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Late Onset Fetal Growth

Restriction

Dr.Jebakkani
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Introduction

 A fetus with an estimated weight below the 10th percentile for a given
gestational age is consid-ered to have fetal growth restriction (FGR), also
called intrauterine growth restriction (IUGR)
 The World Health Organization (WHO) defines FGR as birth weight <2500
g for developing countries, but this defini-tion is not universally accepted.
 The term small for gestational age (SGA) is sometimes used for a fetus
exhibiting less than expected growth (<10th percentile), but this includes
both constitutionally small but healthy fetuses (50%–70%) and fetuses that
are actually growth restricted (20%)
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Classification

 Morphological Classification
 Symmetric growth restriction
 Asymmetric growth restriction
 Functional or phenotypical
Classification
 Early Onset < 32 weeks
 Late Onset > 32 weeks
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Late Onset Fetal Growth Restriction

 Fetuses with late-onset FGR weigh >10th percen-tile but have not
achieved their growth potential since the growth restriction sets in
after 34 weeks.
 This may account for perinatal deaths that occur in fetuses of
‘normal’ weight.
 The condition is difficult to diagnose except by Doppler studies of
the middle cerebral artery (MCA) and umbilical artery.
 Routine screening for this condition is not warranted.
 IGF’s Maternal Factors 5
Classification

Fetal Intrauterine
Fetus
genome environment

Insulin
Placental Factors
Thyroxine

Maternal Nutrition Placental Perfusion

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Fetal Surveillance

 AFV  Safe to manage pregnancy expectantly

 Oligohydramnios  Absent or reversed flow

 Highly suggestive of FGR  60%-70% obliteration of placental arteries

 Increased risk of perinatal mortality  Fetal hypoxia

 Significant increase in perinatal morbidity and
 BPP mortality
 Helps in timing of delivery  Should be delivered
 Frequency Depends on severity of FGR  MCA Doppler
 UA Doppler  High diastolic flow (brain-sparing effect)
 Reduced end diastolic flow  Fetal hypoxia
 30% of villus vasculature has ceased to function  Ductus venosus Doppler
 Perinatal morbidity still low
 Absent or reversed ductus venous a-wave
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Reduction in liver size
Reduction in umbilical Venous flow
Decrease in abdominal circumference

Increased MCA diastolic flow Reduction in umbilical artery

Decrease in pulsatility index Diastolic flow(increase in pulsatility index)

Absent /reversed diastolic flow in umbilical artery Low cerebral Placental ratio

Late decelerations on nonstress test Absent/reversed diastolic flow in ductus venous

Sequence of event in decompensation of growth restricted fetus


Clinical Difference
Early Onset
Less Common (30%) but more Severe
More difficult to Manage
Associated with hypertensive disorders and
placental dysfunction
Confirmed with umbilical artery
abnormalities that precede decreased MCA
impedance
Associated with earlier deterioration of the
fetal condition
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Late Onset
More Common (70%) but less severe
More difficult to Diagnose
Usually not associated with hypertensive
disorders
Confirmed with decreased MCA impedance
rather than umbilical artery Doppler flow,
which may be normal
Associated with late unexpected still birth
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Figure 2 The normal umbilical artery flow velocity waveform has marked positive end-
diastolic velocity that increases in proportion to systole toward term (A). Moderate
abnormalities in the villous vascular structure raise the blood flow resistance and are
associated with a decline in end-diastolic velocities (B). When a significant proportion of
the villous vascular tree is abnormal (50-70%), end-diastolic velocities may be absent (C)
or even reversed (D). Depending on the magnitude of placental blood flow resistance and
the fetal cardiac function, reversal of end-diastolic velocities may be minimal (D),
moderate (E), or severe (F). In the latter case precordial venous flows were universally
abnormal
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Figure 4 In the ductus venosus blood flow is always antegrade

throughout the cardiac cycle under normal circumstances. Pulsatility is
less pronounced in waveform patterns obtained at the inlet (A) versus
the outlet (B). With impaired cardiac forward function there is a
decline in forward flow during atrial systole (C). If progressive atrial
forward flow may be lost (D) or reversed (E, F). 
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