William M. Gilbert, MDRegional Medical Director, Sutter Health &Clinical Professor Department of OB/GYN

University of California, Davis

� Speaker honorarium - Lumara Health � No conflicts with respect to this lecture

A. One SDB. Two SDC. Three SDD. None of the above

17% 16%21%

47%

A. AC < 10% centileB. AC < 5th% centileC. AC < 3rd centileD. None of the above

11%

43%

27%

19%

� Definitions◦ Birth weight < 2500 gm◦ EFW < 10th centile◦ Abdominal circumference < 10th centile◦ EFW < 10th centile AND abnormal Dopplers◦ AC < 10th centile AND abnormal Dopplers

� SGA relates to newborns < 10th centile

� 40% of total birth weight due to genetic factors◦ Maternal primary influence� IUGR in mother increased in offspring

� 60% environmental factors◦ Nutrition◦ Smoking◦ Placental factors

� Maternal medical conditions◦ Pregestational diabetes◦ Renal insufficiency◦ Autoimmune disease◦ Cyanotic cardiac disease◦ Pregnancy related hypertension� Chronic HTN, Gest HTN, PE

◦ Antiphospholipid antibody syndrome

� Substance use and abuse� Multiple gestations� Teratogen exposure◦ Chemo agents, valproic acid, antithrombotic drugs

� Infectious disease◦ TORCH, CMV, malaria, syphilis, Zika

� Genetic and structural disorders ◦ T-13, T-18, CHD or gastroschisis

� Placental disorders

� Before birth◦ Increase in Stillbirth, C/S for fetal distress, meconium staining of amniotic fluid

� Afterbirth - Birth weight < 10th centile◦ PVL, CP◦ Later life:� Hypertension� Heart disease� DM

� Indirect measure of blood flow� Not a good screening tool alone� Is effective with IUGR fetuses� Becomes abnormal before FHT variability

� Fd = 2F*V*COS theta1540 cm/sec

� Most useful with diagnosing fetal anemia◦ Used with rH isoimmunization and anti Kell◦ Did away with:� Amniocentesis for Delta-OD450� Use of the Lilly curve

� With fetal hypoxia◦ Decreased resistance allowing an increase in blood flow to the brain

� Ireland -1200 consecutive pregnancies EFW< 10th centile

� 1/2010 through 6/2012� Examined EFW or AC <10th, <5th, <3rd centile◦ Every two weeks

� Abnormal Doppler, oligohydramnios� Adverse Outcome index◦ Death, IVH, RDS, PVL, HIE, BPD, sepsis

� Average maternal age - 30 years old� 83% white European decent� Mean GA at enrollment - 30.1 weeks� Mean Delivery GA - 37.8 weeks� NICU admission - 28%� Adverse outcome 5.2%� Mortality 0.7%� 72% had a normal outcome

� EFW < 10th centile alone: ◦ No increase in M&M

� Real increase in Morbidity and Mortality◦ Abnormal UA Doppler in all EFW < 10th centile◦ Oligohydramnios important only with EFW < 3rd

centile◦ Only weight related basis was EFW < 3rd centile

� 1/2008 through 7/2012� EFW < 10th centile 789 with IUGR (7%)� Excluded: multiples, anomalies, absent or reversed Doppler EDVs

� Leaving 512◦ 394 with normal UA Doppler◦ 118 with UA Doppler > 95th centile

� Protocol to get Abnl UA Doppler to 37 weeks ◦ 36 4/7 weeks◦ Birth weight < 10th centile - 84.7%◦ Mean 2.178 kg

� Normal UA Doppler to 39 weeks◦ 37 6/7 weeks◦ Birth Weight < 10th centile - 66.2%◦ Mean 2.532 kg

� After controlling for demographic and GA at delivery etc

� No difference in:◦ NICU admissions◦ Composite neonatal morbidity◦ Perinatal deaths

� Conclude: In cases of IUGR with:◦ Abnormal UA Doppler, delivery at 37 weeks ◦ Equals 39 weeks with normal UA Dopplers

� Ratio of MCA Doppler PI to UA PI� Retrospective cohort study IUGR pregnancies� Adverse outcomes, IVH, death, NRFHT, pH< 7.0, Apgar at 5 < 7, PVL, RDS

� 183 identified with 70 at least 1 adverse event

� Compared CPR < 1.08 and CPR < 5th centile

� CPR predictive of poor outcome in:◦ AGA fetuses◦ SGA fetuses

� May be a screening tool for ALL pregnancies in the third trimester

� Better than the biophysical profile� Better than UA and MCA Dopplers alone

� Definition of IUGR is not well defined◦ EFW < 10th centile most commonly used◦ EFW < 3rd centile more predictive of poor outcome◦ With Abnormal UA Doppler, real increased risk of poor outcome

◦ Oligohydramnios - Less important but still recommended

� CPR appears to be better for identifying adverse outcome but further confirmatory studies needed

� Day to Day management◦ Suspect IUGR? Ultrasound including UA Doppler◦ EFW < 10th centile with UA Doppler normal?� Deliver at 39 weeks, Repeat US in 2-3 weeks� NSTs OK

◦ EFW < 10th centile and UA Doppler Abnormal?� Deliver at 37 weeks or earlier PRN� NSTs definitely

� Absent or Reversed End Diastolic velocities?◦ Hospitalize and or deliver