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Disclosures
 None
Lavenia Carpenter, MD
Associate Professor
Division of Maternal-Fetal Medicine
Department of Obstetrics and Gynecology
Vanderbilt University
Objectives
Definitions
 Why screen
 Fetal growth restriction – Failure of a fetus to reach its
growth potential
 Who to screen
 When to screen/when to test
 What test(s) to use
 Small for gestational age newborns – EFW < 10th% or
AC< 10th%
 Severe SGA - < 3rd%
 Where are we going
 LBW- < 2500 gms
WHY?
 Risk of fetal death
 1.5% with EFW< 10th%
 2.5% with EFW < 5th%
 Morbidity – Neonatal: hypoglycemia,
hyperbilirubinemia, hyopthermia, IVH, NEC, seizures,
sepsis, RDS ….. neonatal death
 Morbidity – Childhood: congnitive delay and
Adulthood: higher risk for chronic disease (Barker
hypothesis)
Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice.
Resnik, Robert, MD; Creasy, Robert K., MD.Published January 1, 2014. Pages 743-755.e4. © 2014.
Morbidity and mortality in 1560 small-for-gestational-age fetuses.
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Overall stillbirth rate of 4.2/1000 but 2.4/1000 without FGR
Average delivery 10 days earlier when detected
Population-Based Estimates of In-Unit Survival for
Very Preterm Infants - female
Population-Based Estimates of In-Unit Survival for Very
Preterm Infants - male
Balance of risks/benefits of early
delivery
Barker hypothesis
stillbirth
neonatal demise
morbidity
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Barker hypothesis
Barker hypothesis
Thrifty phenotype
WHO?
 Maternal risk factors
 History of FGR
 Diabetes, hypertension, autoimmune disorders, renal disease
 Tobacco or other substance use
 Low pre-pregnancy birth weight
 High altitude
 Pregnancy course
 Poor weight gain
 Preeclampsia
 Short fundal height

Cheryl Lyn Walker & Shuk-mei Ho; Nature Reviews Cancer 12, 479-486 (July 2012)
MATERNAL
Chronic illnesses
Substance abuse
Preeclampsia
Age
Parity
Malnutrition
PLACENTAL
Etiologies
FETAL
Aneuploidy
Genetic syndromes
Multiples
Gender
ENVIRONMENT
Infections
Altitude
Nutrition
Correlation for birth weight
Between
r
Monozygotic twins
0.54
Full siblings
0.52
Half siblings common mother
0.58
Half siblings common father
0.10
First cousins common maternal grandparents
0.135
First cousins common paternal grandparents
0.015
Robson ER, Human growth Vol 1: Principles and prenatal growth New York: Plenum press 1978
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Maternal constraint
 Small breed embryo transplanted to large breed uterus
will growth larger than a small breed embryo
remaining in a small breed uterus
 Multiple gestation in humans
Maternal nutrition
 Starvation effect most pronounced in third trimester
(Holland example)
 Starvation in the first trimester with normal
birthweight daughters but small granddaughters –
epigenetic effects
Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice.
Resnik, Robert, MD; Creasy, Robert K., MD.Published January 1, 2014. Pages 743-755.e4. © 2014.
Median growth rate curves for single and multiple births in California, 1970-1976
Fetus
Placenta
 Genetic potential
 Placental growth (mass) in first half of pregnancy with
remodeling (terminal villi) in later half of pregnancy
 Fetal growth in second half of pregnancy
Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice.
Resnik, Robert, MD; Creasy, Robert K., MD.Published January 1, 2014. Pages 743-755.e4. © 2014.
Weight-for-age gender-specific curves (solid line) for girls (A) and boys (B) compared with Lubchenco unisex curves ( dashed line)
starting at 24 weeks.
Fetomaternal immune cross-talk and its consequences for maternal and offspring's health
Petra C Arck1,
& Kurt Hecher1,
Journal name:Nature Medicine Volume: 99, Pages:548–556 Year published:(2013) DOI:
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Placental surface areas at different gestational ages. () areas of intermediate villi; () areas of terminal villi.
(Adapted from The Physiology of the Human Placenta, by Page K, Figure 2.7, published by UCL press).
When
Illustration of uterine and placental vasculature in the non-pregnant, pregnant and immediate post-partum state. Normal pregnancy is
characterized by the formation of large arterio-venous shunts that persist in the immediate post-partum period. By contrast
pregnancies complicated by severe preeclampsia are characterized by minimal arterio-venous shunts, and thus narrower uterine arteries
characterized with “low flow and high resistance.” Red shading = arterial; blue shading = venous. Adapted from Burton et al. Placenta
2009; 30 (6), 473-482. Adapted from Placenta, Burton et al. 2009
EGA
 Maternal risk factors
Clinical or Sonographic
+/- 2SD
 Poor weight gain
IVF
+/- 1 day
 Size less than dates (fundal height)
Ovulation induction or AI
+/- 3 days
 Pregnancy associated hypertension
Ultrasound EGA < 8 6/7 (CRL)
+/- 5 days
 Abnormal serum screening
9-13 6/7 (CRL)
+/- 7 days
 Uncertainty in dating
14-15 6/7 (BPD, HC, AC, FL)
+/- 7 days
16-21 6/7 (BPD, HC, AC, FL)
+/- 10 days
 Abnormal placentation
 Timing of testing dependent upon risk factor
22-27 6/7 (BPD, HC, AC, FL)
+/- 14 days
ACOG committee opinion Estimating Due Date No. 611 Oct 2014
>28 (BPD, HC, AC, FL)
+/- 21 days
<10th%
<3rd%
Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice.
Resnik, Robert, MD; Creasy, Robert K., MD.Published January 1, 2014. Pages 743-755.e4. © 2014.
Fetal weight as a function of gestational age by selected references.
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WHAT (test to use)?
 Cardiotocography or NST
 Biophysical profile
 Doppler studies
Nonstress test (NST)
Moderate variability
Accelerations associated
with maternal palpation
FMs (accelerations graded
for gestation) on 20minute NST
FM and accelerations not
coupled
Insufficient accelerations,
absent accelerations, or
decelerative trace
Minimal or absent
variability
Fetal Variable
Normal Behavior (score = 2)
Abnormal Behavior (score = 0)
Fetal breathing
movements (FBMs)
Intermittent, multiple episodes of
more than 30 sec within a 30-min
biophysical profile (BPP) time frame
Hiccups count
If continuous FBMs for 30 min, rule
out fetal acidosis
Continuous breathing without cessation
Completely absent breathing or no
sustained episodes
Body or limb
movements
At least three discrete body
movements in 30 min
Continuous, active movement
episodes equal a single movement
Includes fine motor movements,
rolling movements, and so on, but not
rapid eye movements or mouthing
movements
Three or fewer body or limb movements in a
30-min observation period
Devoe, L, Glob. libr. women's med.,
(ISSN: 1756-2228) 2008; DOI
10.3843/GLOWM.10210
Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice.
Bahtiyar, Mert Ozan, MD; Copel, Joshua A., MD.Published January 1, 2014. © 2014.
Fetal tone or posture
Demonstration of active extension
with rapid return to f lexion of fetal
limbs and brisk repositioning or trunk
rotation
Opening and closing of hand or
mouth, kicking, and so on
Low-velocity movement only
Incomplete f lexion, f laccid extremity
positions, abnormal fetal posture
Must score 0 when fetal movement (FM) is
completely absent
Amniotic f luid
evaluation
At least one pocket larger than 2 cm
with no umbilical cord (text discusses
subjectively decreased f luid)
No cord-free pocket greater than 2 cm or
multiple definite elements of subjectively
reduced amniotic f luid volume
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BPP – gradual hypoxia concept
 NST and FBM
 Movement
 Tone
 AFV (chronic)
Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice.
Bahtiyar, Mert Ozan, MD; Copel, Joshua A., MD.Published January 1, 2014. © 2014.
BPP and cord pH
Vintzileos et al. Obstet Gynecol 1987;70:196
BPP
Interpretation
Predicted PNM/1000 *
Recommended
Management
10/10, 8/8, 8/10 (AFV
normal)
No evidence of fetal
asphyxia
Less than 1/1000
No acute intervention on
fetal basis; serial testing
indicated by disorderspecific protocols
8/10-oligo
Chronic fetal compromise
likely (unless ROM is
proved)
89/1000
For absolute
oligohydramnios, prove
normal urinary tract,
disprove undiagnosed ROM,
consider antenatal steroids,
and then deliver
Repeat testing immediately,
before assigning final value
If score is 6/10, then 10/10,
in two continuous 30minute periods, manage as
Equivocal test; fetal
Depends on progression
6/10 (AFV normal)
10/10
asphyxia is not excluded
(61/1000 on average)
For persistent 6/10, deliver
the mature fetus, repeat
within 24 hr in the
immature fetus, then deliver
Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice.
if less than 6/10
Bahtiyar, Mert Ozan, MD; Copel, Joshua A., MD.Published January 1, 2014. © 2014.
4/10
Acute fetal asphyxia likely
If AFV-oligo, acute on
chronic asphyxia very likely
2/10
Acute fetal asphyxia likely
with chronic
91/1000
125/1000
Deliver by obstetrically
appropriate method, with
continuous monitoring
Deliver for fetal indications
(frequently requires
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BPP and medications
 Beta andrenergics
 Possible increase in FBM
 Steroids
 Reduction in FBM and FM and non-reactive NST has been
described
 Magnesium sulfate
 Possible decrease in FBM and NST
 Opiods
 Fasting
 Hyperglycemia may increase FBM in presence of acidemia
 fasting may decrease FBM
Signore C, Freeman R and Spong C. Obstet Gynecol. Mar 2009;
113(3): 687–701
Risk for mortality morbidity due to
prematurity
 http://www.nichd.nih.gov/about/org/der/branches/p
pb/programs/epbo/pages/epbo_case.aspx
http://www.nichd.nih.gov/about/org/der/br
anches/ppb/programs/epbo/pages/epbo_ca
se.aspx
<10th%
<3rd%
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Umbilical artery
Doppler studies
 Umbilical artery
 Middle cerebral artery
 Ductus venosus
 Uterine artery
http://www.vanderbilthealth.com/includes/healthtopics/calc.php?
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Middle cerebral artery
Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice.
Bahtiyar, Mert Ozan, MD; Copel, Joshua A., MD.Published January 1, 2014. © 2014.
Abnormal
MCA
Abnormal
umbilical
artery
Abnormal
ductus
venosus
Cerebroplacental ratio (CPR) in relation to gestational age.
The curves indicate the 5th, 10th, 90th, and 95th percentile values for pregnancies with and
without morbidity and perinatal complications. The interval between Doppler imaging and
delivery was less than 2 weeks. Open circles, <10th percentile, no morbidity;
filled circles, <10th percentile, with morbidity.
Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice.
Bahtiyar, Mert Ozan, MD; Copel, Joshua A., MD.Published January 1, 2014. Pages 211-217.e1. © 2014.
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TRUFFLE 2011
Where?
 “Although the difference in proportion of infants
 Expansion in use of customized fetal growth charts
surviving without neuroimpairment was nonsignificant at the primary endpoint, timing of delivery
based on the study protocol using late changes in the
DV waveform might produce an improvement in
developmental outcomes at 2 years of age.”
 Cell free fetal DNA for evaluation of genetic
syndromes
 Biochemical markers to help distinguish small normal
from placental dysyfunction
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Placenta on chip
THANK YOU!
For Immediate Release: Thursday, June 18, 2015
Researchers design placenta-on-a-chip to better understand pregnancy
http://www.nih.gov/news/health/jun2015/nichd-18.htm
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