Fetal growth restriction Frequency In world : 10 % In Iran : 10 % In Isfahan : ??? (5000 / year )

FIRST CASE 27years G2 l1 GA : 28w 2d (by LMP) Fundal height : 24 cm

History Past medical history : no problem Family history : no problem Social history : secondhand smoker Obstetrical history : down risk is low. Anomaly scan is normal . She has a son 5 years that is healthy. His birth weight has been 2100gr at term. Physical exam : normal . BMI=18.5

Sonography from three days ago Presentation :Cephalic Placenta : Anterior HC :232mm 27weeks ,1days AC :218mm 26weeks,2days <10% FL :49mm 26weeks EFW :920 gr <10% AFI : Normal

Second case 40y , G3L2(c/s) / GA = 35weeks 1days (LMP) GA= 33weeks ,1 day( US 8 weeks ) FH : 30 cm PMH : no problem OBH : down screening =low risk ,anomaly scan=normal Ultrasonography: HC : 301 mm 33 weeks AC : 252 mm 30 weeks , 2 days < 3 % FL : 59 mm 31 weeks EFW : 1332 gr < 3 % AFI : 50 mm

US Doppler MCA PI : 1.27 < 5 % Um.A EDF : absent Uterine A. PI : 1.19

SGA vs. FGR Symmetrical FGR vs. Asymmetrical FGR Early FGR vs. Late FGR

All women should be assessed for risk factors for a SGA fetus to identify those who require increased surveillance.

Minor risk factor Maternal age > 35 years Null parity BMI <20 Smoker 1-10 cigarettes per day Pregnancy interval < 6 months Pregnancy interval >60 months Past history from preeclampsia IVF singleton Low fruit intake pre–pregnancy

Major risk factor Maternal age > 40 years Daily vigorous exercise Previous SGA baby Smoker ≥ 11 cigarettes per day Previous stillbirth Maternal SGA Paternal SGA

Major risk factor Preeclampsia Maternal Medical disease (APS) Heavy bleeding similar to mense Echogenic bowel Low maternal weight Low PAPP-A

Women who have a major risk factor (Odds Ratio >2 Women who have a major risk factor (Odds Ratio >2.0) should be referred for serial ultrasound . Measurement of fetal size and assessment of wellbeing with umbilical artery Doppler from 26–28weeks of pregnancy .

Women who have three or more minor risk factors should be referred for uterine artery Doppler at 20–24 weeks of gestation .

Women with an abnormal uterine artery Doppler at 20–24 weeks (PI>95%) and/or notching should be referred for serial ultrasound measurement of fetal size and assessment of wellbeing with umbilical artery Doppler commencing at 26–28 weeks of pregnancy.

Women with a normal uterine artery Doppler do not require serial measurement of fetal size and serial assessment of wellbeing with umbilical artery Doppler unless they develop specific pregnancy complications, for example antepartum hemorrhage or hypertension. They should be offered a scan for fetal size and umbilical artery Doppler during the third trimester.

Serial ultrasound measurement of fetal size and assessment of wellbeing with umbilical artery Doppler should be offered in cases of fetal echogenic bowel.

Timing delivery Abnormal DV(A/R a wave) or umbilical vein(pulsetile) with every GA . Umbilical artery reverse EDV until 30-32 weeks Umbilical artery absent EDV until 32-34 weeks Umbilical artery high RI until 36- 37 weeks Constitutional IUGR : 37-40 weeks

Intervention SGA 24+0 and 35+6 weeks before delivery : antenatal corticosteroids Biophysical profile should not be used for fetal surveillance in preterm SGA fetuses. smoking cessation.

Indication of C/S Fetal acidemia Spontaneous late deceleration Absent /reverse umbilical artery EDV