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Transcript of Small for Gestational Age (SGA) Fetus. Diagnostic and Management Dilemmas. Dr. Dan Valsky Fetal...
![Page 1: Small for Gestational Age (SGA) Fetus. Diagnostic and Management Dilemmas. Dr. Dan Valsky Fetal Medicine Unit Department of Obstetrics and Gynecology Hadassah.](https://reader036.fdocuments.us/reader036/viewer/2022062304/56649e035503460f94aef269/html5/thumbnails/1.jpg)
Small for Gestational Age (SGA) Fetus.Diagnostic and Management Dilemmas.
Dr. Dan Valsky
Fetal Medicine UnitDepartment of Obstetrics and Gynecology Hadassah University Hospital - Mt. Scopus
Jerusalem, Israel
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• Before the early 1960s, it was assumed that a newborn with a birth weight less than 2500 g was “premature.”
• Lubchenco recognized that there exists a cohort of newborns who do not achieve their growth potential, and that their failure to do so imparts a significant burden of increased perinatal mortality as well as short- and long-term childhood morbidity.
• Hansmann in 1973 incorporated the concept of evaluating fetal growth in reference to percentiles
SGA: Definition and Diagnosis
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Early IUGR: Definition and Diagnosis
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. 10הערכת משקל עוברית מתחת לאחוזון • SGAכל עובר בקטגוריה זו נכנס להגדרה של •
(Small for Gestational Age) . מוקדםSGA שבועות נקרא 32 מתחת ל-SGAאבחון • מאוחר. SGA שבועות נקרא 32 מעל SGAאבחון •
הגדרה
p10 p50
IUGR+SGA NORMAL+IUGR
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– מדידת המרחק בין החלק העליון של קליניקה•הסימפיזיס פוביס עד לפונדוס. לאור רגישות נמוכה
של שיטה זו היא אינה מהווה כיום נדבך חשוב SGAבאבחנה של
– הוא הכלי העיקרי באבחון. אולטרה סאונד•ההערכה כוללת :
וידוא גיל ההריון.
ביצוע ביומטריה עוברית וחישוב משקל העובר.
קביעת אחוזון.
אבחנה
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גיל ההריון נקבע על פי תאריך הוסת האחרונה במידה •והוסתות סדירות ועל פי בדיקת אולטרה סאונד בשבועות
של העובר CRLמוקדמים כאשר הדיוק של מדידת האורך ימים. 3הוא +/-
13תיקון לגיל ההריון ייעשה אם בדיקת על-קול שבוצעה ב-•, או אם ימים6מ-השבועות הראשונים תגלה פער של יותר
תגלה פער 14-20בדיקת על-קול שבוצעה בין השבועות . ימים10מעל
מוקדם USבשבועות מתקדמים יותר של ההריון, כאשר אין •לתארוך מדויק, יש להשתמש במדידה של הצרבלום. קוטר
( אינו מושפע כמעט מקצב גדילת העובר. TCDהצרבלום )
אבחנה: וידוא גיל ההריון
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אפשר לחשב את משקל העובר על פי נוסחאות •שונות הכוללות בתוכן את מדדי הראש, הבטן
והפמור של העובר.
ביומטריה עוברית אבחנה:
HC & BPD AC FL
+ + =EFW
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משקל העובר יתורגם לאחוזון על פי טבלה •המייצגת גדילת עוברים בקרב האוכלוסיה
הנבדקת.
אבחנה: קביעת אחוזון
p10 p50
IUGR+SGA NORMAL+IUGR
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Abnormal Fetus
IUGR
SGA Constitutional
Fetal Abnormalities• Aneploidy• Malformations• Infections• Multiple
Gestations
Placental Abnormalities• Chorioangioma• Confined placental
mosaisism• Chronic placental abruption• Idiopathic Placental
Insufficiency
Maternal Diseases• Vascular/renal• Thrombophilias• Drugs• Extreme
undernutrition
SGA: Definition and Diagnosis
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בירור : גורמים עובריים
שלילת מומים אנטומיים•
ביצוע אקו לב עוברי•
הערכת שליה וחבל טבור•
יעוץ גנטי•
שלילת סימני זיהום תוך רחמי•
בדיקת זרימות )דופלר( •
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IUGR
Fetal Abnormalities• Aneploidy• Malformations• Infections• Multiple
Gestations
Placental Abnormalities• Chorioangioma• Confined placental
mosaisism• Chronic placental abruption• Idiopathic Placental
Insufficiency
Maternal Diseases• Vascular/renal• Thrombophilias• Drugs• Extreme
undernutrition
Early IUGR: Definition and Diagnosis
85%15%
SGA Constitutional
Abnormal Fetus
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MANAGEMENT
• Risk factors assessment and modification• Interval growth evaluation• NST• BPP• Doppler studies
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Types of Doppler
Pulse Doppler Color Doppler Power Doppler
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Doppler systolic-diastolic waveform indices of blood flow velocity.
• S/D Ratio • (S-D)/S - resistance index (RI)• (S-D)/mean – pulsatility index (PI)
S
D
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Umbilical Artery
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Umbilical Artery
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Umbilical artery
• UA Doppler indices correlate with fetal levels of glucose, AA,blood gases, and could be a surrogate measurement of placental function *
• UA is a risk discriminator tool in the management of SGA fetuses**
• Increased UA impedance (AREDF) is associated with an increased risk for perinatal mortality, morbidity and long term abnormal neurodevelopment***
• The use of UA Doppler associated with 30% reduction in perinatal mortality and improvement of number of perinatal outcomes ****
Early IUGR: Definition and Diagnosis
* Karsdorp, Eur J Obstet Gynecol Reprod Biol, 1994, Nicolaides, BMJ,1998** Ott WJ, JUM, 2000, Bashat AA, AJOG, 2000*** Cosmi E, Obstet Gynecol, 2005, Valcamonico, AJOG, 1994**** Nelson JP, Cochrane Database, 2000
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PEG
Early IUGR: Definition and Diagnosis
10-15%85-90%
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Middle Cerebral Artery (MCA)
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Ductus venosus (DV)
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Early IUGR: Doppler Assessment
Placental Resistance
Subclinical placental disease
Compensated hypoxia Decompensated hypoxia )acidosis(
Fetal death
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Early IUGR: Doppler Assessment
Placental Resistance
Subclinical placental disease
Compensated hypoxia Decompensated hypoxia )acidosis(
Fetal death
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Early IUGR: Doppler Assessment
Placental Resistance
Subclinical placental disease
Compensated hypoxia Decompensated hypoxia )acidosis(
Fetal death
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Early IUGR: Doppler Assessment
Placental Resistance
Subclinical placental disease
Compensated hypoxia Decompensated hypoxia )acidosis(
Fetal death
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Placental Resistance
Subclinical placental disease
Compensated hypoxia Decompensated hypoxia )acidosis(
Fetal death
Early IUGR: Intervention threshold
ABC
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Placental Resistance
Subclinical placental disease
Compensated hypoxia Decompensated hypoxia )acidosis(
Fetal death
Early IUGR: Intervention threshold
<28w28-32w>32w Abnormal BPP