1. IN THE NAME OF GOD

2. SMALL FOR GESTATIONAL AGE

3. CASE 1 27years G1 GA : 28w 2d (by sono 8w :28w 3d )
Fondal height : 24 cm

4. Sono 3 days ago BPD :24W 3D AC : 22 W FL : 21 W AFI : NL Severe IUGR
BPP: breath: AF: tone:2
Doppler : increased Umbilical artery RI

5. Diagnostic criteria AC < 10% and EFW < 10% : SUSPECTED TO IUGR
AC < 10% and EFW > 10% : at risk to IUGR

6. 27years ,G1
GA : 28w 2d (by sono 8w :28w 3d )
C.C : fundal height 24 cm بیمار مورد شناخته شده تالاسمی اینترمدیا که 10 سال قبل اسپلنکتومی شده است -2هفته بعد از اسپلنکتومی دچار ترومبوفلبیت عروق کبدی می شود و تحت درمان با هپارین و وارفارین تا 1 ماه پس از ترخیص قرار میگیرد -از 10 سال قبل تا کنون آسپیرین مصرف می کند 1سال پس از اسپلنکتومی کوله سیستکتومی می شود -از 10 سال قبل تزریق خون نداشته -از ابتدای بارداری تحت درمان با هپارین به صورت 5000 واحد BD بوده است

7. ultrasonography Gestational age BPD ,HC,AC,FL TCD EFW AFI
Doppler sonography
BPP

8. sonography : after 2days
BPD : 24W
HC : 24W 2D
AC : 24W 1D
FL :23W 3D
EFW : 539 g
AFI : 10cm
Umbilical artery : reversed EDV
Ductus venosus : NL
BPP : 10/10

10. symmetric IUGR
Associated conditions:
- Genetic
- Congenital anomalies
- Intrauterine infections
- Substance abuse
- Cigarette smoking
- Therapeutic irradiation

11. management Anomaly scan
Karyotyping identification : severe early onset IUGR , Symmetrical IUGR ,polyhydramnious ,stractural anomaly .
Echocardiography
Serology :CMV ,RUBELLA , VARICELLA

12. Algorithm IUGR yes TORCH stigmata  work-up? no
Dysmorphic features  work-up?
Maternal/placental explanation work-up?
Maternal drug use tox screen
Unknown cause

13. Follow up
Growth curve (biometry)
Doppler
BPP
NST

14. Frequency of fetal surveillance
Normal doppler & AFI : fortnightly
umbilical artery end diastolic flow is present :
weekly Doppler
BPP twice weekly
Absent or reversed end diastolic flow in the umbilical artery :
hospital admission
daily BPP and Doppler

15. BPP daily FGR < 5 % Severe oligohydramnious Absent / reverse EDV
Equivocal BPP ( 6/10 )

16. Sonography after than 18 days
BPP : 26w 5d
HC : 25w 6d
AC : 24w 6d
FL : 24w 2d
EFW : 615 g
AFI : 10 cm
Umbilical artery reversed EDV
DV : flow a wave decreased

18. GA : 30w 2d
C/S
Female : 630 gr

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

20. CASE 2 40y , G3L2(c/s) GA : 35w 1d but by sono 8 weeks : 33w 1d
FH : 30 cm
PMH : no problem
OBH : neg
US :
BPD : 28w 3d
HC : 28w 3d
AC : 25w
FL : 26w
HL : 24w 5d
EFW : 746g
AFI : 5 cm
doppler : NL

22. intervention
SGA and 35+6 weeks before delivery : antenatal corticosteroids.
Magnesium : under 30 week.
smoking cessation.
Antithrombotic therapy appears to be a promising therapy for preventing SGA in high risk women.However there is insufficient evidence, especially concerning serious adverse effects, to recommend
its use.

23. Sonography after than 16 days
BPD : 29W 3D
AC : 26w
FL : 26W 5D
EFW : 767 g
AFI : 2 cm
BPP : 8/10
DOPPLER : NL

24. GA : 33w 1d
GA : 35w 3d
BPD : 28w 3d
HC : 28w 3d
AC : 25w (191 mm)
FL : 26w
HL : 24w 5d
EFW : 746g
AFI : 5 cm
BPD : 29W 3D
HC : 28w 5d
AC : 26w (200 mm)
FL : 26W 5D
EFW : 767 g
AFI : 2 cm

25. During 16 days : growth arrest .
GA 35w 3d : C/S
BW : 825 gr

26. Case 3 29y , G2ab1 GA : 30w 4d (by sono 13w : 30w 6d ) BPD=27W 4D
FH=26 cm
PMH : NEG
DH: heparin
Sono : GA : 29 w 6 d
BPD=27W 4D
HC : 27W 6D
AC : 25W 4D
FL : 25W 4D
EFW: 765 g
AFI : 67 mm
BPP : 10/10
DOPPLER : NL

28. Sono ( GA : 30w 4d)
AFI < 5 cm
BPP=6/8 (breath=0)
RI MCA/ RI UMA=0.67/0.79
Hospitalization

29. Sono ( GA : 31 w 6d )
AFI < 5 cm
Doppler : absent EDV in umbilical artery
BPP=10/10

31. AFI =severe oligohydramnious EFW= 997 gr BPP=8/8
After than 15 days
AFI =severe oligohydramnious
EFW= 997 gr
BPP=8/8
در سن حاملگی 32 هفته و 5 روز به صورت اوژانسی به دلیل پره اکلامپسی شدید ترمیناسیون انجام شد

32. Timing delivery
Abnormal DV(A/R a wave) or umbillical vein(pulsetile) with every GA .
Umbilical artery reverse EDV until weeks
Umbilical artery absent EDV until weeks
Umbilical artery high RI until weeks
Constitutional IUGR : weeks

33. Indication delivery after than 34 weeks
Maternal comorbidity
arrest of growth
Oligohydramnious
A/R EDV umbilical artery
MCA PI < 5%
BPP < 4
Recurrent deceleration FHR

34. Recurrence risk in second pregnancy
First pregnancy AGA : 9%
First pregnancy SGA : 29%
First and second pregnancy SGA : 44%

35. Management of subsequent pregnancy
cessation of smoking and alcohol intake
balanced energy/protein supplementation
Avoiding a short or long interpregnancy interval

36. Screening option
Low risk : fundal height (exception large myoma ,BMI > 35)
High risk : ultrasonography
Biochemical : low PAPP-A , high AFP
Uterine artery doppler

37. MINOR RISK FACTORS Maternal age > 35 yrs Nulliparity BMI <20
Smoker 1-10 per day
Pregnancy interval < 6 mo
Pregnancy interval >30 mo
Paternal SGA

38. Major risk factors Maternal age > 40 yrs Daily vigorous exercise
Previous SGA baby
Smoker >11 per day
Previous stillbirth
Maternal SGA
Preeclampsia
Maternal Medical disease
Heavy bleeding similar to mense
Echogenic bowel
Low maternal weight
Low PAPP-A

39. RCOG
"Advise women at high risk of pre-eclampsia to take 75 mg of aspirin* daily from 12 weeks until the birth of the baby. Women at high risk are those with any of the following: • hypertensive disease during a previous pregnancy • chronic kidney disease • autoimmune disease such as systemic lupus erythematosis or antiphospholipid syndrome • type 1 or type 2 diabetes • chronic hypertension.

40. RCOG
Advise women with more than one moderate risk factor for pre-eclampsia to take 75 mg of aspirin* daily from 12 weeks until the birth of the baby. Factors indicating moderate risk are: • first pregnancy • age 40 years or older • pregnancy interval of more than 10 years • body mass index (BMI) of 35 kg/m² or more at first visit • family history of pre-eclampsia • multiple pregnancy.