King Edward Memorial Hospital King Edward Memorial Hospital Obstetrics & Gynaecology Obstetrics & Gynaecology CLINICAL PRACTICE GUIDELINE Small for Gestational Age and Intrauterine Growth Restriction: Management of This document should be read in conjunction with the Disclaimer Contents Antenatal Clinic Flowchart for Diagnosis & Management of IUGR .......... 3 Flow chart for Suspected SGA ................................................................ 4 Flow chart for Confirmed IUGR ............................................................... 5 Suspected Small for gestational age fetus: MFAU QRG ......................... 6 Criteria for Referral ................................................................................................. 6 Assessment ............................................................................................................ 6 Subsequent Visits for Confirmed SGA .................................................................... 6 Ultrasound Assessment .......................................................................................... 6 CTG monitoring ....................................................................................................... 7 Management ........................................................................................................... 7 Intrauterine Growth Restriction ............................................................... 8 Aim .......................................................................................................................... 8 Background Information .......................................................................................... 8 Key Points ............................................................................................................... 9 Screening and Diagnosis ........................................................................................ 9 Determination of Gestational Age ........................................................................... 9 Abdominal Palpatation .......................................................................................... 10 Fundal - Symphysis Measurements ...................................................................... 10 Ultrasound examination ........................................................................................ 10 Management ......................................................................................................... 10 Assess for causes of IUGR ................................................................................... 10 Ultrasound Surveillance ........................................................................................ 11 CTG Monitoring ..................................................................................................... 11 Anticipated Preterm Birth ...................................................................................... 11 Page 1 of 18 SGA & IUGR Timing of Delivery ................................................................................................. 11 Intrapartum management ...................................................................................... 12 Small for Gestational Age Fetus ........................................................... 13 Aim ........................................................................................................................ 13 Background Information ........................................................................................ 13 Key Points ............................................................................................................. 14 Diagnosis .............................................................................................................. 14 Management ......................................................................................................... 14 Risks for IUGR/SGA ............................................................................................. 14 Assess for causes of the SGA and/or the IUGR fetus ........................................... 15 Fetal Surveillance ................................................................................................. 15 Cardiotocograph monitoring (CTG) ....................................................................... 16 Medical review and Antenatal Care ...................................................... 16 References ........................................................................................... 17 Obstetrics & Gynaecology Page 2 of 18 SGA & IUGR Antenatal Clinic Flowchart for Diagnosis & Management of IUGR Assess Risk factors at booking FSH at every visit Are measurements small for dates? AND/OR are IUGR risk factors present?(1 major or 3 minor) Check gestational age is correct(dating scan) Review anatomy scan /FTS/possible causes. Discuss with the obstetric team if measuring small for dates Document the plan in the antenatal record and MR004 Obstetric Instruction Sheet Diagnose Arrange ultrasounds · AFI/Dopplers/fetal biometry/BPP · Anatomy (if not already performed) AC or EFW < 10th centile or No Yes Serial ultrasound indicates SGA/IUGR? Manage · Serial ultrasounds Routine Care · Schedule ultrasounds and antenatal visits on the same day · If SGA is confirmed but not IUGR and there is no fetal compromise, document an individualised care plan Normal PI or RI >2SD Abnormal AREDV UA Doppler EDV present UA Doppler Daily UA Doppler Fortnightly Twice weekly DV Doppler · UA Doppler UA Doppler CTG > 32/40 · MCA Doppler CTG > 32/40 · AC & EFW Birth · Recommended by 32 weeks, after Birth steroids. · Offer by 37 weeks-timing d/w consultant · Consider 30-32 weeks · Recommended by > 34 weeks if · Recommended < 32 weeks after Static growth over 34 weeks steroids if abnormal DV Doppler &/or th MCA Doppler PI <5 centile CTG · Consider steroids if CS birth & appropriate > 24 weeks & EFW >500g Obstetrics & Gynaecology Page 3 of 18 SGA & IUGR Flow chart for Suspected SGA FLOW CHART FOR THE (SUSPECTED) SMALL FOR GESTATION FETUS Woman presents to MFAU with suspected SGA fetus Midwife/RMO takes medical/obstetric history and performs a physical examination An ultrasound is performed. Is a SGA fetus confirmed? NO YES Allow home after Are there signs of fetal discussion with the compromise? Registrar. Does the growth cross centiles / is there a change in growth velocity? Routine follow up with usual health care provider YES NO Review by Registrar/Consultant Urgent review by the Registrar Arrange: or Consultant • Ultrasound weekly for AFI, BPP, and Doppler studies • Ultrasound fortnightly for biometry • CTG monitoring according to CONFIRMED IUGR gestation and medical decision Refer to the following sections: • Intrauterine growth Restriction • Maternal Fetal Assessment Unit – Quick Reference guide assessment for confirmed fetal A confirmed SGA fetus that is intrauterine growth restriction constitutionally small with no other abnormal clinical features will require individual medical management plan. Obstetrics & Gynaecology Page 4 of 18 SGA & IUGR Flow chart for Confirmed IUGR FLOW CHART FOR MANAGEMENT OF CONFIRMED INTRA-UTERINE GROWTH RESTRICTION Woman presents to MFAU with confirmed IUGR Midwife/RMO performs assessment as outlined in the Quick Reference Guide Midwife/RMO reviews all maternal and fetal assessments Are all the measurements/tests within the normal limits? YES NO Inform the Obstetric Inform the Level 3 team of the results. Obstetric team Registrar Arrange review in the / Consultant and antenatal clinic or MFAU arrange urgent review. as appropriate. ABNORMAL RESULTS INCLUDE: Arrange continued CTGs weekly or biweekly • two or more Non Reactive assessment and • features suggestive of fetal compromise review in MFAU. Ultrasound results • AFI persistently low or decreasing Team Consultant review • Abnormal Doppler studies as required. • Fetal growth plateau or declining • No fetal movements observed during the scan Fetal movements • Maternal reporting of decreased fetal movements Obstetrics & Gynaecology Page 5 of 18 SGA & IUGR Suspected small for gestational age fetus: MFAU QRG Criteria for Referral Antenatal women for whom there is clinical suspicion of a suspected ‘small for gestational age’ (SGA) fetus at or more than 24 weeks gestation. Assessment 1. Confirm the gestational age by the woman’s dating ultrasound or last menstrual period dates. Ensure a copy of the ultrasound report is available in the medical records. 2. Review the result of the First Trimester and Second Trimester Screen if available. Ensure a copy of the result is in the woman’s medical records. 3. Document the medical and obstetric history. Note any risk factors that may contribute to a SGA fetus. 4. Palpate the abdomen as appropriate to determine: · Symphysis fundal height · Lie · Presentation 5. Arrange an ultrasound scan for fetal biometry, amniotic fluid index (AFI), umbilical artery (UA) Doppler velocities. 6. On confirmation of SGA diagnosis: · If more than 32 weeks gestation, commence cardiotocography (CTG) monitoring. · If less than 32 weeks gestation discuss with Registrar or Consultant if CTG monitoring is required. Subsequent Visits for Confirmed SGA Ultrasound and CTG monitoring management will be altered according to the clinical picture and the medical management plan. See the section on Intrauterine growth restriction for antenatal management of the SGA fetus confirmed as intrauterine growth restricted. Ultrasound Assessment Fortnightly ultrasound assessment for biophysical