Essay 290 - SGA

a) Initial assessment 

Confirm dates are accurate from early scans. From history, I will identify risk factors for SGA in this woman such as she herself being a SGA baby, paternal SGA and smoking histoyr. I will also ask about fetal movement as SGA is associated with intrauterine deaths. Frequent daily exercise is also a risk factor for small for gestational age. Low fruit intake also predisposes her to carry a SGA fetus.

On examination, I will check her weight, height and calculate her BMI. Low BMI is associated with SGA, whilst high BMI will make monitoring of fetal growth difficult. Blood pressure will be taken as PIH is associated with SGA. I will measure symphyseal fundal height and plot it against a customised chart. If it is below tenth centile, she will need a scan for estimated fetal weight and abdominal circumference and both also plotted on customised chart to detect SGA. Doppler study of umbilical artery will be carried out if SGA is present.

b) This is small for gestational age. She will need regular follow up at specialist antenatal clinic 2-4 weekly. Growth scan need to be repeated at least 3 weeks apart to minimize false positive rates of fetal growth restriction. If Doppler study of umbilical artery is normal, it will need to be repeated in 2 weeks. If Doppler study of umbilical artery is abnormal, that is to say 2 standard deviation above normal, umbilical artery Doppler needs to be repeated twice weekly. Absent and reversal of end diastolic flow of umbilical artery will need daily Dopler study. Uterine artery Doppler has lmited value when SGA is diagnosed at 28 weeks' gestation. CTG should not be used as only form of surveillance in SGA fetuses. Interpretation of CTG should based on short term variation from computerized analysis. Amniotic fluid volume should be based on single deepest vertical pool. Biophysical profile should not be used for fetal surveillance in her. If umbilical artery Doppler is abnormal, ductus venosus Doppler should be used to time delivery. If umbilical artery Doppler is abnormal wtih absent or reversed end diastolic volume, delivery will be offered at 32 weeks or if ductus venosus Doppler becomes abnormal. If SGA with normal umbilical atery Doppler, offer delivery at 37 weeks with a senior obstetrician involvement.

c) 

Multidisciplianry care involving senior obsetrician, neonatologist and special care baby unit team is important. If special care baby unit is not available, arrangement for in utero transfer to tertiary hospital to decrease perinatal morbidity. Antenatal steroids should be administered to reduce neonatal respiratory distress syndrome before delivery. Magnesium sulphate administration prior to delivery is given to mother for fetal neuroprotection.

(A)I would start with taking a history of her menstrual cycle and check her booking visit and dating scan to confirm the period of gestation is correct.I would look into presence of risk factors that can cause IUGR like smoking,alcohol,drug abuse and medication .Rule out any family history of chromosomal abnormality and hereditary diseases.Any exposure to infections in current pregnancy is ruled out.I would check on her hand held notes if she had accepted down's screening and its result.

I would check her BP,urine dipstix to rule out PET as the cause of uteroplacental insufficiency.I will measure symphisio-fundal height.I will enquire about fetal movements and any fluid loss per vagina during this pregnancy.

(B)I will inform her that since this baby is on the 5th centile, will require regular monitoringof the baby and to contact hospital/midwife if at ant time she is concerned about the fetal movements.She will require serial doppler and growth scans .

If the umbilical artery doppler is normal she can be advised to have doppler every 2wk and growth scan every 3wk.I would also requet for MCA doppler .If ther is any static growth or abnormal MCA or PI<5th centile would recommend delivery after 34wks.

If the umbilical artery doppler is abnormal but EDF present then I would advice twice weekly dopplers and weekly growth scans. Cosider delivery after 34 wks if static growth or doppler worsens.Deliver by 37wks.

If dopplers are abnormal with absent or reversed EDF then she is advised to be monitored as inpatient.She needs daily CTG ,daily umbilical artery doppler along with Ductus venosus doppler and weekly growth scans.Consider delivering at 30-32wks  even if ductus venosus doppler normal and recommend delivery if ctg or Ductus Venosus abnormal.Deliver by 32wks after course of steroids.

(C) She should  receives a course of steroid to reduce Fetal respiratory distress syndrome and intraventricular haemorrhage .Betamethasone/Dexamethasone  depending on the individual trust policy.Betamethasone IM  12 mg 24 hrs apart 2 doses or Dexamethasone IM 4doses 12 hr apart.Best results are obtained if delivered after 24hrs and within 7days of last dose.

Cosider giving magnisium sulphate IV  4mg loading dose followed by  1mg/hr for 24 hrs. for neurological development.

Important that she is seen by the paediatrician before delivery to discuss the prognosis and plan of care of the  neonate.

If the NNU does not have facilities to take care of 30wk baby she should be transferred to a higher center with such facilities.

As this baby is already compromised induction would not be the best option hence I would recommend Caesarean Section to reduce Perinatal morbidity and make sure senior paediatric team is awailable during the delivery.

Explanation

RCOG-note-

In the presence of large masses with solid components (for example large dermoid cysts) laparotomy

may be appropriate

SGA Baby

A)

The patient is assessed by taking a detailed history for the risk factors  of small for gestational age baby, like heavy smoking, alcohol, bleeding in early pregnancy, cocaine abuse, viral infections such as CMV, rubella, toxoplasmosis or malaria in early pregnancy. She is asked for history of PIH, preeclampsia, and thrombophilia and anti phospholipid syndrome, the thyroid disorder. She is asked about any medicines taken before or during pregnancy.  Her current obstetric record is reviewed for serum screening markers, screening for any aneuploidy and viral serology like HIV, hepatitis and syphilis. Pulse, blood pressure, BMI and pallor for anaemia are noted. Serial measurement of symphysiofundal height on the customised growth chart corrected for patient age, weight, parity, ethnicity is checked because it has a good predicting value in detecting SGA foetus.

B)

As the baby is at 5^th centile, which is below, the minimum level (10^th centile) required for the diagnosis of SGA, she should be told of the diagnosis and poor perinatal outcome associated with it. Frequent antenatal visits by a senior obstetrician, midwife is needed. Blood pressure and proteinuria is noted at each visit, haemoglobin is checked to rule out anaemia. She needs serial ultrasound growth scans for estimated foetal weight and abdominal circumference plotted on the customised growth chart. Deepest Amniotic fluid pool volume is noted for the foetal well being. The reduced volume is associated with poor foetal outcome. Umbilical artery Doppler studies are done to see the flow and resistance index. Umbilical artery Doppler serial growth scans has a moderate predictive value in the detection of foetal growth restriction. If the umbilical artery Doppler is normal then 3 weekly growth scans and umbilical artery Doppler is advised every 2 weeks. Middle cerebral artery Doppler has a moderate predictive value in assessing foetal hypoxia after 34 weeks and helps to time the delivery. If the end diastolic flow is present but the (RI)>2SD then every 2 weekly growth scans and umbilical artery Doppler is advised twice weekly. If the end diastolic flow is absent or reversed then weekly growth scan and daily umbilical artery Doppler is recommended to detect the early foetal hypoxia or acidemia to time the delivery. CTG and biophysical profile are not used as a surveillance tool because they have a poor predictive value for perinatal outcome but can be used if there is absent or revered end diastolic flow on umbilical artery Doppler to detect acute hypoxia along with Doppler studies. Umbilical vein Doppler will tell the reversal of flow in case of severe cardiac compromise of the foetus so that the delivery is planned earlier. Ductus venosus Doppler will tell about the right atrial pressure and will show reverse flow in case of foetal cardiac compromise, it has a moderate predicting value in timing the delivery. Depending upon the above studies results delivery is recommended as soon as the foetal compromise is detected.

C)

As the delivery is decided at 30 weeks the patient is fully counselled about it and the mode of delivery should be by caesarean section as it will be the safest option for the baby with severe IUGR at 30 weeks of gestation. The patient is delivered in consultant led unit involving anaesthetist and neonatologist. The neonatologist should be informed and present at the time of delivery and he should be involved in counselling the mother about increased perinatal mortality and morbidity in the baby with severe IUGR. Corticosteroids like betamethasone 12.5milligram 2 doses 24 hours apart given to mother to improve the foetal lung maturity and reduce the respiratory distress syndrome. Magnesium sulphate use is considered, as it is associated with decreased risk of intraventricular haemorrhage in the preterm baby. Senior obstetrician should perform the caesarean section as the lower segment is not fully formed at 30 weeks and care is taken to minimise pressure on the foetal head during delivery. Outlet forceps use can be considered for it. The baby should be transferred to neonatal unit for subsequent care.

She is a healthy lady  and anomaly scan at 20 weeks  was  normal that means   fetus became small for gestational age (SGA) after that period .  She is a nulliparous woman this is a risk factor for SGA. I will ask about ethnicity as  African American and Indian Asian  ethnicity is a risk factor .I will ask about social deprivation , unmarried  marital status ,domestic violence  ,daily vigorous exercise , non using of fruits and  green vegetables ion her diet all these are risk factors .Maternal and paternal   history of  SGA  is important and family history of  chromosomal anomalies  will be asked . Smoking , drug abuse or excessive use of caffeine   will be asked .I will ask about  bleeding during pregnancy  as  bleeding in early pregnancy  is associated with SGA  or bleeding  at present may indicate abruption. I will confirm   1^st  trimester  screening tests  were done or not if yes  what was result unexplained  low PAPA   is associated with SGA.

During examination I  will  check   for  anemia  as it is associated with SGA .I will calculate  BMI  as  BMI  less than  20  is associated with SGA  and a high BMI  may be a risk factor and  also examination is difficult  . I will check BP   if raised I will check  urine dipstick for proteins as PIH  and PET are important risk factors and need  careful l managment .I will check  fundal   height  and plot it  against customized  chart . If  it  is  below 10^th centile  I will arrange for an ultrasound  at  fetal medicine unit  for estimated fetal weight  and abdominal circumference   and minor anatomical defects which  might had been missed at routine anomaly scan .

B   this is a small for gestational  age  and should be followed at consultant based clinic.

Growth scans  should be repeated  minimum 3  weeks apart as more frequent have poor predictive value .It should  include estimated fetal  weight and abdominal circumference  as  these are more predictive than other parameters like head circumference or femur length.

Umblical  artery   doppler  are carried out for surveillance   if these are normal need to be repeated every 2 weeks  . If  umbilical artery  doppler  is abnormal ( PI  2 standard deviation above for gestational age )  it should be repeated  twice weekly  in fetuses where end diastolic flow is present  and daily  in whom absent or reverse end diastolic flow. Ductus venosis  doppler  should be used  in SGA  preterm fetuses  to time delivery in these fetuses  middle cerebral artery  flow is less predictive. In term fetuses  MCA doppler is  moderately predictive and should be used  to time delivery .CTG should not be used as only form  of  surveillance    and when used   interpretation should be on  shortterm fetal heart rate variation  from computarised analysis. Ultrasound estimation  of amniotic fluid  volume should not be only form of surveillance and when used  should  be interpreted on deepest vertical pool.  Biophysical profile shoud not be used for surveillance of SGA  in preterm fetuses .

C      Delivery should  planned  in  a consultant led unit  with  involvement of  multidisciplinary  team  i.e  senior obstetrition , neonatologist,  and  NICU   team  .If  NICU  facilities are not available  arrangements for  intrauterine transfer   carried out. She should receive  steroid  cover   as per protocol to minimize  chances of respiratory  distress  syndrome, intraventricular    hemorrhage  and neonatal death.  Megnicium SO4  should be    given to  mother for fetal neuroprotection . Arrangement  for   C/section carried out as this  will be best option at 30 weeks  SGA  fetus  while mother is also not  in labour and is a nulliparous .

I will take a history to identify risk factors for small for a gestational age (SGA) fetus.  I will ask if she had heavy bleeding in early pregnancy as this is a major risk factor. I will ask if the birth weight of herself or her partner is known. If they were SGA then the chance that their baby is SGA increases. I will take a drug history. Use of cocaine or cigarettes, especially , more than 11 cigarettes daily is a significant risk. Moderate alcohol intake also increases her risk.

Low dietary intake of fruits and vegetables as well as daily vigorous exercise increases her risk. I will check if she had first trimester Down’s syndrome screening for the PAPP-A value. Less than 0.415 MoM is a major risk factor for SGA fetus.

I will measure her height and weight and calculate her BMI. I will measure blood pressure and do urinalysis to check for proteinuria. Pre-eclampsia is associated with an increased risk. I will request an ultrasound foe estimated fetal weight, abdominal circumference and umbilical artery Doppler studies.

b) Umbilical artery Doppler waveform( UADW) studies will be used as the primary surveillance tool as it has been shown to reduce perinatal morbidity and mortality. If normal, it will be repeated fortnightly. If abnormal with positive end diastolic velocity, it will be repeated twice weekly. If end-diastolic flow is absent or reversed, it will be repeated daily.

Ductus Venosus Doppler will be done for surveillance and also to time delivery if abnormal UADW. It has moderate predictive value for fetal acidaemia and perinatal death.

Neither conventional CTG, nor liquor volume will be used independently for monitoring. If CTG is used, computerized analysis of short-term fetal heart rate variation should be used to improve prediction of adverse outcome. Oligohydramnios is useful for predicting labour outcome not perinatal outcome.

Biophysical profile is time consuming and associated with increased caesarean section rate but no improvement in perinatal outcome. It will not be used .

Middle cerebral artery Doppler has limited value in predicting outcome in preterm babies and will not be used for surveillance.

c) Two doses betamethasone 12 mg will be given 24 hours apart to reduce the risk of respiratory distress syndrome, intraventricular haemorrhage, necrotizing enterocolitis and neonatal death. The neonatologist will be informed.

Delivery will take place in a hospital with neonatal intensive care facilities . If not available, arrangements will be made for in-utero transfer to a hospital with this facility. Caesarean section will be offered. If vaginal delivery is preferred, continuous electronic fetal monitoring will be offered.

(a)    A detailed history of LMP, cycle regularity and interval along with early scans would rule out wrong dates. History of early pregnancy bleeding is taken as it can be associated with SGA. Family history of preeclampsia in the first degree relatives is asked for as it may be associated with increased risk in the woman and of SGA. History of smoking (specially more than 11 cigarettes a day), alcohol intake and drug usage (cocaine) is taken as they may be associated with SGA. History of daily vigorous exercise and stress at home or domestic violence could be associated with SGA. During her examination, height & weight, BMI are calculated. A low BMI that is less than 20 may be a risk factor for SGA. Blood pressure is noted, a rise in which may indicate associated preeclampsia. Symphysiofundal height is noted and plotted on a customized chart. Investigations would include full blood count to rule out anaemia as it can be associated with SGA. Urine for proteinurea to exclude PET. Serological tests for toxoplasmosis and CMV are taken as they are associated with SGA. Tests for syphilis & malarial parasites (if indicated) are taken. Ultrasonography for AC and EFW if less than 10^th centile, SGA is diagnosed.

(b)   At presentation she is monitored with umbilical artery doppler studies and if normal, it is repeated every two weeks. If Doppler studies are abnormal (raised PI & RI more than 2 SD) monitoring is repeated twice weekly if end diastolic velocities are present and daily if end diastolic velocities are absent / reversed. Computerised CTG can be used as it is objective and consistent & unlike conventional CTG, it has a lesser intra & inter-observer variability. The interpretation should be based on short term fetal heart variation which if = or < 3ms is associated with higher rate of metabolic acidaemia. Amniotic fluid volume can also be used and should be based on single deepest vertical pocket, less than 2 cm being significant. Biophysical profile should not be used for fetal surveillance in pre-term SGA fetuses due to high false negative rates. MCA Doppler also has a limited accuracy in preterm SGA fetus and should not be used to time delivery.

(c)    Perinatal outcome is optimised by a single dose of corticosteroids before delivery. Senior obstetrician input and inutero transfer to a tertiary care would also improve outcome. The most important being correct timing of delivery which will be a balance between the risk of prematurity and the danger of continuing intrauterine life. This is best determined by study of venous Doppler studies. The reversal of ‘a’ wave in ductus venosus and pulsatile flow in umbilical vein a have a high predictive value for fetal metabolic acidaemia & its occurrence should warrant immediate delivery.          

A) History should be targetted to identify risk factors for growth restriction, in particular past medical history, past obstetric history, current obstetric history and social history. Factors of significance are: extremes of maternal age (<20, >40); history of hypertension, diabetes, systemic lupus etc; past history of small for gestational age baby or preeclampsia; current history of gestational hyperension, preeclampsia, gestational diabetes, recurrent antepartum haemorrhage; social history of smoking, cocaine use, domestic violence, daily rigorous physical exercise. Examination to calculate body mass index (if not calculated at booking) should include measurement of height and weight. Blood pressure measurement and urinalysis should be performed to detect any developing preeclampsia. The abdomen should be examined and the symphysiofundal height should be plotted on a customised growth chart. Less than the 10th centile identifies a baby requiring further investigation by ultrasound scan.

B) Measurements should be plotted on customised charts. Estimated fetal weight under the 10th centile identifies this baby as small for gestational age. Management of this pregnancy should be under obstetric review is ultrasound monitoring of growth and umbilical artery dopplers. Growth scans should be performed at 3 weekly intervals and umbilical artery dopplers at 2 weekly intervals if normal. In fetuses under 32 weeks ductus venosus dopplers should be monitored if the umbilical artery dopplers are abnormal, in fetuses from 32 weeks the middle cerebral artery doppler should be monitored. If the umbilical atery pressure index is > 2 standard deviations from the mean then dopplers should be monitored twice weekly but if there is absent or reversed end-diastolic flow of the umbilical artery doppler then dopplers should be monitored daily. Ductus venosus or middle cerebral artery doppler abnormalities should be used to time delivery. Biophysical profiling, amniotic fluid idex and cardiotocography have been shown not be be effective methods of monitoring small for gestational age fetuses.

C) Corticosteroids should be given prior to delivery up to a total dose of 24mg, either 12mg betamethasone 24 houly or 6mg dexamethasone 6 hourly. Liaison with the neonatal team is important to ensure that there is a cot available and the neonatal team is aware of the intended delivery. If the local unit is unable to provide adequate care depending of the size and gestation of the baby then an in utero transfer to an appropriate unit should be organised. In severe intrauterine growth restriction with absent or reversed end-diastolic flow then a caesarean section is recommended. At delivery the cord should be "milked" to reduce the risk of neonatal anaemia and the neonatalogy team should be present.

A healthy 23 year old nulliparous woman has been referred to the antenatal clinic at 28 weeks gestation because the fetus is thought to be small for gestational age. Anomaly scan at 20 weeks was normal. (a) Discuss your initial assessment [6 marks].

asking about the menstrual history regarding LMP, regularity and previous method of contraception to revise the EDD.asking about risk factors for SGA as smoking,alcohol consumption during pregnancy,vigorous daily exercises,paternal and maternal SGA and unexplained APH.asking about symptoms of PIH and PET as headache,blurring of vision and epigastric pain as it may be complicated by growth restriction.asking about flu like illnesses in early pregnancy that may be cause congenital infections.asking about family history of congenital anomalies the may be associated with growth restriction.asking about fetal movements since SGA is associated with IUFD..examination include measuring blood pressure for hypertension,weight and height and BMI since most SGA babies are constitutionally small.neurological examination if PET suspected.abdominal examination for symphysio-fundul height and plotting it against customised chart.auscultation of FH ensure viable fetus.investigations include ultrasound fetal biometry (EFW and AC),SGA diagnosed if one reading less than 10 th centile or by 2 measurements 3 weeks apart showing static or slow growth.if SGA diagnosed umbilical artery doppler is indicated as the primary surveillance method.screening for CMV and toxoplasmosis is indicated and also screening for syphilis and malaria in high risk women.if PET suspected a FBC, liver and renal functions should be done.

(b) The estimated fetal weight is on the 5^th centile. Evaluate the options for antenatal fetal monitoring [11 marks].

antenatal fetal monitoring will primarily be by umbilical artery doppler as the primary surveillance method,it reduces perinatal morbidity and mortality and should be repeated fortnightly if normal,if reduced end diastolic velocity it should be repeated twice weekly and if absent or reversed end diastolic velocity (AREDV) it should be repeated daily.ultrasound estimated fetal weight and abdominal circumference has moderate prediction of adverse neonatal outcome and reduced perinatal morbidity and mortality and has the advantage of being validated by birth weight and using customised charts,it should be repeated fortnightly if normal umbilical artery doppler and weekly if abnormal umbilical artery doppler.middle cereberal artery doppler has low prediction for adverse neonatal outcome in preterm SGA and moderate prediction for term SGA and can't be used to time delivery in preterm SGA.it should be done fortnightly if normal umbilical artery doppler.ductus venosus doppler has moderate prediction of adverse neonatal outcome and can be used to time delivery in preterm SGA.it should be repeated daily if AREDV.cCTG is indicated if AREDV and ductus venosus doppler is not available,result interpretation should be computerised and delivery indicated if < 3 ms.amniotic fluid volume in terms of deepest fluid pocket should not be used alone to monitor the fetus.BPP has no value in this context.uterine artery doppler has no value in the third trimester.monitoring fetal movements by the mother is not of value however she should be warned to notify her midwife if she experiences reduced fetal movements.

(c) Delivery is indicated at 30 weeks gestation. Discuss the steps that may be taken in the antenatal period to optimise perinatal outcome [3 marks]

perinatal outcome can be optimised by following the proper fetal monitoring strategy.woman should be under the care of a consultant obstetrician,experienced midwife,sonographer and neonatologist input.antenatal steroids are indicated when delivery is expected before 37 weeks or if delivery by caesarean section at 37 weeks.timing delivery at 37 weeks if normal or reduced umbilical artey doppler and normal MCA or at 32 weeks if AREDV even with normal ductus venosus doppler.mode of delivery is vaginal unless obstetric indication for caesarean section,however fetal distress ie expected so woman should be admitted early in labour for continous EFM. with AREDV caesarean section is recommended.delivery should be planned in consultant led unit with facilities for emergency caesarean section and neonatal resuscitation.al delivery plans and fetal monitoring strategy should be clearly documented in the woman's notes.

a.)Initial assessment begins by confirming her period of gestation from the menstrual history for LMP and dating scan at the booking visit. A detailed history to identify risk factors for SGA is taken like bleeding episodes in pregnancy which a major risk factor and suggests placental abruption .Confirm maternal birth weight if possible as history of maternal or paternal SGA is a known factor for constitutional SGA seen in 50% of cases. .Personal history of heavy smoking (> 11 cigarettes /day ), moderate alcohol intake and drugs e.g. cocaine misuse is associated with IUGR.

Note for antenatal infections likeToxoplasmosis, Rubella, Cytomegalovirus and Malaria. Social history of domestic violence, support from partner, poor dietary intake esp  fruits, vegetables and vigorous exercise increases her risk. Note her ethnic background as Asian Indian or African American is a risk factor. Review the obstetric record as nulliparity is a risk factor. Serum screening markers for aneuploidy showing low PAPP-A associated with SGA. Presence of foetal movements is noted as Intrauterine death associated with IUGR.History of PIH,Thrombophillia,Thyroid disorder is confirmed.

Examination for BP, P, BMI since anaemia and low BMI are associated with SGA. .Urinalysis for proteinuria to exclude PET that increases risk of IUGR.Serolological test for CMV and Toxoplasmosis and test for Malaria and Syphilis in high risk women if indicated.

Serial measurements of symphysiofundal height plotted on customised growth chart is a good predictor of IUGR and if less than 10^thcentile should be further investigated by an Ultrasound scan for AC and EFW to rule out SGA.

b.)Being a SGA pregnancy, she will be under care in a consultant led unit with more frequent antenatal visits. Serial growth scans and Umbilical Artery Doppler studies to note the flow and resistance index will be the primary surveillance tool. If the umbilical artery Doppler scan is normal she will be advised to repeat it every two weeks and growth scan every three weeks.

 If abnormal with end diastolic velocity present, it will be repeated twice weekly and if end diastolic velocity absent it will be done daily.Ductus Venosus Doppler studies have moderate predictive value for foetal acaedemia and perinatal death in preterm SGA foetus and are recommended to time delivery.

CTG should not be used as the only form of surveillance except for interpretation on short term fetal heart rate variation on computerised analysis. Amniotic fluid volume measured by deepest vertical pocket on Ultrasound is also not used as the only form of surveillance. Biophysical profile is not recommended in preterm SGA foetus.Middle cerebral artery doppler studies are recommended in term SGA to time delivery.

 Consider Delivery at 30-32 weeks if evidence of foetal compromise as suggested by the abnormal Umbilical artery Doppler with absent or reversed end diastolic velocity (AREDV ) or if static growth after a course of steroids.

c.)Once the delivery is planned at 32 weeks, she will be counselled about the prognosis and the increased perinatal morbidity and mortality associated with preterm SGA foetus jointly with the Neonatologist. The delivery will be in a consultant led unit with Special care baby unit facilities   preferably by Caesarean Section. Inform the Anaesthetists , Neonatologists and SCBU team.

 Administer Corticosteroids as Betamethasone 12 mg two doses 24 hrs apart to reduce the risk of respiratory distress syndrome, intraventricular haemorrhage, necrotising enterocolitis and neonatal death.

Magnesium sulphate can be considered for neurological development of foetus. Continuous foetal monitoring to be done if vaginal delivery planned. If SCBU facilities not available consider inutero transfer to a hospital with facilities and a neonatologist to be present at delivery.

A)

I will ask about the history of risk factors for SGA,like smoking and no.of cigarettes  per day.i will ask about cocine use.

I will ask her about history of  vigorous exercise daily

.i will ask for her nutrition , fruit intake and  weight gain.

I will ask history of chronic diseases like SLE,DM ,renal disease,chronic hypertention as all these can cause placental insufficiency.

History of early pregnancy bleeding or any episode of antepartum bleeding  should be asked. .Family history especially maternal or paternal SGA  should be asked .

History of any infections during pregnancy like Malaria or travel to endemic areas should be asked

.History of flu like illness during pregnancy should be taken.if any down syndrome screening done for her and any hand held notes available to look for  PAPP results .I will ask if pregnancy spontaneous or assisted .I will measure her BMI.I will measure blood pressure .I will check SFH and plot it on customized chart as it may improve prediction for SGA.

B)  The fetus is  SGA and I will inform this to the mother .i will inform mother about close and frequent monitoring needed for fetus.THIs patient should have serial growth scan every two weeks in addition to assessment of amniotic fluid and Doppler of umbilical artey.Amniotic fluid volume should be assessed by using maximum deep vertical pocket.If her ultrasound shows normal amniotic fluid and Doppler(including middle cerebral artey Doppler,) but growth on 5^th centile I will repeat ultrasound after two weeks for Doppler and AF .More frequent Doppler survielence may be appropriate in this severe SGA.Growth scan should be repeated at least after three weeks.Consider deleivery if static growth over 3-4 weeks or if reach 37 weeks.

If Umblical artey Doppler abnormal  that is PI or RI more than +2SDs above mean for gestational age but positive end diastolic flow Doppler should be done twice weekly and weekly growth scan(AC/EFW)Deleiver by 37 week or if static growth over 3 to 4 weeks.

If the  umbilical artey shows  abnormal Doppler with abset or reverse end diastolic flow daily umbilical artey Doppler plus  Ductus Venosus doppler   ,growth scan weekly (AC/EFW) and computerized CTG daily using short term fetal heart variability and comuterised analysis.deleivery by 32 weeks after steroids .Deleiver if ductus venosus or cCTG abnormal before 32 weeks.Consider deleivery at 30-32 weeks even DV Doppler normal.

IF Umblical artery dopler normal ,MCA  Doppler should be used to time deleivery in SGA fetuses  if after 32 weeks as it has moderate predictive value .MCA has limited accuracy in preterm SGA.in pre term Ductus venosus  and umbilical vein have moderate predictive value for fetal Acidosis and should be used to time deleivery.CTG alone should not be used and Biophysical profile should not be used in preterm SGA..Deeepst  vertical pocket  should be used to interpret  amniotic fluid volume.

C)

I will give a course of steroid (2 doses of 12 mg betamethasone 24 hour apart or 4 doses of dexamethasone 6 mg 12 hours apart)at least 24 to 48 hour before .it will improve perinatal outcome(IVH,RDS)AND MAGNESIUM SULFATE to reduce risk of cerebral palsy.Neonatology colleague should be informed and available . Check for availability of SCBU cots.Shift the mother in utero to a centre where SCBU available .

a)Initial assessment aims at reaching a diagnosis  of SGAand identifying whether the fetus is constitutionally SGA or growth restricted and hence at risk of perinatal morbidity and mortality.

Ethnicity of woman is enquired,as fetal growth is influenced by the ethnicity .

Menstrual history is taken with regards to LMP and regularity of her cycles .Wrong dates and irregular cycles may lead to suspicion of small for gestational age fetus.

Examination include   height ,weight and BMI .Customized charts based on ethnicity ,height and weight increase the sensitivity of identifying SGA fetus.

Abdominal examination by palpation is not accurate and hence not recommended. Symphysial fundal height is measured .It  has low  sensitivity ,20%. When symphysial-fundal height measurement is plotted on customized chart  sensitivity is increased to more than 30%.in identifying SGA fetus .If the measurements  falls below 10^th centile on the customized chart, woman should be referred for USS biometry.

Invsestigations include USS for fetal biometry and EFW .If abdominal circumference  or EFW measure less than 10^th centile ,it will diagnose SGA fetus. Furhter investigation include umbilical artery doppler velocimetry.Abnormal Doppler values will identify growth restricted fetus.

b)With EFW below 5^th centile ,the fetus should be monitored by Umbilical Artery dopplers.It is recommended as primary tool for fetal monitoring as it has shown to reduce perinatal morbidity and mortality. If the Doppler indices i.e pulsatility index(PI) or Resistive index (RI) are normal ,further monitoring may be done by every 14days.

If Doppler indices PI or RI are raised +-2SD,but end diastolic velocities are present ,she should have growth scan every week and dopplers twice a week.In case of absent or reversed end diastolic velocity ,growth scans are done weekly and  dopplers are done daily.This surveillance has been found to predict acidosis and timely delivery would  prevent fetal death.Women followed by Umbilical artery dopplers have been found to have fewer inductions and caesarian sections.

CTG is  not recommended as the only form of surveillance.Fetal heart rate variation is the most useful predictor of fetal well being in SGA fetus. Computerized CTG analysis of fetal rate variation has been found to be more useful .

Amniotic fluid measurement is best done by taking single deep vertical pool.If less than 2cm ,it is oligohydramnios .It has not been shown to predict perinatal outcome if used as the only method of fetal surveillance. Oligohydramnios  during labor has been found to be associated with increased risk of CS.

Biophysical profile  is not recommended for fetal monitoring in  preterm SGA fetus ,as it has been shown to have high false negative results.

Middle cerebral atrtery has been found to be useful surveillance tool in SGA fetus after 32wks.

Dctus venosus Doppler has moderate predictive value for fetal academia and adverse outcome in  preterm fetus.

Hence if the Umbilical artery Doppler is abnormal with AREDV,she should have daily DV Doppler and CTG. Fetus should be delivered any time if there are abnormalities on DV Doppler or CTG

Delivery is also recommended if by 32wks ,even if DV dopplers are normal.

c)Corticosteroids are given to improve fetal maturity and reduce neonatal morbidity and mortality. Magnesium sulphate given to mother has been  found to reduce incidence of cerebral  palsy.NICU should be informed for bed.If acilities are not available,she should be transferred to an appropriate centre. Neonatologist should be informed to attend delivery.

a)Initial assessment aims at reaching a diagnosis  of SGAand identifying whether the fetus is constitutionally SGA or growth restricted and hence at risk of perinatal morbidity and mortality.

Ethnicity of woman is enquired,as fetal growth is influenced by the ethnicity .

Menstrual history is taken with regards to LMP and regularity of her cycles .Wrong dates and irregular cycles may lead to suspicion of small for gestational age fetus.

Examination include   height ,weight and BMI .Customized charts based on ethnicity ,height and weight increase the sensitivity of identifying SGA fetus.

Abdominal examination by palpation is not accurate and hence not recommended. Symphysial fundal height is measured .It  has low  sensitivity ,20%. When symphysial-fundal height measurement is plotted on customized chart  sensitivity is increased to more than 30%.in identifying SGA fetus .If the measurements  falls below 10^th centile on the customized chart, woman should be referred for USS biometry.

Invsestigations include USS for fetal biometry and EFW .If abdominal circumference  or EFW measure less than 10^th centile ,it will diagnose SGA fetus. Furhter investigation include umbilical artery doppler velocimetry.Abnormal Doppler values will identify growth restricted fetus.

b)With EFW below 5^th centile ,the fetus should be monitored by Umbilical Artery dopplers.It is recommended as primary tool for fetal monitoring as it has shown to reduce perinatal morbidity and mortality. If the Doppler indices i.e pulsatility index(PI) or Resistive index (RI) are normal ,further monitoring may be done by every 14days.

If Doppler indices PI or RI are raised +-2SD,but end diastolic velocities are present ,she should have growth scan every week and dopplers twice a week.In case of absent or reversed end diastolic velocity ,growth scans are done weekly and  dopplers are done daily.This surveillance has been found to predict acidosis and timely delivery would  prevent fetal death.Women followed by Umbilical artery dopplers have been found to have fewer inductions and caesarian sections.

CTG is  not recommended as the only form of surveillance.Fetal heart rate variation is the most useful predictor of fetal well being in SGA fetus. Computerized CTG analysis of fetal rate variation has been found to be more useful .

Amniotic fluid measurement is best done by taking single deep vertical pool.If less than 2cm ,it is oligohydramnios .It has not been shown to predict perinatal outcome if used as the only method of fetal surveillance. Oligohydramnios  during labor has been found to be associated with increased risk of CS.

Biophysical profile  is not recommended for fetal monitoring in  preterm SGA fetus ,as it has been shown to have high false negative results.

Middle cerebral atrtery has been found to be useful surveillance tool in SGA fetus after 32wks.

Dctus venosus Doppler has moderate predictive value for fetal academia and adverse outcome in  preterm fetus.

Hence if the Umbilical artery Doppler is abnormal with AREDV,she should have daily DV Doppler and CTG. Fetus should be delivered any time if there are abnormalities on DV Doppler or CTG

Delivery is also recommended if by 32wks ,even if DV dopplers are normal.

c)Corticosteroids are given to improve fetal maturity and reduce neonatal morbidity and mortality. Magnesium sulphate given to mother has been  found to reduce incidence of cerebral  palsy.NICU should be informed for bed.If acilities are not available,she should be transferred to an appropriate centre. Neonatologist should be informed to attend delivery.

a)Initial assessment aims at reaching a diagnosis  of SGAand identifying whether the fetus is constitutionally SGA or growth restricted and hence at risk of perinatal morbidity and mortality.

Ethnicity of woman is enquired,as fetal growth is influenced by the ethnicity .

Menstrual history is taken with regards to LMP and regularity of her cycles .Wrong dates and irregular cycles may lead to suspicion of small for gestational age fetus.

Examination include   height ,weight and BMI .Customized charts based on ethnicity ,height and weight increase the sensitivity of identifying SGA fetus.

Abdominal examination by palpation is not accurate and hence not recommended. Symphysial fundal height is measured .It  has low  sensitivity ,20%. When symphysial-fundal height measurement is plotted on customized chart  sensitivity is increased to more than 30%.in identifying SGA fetus .If the measurements  falls below 10^th centile on the customized chart, woman should be referred for USS biometry.

Invsestigations include USS for fetal biometry and EFW .If abdominal circumference  or EFW measure less than 10^th centile ,it will diagnose SGA fetus. Furhter investigation include umbilical artery doppler velocimetry.Abnormal Doppler values will identify growth restricted fetus.

b)With EFW below 5^th centile ,the fetus should be monitored by Umbilical Artery dopplers.It is recommended as primary tool for fetal monitoring as it has shown to reduce perinatal morbidity and mortality. If the Doppler indices i.e pulsatility index(PI) or Resistive index (RI) are normal ,further monitoring may be done by every 14days.

If Doppler indices PI or RI are raised +-2SD,but end diastolic velocities are present ,she should have growth scan every week and dopplers twice a week.In case of absent or reversed end diastolic velocity ,growth scans are done weekly and  dopplers are done daily.This surveillance has been found to predict acidosis and timely delivery would  prevent fetal death.Women followed by Umbilical artery dopplers have been found to have fewer inductions and caesarian sections.

CTG is  not recommended as the only form of surveillance.Fetal heart rate variation is the most useful predictor of fetal well being in SGA fetus. Computerized CTG analysis of fetal rate variation has been found to be more useful .

Amniotic fluid measurement is best done by taking single deep vertical pool.If less than 2cm ,it is oligohydramnios .It has not been shown to predict perinatal outcome if used as the only method of fetal surveillance. Oligohydramnios  during labor has been found to be associated with increased risk of CS.

Biophysical profile  is not recommended for fetal monitoring in  preterm SGA fetus ,as it has been shown to have high false negative results.

Middle cerebral atrtery has been found to be useful surveillance tool in SGA fetus after 32wks.

Dctus venosus Doppler has moderate predictive value for fetal academia and adverse outcome in  preterm fetus.

Hence if the Umbilical artery Doppler is abnormal with AREDV,she should have daily DV Doppler and CTG. Fetus should be delivered any time if there are abnormalities on DV Doppler or CTG

Delivery is also recommended if by 32wks ,even if DV dopplers are normal.

c)Corticosteroids are given to improve fetal maturity and reduce neonatal morbidity and mortality. Magnesium sulphate given to mother has been  found to reduce incidence of cerebral  palsy.NICU should be informed for bed.If acilities are not available,she should be transferred to an appropriate centre. Neonatologist should be informed to attend delivery.

a)Initial assessment aims at reaching a diagnosis  of SGAand identifying whether the fetus is constitutionally SGA or growth restricted and hence at risk of perinatal morbidity and mortality.

Ethnicity of woman is enquired,as fetal growth is influenced by the ethnicity .

Menstrual history is taken with regards to LMP and regularity of her cycles .Wrong dates and irregular cycles may lead to suspicion of small for gestational age fetus.

Examination include   height ,weight and BMI .Customized charts based on ethnicity ,height and weight increase the sensitivity of identifying SGA fetus.

Abdominal examination by palpation is not accurate and hence not recommended. Symphysial fundal height is measured .It  has low  sensitivity ,20%. When symphysial-fundal height measurement is plotted on customized chart  sensitivity is increased to more than 30%.in identifying SGA fetus .If the measurements  falls below 10^th centile on the customized chart, woman should be referred for USS biometry.

Invsestigations include USS for fetal biometry and EFW .If abdominal circumference  or EFW measure less than 10^th centile ,it will diagnose SGA fetus. Furhter investigation include umbilical artery doppler velocimetry.Abnormal Doppler values will identify growth restricted fetus.

b)With EFW below 5^th centile ,the fetus should be monitored by Umbilical Artery dopplers.It is recommended as primary tool for fetal monitoring as it has shown to reduce perinatal morbidity and mortality. If the Doppler indices i.e pulsatility index(PI) or Resistive index (RI) are normal ,further monitoring may be done by every 14days.

If Doppler indices PI or RI are raised +-2SD,but end diastolic velocities are present ,she should have growth scan every week and dopplers twice a week.In case of absent or reversed end diastolic velocity ,growth scans are done weekly and  dopplers are done daily.This surveillance has been found to predict acidosis and timely delivery would  prevent fetal death.Women followed by Umbilical artery dopplers have been found to have fewer inductions and caesarian sections.

CTG is  not recommended as the only form of surveillance.Fetal heart rate variation is the most useful predictor of fetal well being in SGA fetus. Computerized CTG analysis of fetal rate variation has been found to be more useful .

Amniotic fluid measurement is best done by taking single deep vertical pool.If less than 2cm ,it is oligohydramnios .It has not been shown to predict perinatal outcome if used as the only method of fetal surveillance. Oligohydramnios  during labor has been found to be associated with increased risk of CS.

Biophysical profile  is not recommended for fetal monitoring in  preterm SGA fetus ,as it has been shown to have high false negative results.

Middle cerebral atrtery has been found to be useful surveillance tool in SGA fetus after 32wks.

Dctus venosus Doppler has moderate predictive value for fetal academia and adverse outcome in  preterm fetus.

Hence if the Umbilical artery Doppler is abnormal with AREDV,she should have daily DV Doppler and CTG. Fetus should be delivered any time if there are abnormalities on DV Doppler or CTG

Delivery is also recommended if by 32wks ,even if DV dopplers are normal.

c)Corticosteroids are given to improve fetal maturity and reduce neonatal morbidity and mortality. Magnesium sulphate given to mother has been  found to reduce incidence of cerebral  palsy.NICU should be informed for bed.If acilities are not available,she should be transferred to an appropriate centre. Neonatologist should be informed to attend delivery.

a)Initial assessment aims at reaching a diagnosis  of SGAand identifying whether the fetus is constitutionally SGA or growth restricted and hence at risk of perinatal morbidity and mortality.

Ethnicity of woman is enquired,as fetal growth is influenced by the ethnicity .

Menstrual history is taken with regards to LMP and regularity of her cycles .Wrong dates and irregular cycles may lead to suspicion of small for gestational age fetus.

Examination include   height ,weight and BMI .Customized charts based on ethnicity ,height and weight increase the sensitivity of identifying SGA fetus.

Abdominal examination by palpation is not accurate and hence not recommended. Symphysial fundal height is measured .It  has low  sensitivity ,20%. When symphysial-fundal height measurement is plotted on customized chart  sensitivity is increased to more than 30%.in identifying SGA fetus .If the measurements  falls below 10^th centile on the customized chart, woman should be referred for USS biometry.

Invsestigations include USS for fetal biometry and EFW .If abdominal circumference  or EFW measure less than 10^th centile ,it will diagnose SGA fetus. Furhter investigation include umbilical artery doppler velocimetry.Abnormal Doppler values will identify growth restricted fetus.

b)With EFW below 5^th centile ,the fetus should be monitored by Umbilical Artery dopplers.It is recommended as primary tool for fetal monitoring as it has shown to reduce perinatal morbidity and mortality. If the Doppler indices i.e pulsatility index(PI) or Resistive index (RI) are normal ,further monitoring may be done by every 14days.

If Doppler indices PI or RI are raised +-2SD,but end diastolic velocities are present ,she should have growth scan every week and dopplers twice a week.In case of absent or reversed end diastolic velocity ,growth scans are done weekly and  dopplers are done daily.This surveillance has been found to predict acidosis and timely delivery would  prevent fetal death.Women followed by Umbilical artery dopplers have been found to have fewer inductions and caesarian sections.

CTG is  not recommended as the only form of surveillance.Fetal heart rate variation is the most useful predictor of fetal well being in SGA fetus. Computerized CTG analysis of fetal rate variation has been found to be more useful .

Amniotic fluid measurement is best done by taking single deep vertical pool.If less than 2cm ,it is oligohydramnios .It has not been shown to predict perinatal outcome if used as the only method of fetal surveillance. Oligohydramnios  during labor has been found to be associated with increased risk of CS.

Biophysical profile  is not recommended for fetal monitoring in  preterm SGA fetus ,as it has been shown to have high false negative results.

Middle cerebral atrtery has been found to be useful surveillance tool in SGA fetus after 32wks.

Dctus venosus Doppler has moderate predictive value for fetal academia and adverse outcome in  preterm fetus.

Hence if the Umbilical artery Doppler is abnormal with AREDV,she should have daily DV Doppler and CTG. Fetus should be delivered any time if there are abnormalities on DV Doppler or CTG

Delivery is also recommended if by 32wks ,even if DV dopplers are normal.

c)Corticosteroids are given to improve fetal maturity and reduce neonatal morbidity and mortality. Magnesium sulphate given to mother has been  found to reduce incidence of cerebral  palsy.NICU should be informed for bed.If acilities are not available,she should be transferred to an appropriate centre. Neonatologist should be informed to attend delivery.

a)Initial assessment aims at reaching a diagnosis  of SGAand identifying whether the fetus is constitutionally SGA or growth restricted and hence at risk of perinatal morbidity and mortality.

Ethnicity of woman is enquired,as fetal growth is influenced by the ethnicity .

Menstrual history is taken with regards to LMP and regularity of her cycles .Wrong dates and irregular cycles may lead to suspicion of small for gestational age fetus.

Examination include   height ,weight and BMI .Customized charts based on ethnicity ,height and weight increase the sensitivity of identifying SGA fetus.

Abdominal examination by palpation is not accurate and hence not recommended. Symphysial fundal height is measured .It  has low  sensitivity ,20%. When symphysial-fundal height measurement is plotted on customized chart  sensitivity is increased to more than 30%.in identifying SGA fetus .If the measurements  falls below 10^th centile on the customized chart, woman should be referred for USS biometry.

Invsestigations include USS for fetal biometry and EFW .If abdominal circumference  or EFW measure less than 10^th centile ,it will diagnose SGA fetus. Furhter investigation include umbilical artery doppler velocimetry.Abnormal Doppler values will identify growth restricted fetus.

b)With EFW below 5^th centile ,the fetus should be monitored by Umbilical Artery dopplers.It is recommended as primary tool for fetal monitoring as it has shown to reduce perinatal morbidity and mortality. If the Doppler indices i.e pulsatility index(PI) or Resistive index (RI) are normal ,further monitoring may be done by every 14days.

If Doppler indices PI or RI are raised +-2SD,but end diastolic velocities are present ,she should have growth scan every week and dopplers twice a week.In case of absent or reversed end diastolic velocity ,growth scans are done weekly and  dopplers are done daily.This surveillance has been found to predict acidosis and timely delivery would  prevent fetal death.Women followed by Umbilical artery dopplers have been found to have fewer inductions and caesarian sections.

CTG is  not recommended as the only form of surveillance.Fetal heart rate variation is the most useful predictor of fetal well being in SGA fetus. Computerized CTG analysis of fetal rate variation has been found to be more useful .

Amniotic fluid measurement is best done by taking single deep vertical pool.If less than 2cm ,it is oligohydramnios .It has not been shown to predict perinatal outcome if used as the only method of fetal surveillance. Oligohydramnios  during labor has been found to be associated with increased risk of CS.

Biophysical profile  is not recommended for fetal monitoring in  preterm SGA fetus ,as it has been shown to have high false negative results.

Middle cerebral atrtery has been found to be useful surveillance tool in SGA fetus after 32wks.

Dctus venosus Doppler has moderate predictive value for fetal academia and adverse outcome in  preterm fetus.

Hence if the Umbilical artery Doppler is abnormal with AREDV,she should have daily DV Doppler and CTG. Fetus should be delivered any time if there are abnormalities on DV Doppler or CTG

Delivery is also recommended if by 32wks ,even if DV dopplers are normal.

c)Corticosteroids are given to improve fetal maturity and reduce neonatal morbidity and mortality. Magnesium sulphate given to mother has been  found to reduce incidence of cerebral  palsy.NICU should be informed for bed.If acilities are not available,she should be transferred to an appropriate centre. Neonatologist should be informed to attend delivery.

a)Initial assessment aims at reaching a diagnosis  of SGAand identifying whether the fetus is constitutionally SGA or growth restricted and hence at risk of perinatal morbidity and mortality.

Ethnicity of woman is enquired,as fetal growth is influenced by the ethnicity .

Menstrual history is taken with regards to LMP and regularity of her cycles .Wrong dates and irregular cycles may lead to suspicion of small for gestational age fetus.

Examination include   height ,weight and BMI .Customized charts based on ethnicity ,height and weight increase the sensitivity of identifying SGA fetus.

Abdominal examination by palpation is not accurate and hence not recommended. Symphysial fundal height is measured .It  has low  sensitivity ,20%. When symphysial-fundal height measurement is plotted on customized chart  sensitivity is increased to more than 30%.in identifying SGA fetus .If the measurements  falls below 10^th centile on the customized chart, woman should be referred for USS biometry.

Invsestigations include USS for fetal biometry and EFW .If abdominal circumference  or EFW measure less than 10^th centile ,it will diagnose SGA fetus. Furhter investigation include umbilical artery doppler velocimetry.Abnormal Doppler values will identify growth restricted fetus.

b)With EFW below 5^th centile ,the fetus should be monitored by Umbilical Artery dopplers.It is recommended as primary tool for fetal monitoring as it has shown to reduce perinatal morbidity and mortality. If the Doppler indices i.e pulsatility index(PI) or Resistive index (RI) are normal ,further monitoring may be done by every 14days.

If Doppler indices PI or RI are raised +-2SD,but end diastolic velocities are present ,she should have growth scan every week and dopplers twice a week.In case of absent or reversed end diastolic velocity ,growth scans are done weekly and  dopplers are done daily.This surveillance has been found to predict acidosis and timely delivery would  prevent fetal death.Women followed by Umbilical artery dopplers have been found to have fewer inductions and caesarian sections.

CTG is  not recommended as the only form of surveillance.Fetal heart rate variation is the most useful predictor of fetal well being in SGA fetus. Computerized CTG analysis of fetal rate variation has been found to be more useful .

Amniotic fluid measurement is best done by taking single deep vertical pool.If less than 2cm ,it is oligohydramnios .It has not been shown to predict perinatal outcome if used as the only method of fetal surveillance. Oligohydramnios  during labor has been found to be associated with increased risk of CS.

Biophysical profile  is not recommended for fetal monitoring in  preterm SGA fetus ,as it has been shown to have high false negative results.

Middle cerebral atrtery has been found to be useful surveillance tool in SGA fetus after 32wks.

Dctus venosus Doppler has moderate predictive value for fetal academia and adverse outcome in  preterm fetus.

Hence if the Umbilical artery Doppler is abnormal with AREDV,she should have daily DV Doppler and CTG. Fetus should be delivered any time if there are abnormalities on DV Doppler or CTG

Delivery is also recommended if by 32wks ,even if DV dopplers are normal.

c)Corticosteroids are given to improve fetal maturity and reduce neonatal morbidity and mortality. Magnesium sulphate given to mother has been  found to reduce incidence of cerebral  palsy.NICU should be informed for bed.If acilities are not available,she should be transferred to an appropriate centre. Neonatologist should be informed to attend delivery.

a)Initial assessment aims at reaching a diagnosis  of SGAand identifying whether the fetus is constitutionally SGA or growth restricted and hence at risk of perinatal morbidity and mortality.

Ethnicity of woman is enquired,as fetal growth is influenced by the ethnicity .

Menstrual history is taken with regards to LMP and regularity of her cycles .Wrong dates and irregular cycles may lead to suspicion of small for gestational age fetus.

Examination include   height ,weight and BMI .Customized charts based on ethnicity ,height and weight increase the sensitivity of identifying SGA fetus.

Abdominal examination by palpation is not accurate and hence not recommended. Symphysial fundal height is measured .It  has low  sensitivity ,20%. When symphysial-fundal height measurement is plotted on customized chart  sensitivity is increased to more than 30%.in identifying SGA fetus .If the measurements  falls below 10^th centile on the customized chart, woman should be referred for USS biometry.

Invsestigations include USS for fetal biometry and EFW .If abdominal circumference  or EFW measure less than 10^th centile ,it will diagnose SGA fetus. Furhter investigation include umbilical artery doppler velocimetry.Abnormal Doppler values will identify growth restricted fetus.

b)With EFW below 5^th centile ,the fetus should be monitored by Umbilical Artery dopplers.It is recommended as primary tool for fetal monitoring as it has shown to reduce perinatal morbidity and mortality. If the Doppler indices i.e pulsatility index(PI) or Resistive index (RI) are normal ,further monitoring may be done by every 14days.

If Doppler indices PI or RI are raised +-2SD,but end diastolic velocities are present ,she should have growth scan every week and dopplers twice a week.In case of absent or reversed end diastolic velocity ,growth scans are done weekly and  dopplers are done daily.This surveillance has been found to predict acidosis and timely delivery would  prevent fetal death.Women followed by Umbilical artery dopplers have been found to have fewer inductions and caesarian sections.

CTG is  not recommended as the only form of surveillance.Fetal heart rate variation is the most useful predictor of fetal well being in SGA fetus. Computerized CTG analysis of fetal rate variation has been found to be more useful .

Amniotic fluid measurement is best done by taking single deep vertical pool.If less than 2cm ,it is oligohydramnios .It has not been shown to predict perinatal outcome if used as the only method of fetal surveillance. Oligohydramnios  during labor has been found to be associated with increased risk of CS.

Biophysical profile  is not recommended for fetal monitoring in  preterm SGA fetus ,as it has been shown to have high false negative results.

Middle cerebral atrtery has been found to be useful surveillance tool in SGA fetus after 32wks.

Dctus venosus Doppler has moderate predictive value for fetal academia and adverse outcome in  preterm fetus.

Hence if the Umbilical artery Doppler is abnormal with AREDV,she should have daily DV Doppler and CTG. Fetus should be delivered any time if there are abnormalities on DV Doppler or CTG

Delivery is also recommended if by 32wks ,even if DV dopplers are normal.

c)Corticosteroids are given to improve fetal maturity and reduce neonatal morbidity and mortality. Magnesium sulphate given to mother has been  found to reduce incidence of cerebral  palsy.NICU should be informed for bed.If acilities are not available,she should be transferred to an appropriate centre. Neonatologist should be informed to attend delivery.

I would ask about the fetal movements. I would ask about history of smoking or cocaine use.Other risk factors for SGA  like herself  and parner were SGA should be asked

Examination for BP and urinalysis for proteinuria to exclude pre eclampsia since it is associated with SGA.

Symphysiofundal height should be measured and plotted in customised chart.If it is less than 10th centile .ultrasound should be done for measurement of fetal size by abdominal circumference and fetalweight.

B// She should be offered serial assessment of fetal size by ultrasound and fetal wellbeing   umbilical artery doppler. For measuring growth velocity by AC or EFW they should be atleast 3 weeks apart, and using customised centiles. If UA doppler is normal ultrasound should be repeated fortnightly,and delivery planned at 37 weeks. If static growth for morethan 3-4 weeks at 34 weeks/ . If UA doppler  shows PI  or RI more than 2 standard deviation and diastolic flow present weekly ultrasound and twice weekly UA doppler should be repeated. Delivery around 37 wks or at 34 weeks if static growth.after giving steroids. If absent or reverersed end diastolic flow should be refered to fetal medicine specialist opinion. Daily UA doppler and Ductus venosus doppler,Daily ctg should be done and interpretation should be by the shortterm variabilty by computer analysis..Delivery should be planned according to ductus venosus flow .Delivery should be planned arond 30-32 weeks .

C, Delivery should be in a tertiary care hospital with intensive neonatal care facilities. Multidisciplinary care involving senior obstetrician, neonatologist should be involved .Steroids in the form of 12 mg betamethasone should be given 24 hrs apart to reduce respiratory distress, intraventricular haemorrhage and necrotising enterocolitis. Magnesium sulphate 4gm stat and 1gm/ hr for 24 hours before delivery should be given as this is shown to reduce cerebral palsy

A.My initial assessment will start with enquiring about the perception of fetal movements from the woman as maternal perception of fetal movements is reassuring.A history of smoking,alcohol or any other recreational drugs as these are associated with Intrauterine fetal growth restriction(IUGR).History of maternal or paternal growth restriction is associated with IUGR in the fetus.Check BP and proteinuria to rule out any pregnany induced hypertension/preeclamspsia.Check maternal weight and BMI as the fetus could be constitutionally small .Measure the symphysis fundal height and plot it on a customized growth chart as this is a good predictor of IUGR.Growth scan to measure AC and estimated fetal growth (EFW) along with liquor volume and Umbilical artery Doppler should be performed.

B.Growth on the 5^thcentile is consisted with intrauterine growth restriction.The woman should be managed under a Consultant led antenatal unit.Growth scan should be done every 3-4 weeks.Umbilcal artery Doppler if normal should be repeated every 2 weeks.If Umbilical artery Doppler shows absent or reverse end diastolic flow,then it should be  monitored daily.Any changes in Ductus venosus or pulsations in the umbilical vein should promt immediately delivery.Threshold for cesarean section in view of fetal compromise should be documented in the womans notes. In case of absent/reverse end diastolic flow in umbilical artier Doppler,delivery should be considered by 30 weeks and definitely the fetus should be delivered by 32 weeks.Liqour volume should be measured along with AC and EFW every two weeks.If the the Umbilical artery Doppler is normal or shows increased resistance flow,then delivery should not be delayed beyond 37 weeks.CTG monitoring should be done daily to look for any acute episodes of fetal compromise.

Woman should be advised strict fetal kick count monitoring.She should be advised to report any changes in the fetal movements immediately to the clinic.

C.The woman should deliver in a Consultant unit with facilities for NICU.The woman should be given steroids –Betamethasone 12 mg 24 hours apart intramuscular as this decreases the incidence of respiratory distress syndrome,necrotizing entrocolitis and intraventricular heamorrhage.MGSO4 should be considered to prevent risk of cerebral palsy in the preterm fetus 48hours before delivery. 

(a) First, I would check that her dates are correct using an earlier dating scan. Then, I would review her case notes for major risk factors of small fetuses such as history of antepartum haemorrhage or an abnormally low PAPP-A during her earlier Downs screening test.  I would ask about other major risk factors such as  heavy cigarette smoking (more than 10 cigarettes/day), cocaine use, daily vigorous exercise and the woman being a small baby herself.  I would take a medical history to identify other major risk factors such as chronic hypertension, diabetes, vascular disease or renal impairment. I would also enquire about minor risk factors such as light cigarette smoking (10 or less  cigarettes/day) and the father being a small baby himself.

On examination, blood pressure is taken to identify hypertension.  Body mass index (BMI) is calculated as a low BMI is a minor risk factor for small fetuses. Symphysis fundal height (SFH) is measured and plotted on a customised chart. 

On investigations, urine dipstix is performed to look for proteinuria to identify either renal impairment or pre-eclampsia.  If BMI >35, consider using ultrasound for serial growth assessment as SFH measurements may be inaccurate.  If SFH < 10th centile, refer for fetal growth scan.

(b) The purpose of surveillance is to predict fetal acidaemia and to allow timely delivery.

There is good evidence to support umbilical artery doppler in the management of high risk fetuses.  It is effective and when compared to CTG, it is associated with reduced use of antenatal resources, reduced induction of labour and caesarean sections for fetal distress. However, in a low risk population, there is no conclusive evidence that it benefits mother or baby. As this is a severely SGA fetus (high risk), umbilical artery doppler should be the primary surveillance tool as it has been shown to reduce perinatal morbidity and mortality in high risk populations.

Ductus venosus (DV) doppler has moderate predictive value for acidaemia and adverse outcome and should be used in preterm SGA fetus with abnormal umbilical artery doppler and to time delivery.

Middle cerebral artery (MCA) doppler is used to detect fetal hypoxia in SGA fetuses.  In the preterm SGA fetus, it has limited accuracy to predict acidaemia and adverse outcome and should not be used to time delivery. In the term SGA fetus with normal umbilical artery doppler, an abnormal MCA PI < 5th centile has moderate predictive value for fetal acidaemia and should be used to time delivery.

Conventional CTG has been commonly used for fetal monitoring. However, there is no clear evidence that it improved perinatal mortality and is associated with increased use of antenatal resources (hospital admission, inpatient stays). Computerised CTG, on the other hand, has been showed to reduce perinatal mortality.  Compared to conventional CTG, it is more objective and consistent.  Given its limitations, CTG should not be the only form of surveillance used in SGA fetuses.

Amniotic fluid volume, using either single deepest vertical pocket (SDVP) or amniotic fluid index (AFI), has also been commonly used for fetal monitoring. There is no evidence to suggest that one method is superior to the other in prevention of adverse perinatal outcomes but there is some evidence that a reduced SDVP is associated with increased perinatal mortality.  Hence, interpretation of amniotic fluid should be based on SDVP. This effectiveness of this method is limited as there is also no evidence to show that perinatal morbidity or mortality is increased in SGA fetuses with oligohydramnios.  In addition, it is associated with an increased risk of caesarean for fetal distress but not acidaemia.

Biophysical profile (BPP) include fetal breathing movements, body movements, tone, amniotic fluid volume and CTG.  Each variable is given a score of two.  Reducing BPP scores is associated with lower antenatal umbilical venous pH and increasing perinatal mortality. However, BPP is time consuming and incidence of an equivocal result is high.  It is also associated with an increased in caesarean rates but no improvement in perinatal outcome.  In preterm SGA fetuses, BPP is not predictive of fetal acidaemia and has high false negative rates and hence, is not recommended.

(c) Antenatal corticosteroids (two doses of betamethasone 12mg 12-24 hours apart) should be administered and delivery should take place at least 24 hours but less than 7 days after completion of last dose of steroid.

Caesarean delivery is indicated if there is absent end diastolic flow and should be performed by a senior obstetrician or a senior trainee under the direct supervision of a senior obstetrician.

Senior neonatal support (including equipment and NICU) should be on standby in the operating theatre in view of likely neonatal respiratory distress and need for resuscitation.

A healthy 23 year old nulliparous woman has been referred to the antenatal clinic at 28 weeks gestation because the fetus is thought to be small for gestational age. Anomaly scan at 20 weeks was normal. (a) Discuss your initial assessment [6 marks]. 

a) Discuss your initial assessment.

Ask about past medical history of renal disease, diabetes, hypertension and autoimmune diseases. Ask if she smokes, number of cigarettes and whether she uses cocaine. Enquire if she has a past obstetric history of stillbirth or small for gestational age (SGA) fetus, and if the parents were SGA infants. Ask if she has experienced heavy vaginal bleeding this pregnancy Review her notes for whether any PAPP-A was done as part of first trimester screen, as value <0.4 MoM is a risk factor for SGA. All of the above are important as they are major risk factors for SGA. Minor risk factors such as low pre-pregnancy fruit intake, smoking under 10 sticks a day and having a pregnancy interval under 6 months or over 60 months should also be asked. 

On physical examination, measure symphyseal-fundal height (SFH) and plot this on a customised growth chart. If this is under the 10th centile refer for ultrasound scan to measure abdominal circumference and estimated fetal weight. AC & EFW under 10th centile would confirm diagnosis of SGA and an umbilical doppler should be done. If she has a history of large fibroids or obesity with BMI >35, SFH should not be done and she should be referred for ultrasound.

(b) The estimated fetal weight is on the 5^th centile. Evaluate the options for antenatal fetal monitoring [11 marks]. 

Umbilical artery (UA) doppler is the recommended mode of monitoring as it reduces perinatal mortality & morbidity. Abnormal values such as PI or RI > 2SD and absent or reduced end diastolic flow (A/REDF) should prompt closer monitoring. Middle cerebral artery doppler is useful for timing delivery in term fetuses with normal dopplers, as reduced MCA PI and reduced MCA PI/UA PI ratio have moderate predictive value for acidosis at birth. It has reduced accuracy in preterm infants. Venous doppler (ductus venosus and umbilical vein) are done when there is absent or reduced end diastolic flow to time delivery in preterm fetuses, as reversed a wave or pulsatile flow in UV doppler are moderately predictive for acidemia in preterm fetuses with abnormal dopplers.  Disadvantage of dopplers is that they require training and are time consuming. 

Amniotic fluid volume (AFV) measured via amniotic fluid index and deepest vertical pool have poor correlation with actual AFV. It is not useful as the sole mode of surveillance. 

CTG has poor specificity especially in preterm fetuses. Continuous monitoring is also tiring for the patient and not cost effective. Computerised analysis of variability is useful in timing delivery of fetuses with A/REDF and values less than or equal to 3 should prompt consideration of delivery.

Biophysical profile uses 5 components to form a total score. This method is time consuming and not suitable for preterm fetuses as it has higher false negative rates.

Routine counting of fetal movements is of uncertain value and may cause maternal anxiety. However it would be useful to educate women on the importance of seeking medical attention if she notices reduced fetal movements. 

(c) Delivery is indicated at 30 weeks gestation. Discuss the steps that may be taken in the antenatal period to optimise perinatal outcome [3 marks]

Antenatal steroids will reduce risk of respiratory distress syndrome, necrotising enterocolitis, intraventricular haemorrhage, NICU admission, perinatal death, especially if completed between 24 hours and 7 days of delivery. Magnesium sulphate infusion may be considered as it has been shown to reduce risk of cerebral palsy and poor functional outcome. Caesarean section should be discussed with the mother in fetuses with A/REDF as such fetuses are likely to be poorly tolerant of the stress of labour. Delivery plan should be document and delivery should be planned in conjunction with neonatalogists trained in neonatal resuscitation and in unit with facilities available for neonatal resuscitation. 

a)Detailed history including menstrual history. I will check the date of last menstrual period, regularity & certainty as wrong date may be misinterpreted as small for gestational age. I will review the dating scan done on first trimester. I will ask the woman about awareness of fetal movements & I will check fetal heart beat abdominally by hand held Doppler,I will ask about history of  bleeding in earlier weeks, also symptoms suggestive of preeclampsia such as headache blurred vision or epigastric pain. Also I will ask about smoking or drug abuse.  Examination should include measuring blood pressure & symphysial fundal height using customized charts.

B) Fetal monitoring by umbilical artery Doppler studies is helpful  measuring pulsatility index (PI), resistance index (RI), end diastolic volume (EDV). If normal findings, continue monitoring of fetal biometry& weight, middle cerebral artery & umbilical artery Doppler studies fortnightly. Consider delivery by 37 weeks. Consider delivery by 34 weeks if middle cerebral artery PI < 5^th  centile or static growth for 3-4 weeks.

Abnormal finding including umbilical artery PI, RI but with persistent EDV necessitate to repeat fetal biometry & weight weekly, & umbilical artery Doppler twice weekly. Consider delivery by 37 weeks. Delivery is considered by 34 weeks if ststic growth for 3 weeks.

If reduced or absent EDV, monitoring of fetal weight weekly & umbilical artery, ductus venosus (DV) Doppler daily. Use computarised CTG if DV in not possible or unreliable. Consider delivery by 32 weeks. Deliver before 32 weeks if abnormal DV, abnormal CTG with reduced variability<3 or umbilical venous pulsations appear.

c)I will consider antenatal corticosteroids : betamethasone 12 mg intramuscular 24 hours apart to enhance fetal lung maturity. Try to deliver 48 hours after steroids therapy to optimize its effect. Referral to fetal medicine unit is also helpful in improving monitoring & timing of delivery. I will discuss with neonatologist as regard possible need for SCBU admission. Refer the woman to another unit if not available SCBU service or unable to accept the baby. Proper counseling of the woman with the help of neonatologist as regard possible SCBU admission & expected prognosis    

My assessment would begin by confirming her dates by enquiring about her menstrual history and correlating with the dating scan. I would then begin by taking a comprehensive history for the risk factors for SGA. This would include her age, obstetric history(h/o previous SGA or stillbirth), personal history(cocaine abuse or smoking), past medical history(chronic HTN, diabetes with vascular complications, APLA, CKD), H/O maternal or paternal SGA and history of present pregnancy(eg. h/o heavy bleeding in first trimester, unexplained APH, pre-eclampsia). Also h/o travel to a malaria endemic area.

I would also do a thorough general and systemic examination, in particular checking her BMI, BP, cardiovascular system(to rule out cardiac disease) and respiratoty systems(asthma or COPD) & stigmata of other diseases like SLE. In abdominal examination i would measure the SFH because she is beyond 24 weeks against a customized chart not population based chart(since foetal growth depends on numerous factors like age, ethnicity, socio-economic status etc. If SFH is less than the tenth centile or shows slow or static growth by crossing centiles i woulg get an ultrasound done for assessment of foetal size. Ultrasound would also have to be done for those women in which SFH is unreliable eg. those with fibroids, polyhydramnios or BMI >35.

I would also look at her first trimester serum screening to see whether PAPP-A was<.415 MOM and her level two scan to look for soft markers suggestive of SGA like echogenic bowel.

2) Umbilical artery doppler is the primary surveillence tool for SGA. CTG & AFI should not be used as sole surveillance tools. AFI should measure the single deepest vertical pocket(SDVP). Biophysical profile can be used for term SGA foetuses but not for preterm.  I would screen her for CMV, Toxoplasmosis & high risk patients for syphilis and malaria. Umbilical artery doppler should be repeated every 2 weeks if normal. If umbilical A. doppler is abnormal(PI/RI > 2S.D. for mean for gestational age) i would repeat it twice a week if EDV is present and daily if EDV is absent or reversed. Abnormal MCA doppler correlates well with acidaemia and adverse pregnancy outcome in term foetuses and Ductus Venosus doppler can be used for the same in preterm foetuses. Therefore, they can be used to time delivery.

3)To optimize perinatal outcome i would advise admission and give a course of antenatal steroids to help prevent NEC & periventricular leucomalacia. Lifestyle factors like smoking cessation or substance abuse should be addressed antenatally because the woman would be more receptive to changes. Magnesium sulphate can also have a role because of its neuroprotective effect in deliveries at < 30 weeks POG. She should deliver in a consultant-led unit & the plan of care should be dicussed with the woman and her partner. A neonatologist should attend the delivery and prior to timing her delivery SCBU bed vacancy should be checked, if not in-utero transfer can be arranged to a centre where it exists, If absent or reversed EDV is present she should deliver by caeserean section. If induction of labour is planned she should be put on continuous EFM & her high chances of emergency caeserean section explained.