Question

How will you confirm your diagnosis of fetal growth restriction in a G2P1L1 with 30 weeks pregnancy with suspected fetal growth restriction? How will you manage this case? [4+3]

Hint:

Fetal growth restriction is confirmed through ultrasound for fetal biometry and Doppler studies to assess placental function. Early identification helps in managing the condition effectively.
In FGR, management focuses on optimizing maternal conditions, monitoring fetal well-being, administering corticosteroids for lung maturity, and planning delivery based on fetal status and gestational age.

Answer 1

Step 1: Confirming Diagnosis of Fetal Growth Restriction at 30 Weeks of Pregnancy.
Fetal growth restriction (FGR) is suspected in a 30-week pregnant woman with risk factors such as hypertension, diabetes, or a history of poor fetal growth in previous pregnancies. To confirm the diagnosis, the following steps should be taken:
(1) Clinical Assessment:
- Symmetrical FGR: A fetus is considered symmetrical when the entire body is proportionately small. This is often due to genetic factors or chromosomal abnormalities.
- Asymmetrical FGR: If only the fetal abdomen is small (head sparing), it suggests placental insufficiency.
(2) Ultrasound Examination:
- Fetal Biometry: Measure head circumference (H, abdominal circumference (A, and femur length (FL). FGR is diagnosed when the estimated fetal weight (EFW) is below the 10th percentile for gestational age.
- Doppler Studies: Doppler ultrasonography can assess placental blood flow and evaluate the umbilical artery Doppler (systolic/diastolic ratio). Abnormal flow (e.g., increased resistance) is indicative of placental insufficiency, which contributes to FGR.
(3) Biochemical Tests:
- Maternal Serum Testing: Low PAPP-A (pregnancy-associated plasma protein levels may be seen in FGR and help in identifying pregnancies at risk.
- Amniotic Fluid Index (AFI): A low AFI may suggest placental insufficiency and contribute to the diagnosis of FGR.
(4) Assessment of Fetal Movements and Heart Rate:
- Monitor fetal movements and non-stress tests (NST) to evaluate fetal well-being and determine any signs of fetal distress.
Management of Fetal Growth Restriction in a G2P1L1 at 30 Weeks Pregnancy.
The management of a 30-week pregnant woman with suspected FGR involves careful monitoring and a decision about the timing of delivery. The management plan includes:
(1) Close Monitoring:
- Frequent ultrasounds to monitor fetal growth and placental function. This includes regular Doppler studies of the umbilical artery and fetal well-being through non-stress tests (NST) or biophysical profile (BPP).
- Maternal monitoring for signs of hypertension, proteinuria, and pre-eclampsia.
(2) Steroid Administration:
- Antenatal corticosteroids (e.g., betamethasone) are given to accelerate fetal lung maturity if delivery is expected before 34 weeks. This significantly reduces the risk of respiratory distress syndrome in preterm infants.
(3) Manage Underlying Conditions:
- Control maternal hypertension, diabetes, or other systemic conditions contributing to FGR. Use of antihypertensive medications (e.g., labetalol) to manage severe hypertension may be required.
- Optimize nutrition and ensure the mother is well-hydrated and has adequate caloric intake.
(4) Delivery Planning:
- Timing of Delivery: If the fetus is showing signs of fetal distress (e.g., abnormal Doppler, decreased fetal movements, abnormal NST/BPP), or if there is concern for placental insufficiency, early delivery may be indicated. The decision depends on fetal maturity and maternal condition. At 30 weeks, cesarean delivery may be necessary if the fetus is compromised, or induction of labor could be considered in the presence of adequate cervical ripening.
(5) Neonatal Care Post-Delivery:
- Ensure neonatal resuscitation and supportive care for preterm infants, which may include mechanical ventilation and nutritional support.