT1 } });
endSlide.addText("THANK YOU", { x: 1, y: 1.5, w: 11.3, h: 1.5, fontSize: 64, bold: true, color: WHITE, fontFace: "Calibri", align: "center", charSpacing: 8 });
endSlide.addText("Questions & Discussion", { x: 1, y: 3.2, w: 11.3, h: 0.8, fontSize: 28, color: ACCENT1, fontFace: "Calibri", align: "center", italic: true });
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endSlide.addText(
  "\"Recognition of FGR is the single most important factor in preventing FGR-related stillbirth.\"",
  { x: 1, y: 5.1, w: 11.3, h: 1.5, fontSize: 18, color: ACCENT1 + "CC", fontFace: "Calibri", italic: true, align: "center", wrap: true }
);

// SAVE
const outputPath = "/home/daytona/workspace/fgr-seminar/FGR_Seminar_OBG_PG.pptx";
pres.writeFile({ fileName: outputPath }).then(() => {
  console.log("SUCCESS: " + outputPath);
}).catch(err => {
  console.error("ERROR:", err);
  process.exit(1);
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cd /home/daytona/workspace/fgr-seminar && node build_fgr.js

cd /home/daytona/workspace/fgr-seminar && sed -i \ 's/DARK_BG + "22"/"1A3652"/…

ls -lh /home/daytona/workspace/fgr-seminar/FGR_Seminar_OBG_PG.pptx && echo "Slid…