1. Fetal Growth Restriction FGR
Woman’s Hospital School of Medicine Zhejing University
He jin

2. Definition of FGR
Growth at the 10th or less percentile for weight of all fetuses at that gestational age or>37W<2500g
A condition in which a fetus is unable to achieve its genetically determined potential size

3. FGR FGR perinatal mortality rate was 4-6 times normal fetus.
About 22% of children with congenital malformation is accompanied by growth restriction.

4. small for gestational age，SGA
Structure was normal
no malnutrition
no adverse perinatal outcomes
Relating maternal race, parity, weight, height

5. Causes of FGR Maternal causes include the following:
Chronic hypertension
Pregnancy-associated hypertension
Cyanotic heart disease
Class F or higher diabetes
Hemoglobinopathies
Autoimmune disease

6. Causes of FGR Maternal causes include the following:
Protein-calorie malnutrition
Smoking
Substance abuse
Uterine malformations
Thrombophilias
Prolonged high-altitude exposure

7. Causes of FGR Fetal causes include the following: Race sex
Twin-to-twin transfusion syndrome
Multiple gestations
Trisomy 21/18/13
virus infection
Fetal alcohol syndrome

8. Causes of FGR
Placental or umbilical cord causes include the following:
Placental abnormalities
Chronic abruption
Placenta previa
Abnormal cord insertion
Cord anomalies

9. Categories According to fetal growth characteristics, weight and cause
1. Endogenous symmetry
also known as early onset FGR, Rare
harmful factors acting on the zygote or early pregnancy
Reason:
chromosomal abnormalities
intrauterine infection
environmentally harmful substances

10. Categories 2.Exogenous unsymmetry
harmful factors acting on second and third trimester
most of them because the low placental function
PIH, GDM, placenta lesions
3. Exogenous symmetry
One and two types mixed

11. Diagnosis
1. History:
Note : there is any risk factors for FGR during this pregnancy
Asked: appearance of FGR history

12. Diagnosis 2. Signs and symptoms: Continuous determination:
fundal height, abdominal circumference and maternal weight to determine fetal growth.
fundal height
significantly less than the corresponding gestational age
most obvious and most easily identifiable signs

13. Diagnosis Amniotic fluid volumes Amniotic fluid index (AFI)
< 5 cm :the rate of FGR was 19%
> 5 cm :9%
Aaximum vertical pocket (MVP) values
>2 cm : 5%
< 2 cm : 20%
<1 cm :39%

14. Diagnosis Uterine artery Doppler measurement
contribute to the identification of fetuses at risk of FGR
Umbilical artery Doppler measurement
absent end-diastolic velocity
reversed end-diastolic velocity
corroborates the diagnosis of FGR
Middle cerebral artery Doppler
MCA-PSV (peak systolic velocity) is a better predictor of FGR-associated perinatal mortality than any other single measurement

15. Diagnosis and Surveillance
Venous Doppler waveforms
fetal cardiovascular and respiratory responses
Three-dimensional ultrasonography
a 10th percentile femur/ humerus volume threshold

16. Therapeutic options No effective treatments are known First Second
behavioral strategies to quit smoking result in FGR
Second
balanced nutritional supplements
magnesium and folate supplementation
Third
if malaria is the etiologic agent
maternal treatment of malaria can increase fetal growth

17. Treatment Once FGR has been detected---surveillance plan
Maximizes gestational age
Deliver the most mature fetus in the best physiological condition possible
while minimizing the risks of neonatal morbidity and mortality
while minimizing the risk to the mother

18. Treatment
1. general treatment (1) to correct bad habits (2) bed rest (3) increased oxygen concentration
2. positive treatment of various complications

19. Treatment 3. intrauterine treatment
(1) improve uteroplacental blood supply
(2) zinc, iron, calcium, vitamin E and folic acid, amino acid compound
(3) oral low-dose aspirin inhibits the synthesis of thromboxane A2

20. 3. intrauterine treatment
(4) low molecular weight heparin and low-dose aspirin may improve the outcome of FGR
but not yet widely used clinically
requires further clinical trials
(5) the FGR fetus is expected to give birth before 34 weeks
should promote fetal lung maturity

21. 4 obstetric management
(1) chromosomal abnormalities or severe congenital malformations
should early termination of pregnancy.
(2) Placental function is poor
but the treatment is effective
continue to term
intensive care
should not exceed the expected date of delivery

22. intensive care A weekly nonstress test (NST) AFV determination
Biophysical profiles
Doppler assessments
Severe FGR before 32 weeks'
a poor prognosis
therapy must be highly individualized

23. 4. obstetric management (3) termination of pregnancy:
> 34 weeks ,a general treatment is poor
fetal distress, or stop the growth of the fetus more than 3 weeks
pregnancy complications aggravate
< 34 weeks, has been applied to promote fetal lung maturity
(4) the mode of delivery :
fetal malformations
maternal complications of the severity
to evaluate fetal condition

25. Fetal Macrosomia FMS

26. Definition of FMS Defined in several different ways:
Birth weight of g (8 lb 13 oz to 9 lb 15 oz)
Greater than 90% for gestational age
Increased dystocia, perinatal mortality
Affects 7-15% of all pregnancies

27. Influencing factors Gestational diabetes mellitus(GDM) Genetics Racial
class A, B, and C ，26%
Genetics
Racial
Ethnic
Duration of gestation
Neonatal sex
Other: nutrition, parity, polyhydramnios

28. Diagnosis Measure birth weight after delivery
Only
retrospective
Perinatal diagnosis difficult
often inaccurate
no risk factors can predict it accurately enough to be used clinically
most FMS do not have identifiable risk factors

29. Diagnosis BMI ≥ 30 kg/m、体重增加过多
Fundal height measurements: 3-4 cm larger than the gestational age in the third trimester
inaccurate
are influenced by maternal size, the amount of amniotic fluid, the status of the bladder, pelvic masses (eg, fibroids), fetal position 2

30. Diagnosis B ultrasound Biparietal diameter>10 femur length>8
chest circumference/ shoulder diameter ：rule out shoulder dystocia
abdominal circumference>33，>35
FSTT >2

31. FMS on neonates injury Neonatal morbidity Neonatal birth trauma
Intrauterine death (GDM infants)
NICU admissions
≥4500 g vs ≤4000 g (9.3% vs 2.7%).
Shoulder dystocia was 10 times higher
≥4500 g vs ≤4000 g (4.1% vs 0.4%).

32. FMS on mothers injury Birth canal lacerations Cesarean delivery
Perineal
Vaginal
cervical
Cesarean delivery
Postpartum hemorrhage (PPH)
Infection

33. gestation period treatment
Screening GDM
Weight Control
The recommendations for weight gain
the Institute of Medicine (IOM): guidelines published in 1990
The suggested weight gain
normal BMI : –15.9 kg (25–35 lb)
overweight : –11.2 kg (15–25 lb)
obese : kg (15 lb)

34. Treatment during delivery
Can not simply decide to do Cesarean delivery：Consider Multiple Factors
Cesarean delivery：>
Vaginal delivery
Strengthen the observation of labor
Shoulder dystocia
Birth canal injury

35. Neonatal treatment Fetal macrosomia Prevention of low blood sugar
early inleakage
Aggressive treatment of hyperbilirubinemia
Blu-ray treatment
Neonatal hypocalcemia
Calcium

36. Shoulder Dystocia SD

37. Definition of SD
An uncommon obstetric complication of cephalic vaginal deliveries
The fetal shoulders do not deliver after the head has emerged from the mother’s introitus
one or both shoulders become impacted against the bones of the pelvis
Emergency in intrapartum

39. Antepartum risk factors
Listed below in order of importance:
History of SD in a prior vaginal delivery
Fetal macrosomia
having a disproportionately large body compared to head
Diabetes/impaired glucose tolerance
Excessive weight gain (>35 lb)
Obesity
Postterm pregnancy
胎儿异常

40. Intrapartum risk factors
Precipitous second stage (<20 min)
Operative vaginal delivery (vacuum, forceps, or both)
Prolonged second stage
Without regional anesthesia
>2 h for nulliparous patients
> 1h for multiparous patients
With regional anesthesia
>3 h for nulliparous patient
>2 h for others
Induction of labor for impending macrosomia

41. Diagnosis
More than customary traction needed to deliver the fetal trunk
The need to perform ancillary maneuvers to complete delivery
A minority of SD deliveries
The turtle sign
The fetal head retracts against the perineum after it delivers

42. Treatment An obstetric emergency
SD can result in significant fetal and maternal harm if not resolved in a competent and expedient manner
A 6-minute head-to-body interval has been demonstrated to be safe
Beyond that time, there is increased risk
neonatal depression, acidosis, asphyxia, central nervous system damage, or even death

43. Table 1 SD maneuvers Fetal Maneuvers Maternal Maneuvers Rubin maneuver
McRoberts maneuver 
Jacquemier maneuver (posterior arm delivery)
Suprapubic pressure 
Woods screw maneuver 
Gaskin maneuver
(all-fours)
Zavanelli maneuver (cephalic replacement)
Sims maneuver
(lateral decubitus)
Cleidotomy
Ramp maneuver
Shute forceps maneuver
Symphysiotomy

44. McRoberts maneuver

45. Suprapubic pressure

46. Rubin maneuver
posterior arm delivery

47. Fetal Death

48. Definition of Fetal Death
A death that occurs after 20 weeks constitute a fetal demise or stillbirth.
Many states use a fetal weight of 350 g or more to define a fetal demise
Although this definition of fetal death is the most frequently used in medical literature
it is by no means the only definition in use.

49. Causes of Fetal Death
The etiology of FD is unknown in 25-60% of all cases
1. fetal hypoxia
The most common reason, about 50%      
maternal factors
fetal factors
Placenta
abnormal cord

50. Causes of Fetal Death Maternal： Fetal：
Small artery insufficiency of blood
Lack of red cells carrying oxygen deficiency
hemorrhagic disease
Uterine factor
GDM, ICP
Fetal：
Severe dysfunction of the cardiovascular system
Fetal malformations

51. Causes of Fetal Death Placental pathology umbilical core abnormality
One prospective study: 64.9%
higher rates of FD secondary to placental pathology
disfunction
structural abnomalities
abruption
infection
umbilical core abnormality
Present，procidentia，clasp，to tie a knot

52. Causes of Fetal Death 2. Genetic mutations and chromosomal aberrations
Parents suffering from genetic diseases
during pregnancy
use of teratogenic drugs
exposure to radiation
chemical poisons
Embryonic genes and chromosome aberration
Fetal malformations, miscarriage or death

53. Diagnosis of Fetal Death
History and physical examination
limited value
Death must be confirmed by ultrasonographic
visualization of the fetal heart
the absence of cardiac activity
In fact, the following description is rarely
Macerated fetus
fetus compressus
fetus papyraceus

54. Management of Fetal Death
Once the diagnosis has been confirmed，the patient should be informed of her condition
Often, allowing the mother to see the lack of cardiac activity helps her to accept the diagnosis.
Immediate treatment
Method of least damage to the mother
Labor induction

55. Management of Fetal Death
Medicine intra-amniotic injection
Preinduction cervical ripening followed by intravenous oxytocin
Mifepristone and prostaglandin induction of labor
Patients with a history of a prior cesarean delivery should be treated cautiously
the risk of uterine rupture

56. Management of Fetal Death
When a dead fetus has been in utero for 3-4 weeks
Fibrinogen, blood plate levels may drop
leading to a coagulopathy
heparin therapy
Rarely: because of earlier recognition and induction
In some cases of twin pregnancies
induction after the death of a twin may be delayed
to allow the viable twin to mature

57. Thanks four your listening