MONITORING
CLAP/WR - PAHO/WHO CLAP/WR FETAL GROWTH
Fescina RH Self - Instruction De Mucio B Martínez G Alemán A Manual Sosa C Mainero L Rubino M
2nd edition Monitoring Fetal Growth Self - Instruction Manual 2nd. edition Monitoring Fetal
Latin American Center for Perinatology 1586.02 Women & Reproductive Health - CLAP/WR
Scientific Publication CLAP/WR 1586.02 2011 Monitoring Fetal Growth
Self-Instruction Manual 2nd edition
Fescina RH De Mucio B Martínez G Alemán A Sosa C Mainero L Rubino M
Latin American Center for Perinatology Women and Reproductive Health CLAP/WR Familiy and Community Health Pan American Health Organization / World Health Organization
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2 Monitoring Fetal Growth TABLE OF CONTENTS Pag 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 EITHER UNRELIABLE OR UNKNOWN IN PREGNANT WOMEN CAPTURED LATE FOR CONTROL t (SPXUISBUFQBUUFSOTCBTFEPOUIFFBSMJFSWBMVF t 5IFGFUBMBCEPNJOBMDJSDVOGFSFODFGFNVSMFOHUISBUJP DIFFERENTIAL DIAGNOSIS BETWEEN A FETUS WITH APPROPRIATE GROWTH AND IUGR WITH UNCERTAIN LMP AND LATE CAPTURE DIFFERENTIAL DIAGNOSIS BETWEEN SYMMETRIC IUGR AND ERROR IN THE ESTIMATION OF GESTATIONAL AGE BY LMP PROPOSALS FOR THE SOUND USE OF THE FETAL GROWTH SURVEILLANCE METHODS OBSTETRIC MANAGEMENT OF INTRAUTERINE GROWTH RESTRICTION " "OUFOBUBMNBOBHFNFOU # $IJMECJSUI 42 $ %VSJOHMBCPS EXERCISES USING THE PERINATAL COMPUTING SYSTEM FOR THE ASSESSMENT AND MONITORING OF FETAL GROWTH t 8FJHIUCZHFTUBUJPOBMBHF t -JTUJOHPGNFEJDBMSFDPSET t 3JTLFTUJNBUJPOT t )JTUPSZPG-#8 t 4NPLJOHIBCJU t 1SFDMBNQTJB t .VMUJQMFQSFHOBODZ t #BTJDTUBUJTUJDT t 'JSTUUSJNFTUFS t 4FDPOEUSJNFTUFS t 5IJSEUSJNFTUFS t 'PVSUIUSJNFTUFS t "OTXFSTUPUIFFYFSDJTFTVTJOHFSTUPUIFFYFSDJTFTVTJOHUIFQFSJOBUBMJOGPSNBUJPO TZTUFNGPSUIFBTTFTTNFOUBOENPOJUPSJOHPGGFUBMHSPXUI
Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 3
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BIBLIOGRAPHY
Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 4 Monitoring Fetal Growth MONITORING FETAL GROWTH
SELF-INSTRUCTION MANUAL
INTRODUCTION
1RUPDOHPEU\RIHWDOJURZWKFDQEHGH¿QHGDVWKHJURZWKWKDWUHVXOWVIURP uneventful cell division and growth, yielding a full-term term infant with full H[SUHVVLRQRILWVJHQHWLFSRWHQWLDODVLWVHQGSURGXFW7KLVLVYHU\GLI¿FXOW WRGHWHUPLQHLQFOLQLFDOSUDFWLFHEHFDXVHLWLVLPSRVVLEOHWRPHDVXUHWKH IHWXV¶V LQWULQVLF JURZWK SRWHQWLDO +HQFH WKH GLDJQRVLV RI QRUPDO IHWDO JURZWKLVEDVHGRQWKHFRPSDULVRQRIWKHDQWKURSRPHWULFPHDVXUHPHQWV RI WKH VXVSHFWHG DEQRUPDO QHZERUQ DJDLQVW VWDQGDUGV REWDLQHG IURP neonates considered “healthy” on the grounds that they are the product of SUHJQDQFLHVZLWKQRNQRZQDEQRUPDOLWLHV
For practical clinical purposes, a fetus is considered to have an intrauterine JURZWKUHVWULFWLRQ ,8*5 ZKHQLWVZHLJKWLVHVWLPDWHGWREHORZHUWKDQWKH ZHLJKWDSSURSULDWHIRULWVJHVWDWLRQDODJH,IWKHFKLOGLVERUQDWWKHWLPHRI GLDJQRVLVLWVZHLJKWZRXOGEHEHORZWKHORZHUOLPLWRIWKHVWDQGDUGELUWK ZHLJKWIRUWKDWVSHFL¿FJHVWDWLRQDODJH0RVWDXWKRUVDJUHHWKDWWKLVORZHU OLPLW 6*$ FRUUHVSRQGV WR SHUFHQWLOH RI WKH JHVWDWLRQDO DJH FXUYH +RZHYHULWLVLPSRUWDQWWRKLJKOLJKWWKDWWKLVGH¿QLWLRQRIJURZWKUHVWULFWLRQ LQFOXGHVDVDEQRUPDORIWKHSRSXODWLRQRIQRUPDOQHZERUQV7KHUHLV HYLGHQFHWKDWWKHRFFXUUHQFHRIDGYHUVHSHULQDWDORXWFRPHVLVPRUHOLNHO\ LQWKRVHLQIDQWVWKDWGHYLDWHPRUHIURPWKHWKSHUFHQWLOHDVWKRVHWKDW DUHEHORZSHUFHQWLOH
In a strict sense, it is important to consider that:
D QRWDOOFKLOGUHQZLWKDELUWKZHLJKWOHVVWKDQWKHWK SHUFHQWLOHYDOXHVKDYHDQ,8*5 WKLVFRXOGEHWKHFDVHRI a normal child with a low growth potential. E $ELUWKZHLJKWDERYHWKHWKSHUFHQWLOHGRHVQRW QHFHVVDULO\UXOHRXWWKHGLDJQRVLVRI,8*5VLQFHLWPD\ KDYHEHHQDIHWXVWKDWKDGJURZQZHOOXSWRDFHUWDLQ SRLQWGXULQJSUHJQDQF\EXWWKHQLWEHJLQVWRIDOOEHKLQG VRHYHQZKHQWKH¿QDOZHLJKWLVRYHU3WKHUHZDV indeed a growth restriction that led it to go, for instance, IURPSHUFHQWLOH WRSHUFHQWLOH
Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 5
Exercise 1 Case A Case B 30 weeks 1800 g. 900 g. 35 weeks 2300 g. 1900 g. 40 weeks 3000 g. 2800 g. 5000 P 4000 90 P 3000 10 Grams 2000 1000 25 27 29 31 33 35 37 39 41 Amenorrhea, in weeks Figure 1 – Weight by GA curve, showing P10 and P90 ,IWKHYDOXHVDUHSORWWHGLQ)LJXUH\RXZLOOVHHWKDWFDVH$DOZD\VIDOOVEHWZHHQ 3DQG3 ZKLOHFDVH%LVDOZD\VEHORZ3 +RZHYHU WKH FRXUVH HYLGHQFHG E\ WKH FXUYHV LQGLFDWHV ZHLJKW GHWHULRUDWLRQ LQ FDVH$ SHUFHQWLOH GURS ZKLOH FDVH % UHPDLQV DOZD\V ZLWKLQ WKH VDPH SHUFHQWLOH7KHUHIRUHVWULFWO\VSHDNLQJFDVH$LVDQ,8&5ZLWKRXWEHLQJD6*$ ZKLOHFDVH%LVD6*$EXWQRWDUHVWULFWLRQ Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 6 Monitoring Fetal Growth ,QDQDWWHPSWWRSDUWLDOO\DYRLGWKHVHSUREOHPVRWKHUDXWKRUVSURSRVHGXVLQJ WKHFRQFHSWRIQRUPDOJURZWKDWELUWKEDVHGRQFHUWDLQZHLJKWOLPLWVIRUH[DPSOH JUDPV WKHWHUPORZELUWKZHLJKW /%: LVDSSOLHGWRDOOQHZERUQVZHLJKLQJ OHVVWKDQJUDPVDWELUWKUHJDUGOHVVRIJHVWDWLRQDODJH &RQVLGHULQJMXVWWKHELUWKZHLJKWDOVRSRVHVDVHULRXVSUREOHPEHFDXVHLWGRHV not provide an accurate estimation of the proportion of small for gestational age 6*$ LQIDQWV $WWKHHQGRIJHVWDWLRQWKHWKSHUFHQWLOHUHDFKHV J GHSHQGLQJ RQ WKH VWDQGDUG XVHG 7KHUHIRUH DOO LQIDQWV ZHLJKLQJ EHWZHHQDQG JWKDWDUHUHDOO\VPDOOIRUJHVWDWLRQDODJHZRXOG QRWEHFODVVL¿HGDVVXFKLIRQHDSSOLHVWKHGH¿QLWLRQWKDWFRQVLGHUVDJ OLPLW7KLVZHLJKWUDQJH IURPWR J DFFRXQWVIRUPRVWFKLOGUHQ ERUQVPDOOIRUJHVWDWLRQDODJH Exercise 2 Let us review the concepts of SGA and LBW. Try to locate the 4 values listed below in Figure 1. Rank the G. A. Weight case Case C 35 2600 grs. Case D 37 2300 grs. Case E 39 2800 grs. Case F 39 3350 grs. 'HVSLWHWKHDERYHLVVXHVZKLFKVKRXOGEHWDNHQLQWRDFFRXQWDQGDUHXQGHU LQYHVWLJDWLRQWKHZHLJKWE\JHVWDWLRQDODJHVWDQGDUGVDUHVWLOOKHOSIXOWRFODVVLI\ infants. ,WLVIUHTXHQWWRVHHLQDGHTXDWHFXUYHVZLWKPHWKRGRORJLFDOSUREOHPVRUORFDORU foreign standards developed ignoring certain factors that alter fetal growth and Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 7 DFWDVFRQIRXQGLQJYDULDEOHVWKDWQHHGWREHFRQWUROOHG7KHVHIDFWRUVLQFOXGH DPRQJRWKHUV WKHPRWKHU¶VZHLJKWJDLQVPRNLQJKDELWVDQGVRFLRHFRQRPLF OHYHO)RUH[DPSOHWKHELUWKZHLJKWREVHUYHGLQ$EHUGHHQ6FRWODQGKDGFKDQJHG \HDUVDIWHUWKH¿UVWGHVFULSWLRQRIWKHVWDQGDUGVLQ *URZWKVWDQGDUGV VKRXOGEHUHYLVHGHYHU\\HDUVWRVHHLIWKH\KDYHFKDQJHGVRVXEVWDQWLDOO\LQ the population, as to warrant changing the reference standards. )LJXUHVKRZVWKHFXUYHREWDLQHGDWWKH/DWLQ$PHULFDQ&HQWHUIRU3HULQDWRORJ\ 7KHVDPSOHLQFOXGHGQHZERUQV 1% IURPSXEOLFKRVSLWDOVLQ0RQWHYLGHR 8UXJXD\6DR3DXOR%UD]LODQG%XHQRV$LUHVDQG1HXTXpQ$UJHQWLQD 5000 P 4000 90 P 3000 10 Gramos 2000 1000 25 27 29 31 33 35 37 39 41 Amenorrhea in weeks Figure 2 – Standards developed by CLAP/WR for neonatal weight by gestational age Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 8 Monitoring Fetal Growth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¶VSHULQDWDOULVNLVKLJKHUGXH WRWKHDVVRFLDWLRQRIWZRFRQGLWLRQV Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 9 FACTORS AFFECTING INTRAUTERINE GROWTH *URZWKLPSOLHVDSURFHVVRIV\QWKHVLVUDQJLQJIURPVLPSOHPROHFXOHV WR FRPSOH[ ELRPROHFXOHV WKLV SURFHVV RFFXUV VLPXOWDQHRXVO\ ZLWK FHOO differentiation, and it leads to the development of organs and tissues in charge of complex and interrelated functions. $OWKRXJKWKHLQWLPDWHSURFHVVHVUHPDLQXQNQRZQLWLVDNQRZQIDFWWKDW JURZWKFDQEHDOWHUHGE\VHYHUDOIDFWRUV&XUUHQWNQRZOHGJHVKRZVWKDW DERXWRIWKHFDVHVRI,8*5DUHDVVRFLDWHGZLWKFHUWDLQVSHFL¿FULVN IDFWRUV 7KHVHIDFWRUVFDQEHEURNHQGRZQGHSHQGLQJRQWKHWLPH at which they are detected: a) Preconception risk factors, E 5LVNVLGHQWL¿HGGXULQJSUHJQDQF\ c) Environmental and behavioral risks a) Preconception risk factors :RPDQ¶VORZHGXFDWLRQDQGORZVRFLRHFRQRPLFVWDWXV 2. ([WUHPHDJHV RU!\HDUV 6KRUWKHLJKW FP 4. Severe malnutrition &KURQLFGLVHDVHV K\SHUWHQVLRQNLGQH\GLVHDVHGLDEHWHVZLWK vascular disease, chronic lung disease, mesenchymal diseases ZLWKYDVFXODUFKDQJHVKHPRJORELQRSDWKLHV +LVWRU\RI6*$ b) Risk factors detected during pregnancy 0XOWLSOHSUHJQDQF\ 2. :HLJKWJDLQRIOHVVWKDQNJDWWHUP %LUWKLQWHUYDORIOHVVWKDQPRQWKV 4. Pregnancy-induced hypertension / preeclampsia-eclampsia Antiphospholipid syndrome Anemia ,QIHFWLRQV YLUDO UXEHOOD F\WRPHJDORYLUXV YDULFHOOD KHUSHV ]RVWHU 3DUDVLWLF WR[RSODVPRVLVPDODULD Congenital malformations *HQHWLFGLVRUGHUV Exposure to teratogens Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 10 Monitoring Fetal Growth c) Environmental and behavioral risk factors 6PRNLQJGXULQJSUHJQDQF\ 2. Heavy alcohol consumption Excessive consumption of caffeine 4. Drug Addiction +LJKDOWLWXGHDERYHVHDOHYHO Stress /DFNRIRULQDGHTXDWHDQWHQDWDOFDUH([FHVVLYHSK\VLFDOZRUN Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 11 PHYSIOPATHOGENESIS OF INTRAUTERINE GROWTH RESTRICTION 6*$VDUHFODVVLFDOO\GLYLGHGLQWRWZRW\SHV LQWKHFDVHRIV\PPHWULF6*$VDOO PHDVXUHV KHDGFLUFXPIHUHQFHOHQJWKZHLJKW DUHUHGXFHGDQGDV\PPHWULF 6*$VRQO\KDYHDZHLJKWUHGXFWLRQZLWKQRUPDOVL]HGKHDGFLUFXPIHUHQFH DQGERG\OHQJWK 7KHIRUPHUDUHXVXDOO\GXHWRFDXVHVWKDWRFFXU DWHDUO\VWDJHVRISUHJQDQF\ HJFKURPRVRPDODEQRUPDOLWLHVUXEHOODHWF In the latter, the asymmetric growth is due to insults that appear in the third WULPHVWHU HJSUHJQDQF\LQGXFHGK\SHUWHQVLRQ 7KHVHGLIIHUHQWJURZWKGLVRUGHUVDUHGXHWRWKHDV\QFKURQRXVJURZWKUDWHVRI the various tissues, i.e., tissues present their hyperplasia at different times of JHVWDWLRQ7LVVXHVDUHPRUHVHQVLWLYHWRGDPDJHDWWKHLUSHDNJURZWKUDWH7KH so-called critical period. )LJXUHVKRZVWKDWWKHJURZWKSHDNRIWKHQHXUDOWLVVXHLVDURXQGZHHNV JHVWDWLRQ ZKLOH WKH DGLSRVH WLVVXH FKDQJHV JURZV PRUH DW ZHHNV JHVWDWLRQ Acts at the Early and critical period Results prolonged Neurons Yes Reduced head cir. harm Symmetric Long bones Yes “ Length SGA Late Adipositosis Yes “ Weight onset Neurons No Normal head circ. harm Asymmetric Long bones No Normal length SGA Adipositosis Yes Reduced weight Long Neurons Adiposytes bones Growth rate Growth 15 20 25 30 35 40 Weeks of gestation Figure 3 – Critical periods of the different tissues and perinatal outcomes depending on the time of occurrence and the duration of the noxa Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 12 Monitoring Fetal Growth $QR[DWKDWDFWVHDUO\DQGLVPDLQWDLQHGWKURXJKRXWSUHJQDQF\ HJUXEHOOD ZLOOLPSDLUJURZWKRYHUDOO OHQJWKZHLJKWKHDGFLUFXPIHUHQFH DQGLWZLOOUHVXOW LQ D KDUPRQLF DQG V\PPHWULF JURZWK UHVWULFWLRQ NQRZQ DV :LQLFN¶V W\SH *5 RU &DPSEHOO¶V ORZ SUR¿OH ,Q FRQWUDVW ZKHQ WKH QR[D DFWV ODWHU HJSUHHFODPSVLD LWVZRUVWLPSDFWLVRQZHLJKWZKLOHKHLJKWDQGKHDG FLUFXPIHUHQFH WHQG WR UHPDLQ ZLWKLQ QRUPDO UDQJHV7KLV JURZWK UHVWULFWLRQ LV GLVKDUPRQLRXV DQG DV\PPHWULF DQG LW LV NQRZQ DV :LQLFN¶V W\SH ,, RU &DPSEHOO¶VODWHÀDWWHQLQJ 7KHDERYHLVZKDWXVXDOO\KDSSHQVEXWLWLVQRWHZRUWK\WKDWLIDQRIIHQGLQJ DJHQWDFWVODWHUDQGLWLVVHYHUHHQRXJKLWPD\LPSDFWRQWKHVL]HRIWKHVNXOO EXWWRDOHVVHUH[WHQWWKDQRQZHLJKW WKHEHVWLQGLFDWRURIWKHODWWHUSDUDPHWHU LVWKHIHWDODEGRPLQDOFLUFXPIHUHQFH )$& Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 13 DIAGNOSIS $QWHQDWDO VXUYHLOODQFH RI IHWDO JURZWK VKRXOG LQFOXGH D GLDJQRVWLF VFUHHQLQJPHWKRGVWREHXVHGURXWLQHO\LQDQWHQDWDOFDUHDWDOOWKHOHYHOV RIFDUHDQGE PHWKRGVWRFRQ¿UPWKHGLDJQRVLVWKDWUHTXLUHDFHUWDLQOHYHO of technological complexity, and that are generally found in specialized facilities. 6WDQGDUGVRIFDUHVKRXOGSURSRVHSUHYHQWLRQVWUDWHJLHVWKDWHQDEOHWKH monitoring of fetal growth for the entire population of pregnant women, XVLQJDWLHUHGGHFLVLRQPDNLQJV\VWHPWKDWIDFLOLWDWHVDUDWLRQDOGLVWULEXWLRQ of resources. ,Q JHQHUDO WKH ¿UVW FRQWDFW EHWZHHQ WKH ZRPDQ DQG WKH KHDOWK WHDP RFFXUVZKHQWKHZRPDQLVDOUHDG\SUHJQDQWVRWKHLGHQWL¿FDWLRQRIULVN IDFWRUV DQG VXEVHTXHQW LQWHUYHQWLRQV KDV WR EH GRQH GXULQJ DQWHQDWDO FDUH ZKLFK VKRXOG VWDUW HDUO\ EH UHJXODU FRQWLQXRXV DQG XQLYHUVDO FRYHUDJH $QHDUO\FDSWXUHDOORZVWKHWHDPWRGHWHFWULVNIDFWRUVHQDEOLQJWKHP WRFRUUHFWWKRVHWKDWDUHPRGL¿DEOH LQDGGLWLRQLQVXEVHTXHQWFRQWUROV WKHSUHJQDQWZRPDQVKRXOGEHDVVHVVHGWRUDWLI\RUUHFWLI\WKHSULPDU\ diagnosis, and thus decide what level of complexity is appropriate for that delivery. 0DQ\ VFRULQJ V\VWHPV KDYH EHHQ SURSRVHG WR LGHQWLI\ SUHJQDQFLHVDW LQFUHDVHGULVNRISURGXFLQJVPDOOIRUJHVWDWLRQDODJHLQIDQWVEXWWKH\DOO IDLOHGWRPHHWWKHH[SHFWDWLRQVIROORZLQJWKHRULJLQDOSXEOLFDWLRQ For this reason, instead of a scoring system, we recommend using a list RIIDFWRUVDVVRFLDWHGZLWK,8*5DQGZKRVHSUHVHQFHLQWKHSUHJQDQW ZRPDQPD\HQDEOHWKHKHDOWKFDUHSURYLGHUVWRLGHQWLI\WKHFDVHDWD KLJK ULVN RI ,8*5 7KH VHOHFWLRQ RI WKH IDFWRUV PXVW EH PDGH WDNLQJ LQWR DFFRXQW DPRQJ RWKHU FULWHULD WKHLU IUHTXHQF\ LQ WKH SRSXODWLRQ WKHGHJUHHRIDVVRFLDWLRQZLWKGDPDJHDQGWKHLUVWDWLVWLFDOVLJQL¿FDQFH )RUH[DPSOH7DEOHSURYLGHVDOLVWRIIDFWRUVGHYHORSHGE\&/$3ZLWK WKHLUFRUUHVSRQGLQJIUHTXHQF\LQWKHSRSXODWLRQUHODWLYHULVN 55 DQG FRQ¿GHQFH LQWHUYDO 7KH SRSXODWLRQ LQFOXGHG SUHJQDQW ZRPHQ IURP SXEOLF KRVSLWDOV LQ 0RQWHYLGHR 8UXJXD\ 6DR 3DXOR %UD]LO DQG %XHQRV$LUHVDQG1HXTXpQ$UJHQWLQD 7KHRGGVRIGLDJQRVLQJ,8*5DQGWKHPHWKRGVWKDWFDQEHXVHGGHSHQG Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 14 Monitoring Fetal Growth SULPDULO\RQWKHSUHFLVHNQRZOHGJHRIWKHODVWPHQVWUXDOSHULRGDQGWKH 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 in Relative 95% Confidence population % Risk interval History of SGA 14 1.5 1.1 - 2.7 Smoking habit (10 o +) 26 1.6 1.1 - 2.2 Multiple pregnancy 1 3 2.0 - 3.4 Pregnancy-induced hypertension 7 1.4 1.2 - 1.7 Preeclampsia 4 2.1 1.9 - 3.2 Hemorrhage 2nd trimester 0.5 1.6 1.2 - 2.7 Weight gain < 8 kg. 16 2.1 1.3 - 3.5 Oligoamnios 0.5 2.9 1.7 - 5.0 $QRWKHUUHVHDUFKVWXG\LQWKHSRSXODWLRQRI3HORWDV%UD]LOLQ VWXGLHG RWKHUIDFWRUVVXFKDVPDWHUQDODJHXQGHU\HDUV 25 ORZLQFRPH 25 PDWHUQDOKHLJKW FP 25 DQGLQDGHTXDWH DQWHQDWDOFRQWURO 25 Calculation of gestational age *LYHQWKHVLJQL¿FDQFHRINQRZLQJWKHSUHFLVHJHVWDWLRQDODJHWRGHWHUPLQH the duration of pregnancy and properly evaluate fetal growth, we will EULHÀ\UHYLHZWKHFOLQLFDODQGODERUDWRU\PHWKRGVXVHGWRGHWHUPLQHLW 7KHFOLQLFDOPHWKRGPRVWFRPPRQO\XVHGFRQVLVWVRIDVNLQJIRUWKHGDWH RIWKHODVWPHQVWUXDOSHULRGDQGWKHUHJXODULW\RIWKHZRPDQ¶VPHQVHV 7KLV FOLQLFDO GDWD LV EDVHG RQ D PDUNHU UHPHPEHUHG E\ WKH ZRPDQ as an approximation to the time of ovulation and therefore, the time RI FRQFHSWLRQ 7KH DQDPQHVLV VKRXOG EH WDNHQ LQ D TXLHWDQG SULYDWH SODFH DQG LW LV WKH PRUH UHOLDEOH WKH HDUOLHU WKH GDWD DUH FROOHFWHG ,I in addition, this date also coincides with the clinical examination of the IXQGDOKHLJKWDVGH¿QHGLQWKH¿UVWZHHNVRISUHJQDQF\JHVWDWLRQDO DJHLVFRQ¿UPHG:KLOHWKLVPHWKRGLVPRUHVXLWDEOHIRUSDWLHQWVZKRDUH VHHNLQJSUHJQDQF\LWLVHVWLPDWHGWKDWLQRYHURIWKHSRSXODWLRQLWLV QRWWKHPRVWDSSURSULDWHWHFKQRORJ\WRDVVHVVJHVWDWLRQDODJH An alternative method used is the clinical estimation of gestational age E\WKHSK\VLFDOH[DPLQDWLRQRIWKHIXQGDOKHLJKW+RZHYHUWKHUHLVDOVR HYLGHQFHWKDWWKLVWHFKQRORJ\KDVOLWWOHYDOXH 8VHGLQLVRODWLRQ WKLV PHWKRG KDV D YDULDELOLW\ RI ZHHNV H[FHSW IRU PHDVXUHPHQWV Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 15 EHWZHHQDQG FPRUDQGFPIRUZHHNVDQGZHHNV UHVSHFWLYHO\ ZKRVH VSUHDG LV ZHHNV )LQDOO\ IHWDO PRYHPHQWV SHUFHLYHGE\WKHPRWKHUDQG¿UVWDXVFXOWDWLRQRIIHWDOKHDUWEHDWVZLWK 3LQDUG¶V RU 'H /HH¶G VWHWKRVFRSH RU /HH VKRXOG EH DYRLGHG EHFDXVH WKHLUVSUHDGLVZHHNV :KHQLQGRXEWDERXWJHVWDWLRQDODJHWKHXOWUDVRXQGLVWKHRQO\PHWKRG WKDWFDQGLDJQRVHLWDFFXUDWHO\DFFXUDF\EHLQJJUHDWHUWKHHDUOLHULWLV SHUIRUPHG )LJ 6RPHDXWKRUV EHOLHYHWKDWDUHOLDEOHODVWPHQVWUXDOSHULRGLV OHVVSUHFLVHWKDQWKHJHVWDWLRQDODJHHVWLPDWHGE\DQHDUO\XOWUDVRXQG,Q WKH¿UVWWULPHVWHURISUHJQDQF\DQGDIWHUWKHWKZHHNZKHQWKHHPEU\R EHFRPHVYLVLEOHWKHSDUDPHWHUXVHGWRHVWLPDWHJHVWDWLRQDODJHLVWKH crown-to-rump length, which has a linear relationship with gestational DJH,QWKHVHFRQGDQGWKLUGWULPHVWHUWKHSDUDPHWHUXVHGLVWKH%L3DULHWDO 'LDPHWHU %3' LQLVRODWLRQRUFRPELQHGZLWKRWKHUSDUDPHWHUVVXFKDV WKH)HPXU/HQJWK )/ Weeks P95 41 P95 P50 P P 50 37 5 Femur P5 D. BP. 33 Central value and 29 confidence limits for estimating 25 gestational age based on the ultrasound 21 measurements of: 17 Femur length Biparietal D. L.CN P95 Ceph.-Buttocks length 13 P50 P5 9 5 10 16 22 28 34 40 46 52 58 64 70 76 82 88 94 100 mm Figure 4. Estimation of gestational age based on the fetal anthropometric measurements using two-dimensional ultrasound. (21) Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 16 Monitoring Fetal Growth DIAGNOSIS OF IUGR WITH KNOWN OR ESTIMATED GESTATIONAL AGE ,8*5 FDQ EH VXVSHFWHG LQ SUHJQDQW ZRPHQ SUHVHQWLQJ ZLWK D NQRZQ JHVWDWLRQDODJHRULQZRPHQLQZKLFKQRFOLQLFDORUODERUDWRU\IHDWXUHV SHUPLWWRHVWLPDWHWKHJHVWDWLRQDODJHZLWKDQDFFHSWDEOHHUURU%HORZLV WKHVHWWLQJZKHUHWKHJHVWDWLRQDODJHLVNQRZQ $V D JHQHUDO FRQFHSW ZH PXVW FRQVLGHU WKDW ,8*5 LV UDUHO\ GHWHFWHG FOLQLFDOO\ EHIRUH ZHHNV 7KLV FOLQLFDO SLFWXUH FDQ EH DVVRFLDWHG with decreased fetal movements, oligohydramnios, low maternal weight JDLQ )LJ DQGVORZHUJURZWKRUDUUHVWHGHQODUJHPHQWRIWKHXWHUXVLQ relation to the duration of pregnancy. 7KLV ODWWHU FOLQLFDO VLJQ LV LPSRUWDQW IRU WKH GLDJQRVLV ZKLOH WKH VHULDO PHDVXUHPHQW RI WKH IXQGDO KHLJKW ZLWK D ÀH[LEOH DQG LQH[WHQVLEOH PHDVXULQJWDSHSHUIRUPHGDWHDFKDQWHQDWDOYLVLWDOORZVXVWRREVHUYH WKHJURZWKRIWKHXWHUXVDQGWRFRPSDUHLWZLWKWKHQRUPDOSDWWHUQV )LJ Although there is no compelling evidence regarding the use of fundal KHLJKWPHDVXUHPHQWV DQGWKHGHWHFWLRQRI,8*5LWVVHULDOXVHDQG LQFRQMXQFWLRQZLWKRWKHUFOLQLFDOIHDWXUHVKHOSVFRQWUROWKHQRUPDOFRXUVH RIIHWDOJURZWK ,WKDVEHHQUHSRUWHGWKDWDEGRPLQDOSDOSDWLRQGHWHFWV RQO\RIWKH6*$VVRLIWKLVGLDJQRVLVLVVXVSHFWHGDVLVWKHFDVH with the measurement of the fundal height, the diagnosis should always EHFRPSOHPHQWHGZLWKODERUDWRU\WHVWLQJ ,8*5 VKRXOG EH VXVSHFWHG ZKHQ WKH YDOXHV RI PDWHUQDO ZHLJKW JDLQ DUHORZHUWKDQWKRVHFRUUHVSRQGLQJWRWKHWKSHUFHQWLOHRIWKHQRUPDO VWDQGDUGFXUYHRUORZHUWKDQWKHIXQGDOKHLJKWFRUUHVSRQGLQJWRWKHWK SHUFHQWLOHRILWVDSSURSULDWHQRUPDOVWDQGDUGFXUYH$VVKRZQLQ7DEOH ,OO LI ERWK PHWKRGV WKH DEQRUPDO YDOXHV RI PDWHUQDO ZHLJKW JDLQ DQG IXQGDOKHLJKW DUHXVHGLQFRPELQDWLRQWRGH¿QHWKHVXVSLFLRQRI,8*5 VHQVLWLYLW\ WKHDELOLW\WRGLDJQRVHWKHWUXH,8*5 UHDFKHV Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 17 Kg. P 15 90 13 P75 11 P50 9 P25 7 P10 5 3 1 Maternal weight gain 0 16 20 24 28 32 36 40 Weeks of amenorrhea Figure 5. Maternal weight gain in Kg by gestational age. Longitudinal prospective study N = 1023 weight measurements. (22) cm 35 P90 33 P50 31 P10 29 27 25 23 21 19 17 Fundal height 15 13 11 9 7 13 15 17 19 21 23 25 27 29 31 33 35 37 39 sem. Figure 6. Fundal height in cm by gestational age. Longitudinal prospective study. N = 1074 measurements. (23) Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 18 Monitoring Fetal Growth Exercise 3 /RFDWHWKHZHLJKWJDLQYDOXHVIRUJHVWDWLRQDODJHRQ¿JXUHE\VXEWUDFWLQJ WKHXVXDOZHLJKWIURPWKHZHLJKWYDOXHREWDLQHGIRUHDFKZHHNXVLQJWKH GDWDOLVWHGEHORZ0DWHUQDOXVXDOZHLJKW .J WeekMaternal Weight gain weight (kg.) 16 58.7 24 61.5 27 62.5 32 63.0 34 63.5 Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 19 Table II - Maternal weight by height by gestational age (p10-p90). (22) Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 20 Monitoring Fetal Growth -RLQWKHSRLQWVWKDW\RXKDYHIRXQGLQ¿JXUHDQGREWDLQWKHPDWHUQDOZHLJKW 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 /RFDWHLQ¿JXUHWKHIXQGDOKHLJKWYDOXHVIRUHDFKRIWKHJHVWDWLRQDODJHVEHORZ Week Fundal height (cm) 16 14 24 21 27 23 32 24 34 25 -RLQWKHSRLQWVWKDW\RXKDYHIRXQGLQ¿JXUHDQG\RXZLOOREWDLQWKHFRXUVH of the fundal height of this case. 7KHPRWKHU¶VSUHSUHJQDQF\ZHLJKWLVRIWHQQRWDYDLODEOHPDNLQJLWLPSRVVLEOH WRFDOFXODWHKHUZHLJKWJDLQDVVKRZQDERYH,QWKLVFDVHRQHFDQXVHWKH WDEOHWKDWSORWVWKHPDWHUQDOZHLJKWIRUKHLJKWE\JHVWDWLRQDODJH 7DEOH,, 7KHWDEOHVKRZVWKHZHLJKWVFRUUHVSRQGLQJWRSHUFHQWLOHVDQG IRUHDFK gestational age and maternal height. 3UHJQDQWZRPHQZLWKZHLJKWIRUKHLJKWYDOXHVORZHUWKDQSHUFHQWLOHLQGLFDWH DSRRUZHLJKW7KHFDVHVWKHH[FHHGSHUFHQWLOH DUHFRQVLGHUHGH[FHVVLYH )RUH[DPSOHDSUHJQDQWZRPDQWKDWLV FPWDOODWDJHVWDWLRQDODJHRI ZHHNVDQGZHLJKVNJLVZLWKLQWKHQRUPDOYDOXHVIRUZHLJKWDQGKHLJKWVLQFH WKLVYDOXHLVZLWKLQNJ 3 DQG.* 3 Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 21 Exercise 5 6WDWH ZKHWKHU WKH PDWHUQDO ZHLJKW IRU KHLJKW RI WKH SUHJQDQW ZRPHQ UHDFKHG DW WKH JHVWDWLRQDO DJHV OLVWHG EHORZ LV DSSURSULDWH Is maternal weight for Gest. Maternal Maternal height by gestational age height Weight age appropriate? (wk.) (cm.) (kg.) Yes No A 27 154 53 B 20 160 58 C 18 150 46 D 31 156 55 E 36 162 67 If you answered that ladies A, C, and D do not have an appropriate weight IRU WKHLU JHVWDWLRQDO DJH DQG KHLJKW FRQWUDU\ WR ODGLHV % DQG ( \RX KDYH XQGHUVWRRGWKHXVHRIWKHFKDUWFRUUHFWO\,IQRWUHDGIURPSDJHRQZDUG KNOWN AND RELIABLE GESTATIONAL AGE Yes No C Serial measurements Early capture Fundal height Before 20 weeks l Mother’s weight i m Estimation of volume amniotic fluid n e Investigate risk factors i t h Yes No c Values < lower limit a o Oligohydramnios l d Presence of risk factors s No Yes Confirmation ultrasound Estimation of Ultrasound after the C 3rd trimester using o using GA-dependent Gestational age by m t ultrasound –GA independent p e growth indicators By Crown-to-rump length growth factors l s Abd. Circ e t Distance curve of fetal 8-13 weeks Ratio = m abdominal circumference and By BPD after 12 weeks Femur length i Growth rate based on previous e head circumference by By Femur length after n n . value of fetal abdominal g gestational age 13 weeks circumference t a r y Appropriate fetal growth- low D i a g n o s i s o f I U G R risk antenatal control Ruled out Confirmed See algorithm for the differential diagnosis between symmetric and asymmetric IUGR and management Figure 7. Algorithm for the diagnosis of IUGR 7KHUHLVQRGRXEWWKDWXOWUDVRXQGLVWKHPRVWSUHFLVHWHVWDYDLODEOHWRFRQ¿UP WKHGLDJQRVLV 7DEOH,,, $GGHGWRWKLVDGYDQWDJHWKURXJKDQXPEHURI IHWDODQWKURSRPHWULFPHDVXUHPHQWVLWSHUPLWVWRHVWDEOLVKWKHW\SHRIUHVWULFWLRQ 7KH YDULDEOHV PRVW FRPPRQO\ XVHG WR GHWHUPLQH IHWDO JURZWK DQG W\SH RI UHVWULFWLRQDUHWKHIHWDOKHDGDQGDEGRPLQDOFLUFXPIHUHQFHV )LJXUHVDQG Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 22 Monitoring Fetal Growth 7KH PHDVXUHV WKXV REWDLQHG DUH FRPSDUHG ZLWK WKH QRUPDO SDWWHUQV LQ WKLV FDVH XVLQJ WKH JURZWK FXUYHV DFFRUGLQJ WR JHVWDWLRQDO DJH GLVWDQFH FXUYH 2EVWHWULFXOWUDVRXQGDOVRSURYLGHVLQIRUPDWLRQUHJDUGLQJWKHDPRXQWRIDPQLRWLF ÀXLGDQGWKHPDWXULW\RIWKHSODFHQWDZKLFKDUHSDUDPHWHUVXVHGLQWKHFOLQLFDO PDQDJHPHQW RI LQWUDXWHULQH JURZWK UHVWULFWLRQ 7KH VHULDO PHDVXUHPHQWV RI DEGRPLQDO FLUFXPIHUHQFH DQG IHWDO ZHLJKW HVWLPDWLRQ DUH EHWWHU WKDQ WKH LVRODWHG HVWLPDWHV RI IHWDO ZHLJKW IRU WKH GLDJQRVLV RI ,8*5 +RZHYHU WKH LQWHUYDOEHWZHHQXOWUDVRXQGVFDQVVKRXOGEHJUHDWHUWKDQWZRZHHNVWRSUHYHQW DJUHDWHUSURSRUWLRQRILQFRUUHFWGLDJQRVHV IDOVHSRVLWLYHV Head circumference mm 370 P95 350 P50 330 P 310 5 290 270 250 230 210 190 170 150 130 110 90 70 14 16 18 20 22 24 26 28 30 32 34 36 38 40 Weeks of amenorrhea Figure 8 - The fetal head circumference measurements in the symmetric growth restriction (---) fall early (24 weeks) below normal limits (percentile 5), while in the asymmetric restriction (.....) measurements usually remain within normal limits. (15) Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 23 mm. 390 370 350 P50 330 P5 310 290 270 250 230 210 190 170 Abdominal circumference 150 130 110 90 70 15 17 19 21 23 25 27 29 31 33 35 37 39 Weeks of amenorrhea Figure 9 - The fetal abdominal circumference falls below the normal range (percentile 5) around 32 weeks in the types of restrictions, so this measure is the most sensitive indicator. In the case of symmetric restrictions (---), its fall occurs later than the asymmetric restrictions of the head circumference (24 weeks) (.....). (15) Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 24 Monitoring Fetal Growth Table III-Effectiveness of fundal height, maternal weight gain, fetal abdominal circumference, fetal head circumference, BPD and oligoamnios measured by ultrasonography to predict SGA (24) Measured Variable < AGA Sens. Sp. PPV NPP PLR NLR P10 % % % % < P10 20 5 Fundal height (AU) 56 % 91 % 80 % 77 % 6.22 0.48 3 16 53 < P25 18 12 Maternal weight gain (GP) 50 % 79 % 60 % 72 % 2.38 0.63 3 18 46 < P10 < P25 27 16 FH or GP 75 % 72 % 63 % 82 % 2.68 0.35 3 3 9 42 < P5 34 0 Fetal abdominal circumference 94 % 100 % 94 % 94 % 100 0.06 3 2 58 < P5 24 4 Biparietal diameter 67 % 93 % 67 % 67 % 9.57 0.35 3 12 54 < P5 15 0 Head circumference 42 % 100 % 42 % 42 % 100 0.58 3 21 58 Si 10 1 Oligoamnios 28 % 98 % 28 % 28 % 14.0 0.73 No 26 57 3UHYDOHQFHRI,8*5LQWKHSRSXODWLRQXQGHUVWXG\ KLJKULVN $*$ Appropriate for gestational age Sens: Sensitivity Sp:6SHFL¿FLW\ PPV: Positive Predictive Value 139 1HJDWLYH3UHGLFWLYH9DOXH PLR:3RVLWLYH/LNHOLKRRG5DWLR 1/5 1HJDWLYH/LNHOLKRRG5DWLR Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 25 Known gestational age with no doubts Yes No Distance curve of the fetal Fetal Abdominal Circumference/ abdominal circumference Femur Length ratio P10 < 4.25 P10 4.25 Between P5 and P95 Lower than percentile 5 Distance curve of the fetal head Normal growth circumference or femur length or symmetric IUGR Fetal abdominal circumference Between P5 and P95 Lower than P5 growth rate curve based on previous value Increase Increase lower tan as expected expected Normal Asymmetric IUGR Symmetric IUGR Normal fetal growth fetal growth Figure 10. Algorithm for the differential diagnosis between normal fetal growth and symmetric and asymmetric IUGR. Exercise 6 'LIIHUHQWLDOGLDJQRVLVEHWZHHQDSSURSULDWHIHWDOJURZWKDQG,8*5ZLWKNQRZQ DQGUHOLDEOHIHWDOJHVWDWLRQDODJH 7RGRWKLVH[HUFLVH\RXZLOOEHXVLQJIXQGDOKHLJKWFKDUWV SDJH PDWHUQDO ZHLJKWJDLQFKDUWV SDJH IHWDODEGRPLQDOFLUFXPIHUHQFH SDJH IHWDO KHDG FLUFXPIHUHQFH SDJH DQG DOJRULWKPV IRU WKH GLDJQRVLV RI ,8*5 SDJH DQGIRUWKHGLIIHUHQWLDOGLDJQRVLVEHWZHHQIHWXVHVZLWKDSSURSULDWH JURZWKDQGIHWXVHVZLWKV\PPHWULFDQGDV\PPHWULF,8*5 SDJH 7KHH[HUFLVHVKDYHDVHTXHQFHVXFKWKDWWKHTXHVWLRQVVKRXOGEHDQVZHUHGDV they are formulated. Do not go any further with your reading without complying ZLWKWKLVUHTXLUHPHQW 0UV == LV RQ KHU WK ZHHN RI SUHJQDQF\ WKH GDWH RI KHU /03 LV FHUWDLQ DQG LQ DFFRUGDQFH ZLWK DQ HDUO\ XOWUDVRXQG IXUWKHUPRUH VKH KDV DWWHQGHG SUHYLRXV DQWHQDWDO YLVLWV ,Q WKLV KHU IRXUWK YLVLW WR WKH +HDOWK &HQWHU KHU REVWHWULFH[DPLQDWLRQ¿QGLQJVLQFOXGH Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 26 Monitoring Fetal Growth Mrs. ZZ Gestational age 34 weeks Current weight 62 kg. Usual weight 53 kg. Blood pressure 120/70 mmHg. Fundal height 25 cm. Which would be your presumptive diagnosis? Fetus with a normal growth Fetus with a growth restriction Macrosomic fetus (large) None of the above Assuming you can order tests to confirm the diagnosis, which would you ask? Fetal abdominal circumference (ultrasound) Maternal abdominal circumference Biparietal diameter (ultrasound) None of the above ,I\RXFKRVHWKHIHWDODEGRPLQDOFLUFXPIHUHQFHPHDVXUHGE\XOWUDVRXQG\RX DUHRQWKHULJKWWUDFN \RXPD\JRRQ ,I\RXFKRVHDQ\RWKHUDOWHUQDWLYHUHUHDGSDJHVWRDQGVHHWKHDOJRULWKP IRUWKHGLDJQRVLVRI,8*5RQSDJHEHIRUH\RXJRRQ What diagnosis would you suggest and what would you do if the measurement RIWKHIHWDODEGRPLQDOFLUFXPIHUHQFHZDV Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 27 Fetal abdominal circumference Fetal diagnosis 300 mm 266 mm Normal fetal growth IUGR Macrosomic None of the above Fetal abdominal circumference Recommended Management 300 mm 266 mm Proceed with antenatal control for low-risk pregnancy Refer to high risk Special tests to determine IUGR type Oral Glucose Tolerance Test ,IWKHPHDVXUHPHQWRIWKHIHWDODEGRPLQDOFLUFXPIHUHQFHZDVPP WKHGLDJQRVLVLVWKDWRIQRUPDOIHWDOJURZWKVLQFHWKHYDOXHLVEHWZHHQ DQG SHUFHQWLOH RI WKH QRUPDO SDWWHUQ DQG WKHUH ZDV SUREDEO\ DQ HUURULQWKHPHDVXUHPHQWRIIXQGDOKHLJKW7KHDFWLRQUHFRPPHQGHGLVWR FRQWLQXHZLWKORZULVNDQWHQDWDOFDUH ,IWKHPHDVXUHPHQWRIIHWDODEGRPLQDOFLUFXPIHUHQFHZDVPPWKH GLDJQRVLVLV,8*5VLQFHWKHYDOXHLVEHORZWKHSHUFHQWLOHRIWKHQRUPDO pattern. If you decided to continue with special tests to determine the W\SHRI,8*5\RXDUHJRLQJWKHULJKWZD\DQG\RXPD\FRQWLQXH,I\RXU DQVZHUVGRQRWPDWFKWKHVWDWHPHQWVDERYHUHYLHZWKHDOJRULWKPVRQ SDJHVDQG What other assessment would you order? Measurement of fetal head circumference or Femur length Growth rate curves according to previous value Measurement of mother’s height Measurement of estriol levels If you chose the fetal head circumference and femur length, the decision was correct. Otherwise, you should read the diagnostic algorithm to differentiate EHWZHHQQRUPDOIHWDOJURZWKDQGV\PPHWULFDQGDV\PPHWULF,8*5 SDJH EHIRUH\RXJRDQ\IXUWKHU Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 28 Monitoring Fetal Growth %DVHGRQWKHUHVXOWVRIWKHIHWDOKHDGFLUFXPIHUHQFHREWDLQHGWLFNWKHGLDJQRVLV that you consider correct. IUGR Head circumference Symmetric Asymmetric 320 mm. 290 mm. ,I\RXFRQFOXGHGWKDWDPPIHWDOKHDGFLUFXPIHUHQFHLQGLFDWHVDQDV\PPHWULF ,8*5DQGWKH PP+&ZDVDV\PPHWULF,8*5\RXDUHULJKW2WKHUZLVH UHUHDGSDJHVWR Exercise 7. 'LIIHUHQWLDOGLDJQRVLVEHWZHHQIHWXVZLWKDQDSSURSULDWHJURZWKDQG,8*5ZLWK XQUHOLDEOHGDWHRI/03DQGHDUO\FDSWXUH 'RWKLVH[HUFLVHXVLQJWKHGLDJQRVWLFDOJRULWKPVIRU,8*5RQSDJHVDQG 0UV<<KDVEHHQSUHJQDQWIRUDVKRUWWLPH WKHXWHUXVKDVQRWUHDFKHGWKH QDYHODQGVKHFDQQRWUHPHPEHUWKHGDWHRIKHUODVWPHQVWUXDWLRQ What would you do in this case? Check the right answer You would hurry to ask for a test to estimate gestational age You would not worry until the last trimester because it is then that it is important to know it If you answered that you would wait until the last trimester, see the diagnostic DOJRULWKPIRU,8*5RQSDJHDQGUHDGSDJHVWRDJDLQ Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 29 Choose the parameter you consider most important for the cases in which you need to estimate gestational age: Choose the parameter you consider most important when you need to estimate gestational age Crown-Rump Length (CRL) or biparietal diameter (BPD) or femur length according to the size of the fetus Amniotic fluid test Measurement of the fetal abdominal fluid Measurement of fundal height ,I \RX DQVZHUHG &URZQ5XPS /HQJWK &5/ RU ELSDULHWDO GLDPHWHU RU IHPXU length, you can continue. ,I\RXDQVZHUHGDQRWKHUFKRLFHJREDFNWRWKHGLDJQRVWLFDOJRULWKPRQ,8*5 DQGUHDGSDJHDQGSDJHVWRDJDLQ Let us assume that the gestational age was properly estimated, that pregnancy FDUULHG RQ DQG WKDW DW ZHHNV \RX VXVSHFW DQ ,8*5 EHFDXVH WKH IXQGDO KHLJKWDQGWKHPRWKHU¶VZHLJKWJDLQDUHEHORZQRUPDOYDOXHV 3DQG3 UHVSHFWLYHO\ What tests would you order? Calculation of the FAC/Femur Length ratio Measurement of the biparietal diameter None of the above ,I \RX DQVZHUHG IHWDO DEGRPLQDO FLUFXPIHUHQFH \RX DUH ULJKW DQG \RX KDYH XQGHUVWRRGWKHPRVWORJLFDODQGDFFXUDWHZD\RIGLDJQRVLQJ,8*57RGLDJQRVH WKH W\SH RI UHVWULFWLRQ V\PPHWULF RU DV\PPHWULF SURFHHG DV LQ ([HUFLVH EHFDXVHLIWKHJHVWDWLRQDODJHZDVHVWLPDWHGWKURXJKDQHDUO\XOWUDVRXQGWKH GHFLVLRQIROORZVWKHODQHIRUNQRZQJHVWDWLRQDODJHV,I\RXDQVZHUHGWKH)$& FL ratio, later on in the text we will see that the effectiveness of this procedure LVQRWDVJRRGDVWKH)$&DQGLWVKRXOGEHOHIWIRURWKHUVLWXDWLRQV Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 30 Monitoring Fetal Growth DIAGNOSIS OF IUGR WHEN THE GESTATIONAL AGE IS EITHER UNRELIABLE OR UNKNOWN IN PREGNANT WOMEN CAPTURED LATE FOR CONTROL :KHQ D SUHJQDQW ZRPDQ VHHNV FDUH ODWH WKH UHOLDELOLW\ RI XOWUDVRXQG WR HVWLPDWH JHVWDWLRQDO DJH LV KLQGHUHG WKH HVWLPDWHG VSUHDG LQ WKH UG WULPHVWHULVRUZHHNVGHSHQGLQJRQWKHPHDVXUHPHQWLQTXHVWLRQ )LJXUH ,Q WKH DEVHQFH RI UHOLDEOH GDWD RQ JHVWDWLRQDO DJH DV DQ LQGHSHQGHQWYDULDEOHLWLVLPSRVVLEOHWR¿[DSRLQWRQWKH[D[LV,QWKLVFDVH you should use growth indicators that do not depend on gestational age. Growth rate patterns based on the earlier value 7KLV PHWKRGRORJ\ LV XVHG WR GHWHUPLQH WKH LQFUHDVH RI D FHUWDLQ IHWDO PHDVXUHPHQWWREHH[SHFWHGLQDJLYHQSHULRG8QGHUWKHVHFLUFXPVWDQFHV one must refer directly to the ultrasound, as the measurement of the ZHHNLQFUHDVHRIWKHIXQGDOKHLJKWEDVHGRQWKHSUHYLRXVYDOXHKDVD ORZVHQVLWLYLW\ 6SHFL¿FLW\ 2IDOOWKHIHWDOYDULDEOHVVWXGLHG E\XOWUDVRXQGWKHUDWHRIWKHIHWDODEGRPLQDOFLUFXPIHUHQFHJURZWKDVD SUHYLRXVYDOXH )LJXUH LVWKHPRVWHIIHFWLYHSDUDPHWHUIRUGLDJQRVLV VHQVLWLYLW\VSHFL¿FLW\ Exercise 8 Case A 2QDJLYHQGDWHWKHIHWDODEGRPLQDOFLUFXPIHUHQFHZDVPHDVXUHGDQGWKH YDOXHREWDLQHGZDVPP)RXUWHHQGD\VODWHUWKHGLDJQRVWLFSURFHGXUH ZDVUHSHDWHGDQGWKLVWLPHWKHYDOXHZDVPP7KLVPHDQVWKDWLQWKH SDVWWZRZHHNVWKHSHULPHWHULQFUHDVHG PP 3ORWWKLVSRLQWLQ)LJXUHSODFLQJWKHSRLQWDWWKHLQWHUVHFWLRQRIWKH YDOXHRIWKH;D[LV DEVFLVVD DQGWKHYDOXHRIWKH< RUGLQDWH \RX ZLOOQRWLFHWKDWWKHSRLQWLVORFDWHGDERYHWKH3ZKLFKPHDQVWKDWWKH REVHUYHG LQFUHDVH RI WKH )HWDO$EGRPLQDO &LUFXPIHUHQFH LV ZLWKLQ WKH QRUPDOUDQJHEDVHGRQLWVSUHYLRXVYDOXH Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 31 mm. 40 35 30 P90 25 20 P70 P 15 50 P 10 30 5 P10 Fetal abdominal increase at 2 weeks 0 80 100 120 140 160 180 200 220 240 260 280 300 320 340 Previus value of the abdominal circumference Figure 11: Growth rate of fetal abdominal circumference based on an HDUOLHUYDOXH FRQ¿UPUHIHUHQFH Case B Repeat the exercise with the following values: VWXOWUDVRXQGPHDVXUHPHQWRIWKH)HWDO$& PP 2nd ultrasound measurement of Fetal AC DWWZRZHHNV PP &DOFXODWHWKHJURZWKDQGSORWLWRQ)LJ,QWKLVFDVH\RXZLOOQRWLFHWKDW WKHYDOXHREWDLQHGIRUWKHLQFUHDVHLVEHORZ3VRXQOLNHFDVH$WKH IHWXVLQFDVH%LVPRUHOLNHO\WRVXIIHUIURP,8*5 &DOFXODWLQJWKHJURZWKUDWHEDVHGRQWKHSUHYLRXVYDOXHDOORZVDEHWWHU GLDJQRVLVRIWKHV\PPHWULF,8*5V VHQVLWLYLW\ WKDQDV\PPHWULFRU GLVSURSRUWLRQDWH,8*5V VHQVLWLYLW\ 'LVWDQFHFXUYHVDUHDOVRPRUH VHQVLWLYHLQV\PPHWULF,8*5V Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 32 Monitoring Fetal Growth The fetal abdominal circumference /femur length ratio Another method to assess fetal growth independent of gestational age LVWKHIHWDODEGRPLQDOFLUFXPIHUHQFHIHPXUOHQJWKUDWLRZKLFKUHPDLQV FRQVWDQWLHLWKDVWKHVDPHYDOXHEHWZHHQDQGZHHNVRIJHVWDWLRQ 7KHGLVFULPLQDWLQJSRLQWWKDWEHVWFODVVL¿HGWKHIHWXVHVLVSHUFHQWLOH ZLWKDYDOXHRI$Q\YDOXHORZHUWKDQLQGLFDWHVDKLJKSUREDELOLW\ RIDV\PPHWULF,8*57KHVHQVLWLYLW\RIWKLVPHWKRGIRUWKHGLDJQRVLVRI DV\PPHWULF,8*5 GHFUHDVHRIWKHIHWDODEGRPLQDOFLUFXPIHUHQFHZLWKD FRQVWDQWIHPXUOHQJWK LV 9DOXHVHTXDOWRRUJUHDWHUWKDQFRUUHVSRQGWRQRUPDOIHWXVHV ZKHQ ERWKYDOXHVDUHQRUPDO RUDV\PPHWULF,8*5 ZKHQERWKYDOXHVDUH ORZ 7KLVLQDELOLW\WRGLVFULPLQDWHEHWZHHQQRUPDOJURZWKDQGV\PPHWULF ,8*5UHGXFHVWKHGLDJQRVWLFVHQVLWLYLW\RIWKHODWWHUWRRQO\7KH VSHFL¿FLW\IRUERWKUHVWULFWLRQVLV ,WKDVEHHQVKRZQWKDWEDVHGRQLWVSUHYLRXVYDOXHWKHIHWDODEGRPLQDO circumference growth rate has a higher sensitivity for the diagnosis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¿HGXVLQJWKHJURZWKUDWHFXUYHVEDVHGRQDSUHYLRXV value and a new ultrasound examination. If the expected increase is normal, the diagnosis is that of a fetus with normal growth. If, however, the increase is less than expected, we are facing a growth restriction, ZLWKKLJKFKDQFHVRIEHLQJV\PPHWULF Sensitivity for the diagnosis of intrauterine growth restriction in case of uncertain gestational age and late recruitment Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 33 Abdominal Abdominal circumference circumference/Femur based on previous value length ratio Symmetric IUGR 94 % 46 % Asymmetric IUGR 61 % 74 % Exercise 9 DIFFERENTIAL DIAGNOSIS BETWEEN A FETUS WITH APPROPRIATE GROWTH AND IUGR WITH UNCERTAIN LMP AND LATE CAPTURE For this exercise you will use the algorithms for the differential diagnosis EHWZHHQ QRUPDO IHWDO JURZWK DQG V\PPHWULF DQG DV\PPHWULF ,8*5 SDJH 7KHH[HUFLVHKDVDVHTXHQFHVXFKWKDWWKHTXHVWLRQVVKRXOGEHDQVZHUHG as they are formulated. You should not go any further in your reading ZLWKRXWPHHWLQJWKLVUHTXLUHPHQW 0UV;; \ VD\VVKHLVLQWKHODVWWULPHVWHURIKHUSUHJQDQF\DQG VKHKDVQHYHUDWWHQGHGDQWHQDWDOFDUH6KHGRHVQRWNQRZWKHGDWHRI KHUODVWPHQVWUXDOSHULRGEHFDXVHVKHZDVQXUVLQJDEDE\ZKHQVKH EHFDPHSUHJQDQW 6KH UHSRUWV KDYLQJ KDG SUHYLRXV SUHJQDQFLHV WKH ODVW FKLOG ERUQ DW KRPHZHLJKHGJLQDQDSSDUHQWO\XQHYHQWIXOFKLOGELUWK %HORZDUHWKH¿QGLQJVRIWKHJHQHUDOSK\VLFDODQGREVWHWULFH[DPLQDWLRQ Mrs. XX Maternal height 1.55 m. Gestational age Unknown Current weight 60 kg. Usual weight Unknown Weight gain Blood pressure 140/94 mmHg Fundal height 27 cm. 7KHDEGRPLQDOSDOSDWLRQUHYHDOVWKDWWKHIHWXVLVLQFHSKDOLFSUHVHQWDWLRQDQG that it is small in size. Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 34 Monitoring Fetal Growth What diagnoses would you suggest? Fetus with a normal growth Macrosomic fetus (large) None of the above Small fetus for < age or IUGR ,I\RXDQVZHUHGVPDOOIHWXVGXHWRORZHUJHVWDWLRQDODJHRU,8*5\RXKDYH UHDVRQHG FRUUHFWO\ EHFDXVH LW FDQ EH D SUHJQDQF\ DW DQ HDUOLHU JHVWDWLRQDO DJHDQGWKXVWKHIHWXVPXVWEHDSSURSULDWHIRUWKDWDJHRULWPD\EHVPDOO EHFDXVHLWLVJURZLQJOHVVWKDQH[SHFWHG7KHREVWHWULFEHKDYLRXUPD\DWWLPHV EHUDGLFDOO\RSSRVLWH LILWLVD\RXQJHUDJHWKHGHFLVLRQLVWRZDLWZKLOHLILWLVD IXOOWHUPIHWXVZLWKDQ,8*5WKHSUHJQDQF\PXVWEHWHUPLQDWHG VR How would you solve this problem? I would estimate gestational age asking about the date of onset of the first fetal movements I would only estimate gestational age by ultrasound I would assess fetal growth with indicators independent from gestational age I would wait without doing anything ,I\RXDQVZHUHGWRRQO\HVWLPDWHJHVWDWLRQDODJHE\XOWUDVRXQGWKDWZDVQRW FRUUHFW SDJHVWR VLQFHLQWKHODVWWULPHVWHUWKHYDULDELOLW\RIWKHHVWLPDWH LVZHHNV7KDWLVLIWKH\UHSRUWZHHNVLWPD\DFWXDOO\EHZHHNV RUZHHNV DQGWKLVLVDFRQVLGHUDEOHGLIIHUHQFH7KH ZRPDQ¶VFPIXQGDOKHLJKWLVQRUPDOIRUZHHNVDQGLWLVORZIRU ZHHNV7KHUHIRUHWKHGRXEWSHUVLVWVDVWRZKHWKHUWKLVIHWXVLV6*$RU,8*5 If you answered fetal growth assessment with independent indicators of gestational age, you are on the right path, and you may continue Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 35 If the FAC/FL ratio was 4.25, What would be your probable diagnosis? Asymmetric IUGR or fetus with a normal growth IUGR – no matter what type Symmetric IUGR or fetus with a normal growth Certainty of fetus with a normal growth ,I\RXDQVZHUHGV\PPHWULF,8*5RUIHWXVZLWKQRUPDOJURZWK\RXZHUHULJKW 2WKHUZLVHVHHWKHDOJRULWKPRQSDJHDQGUHDGSDJHDJDLQ ,IWKHUDWLRLVOHVVWKDQDQGWKHIHPXULVDEQRUPDOO\ORQJWKLVLQGLFDWHVWKDW WKHIHWDODEGRPLQDOFLUFXPIHUHQFHLQFUHDVHGUHODWLYHO\OHVVWKDQWKHIHWDOIHPXU DVLWXDWLRQREVHUYHGLQDV\PPHWULF,8*5 ZHLJKWLPSDLUPHQWZLWKSUHVHUYHG VL]H Low fetal AC Asymmetric IUGR = = < 4.25 Normal fetal femur length 260 mm Example = = 3.94 66 mm ,IWKHUDWLRLVJUHDWHUWKDQDVLQWKHFDVHRIWKLVIHWXV UDWLR WKH PHDVXUHPHQW RI WKH IHWDO DEGRPLQDO FLUFXPIHUHQFH RU WKH IHWDO IHPXUOHQJWKVKRZSURSRUWLRQDOLW\7KLVPD\EHHLWKHUEHFDXVHWKHWZR PHDVXUHPHQWVDUHQRUPDORUEHFDXVHERWKDUHORZ Fetus with Normal fetal AC normal = = > 4.25 growth Normal fetal femur length 300 mm Example = = 4.55 66 mm Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 36 Monitoring Fetal Growth Low fetal abdominal circumference Symmetric. IUGR = = > 4.25 Low fetal femur length 260 mm Example = = 4.81 54 mm What test would you order to establish the differential diagnosis between 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 BPD Measure the Head Circumference ,I\RXDQVZHUHGWKHIHWDODEGRPLQDOFLUFXPIHUHQFHPHDVXUHPHQWEDVHGRQLWV SUHYLRXVYDOXHDVVKRZQE\WKHXOWUDVRXQGZLWKLQDGD\WHUPWKDWLVSHUIHFW - you have understood the pathophysiology of fetal growth correctly. Otherwise, UHUHDGSDJHVWRDQGUHYLVLWWKHDOJRULWKPRQSDJH 7KH IHWDO DEGRPLQDO FLUFXPIHUHQFH VKRXOG EH PHDVXUHG DJDLQ ZLWKLQ RU ZHHNV LGHDOO\ZKHQHYHUSRVVLEOH ,IWKHLQFUHDVHRIWKHIHWDODEGRPLQDOFLUFXPIHUHQFHFRPSDUHGZLWKLWVSUHYLRXV value: ,VWKHLQFUHDVHH[SHFWHGWKH¿QDOGLDJQRVLVZLOOEHQRUPDOIHWDOJURZWK VKRZV DQ LQFUHDVH WKDW LV OHVV WKDQ H[SHFWHG WKH ¿QDO GLDJQRVLV ZLOO EH V\PPHWULF,8*5 ,QWKH¿UVWSRVVLELOLW\LHQRUPDOIHWDOJURZWKWKHZRPDQLVDOORZHGWRFRQWLQXH ZLWKKHUSUHJQDQF\DQGLQWKHVHFRQGSRVVLELOLW\ZLWKV\PPHWULF,8*5WKHIHWDO YLWDOLW\DQGOXQJPDWXULW\VKRXOGEHH[SORUHGIROORZLQJDVWHSZLVHGHFLVLRQWUHH WKDWLVDSSOLHGLQFDVHVRI,8*5DVZLOOEHGLVFXVVHGODWHU Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 37 DIFFERENTIAL DIAGNOSIS BETWEEN SYMMETRIC IUGR AND ERROR IN THE ESTIMATION OF GESTATIONAL AGE BY LMP *LYHQWKHGLIIHUHQFHVLQWKHREVWHWULFPDQDJHPHQWDQGWKHFRQIXVLRQV LWRIWHQOHDGVWRLWLVLPSRUWDQWWRQRWHWKHGLIIHUHQWLDOGLDJQRVLVEHWZHHQ symmetric growth restriction and an error in the estimation of gestational DJHE\/03 6XVSHFWPLVFDOFXODWLRQRIDPHQRUUKHDEDVHGRQWKH/03ZKHQ x 2QHPHDVXUHPHQWLVEHORZWKHQRUPDOUDQJHEHIRUHZHHNV$W WKDWJHVWDWLRQDODJHWKH,8*5LVUDUHO\H[SUHVVHGRQWKHELSDULHWDO GLDPHWHURUKHDGFLUFXPIHUHQFHDQGPXFKOHVVOLNHO\RQWKHZDLVW circumference x 7KHGLIIHUHQFHEHWZHHQJHVWDWLRQDODJHFDOFXODWHGE\/03DQG HVWLPDWHG E\ XOWUDVRXQG LV ZHHNV RU PXOWLSOHV WKHUHRI PRUH RIWHQZHHNV x ,QWKHFRXUVHRISUHJQDQF\WKHYDOXHVPHDVXUHGE\XOWUDVRXQG JHWJUDGXDOO\FORVHUWRQRUPDO,ILWLVDUHDO,8*5WKH\JHWIDUWKHU DSDUW7KLVLVEHFDXVHWKHIHWXVLVJURZLQJDWDUDWHDSSURSULDWHWR LWVWUXHJHVWDWLRQDODJH KHQFHWKH\RXQJHUWKHIHWXVWKHIDVWHU the growth rate x 7KHJURZWKUDWHFXUYHVEDVHGRQDSUHYLRXVYDOXHRI'%3IHWDO DEGRPLQDO FLUFXPIHUHQFH HWF DUH QRUPDOO\ LQFUHDVHG ,I WKH LQFUHDVHREVHUYHGLVQRUPDOLWLVKLJKO\OLNHO\WKDWWKHIHWXVKDV an appropriate growth. Conversely, if the increase is less than H[SHFWHGWKHPRVWOLNHO\GLDJQRVLVLVIHWDOJURZWKVORZGRZQ 7DEOH ,9 GHVFULEHV WKH GLIIHUHQW DOWHUQDWLYHV WKDW FDQ EH IRXQG XVLQJ distance curves and growth rates. Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 38 Monitoring Fetal Growth Table IV-Behavior of fetal growth when there is an error in the estimation of gestational age by LMP and asymmetric and symmetric growth restriction CURVES At a distance Growth rate based on a previous value B.P.D AC BPD AC Head circ. Head circumference Femur length Femur length Error in the Lower than Normal Normal estimation of normal and tending gestational age to converge Within normal Lower than normal Asymmetric IUGR ranges and diverging Normal Decreased may occur late Symmetric IUGR Lower than normal and diverging Decreased Decreased Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 39 PROPOSALS FOR THE SOUND USE OF THE FETAL GROWTH SURVEILLANCE METHODS 7KH DVVRFLDWLRQ RI IXQGDO KHLJKW LQ SDUDOOHO ZLWK WKH PRWKHU¶V ZHLJKW JDLQ GXULQJ SUHJQDQF\ 7DEOH ,,, KDV D KLJK VHQVLWLYLW\ IRU SUHGLFWLQJ6*$VXUSDVVHGRQO\E\WKHPHDVXUHPHQWRIIHWDODEGRPLQDO FLUFXPIHUHQFHDVPHDVXUHGE\XOWUDVRXQG 7KHGUDZEDFNRIWKHDVVRFLDWLRQIXQGDOKHLJKWPRWKHU¶VZHLJKWJDLQLVWKH KLJKSURSRUWLRQRIIDOVHSRVLWLYHV FRPSOHPHQWWRUHDFKRI339 ZKLFKTXDOL¿HVDVDVFUHHQLQJWHVWEXWQHYHUDVDFRQ¿UPDWLRQ WHVWVLQFHFRQ¿UPDWLRQZRXOGOHDGWRWKHDGRSWLRQRIGHFLVLRQVWKDWPD\EH GHOHWHULRXV WHUPLQDWLRQRISUHJQDQF\LQDIHWXVWKDWLVJURZLQJQRUPDOO\ 7RPRQLWRUIHWDOJURZWKLWLVDGYLVDEOHWRVWDUWFROOHFWLQJWKHULVNIDFWRUV OLVWHGLQ7DEOH,DQGWRPRQLWRUWKHFRXUVHRIIXQGDOKHLJKWDQGPDWHUQDO weight gain at each antenatal care visit. 7KH SUHVHQFH RI ULVN IDFWRUV RU DEQRUPDOO\ ORZ YDOXHV RI DQ\ RI VXFK PHDVXUHVPDNHVLWLPSHUDWLYHWRSHUIRUPDQXOWUDVRXQGH[DPLQDWLRQWR FRQ¿UPRUUXOHRXWWKHGLDJQRVLV )LJ $UHFHQWPHWDDQDO\VLV KDV shown that routine ultrasounds do not improve the detection of intrauterine growth restriction when compared with the scan performed in cases where there is a change in clinical parameters. General population 14% SGA N = 100 P. Fundal No SGA SGA de height Test - 86 14 Test + d < P10 e t and/or e c Weight gain t i < P25 66 34 ó True False False True n - - + + Referral for 63 3 23 11 Special exploration P. Prevalence 31% c o Ultrasound Test Test n 33 - + f Aprox. i 35 weeks r }37 m a Fetal t i 24 10 ó abdominal False True False True n circumf < P5 -- + + 1 23 0 10 Antenatal low Intervention Intervention risk control is lost Figure 12 - Application of different tests to diagnose intrauterine growth UHVWULFWLRQ7KH¿UVWVWHS VFUHHQLQJ VHOHFWHGRISUHJQDQWZRPHQ:KHQ WKHVHXQGHUJRDFRQ¿UPDWLRQWHVWWKHUHDO,8*5FDQEHGHWHFWHG Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 40 Monitoring Fetal Growth 7KHSUHGLFWLYHYDOXHRIDWHVWYDULHVLQDFFRUGLQJWRWKHSUHYDOHQFHRIWKHGLVHDVH WRGLDJQRVH,Q7DEOH,,,WKHSUHGLFWLYHSRVLWLYHYDOXH 339 RIWKHDVVRFLDWLRQRI IXQGDOKHLJKW )+ ZLWKZHLJKWJDLQLV7KLVSUHGLFWLYHYDOXHZDVREWDLQHG LQDVWXG\WKDWHQUROOHGDSRSXODWLRQZLWKDSUHYDOHQFHRI,8*5 7KH SUHYDOHQFH RI LQWUDXWHULQH JURZWK UHVWULFWLRQ LQ VHYHUDO KRVSLWDOV LQ /DWLQ $PHULFDLVDSSUR[LPDWHO\5HFDOFXODWLQJWKHSRVLWLYHSUHGLFWLYHYDOXHIRU WKHQHZSUHYDOHQFH RI,8*5XVLQJ%D\HV¶WKHRUHPZHREWDLQWKHIROORZLQJ ¿JXUHV IRU WKH IHWDO DEGRPLQDO FLUFXPIHUHQFH IRU IXQGDO KHLJKW RU PDWHUQDOZHLJKWJDLQ 7KLVPHDQVWKDWWKHIDOVHSRVLWLYHVLQWKLVWHVW UHDFK7KHKLJKSHUFHQWDJHRIIDOVHSRVLWLYHVVHHQZLWKWKHVHVFUHHQLQJ PHWKRGVOLPLWWKHLUYDOLGLW\IRUGHWHUPLQLQJWKHSRSXODWLRQPRVWOLNHO\WRKDYHWKH GLVHDVH3RVLWLYHFDVHVVKRXOGXQGHUJRDKLJKVSHFL¿FLW\FRQ¿UPDWLRQWHVWVXFK DVWKHXOWUDVRXQGPHDVXUHPHQWRIWKHIHWDODEGRPLQDOFLUFXPIHUHQFH 7KLVVHTXHQFHRIWHVWVSURSRVHGLQ)LJXUHKDVD GLDJQRVWLFVHQVLWLYLW\ 7DEOH9 ZKLFKLVORZHUWKDQWKDWDFKLHYHGE\URXWLQHXOWUDVRXQG 7DEOH ,,, %XWZKHUHDVLQWKHODWWHUFDVHLWLVQHFHVVDU\WRH[SORUHRIWKHSUHJQDQW ZRPHQZLWKXOWUDVRXQGRQO\RQHWKLUGRIWKHP ZRXOGEHH[SORUHGZLWK WKLVVFKHPHLQFUHDVLQJWKHIHDVLELOLW\RILWVLPSOHPHQWDWLRQ Table V - Diagnosis of IUGR using risk factors, fundal height and maternal weight gain as a screening procedure, and XOWUDVRXQGDVDFRQ¿UPDWLRQSURFHGXUHLQDSRSXODWLRQ with a 14% prevalence of IUGR IUGR Yes NO D I A Yes 11 011 G N O S I NO 3 86 89 S 14 86 100 6HQVLWLYLW\ 7HVWSUHGLFWLYH 3RVLWLYH 6SHFL¿FLW\ YDOXH{ 1HJDWLYH 7KH GDWD WKDW DUH SURFHVVHG LQ WKLV 7DEOH9 ZHUH REWDLQHG LQ VWXGLHV FRQGXFWHGE\&/$3 DQGUHFDOFXODWHGIRUDSRSXODWLRQRISUHJQDQW ZRPHQZLWKD,8*5 Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 41 OBSTETRIC MANAGEMENT OF INTRAUTERINE GROWTH RESTRICTION A) Antenatal management *HQHUDO PHDVXUHV 0XOWLSOH LQWHUYHQWLRQV KDYH EHHQ SURSRVHG WR UHGXFH WKH ULVN RI IHWDO JURZWK UHVWULFWLRQ EXW PDQ\ RI WKHP DUH QRW VXSSRUWHG E\ JRRG TXDOLW\ HYLGHQFH 0HDVXUHV OLNH DYRLGLQJ VPRNLQJ DQGLPSURYLQJWKHZRPDQ¶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¿FDQW EHQH¿WLQUHGXFLQJWKH,8*5 ,QWHUPLWWHQWDEGRPLQDOGHFRPSUHVVLRQIRUVXVSHFWHGIHWDOGLVWUHVV VKRZHG D VLJQL¿FDQW LQFUHDVH LQ ELUWK ZHLJKW LQ WKH WUHDWHG JURXS EXW WKHUHLVRQO\RQHVLQJOHVWXG\ZLWKMXVWFDVHV 7UHDWPHQWRIPDWHUQDOGLVHDVHVWKDWDIIHFWIHWDOJURZWK SUHJQDQF\ LQGXFHG K\SHUWHQVLRQ FKURQLF DQHPLD EOHHGLQJ DQG GLDEHWHV DPRQJ others. In the case of hypertensive women, the administration of low doses of DFHW\OVDOLF\OLFDFLG DERXWPJSHUGD\ GXULQJSUHJQDQF\VLJQL¿FDQWO\ GHFUHDVHGWKHSUHYDOHQFHRI6*$LQWKHJURXSWUHDWHG7KHVHORZGRVHV RIDVSLULQUHGXFHWKHSURGXFWLRQRIWKURPER[DQHDQGWRDOHVVHUH[WHQW of prostacyclin, with a predominance of the latter over the former, thus IDYRXULQJYDVRGLODWLRQ7KLVZRXOGUHVXOWLQLQFUHDVHGSODFHQWDOÀRZZLWK WKHFRQVHTXHQWEHQH¿WWRWKHIHWXV$WWKHVHGRVHVQRDGYHUVHHIIHFWV KDYH EHHQ GHVFULEHG LQ WKH PRWKHU WKH IHWXV RU WKH QHZERUQ 7KLV SURWHFWLYHHIIHFWRIDVSLULQZRXOGUHGXFHWKHOLNHOLKRRGRI6*$E\ EHWZHHQDQG Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 42 Monitoring Fetal Growth Table VI - Table VI: Prevention of the birth of small for gestational age infants with low-dose aspirin. The common odds ratio (summary measurement of the results of the 7 VWXGLHV VKRZV WKH VLJQL¿FDQW SURWHFWLYH HIIHFW RI LWV administration. This protective effect of aspirin would reduce the SGA likelihood by 20% (between 10% and 30%) Therapy (%)Contr. (%) Odds ratio (95% confidence internval) Beaufils et al. 4/48 (8.3) 13/48 (28.8) 0.08 0.77 (1985) 0.24 Wallenburg et al. 4/41 (19) 9/23 (39) 0.09 1.41 (1985) 0.37 Wallenburg et al. 4/30 (13.3) 16/27 (59.2) 0.03 0.36 (1985) 0.11 Schiff et al. 2/34 (5.9) 6/31 (19.4) 0.05 1.29 (1985) 0.26 Uzan et al. 19/156 (12) 20/73 (27) 0.18 0.73 (1985) 0.37 Sibai et al. 69/1505 (4.6) 88/1519 (5.8) 0.56 1.08 (1985) 0.78 CLASP 37/4810 (7.7) 401/4821 (8.3) 0.79 1.06 (1985) 0.92 Common 473/6604 (7.1) 553/6542 (8.5) 0.71 0.92 Odds ratio 0.81 0.010.1 1 10 B) Childbirth 7KHKHDOWKFDUHSURIHVVLRQDOIUHTXHQWO\KDVWRIDFHWKHGLOHPPDRIKDYLQJWR FKRRVHEHWZHHQWKHSUHPDWXUHWHUPLQDWLRQRISUHJQDQF\ ULVNRIQHRQDWDO GHDWKGXHWRLPPDWXULW\ RUHOVHWROHWLWFRQWLQXH ULVNRIIHWDOGHDWK 7KH UHVSRQVH WR WKHVH TXHVWLRQV YDULHV GHSHQGLQJ RQ WKH UHVRXUFHV DYDLODEOHLQWKHFHQWHUVFDSDEOHRIRIIHULQJKLJKHUFRPSOH[LW\FDUHZKHUH WKHVHSUHJQDQWZRPHQPXVWEHFRQWUROOHG ,IQRVSHFLDOHTXLSPHQWWRDVVHVVIHWDOKHDOWKLVDYDLODEOHWKHREVWHWULF PDQDJHPHQWFDQEHGHFLGHGNQRZLQJWKHOLNHOLKRRGRIIHWDODQGQHRQDWDO death according to the different gestational ages. 7KHREVWHWULFGHFLVLRQVKRXOGWDNHLQWRDFFRXQWWKHOHYHORIFRPSOH[LW\RIWKH ORFDOQHRQDWDOFDUHDYDLODEOH WKLVFLUFXPVWDQFHLVVRLPSRUWDQWWKDWLWZLOO determine the gestational age at which you decide to interrupt pregnancy. ,QDIHWXVXQGHUZHHNVZLWK,8*5RQHVKRXOGWU\WRGRHYHU\WKLQJ SRVVLEOHWRFRQWLQXHSUHJQDQF\³LQXWHUR´DVWKDWQHZERUQLVYHU\OLNHO\ WRGLHLIELUWKRFFXUVWKHQ2QWKHFRQWUDU\ZKHQLWKDVUHDFKHGZHHNV Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 43 WKHULVNRIIHWDOGHDWKEHJLQVWRLQFUHDVHDQGEHFRPHVJUHDWHUWKDQWKH ULVNRIQHRQDWDOGHDWKSRWHQWLDOO\OHDGLQJWRDQLQGLFDWLRQRIWHUPLQDWLQJ SUHJQDQF\7KHSHULRGZKHUHLWLVGLI¿FXOWWRUHVROYHZKDWWRGRLVWKH LQWHUYDOEHWZHHQDQGZHHNV 7KHEHVWZD\WRGHFLGHLVWRPDNHVXUHRQHKDVWKHUHVRXUFHVWRPRQLWRU WKH SURJUHVV RI IHWDO JURZWK DQG YLWDOLW\ DQG WKXV QRW WR EDVH RQH¶V GHFLVLRQ RQ VWDWLVWLFV EXW RQ WKH LQGLYLGXDO FULWHULD LH VWXG\LQJ HDFK VSHFL¿FFDVHDQGDGMXVWLQJWKHEHKDYLRUDVDSSURSULDWHWRWKDWSUHJQDQF\ If one has special resources to monitor fetal health, in addition to JHVWDWLRQDODJHDQGZKDWFDXVHGWKDWJURZWKUHVWULFWLRQ PRGL¿DEOHIDFWRU K\SHUWHQVLRQPDOQXWULWLRQVPRNLQJ RUQRQPRGL¿DEOHJHQHWLFFDXVHRU PDOIRUPDWLRQV RQHVKRXOGFDUHIXOO\DGGUHVVLVVXHVOLNHWKHVWDWXVRIIHWDO YLWDOLW\IHWDOOXQJPDWXULW\DQGLWVSRVVLEOHDFFHOHUDWLRQWRJHWKHUZLWKWKH course of development, especially once the corrective measures have EHHQLPSOHPHQWHG In preterm pregnancies, if the assessment of fetal vitality shows a fetus in good conditions and the ultrasound shows that the fetus is growing, pregnancy should go on. Otherwise if lung maturity and will interrupt pregnancy. If the fetal lung has not synthesized surfactant, its synthesis ZLOO QHHG WR EH LQGXFHG ZLWK JOXFRFRUWLFRVWHURLGV EHIRUH WHUPLQDWLQJ SUHJQDQF\ )LJ IUGR ZHHNV * ZHHNV * ZHHNV ZHHNV 7UHDWPHQWRIVSHFLILFFRQGLWLRQV5HVW6XSSUHVVLRQRIWR[LFDJHQWV±'LHWDGMXVWPHQW 86PRQLWRULQJRIJURZWK HYHU\ZHHNVXSWR $UUHVWRIJURZWK ZHHNV No Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 44 Monitoring Fetal Growth ,IWKHUHDUHVLJQVVXJJHVWLQJSUHPDWXUHODERUXWHULQHFRQWUDFWLRQVPXVW EHLQKLELWHGRQO\LQWKRVHFDVHVZKHUHLWLVSRVVLEOHWRVWULFWO\FRQWUROIHWDO JURZWKDQGRQHFDQFRQ¿UPWKDWJURZWKKDVQRWEHHQDUUHVWHG7KHPRVW accurate parameter at this point to indicate the termination of pregnancy LVWKHDUUHVWRIIHWDOJURZWKDVVKRZQE\WKHXOWUDVRXQG,IWKHIHWXVVWRSV growing, delaying the termination of pregnancy is associated with and increased fetal mortality. Conversely, the interruption of pregnancy does not worsen the neonatal prognosis. &/$3¶V )HWDO +HDOWK 8QLW IRXQG WKDW IHWXVHV SUHVHQWLQJ ZLWK ,8*5 WKDW VKRZHG VORZLQJ RI WKH JURZWK RI WKHLU DEGRPLQDO FLUFXPIHUHQFH EHORZ WKH SHUFHQWLOH ZHUH PRUH OLNHO\ WR GLH LQ XWHUR RU ZLWKLQ WKH ¿UVW KRXUVRIOLIH%\FRQWUDVWIHWXVHVGLDJQRVHGZLWK,8*5EXWZLWKDEGRPLQDO FLUFXPIHUHQFHYDOXHVZLWKLQWKHDUHDVFRUUHVSRQGLQJWRWKHWRSSHUFHQWLOH DQGORZHVWSHUFHQWLOH )LJ WKHSUREDELOLW\RIG\LQJGURSVVRLIWKH JHVWDWLRQDO DJH LV OHVV WKDQ ZHHNV SUHJQDQF\ PD\ FRQWLQXH ZLWK D strict monitoring of fetal growth. Abdominal circumference 390 370 350 P50 330 P5 Area of 310 alarm 290 270 250 Zone with high death 230 odds 210 190 170 150 130 110 90 70 15 17 19 21 23 25 27 29 31 33 35 37 39 41 Weeks of amenorrhea Figure 14-Normal pattern of fetal abdominal circumference growth with alarm zone and zone of high probability of death. Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 45 6HYHUDOGLDJQRVWLFSURFHGXUHVKDYHEHHQXVHGWRDVVHVVIHWDOYLWDOLW\ PDQ\ RI WKHP KDYH VKRZQ VLJQL¿FDQW ÀDZV IDOVH SRVLWLYHV DQG QHJDWLYHV WKDW PDNH WKHP XVHOHVV IRU WKH SXUSRVH LQWHQGHG LQFOXGLQJ D IUHTXHQF\ RI IHWDOPRYHPHQWV E WKHVHULDODQWHSDUWXPIHWDOFDUGLRWRFRJUDP DQGF WKHIHWDOELRSK\VLFDOSUR¿OH 2WKHUSURFHGXUHVVXFKDVG VHULDO ultrasound assessments evaluating the fetal measurements and functional HOHPHQWV DPQLRWLFÀXLG DQGH WKH'RSSOHURIWKHIHWDODQGSODFHQWDO DUWHULHVKDVVKRZQJRRGHI¿FDF\LQWKHHYDOXDWLRQRIIHWDOKHDOWK Serial ultrasound studies are an essential tool for monitoring fetal well- EHLQJ DQG WR GHWHUPLQH ZKHWKHU JURZWK FRQWLQXHV WR GHWHULRUDWH RU LI RQ the contrary, it recovers its growth pace and exceeds the lowest level in the normal patterns, succeeding to catch-up or recuperating growth. 7KHPHDVXUHPHQWRIWKHDPQLRWLFÀXLGYROXPHWKURXJKYDULRXVWHFKQLTXHV SHUPLWVWRLGHQWLI\ROLJRK\GUDPQLRVDFRQGLWLRQWKDWLQWKHFDVHRI,8*5 LVOLQNHGWRIHWDOROLJXULDUHVXOWLQJIURPWKHDGDSWLYHUHGLVWULEXWLRQRIEORRG ÀRZ'HSHQGLQJRQLWVVHYHULW\WKLVVKRXOGEHVHHQDVDZDUQLQJVLJQIRU termination of pregnancy. 7KHIUHTXHQF\RIPRQLWRULQJIHWDOJURZWKLVDQLPSRUWDQWLVVXHWKDWQHHGV WR EH DGGUHVVHG$V KDV DOUHDG\ EHHQ PHQWLRQHG SHUIRUPLQJ XOWUDVRXQG VFDQVDWLQWHUYDOVRIOHVVWKDQZHHNPD\LQFUHDVHWKHIUHTXHQF\RIIDOVH SRVLWLYHV FRQVHTXHQWO\WKHLGHDOLQWHUYDOLVHYHU\ZHHNVZKLFKDOORZV IRUDPRUHDGHTXDWHHYDOXDWLRQRIJURZWKUDWH 7KHEORRGÀRZ'RSSOHUSDWWHUQVRIWKHSODFHQWDODQGIHWDODUWHULHVDUHDVLJQ RIIHWDODGDSWDWLRQWRVWUHVVIXOVLWXDWLRQV 7KHIHWDODQGIHWDOSODFHQWDO 'RSSOHU SHUIRUPHG WR KLJKULVN SUHJQDQW ZRPHQ KDV VKRZQ D UHGXFWLRQ ERWK RI SHULQDWDO PRUWDOLW\ DQG XQQHFHVVDU\ REVWHWULF LQWHUYHQWLRQV 7KH'RSSOHULQYHVWLJDWLRQRIWKHVKDSHRIWKHÀRZUDWHZDYHFDQSURYLGH useful information. Changes in the values of the different indices employed 5HVLVWDQFH SXOVDWLOLW\ 6' HYLGHQFHG GXULQJ WKH H[SORUDWLRQ RI WKH IHWDO YHVVHOVUHÀHFWWKHUHGLVWULEXWLRQRIEORRGÀRZLQUHVSRQVHWRIHWDOK\SR[LD ,QWKHXPELOLFDODUWHU\WKHIHWDODRUWDDQGWKHUHQDOLOLDFDQGIHPRUDODUWHULHV WKHUDWLRVDUHLQFUHDVHGUHÀHFWLQJDQHQKDQFHGUHVLVWDQFHWREORRGÀRZ ZKHUHDVLQWKHFDURWLGDQGPLGGOHFHUHEUDODUWHULHVWKHUDWLRVDUHUHGXFHG LQGLFDWLQJDJUHDWHUEORRGVXSSO\WRWKHEUDLQ6RPHDXWKRUVUHSRUWWKDWZKHQ this compensatory mechanism is missing, or when the resistance of the PLGGOHFHUHEUDODUWHULHVLVLQFUHDVHGWKHSURJQRVLVRIWKHIHWXVLVGLUH Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 46 Monitoring Fetal Growth 7KH XWHURSODFHQWDO DUWHULHV DUTXDWH DUWHULHV RI WKH XWHUXV VKRZ DQ LQFUHDVHGUHVLVWDQFHWREORRGÀRZPDLQO\ZKHQWKHFDXVHRIWKHUHVWULFWLRQ is a vascular disease in the mother. $FFRUGLQJWRVRPHDXWKRUVWKHDEQRUPDOSDWWHUQVRIWKHÀRZUDWHZDYH VKRZLQJ IHWDO LPSDLUPHQW FDQ DOUHDG\ EH REVHUYHG IURP WR GD\V EHIRUHWKH\FDQEHGHWHFWHGWKURXJKDQDEQRUPDOFDUGLRWRFRJUDSK\DQG WKH\DOVRKDYHDEHWWHUVHQVLWLYLW\DQGVSHFL¿FLW\ $SDWWHUQWKDWGHVHUYHVDWWHQWLRQLVZKHQWKHXPELOLFDODUWHU\ÀRZFDQQRW EHVHHQLQGLDVWROHRUZKHQWKHUHLVQREDFNÀRZ7KLVSDWWHUQKDVEHHQ associated with severe fetal compromise such as acidosis and hypoxia FRQ¿UPHGE\FRUGRFHQWHVLV7KHULVNRIIHWDOPRUWDOLW\IRUWKHVHWZRVLWXDWLRQV LVWRWLPHVKLJKHUWKDQZKHQWKHGLDVWROLFÀRZLVSUHVHQW 7KHLQFUHDVHGUHVLVWDQFHVLQWKHPLGGOHFHUHEUDODUWHU\DUHDOVRHOHPHQWV RIDSRRUSURJQRVLVUHTXLULQJDQDFWLYHREVWHWULFEHKDYLRUIRUWHUPLQDWLQJ SUHJQDQF\ 8QIRUWXQDWHO\ WKHVH WHVWV ZHUH LQFRUSRUDWHG LQWR FOLQLFDO SUDFWLFH ZLWKRXW having completed their validation process, which limits their scope and the LQWHUSUHWDWLRQRIWKHLUUHVXOWV1RQHRIWKHVHWHVWVDORQHVKRXOGGHWHUPLQH PDQDJHPHQWEXWWKH\DUHHOHPHQWVWKDWHQULFKWKHGHFLVLRQPDNLQJSURFHVV C) During labor 7KHURXWHFKRVHQWRWHUPLQDWHSUHJQDQF\VKRXOGEHGLVFXVVHGRQDFDVH E\FDVHEDVLVEXWWKHFDHVDUHDQVHFWLRQLVXVXDOO\WKHVWUDWHJ\RIFKRLFH ZKHQWKHUHLVHYLGHQFHRIVHYHUHIHWDOLPSDLUPHQW In cases where the plan is to have a vaginal delivery, one must consider that these fetuses show a high incidence of acute fetal distress, especially WKHDV\PPHWULFW\SHRI,8*5VRLWLVUHFRPPHQGHGWRHQVXUHDVWULFW clinical monitoring of the fetal heart rate and uterine contractions during ODERU&RQWLQXRXVHOHFWURQLFPRQLWRULQJDQGWKHHYHQWXDODFTXLVLWLRQRI DIHWDOFDSLOODU\EORRGVDPSOHWRVWXG\WKHDFLGEDVHEDODQFHFDQEHRI JUHDWKHOSIRUWKHPDQDJHPHQWRIWKHVHFDVHV Exercise 10 0UV;;LQ([HUFLVH FRPHVEDFNWR\RXWZRZHHNVDIWHUWKH¿UVWVFDQ WKHJHVWDWLRQDODJHZDVWKHQGLDJQRVHGDVZHHNV 6KH FRPHV ZLWK DQ XOWUDVRXQG SHUIRUPHG GD\V DIWHU WKH ¿UVW WKLV QHZXOWUDVRXQGUHSRUWVWKDWWKHLQFUHDVHLQWKHDEGRPLQDOFLUFXPIHUHQFH value is consistent with the earlier ultrasound. Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 47 %DVHGRQWKLVLQIRUPDWLRQ\RXUGLDJQRVLVZRXOGEH Your diagnosis is: Symmetric IUGR Asymmetric IUGR Fetus with a normal growth ,I\RXEHOLHYHWKDWWKLVEDE\KDVDQRUPDOJURZWK\RXUUHDVRQLQJZDVDGHTXDWH ,I\RXPDGHDGLDJQRVLVRI,8*5RIVRPHVRUWUHUHDGSDJHVWR 7KHZRPDQFRQWLQXHVZLWKKHUREVWHWULFFRQWURODQGDWZHHNVJHVWDWLRQWKH\ ¿QGWKDWWKH8+KDVUHPDLQHGDUUHVWHGDWFPZLWKDJZHLJKWJDLQ,QWKLV FRQWH[W\RXVXVSHFWHG,8*5DQGUHTXHVWDQXOWUDVRXQGZKLFKUHSRUWV 35 week fetus; GA based on the previous ultrasound Abdominal circumference 280 mm ( 8VH WKH KHDG FLUFXPIHUHQFH )LJ DQG DEGRPLQDO FLUFXPIHUHQFH )LJ charts and record the course of fetal growth. What is your diagnosis? Symmetric IUGR Asymmetric IUGR Fetus with a normal growth but genetically small ,I\RXUDQVZHULVDV\PPHWULF,8*5\RXDUHZHOORULHQWHG,WLVDFDVHRI,8*5 EHFDXVH IHWDO JURZWK LV EHORZ WKH WK SHUFHQWLOH IRU JHVWDWLRQDO DJH ,W LV DV\PPHWULFEHFDXVHWKHIHWDODEGRPLQDOFLUFXPIHUHQFHIHPXUOHQJWKUDWLRLV LHOHVVWKDQ ZKLFKVKRZVDUHGXFWLRQLQZDLVWFLUFXPIHUHQFHEXW not a reduction in the femur length. Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 48 Monitoring Fetal Growth 7KH IHWXV KDV EHHQ FRQ¿UPHG 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 obstetric ultrasound Monitoring only with fetal eco Doppler ultrasound Monitoring with measurement of the fundal height If your answer was to monitor with eco Doppler and ultrasound your choice ZDV FRUUHFW EHFDXVH WKH XOWUDVRXQG ZLOO DOORZ \RX WR DVVHVV ZKHWKHU WKH IHWXVUHFRYHUVLWVJURZWKUDWH FDWFKXS DQGWKHHFR'RSSOHUZLOOLGHQWLI\WKH IHWDOUHVSRQVHWRWKHVWUHVVLWLVH[SRVHGWRDQGWRHVWDEOLVKWKHULJKWWLPLQJWR WHUPLQDWHWKDWSUHJQDQF\IRUWKHVDNHRIWKHIHWXV 7KHHFR'RSSOHUUHFHLYHGDWWKHQHZYLVLWUHSRUWV XPELOLFDODUWHU\ DEVHQFHRI GLDVWROLFÀRZGXULQJGLDVWROH0LGGOHFHUHEUDODUWHU\ ,3EHORZWKHWKSHUFHQWLOH You decide Schedule a new follow-up visit in 1 week You would admit her to rest at the hospital to promote the fetal catch up Terminate pregnancy If you opted for termination of pregnancy, you have made the right decision. Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 49 EXERCISES USING THE PERINATAL COMPUTING SYSTEM FOR THE ASSESSMENT AND MONITORING OF FETAL GROWTH 7KH FRPSXWHU VRIWZDUH LQ WKH 3HULQDWDO ,QIRUPDWLRQ 6\VWHP 6,3 RIIHUV several options to assess and monitor fetal growth. $VGLVFXVVHGEHORZWKHSURJUDPVWKDWFDQEHXVHGWRWKLVDLPDUH 6HOHFWLRQE\YDULDEOHV 'LVWULEXWLRQRIDYDULDEOH /LVWLQJRI0HGLFDO5HFRUGV 5HSRUWVRIEDVLFLQGLFDWRUV 5LVN(VWLPDWLRQ 7KLVH[HUFLVHLVH[SHFWHGWRVWUHQJWKHQORFDOSODQQLQJDQGHYDOXDWLRQRIDFWLYLWLHV DQGFRQWULEXWHWRHSLGHPLRORJLFDOVXUYHLOODQFHRIIHWDOJURZWK Weight by gestational age 7RGHWHUPLQHWKHSHUFHQWLOHVRIZHLJKWIRUHDFKZHHNRIDPHQRUUKHD6,3 uses the program “Distribution of a variable”. )LUVW\RXPXVWGH¿QHWKHSRSXODWLRQXQGHUVWXG\7KLVZLOOUHTXLUHWKHVHOHFWLRQ RIVLQJOHWRQSUHJQDQFLHVZLWKOLYHELUWKVDQGZHLJKWVHTXDOWRRUJUHDWHUWKDQ JUDPV7KLVVHOHFWLRQLVGRQHXVLQJWKH“Selection by variables”. Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 50 Monitoring Fetal Growth $IWHU FRPSOHWLQJ WKH VHOHFWLRQ EDVHG RQ WKH YDULDEOHV HVWDEOLVKHG XVLQJ WKH program “Distribution of a variable” we put “Gestational age at birth” as D GLVWULEXWLRQ YDULDEOH LQGHSHQGHQW DQG “birth weight” DV D VWXG\ YDULDEOH GHSHQGHQW 7KHIROORZLQJUHSRUWLVREWDLQHGIRUWKHinstitution A: In the previous window, as we position ourselves at each gestational age, WKHSURJUDPFDOFXODWHVWKHELUWKZHLJKWSHUFHQWLOHVIRUWKHLQIDQWVERUQZLWK WKDWJHVWDWLRQDODJHVHOHFWHG,QWKH¿JXUHZHVHHWKDWIRUWKHZHHNVRI JHVWDWLRQWKHWKDQG WKSHUFHQWLOHVIRUELUWKZHLJKWDUHJDQG JUHVSHFWLYHO\ Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 51 %HWZHHQZHHNVDQGZHREWDLQHGWKHIROORZLQJYDOXHVIRUSHUFHQWLOHVDQG Newborn’s weight in grams Weeks p10 p90 34 $ *R WR WKH IROORZLQJ ¿JXUH 1RWH WKDW LW VKRZV D FKDUW RI ZHHNV RI DPHQRUUKHDDQGZHLJKWLQJUDPV7KHWZRSRLQWVWKDWKDYHEHHQPDUNHG FRUUHVSRQGWRWKHYDOXHVRISHUFHQWLOHVDQG IRU ZHHNV &RPSOHWHWKH¿JXUHE\SODFLQJHDFKRIWKHWZRSHUFHQWLOHV DQG LQWKH IROORZLQJZHHNVWDNLQJWKHPIURPWKHWDEOHDERYH2QFHWKHWUDQVFULSWLRQKDV EHHQFRPSOHWHGGUDZDFRQWLQXRXVOLQHWRFRQQHFWWKHSRLQWVFRUUHVSRQGLQJ ZLWKSHUFHQWLOHVDQGDQRWKHURQHZLWKSHUFHQWLOHV 5000 P 4000 90 P 3000 10 Grams 2000 1000 25 27 29 31 33 35 37 39 41 Amenorrhea in weeks Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 52 Monitoring Fetal Growth 1RZZHZLOOUHSHDWWKHVDPHH[HUFLVHEXWLQWKLVFDVHIRUDVHOHFWHG VXESRSXODWLRQ WKDW EHORQJV WR Institution B 8VLQJ WKH “Selection by variables” tool, select the population that meets the following conditions: x Singleton pregnancy and x /LYHQHZERUQ x %LUWKZHLJKWHTXDOWRRUJUHDWHUWKDQJUDPV x 1RPDWHUQDOPRUELGLW\ x 1RQVPRNLQJPRWKHU x Literate mother x Five or more antenatal visits 7KHVHOHFWLRQZLOOORRNDVLQWKH¿JXUHEHORZ 2QFHWKHVHOHFWLRQRIWKHYDULDEOHVVHWKDVEHHQFRPSOHWHGZHXVHWKH program “Distribution of a variable” and place the “Gestational age at birth”DVDYDULDEOHIRUGLVWULEXWLRQDQG“birth weight” as a study YDULDEOH Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 53 7KHUHVXOWLVVKRZQLQWKHIROORZLQJVFUHHQ :HGUDZDWDEOHVLPLODUWRWKDWXVHGLQWKHSUHYLRXVH[DPSOHEXW for this new target population, we have Newborn’s birth weight in grams Weeks p10 p90 Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 54 Monitoring Fetal Growth 3ORWWKHYDOXHVRISHUFHQWLOHVDQG RIWKLVVXESRSXODWLRQRI,QVWLWXWLRQ %RQWKHVDPHD[HV8VHDFURVVLQVWHDGRIWKHSRLQWXVHGSUHYLRXVO\DQG connect them with a dashed line. &RPSDUHERWKGLVWULEXWLRQVDQGFKHFNWKHFRUUHFWRSWLRQVLQWKHOLVWEHORZ %RWKSDWWHUQVDUHWKHVDPHƑ 7KHWKSHUFHQWLOHLVKLJKHULQWKHVHOHFWHGSRSXODWLRQ Ƒ 7KH WKSHUFHQWLOHLVKLJKHULQWKHVHOHFWHGSRSXODWLRQ Ƒ :KLFKGR\RXWKLQNEHVWUHSUHVHQWVWKHJURZWKSRWHQWLDO" 7KHSRSXODWLRQLQInstitution A Ƒ 7KHSRSXODWLRQVHOHFWHGLQInstitution B Ƒ ,QWKHFDVHVZKHUHWKHUHDUHGLI¿FXOWLHVZKDWZRXOGEHWKHEHVW alternatives to calculate percentiles in these cases? x Prolonged study Ƒ x Sum with other similar institutions Ƒ Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 55 1RZGUDZWKHZHLJKWGLVWULEXWLRQRIWKHPopulation of the Institution B VHOHFWHG EDVHG RQ WKH VWDQGDUGV SXEOLVKHG E\ &/$3 GHVFULEHG LQ WKH ¿JXUHEHORZ Grams Amenorrhea in weeks 8QWLO\RXULQVWLWXWLRQKDVLWVRZQSDWWHUQVWRFODVVLI\WKHQHZERUQVLWLV ULJKWWRFKRRVHWKHFXUYHGHYHORSHGE\&/$3 Yes Ƒ 1RƑ Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 56 Monitoring Fetal Growth Listing of medical records historias B-7KH6,3VRIWZDUHOHWV\RXOLVWDVHWRIPHGLFDOUHFRUGVWKDWPHHW certain conditions. In each list, the software displays a document that OLVWVPHGLFDOUHFRUGVVHOHFWHGE\WKHVHOHFWLRQFRQGLWLRQDQGDQXPEHU RIYDULDEOHVWKDWFDQEHFKRVHQE\WKHRSHUDWRU8VLQJWKLVRSWLRQLQWKH ¿JXUHEHORZZHFDQVHHDVDPSOHRIQHZERUQVIURPInstitution A, ZLWKELUWKZHLJKWDQGJHVWDWLRQDODJHGDWD Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 57 /RFDWHRQHE\RQHWKHZHLJKWVRIWKHQHZERUQVLQWKHSDWWHUQVGUDZQ RQWKH¿JXUHXVHGWRSORWWKHSHUFHQWLOHVDQG RIWKHSRSXODWLRQV studied. Count how many small for gestational age (SGA)QHZERUQV DUHLGHQWL¿HGLIWKHFXWWLQJSRLQWXVHGLVWKHWKSHUFHQWLOHRIELUWKZHLJKW E\JHVWDWLRQDODJHtaking as a reference the pattern built with: 6*$ 7KHVDPSOHRI,QVWLWXWLRQ$ZLWKVLQJOHWRQSUHJQDQFLHV 1 7KHVDPSOHVHOHFWHGRI,QVWLWXWLRQ%ZLWK VLQJOHWRQSUHJQDQFLHV 1 7KH¿JXUHEHORZVKRZVWKHSRLQWVRIWKHWDEOHWKDWKDYHEHHQSORWWHGLQ WKHFXUYHGHYHORSHGE\&/$3:5+ Grams Amenorrhea in weeks ,GHQWLI\ D +RZPDQ\6*$VGR\RXGLDJQRVH" 1 E +RZPDQ\/%:V J GR\RXGLDJQRVH" 1 Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 58 Monitoring Fetal Growth 7LFNWKHRSWLRQWKDWEHVWDFFRXQWVIRUWKHGLIIHUHQFH 7KHIDFWWKDWWKH\DUHVLQJOHWRQV Ƒ 7KH\UHVXOWIURPGLIIHUHQWFRQFHSWV Ƒ Complete the following table with the results obtained Reference pattern Population selected Population selected CLAP of Institution A of Institution B Number of SGAs diagnosed Risk estimations C-7KHSURJUDPRQ“Risk estimation” used in the following examples is DQRSWLRQWKDWDOORZV\RXWRFURVVDQ\YDULDEOHVRIWKHSHULQDWDOPHGLFDO UHFRUGRQHDVDYDULDEOHRIH[SRVXUHDQGWKHRWKHUDVDQDGYHUVHUHVXOW DQGWRREWDLQUHODWLYHULVNV 55 ZLWKWKHLUFRUUHVSRQGLQJFRQ¿GHQFH intervals. 7KHWDEOHVEHORZVKRZWKHUHODWLYHULVNV 55 WKHLUFRQ¿GHQFHLQWHUYDOV DQG3RSXODWLRQ$WWULEXWDEOH5LVN 3$5 RIWKHVHIDFWRUV KLVWRU\RI/%: VPRNLQJ KDELW SUHHFODPSVLD DQG PXOWLSOH SUHJQDQF\ RI D SRSXODWLRQ RI OLYH ELUWKV WKDW H[FOXGHG WKRVH ZHLJKLQJ OHVV WKDQ JUDPV 7KH RXWFRPH XVHG WR LQGLFDWH GDPDJH DEQRUPDO UHVXOWV ZDV 6PDOO IRU *HVWDWLRQDO$JH 6*$ Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 59 History of LBW Smoking habit Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 60 Monitoring Fetal Growth Preclampsia Multiple pregnancy Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 61 Fill in the chart below with the data included in the table Damage: SGA Proportion 95% Confidence PAR Risk Factors exposed RR (frequency %) interval % History of LBW Smoking habit Pre-eclampsia Multiple pregnancy Analyze the picture ,GHQWLI\WKHULVNIDFWRUPRVWFRPPRQO\DVVRFLDWHGZLWK6*$ ,GHQWLI\WKHULVNIDFWRUZKRVHFRQWUROZRXOGKDYHPRUHLPSDFWRQ UHGXFLQJWKHIUHTXHQF\RI6*$V ,GHQWLI\WKHIDFWRUVWKDWDUHHDVLHUWRFRQWURO 2IWKHULVNIDFWRUVOLVWHGKHUHLQVHOHFWWKHRQHVZKRVHDSSURDFK\RX WKLQNDUHDSULRULW\DQGH[SODLQZK\ …………………………………………………………………………………... ...... 3URSRVHDVSHFL¿FDFWLRQRQWKHIDFWRUVWKDW\RXKDYHFKRVHQ …………………………………………………………………………………... ...... Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 62 Monitoring Fetal Growth Basic statistics D-7KH“Key Indicators Report” program provides the main indicators of perinatal care and gives a clear overview of some characteristics of the population served and the outcomes of the care provided. On the “Basic Statistics”WDJ\RXZLOOJHWWKH(DUO\1HRQDWDO0RUWDOLW\ Rate, while in the “Newborn” WDJ LQ WKH ELUWK ZHLJKW DQG ZHLJKW E\ JHVWDWLRQDO DJH UHSRUWV \RX ZLOO REWDLQ WKH DSSURSULDWH GDWD IRU 6*$ /%:DQG9/%: 7R REWDLQ LQIRUPDWLRQ E\ SHULRGV \RX PXVW VHOHFW WKHP LQ WKH RSWLRQ “Selection by Dates”7KHIROORZLQJLOOXVWUDWHVWKHVHOHFWLRQRIWKH¿UVW WULPHVWHURI Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 63 3URFHHGLQJWKLVZD\WKHIROORZLQJLQIRUPDWLRQZDVREWDLQHGE\WULPHVWHUV IRUWKHSHUFHQWDJHRI6PDOOIRU*HVWDWLRQDO$JH 6*$ ORZELUWKZHLJKW /%: J DQGYHU\ORZELUWKZHLJKW 9/%: J DQGHDUO\ QHRQDWDO PRUWDOLW\ UDWH (105 RYHU J &RPSOHWH WKH IROORZLQJ LQIRUPDWLRQ IURP WKH IRXU FRQVHFXWLYH WULPHVWHUV RI \HDU RI WKH ,QVWLWXWLRQ%LQWKHWDEOHEHORZWKHVHUHSRUWV First trimester Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 64 Monitoring Fetal Growth Second trimester Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 65 Third trimester Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 66 Monitoring Fetal Growth Fourth trimester Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 67 Trimester ENM rate %o SGA % LBW % VLBW % 1 2 3 4 Tendencia en a disminuir en el año SI NO Tasa MNP %o PEG % BPN % MBPN % $QDO\]HWKHWUHQGRIWKHVHLQGLFDWRUVDQGWLFNWKHFRUUHFWFKRLFHV Tendency to be reduced during the year YES NO ENM rate % SGA % LBW VLBW% Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 68 Monitoring Fetal Growth Answers to the exercises using the perinatal information system for the assessment and monitoring of fetal growth Exercise A - Weight percentiles of Institution A Grams Weeks of amenorrhea Weight percentiles at Institution B Grams Weeks of amenorrhea Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 69 :HLJKWSHUFHQWLOHRI,QVWLWXWLRQ$ B DQG% [[ Grams Weeks of amenorrhea &RPSDUHERWKGLVWULEXWLRQDQGFKHFNWKHFRUUHFWFKRLFHVLQWKHOLVWEHORZ Both patterns are the same Percentile 10 is higher in the selected population Percentile 90 is higher in the selected population :KLFKGR\RXWKLQNEHVWUHSUHVHQWVWKHJURZWKSRWHQWLDO" The population of Institution A Population selected from Institution B :KDWZRXOGEHWKHEHVWDOWHUQDWLYHVWRFDOFXODWHSHUFHQWLOHVLQWKHFDVHV ZKHUHWKHUHDUHGLI¿FXOWLHV" Prolonged study Adding the cases with other similar institutions Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 70 Monitoring Fetal Growth 1RZGUDZWKHZHLJKWGLVWULEXWLRQRIWKH³3RSXODWLRQVHOHFWHGLQInstitution BRYHUWKHVWDQGDUGVSXEOLVKHGE\&/$3IRXQGLQWKH¿JXUHEHORZ Grams Weeks of amenorrhea 8QWLO\RXULQVWLWXWLRQKDVLWVRZQVWDQGDUGVWRFODVVLI\QHZERUQVLWLVULJKW WRFKRRVHWKHFXUYHGHYHORSHGE\&/$3 Ƒ Yes Ƒ1R Exercise B - 2QHE\RQHGLVWULEXWLRQRIWKHZHLJKWVRIWKHQHZERUQV DFFRUGLQJ WR WKH VWDQGDUGV XVHG E\ LQVWLWXWLRQV $ DQG % DQG WKRVH GHYHORSHGE\&/$3:5 Institution A Grams Weeks of amenorrhea Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 71 Institution B Grams Weeks of amenorrhea Grams Weeks of amenorrhea 6PDOO IRU JHVWDWLRQDO DJH XVLQJ WKH WK SHUFHQWLOH RI ELUWK ZHLJKW E\ JHVWDWLRQDODJHDVDFXWRIISRLQWWDNLQJWKHVWDQGDUGVPDGHZLWKWKH following as a reference: 7KHVDPSOHRI,QVWLWXWLRQ$ZLWKVLQJOHWRQSUHJQDQFLHV 1 7KHVDPSOHVHOHFWHGIURP,QVWLWXWLRQ% 1 7KHVWDQGDUGVGH¿QHGE\&/$3:5 1 +RZPDQ\/%:V J DUHGLDJQRVHG WKH&/$3:5VWDQGDUGV 1 Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR 72 Monitoring Fetal Growth 7KHIDFWWKH\DUHVLQJOHWRQV Ƒ 7KH\DUHWKHUHVXOWRIGLIIHUHQWFRQFHSWV Ƒ &RPSOHWHWKHIROORZLQJWDEOHZLWKWKHUHVXOWVREWDLQHG Reference pattern Population selected Population selected CLAP of Institution A of Institution B Number of SGAs 3 5 4 diagnosed Exercise C. Damage: SGA Proportion 95% Confidence PAR Risk Factors exposed RR (frequency %) interval % History of LBW 13.63 1.94 1.58 - 2.37 3.17 Smoking habit 12.47 2.39 2.17 - 2.63 17.44 Pre-eclampsia 13.60 2.05 1.74 - 2.41 4.51 Multiple pregnancy 18.61 3.11 2.68 - 3.61 4.73 0XOWLSOH3UHJQDQF\ 6PRNLQJKDELW 6PRNLQJKDELW DQG 3OHQDU\ Exercise D Trimester ENM rate %o SGA % LBW % VLBW % 1 4.4 5.5 8.3 1.1 2 3.5 6.2 8.9 1.3 3 5.1 6.1 8.7 1.1 4 5.0 5.5 8.5 1.3 Tendency to be reduced during the year YES NO ENM rate % SGA % LBW VLBW% Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR Monitoring Fetal Growth 73 Bibliography 5R\DO&ROOHJHRI2EVWHWULFLDQVDQG*\QHFRORJLVWV7KH investigation and management of the small-for-gestational-age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atin American Center for Perinatology - Women and Reproductive Health CLAP/WR 74 Monitoring Fetal Growth 'HZKXUVW&-%HD]OH\-0&DPSEHOO6$VVHVVPHQWRIIHWDO PDWXULW\DQGG\VPDWXULW\$P-2EVWHW*\QHFRO 0D\ =DPERQDWR$03LQKHLUR57+RUWD%/7RPDVL(>5LVNIDFWRUV IRUVPDOOIRUJHVWDWLRQDODJHELUWKVDPRQJLQIDQWVLQ%UD]LO@5HY 6DXGH3XEOLFD)HE )HVFLQD5/DVWUD/6XJR03DUUHxR-*DUFtD$6FKZDUF]5 (YDOXDFLyQGHGLIHUHQWHVPpWRGRVSDUDODHGDGJHVWDFLRQDO2EVWHW *LQHFRO/DW$PHU /\QFK&'=KDQJ-7KHUHVHDUFKLPSOLFDWLRQVRIWKHVHOHFWLRQRI a gestational age estimation method. 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