{"id":384,"date":"2020-08-13T20:20:57","date_gmt":"2020-08-13T20:20:57","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=384"},"modified":"2020-10-20T17:02:22","modified_gmt":"2020-10-20T17:02:22","slug":"fetal-growth-abnormalities","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/basic_obgyn\/advanced-training\/fetal-growth-abnormalities\/","title":{"rendered":"Fetal Growth Abnormalities"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/9YSCsAp9OOM\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 15:11<\/p>\n<input type='hidden' bg_collapse_expand='69e9c851f32624024154217' value='69e9c851f32624024154217'><input type='hidden' id='bg-show-more-text-69e9c851f32624024154217' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9c851f32624024154217' value='Hide Transcript'><button id='bg-showmore-action-69e9c851f32624024154217' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#fcfafa;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9c851f32624024154217' ><\/p>\n<p>This is a screenshot<br \/>\n00:06<br \/>\nof the title page<br \/>\n00:07<br \/>\nof the aforementioned paper.<br \/>\n00:10<br \/>\nIt was published in 2013,<br \/>\n00:12<br \/>\na review article.<br \/>\n00:13<\/p>\n<p>00:16<br \/>\nAnd this is what we&#8217;re going<br \/>\n00:18<br \/>\nto talk about today in today&#8217;s<br \/>\n00:20<br \/>\npresentation.<br \/>\n00:21<br \/>\nIn section one,<br \/>\n00:21<br \/>\nwe deal with definitions<br \/>\n00:24<br \/>\nbetween SGA and IUGR&#8211;<br \/>\n00:25<br \/>\nthat<br \/>\n00:26<br \/>\nis small for gestational age<br \/>\n00:28<br \/>\nand intrauterine growth<br \/>\n00:29<br \/>\nrestriction.<br \/>\n00:31<br \/>\nIn section two,<br \/>\n00:31<br \/>\nwe talk about the screening<br \/>\n00:33<br \/>\nmethods for these two conditions<br \/>\n00:34<br \/>\nand possible ways in which they<br \/>\n00:36<br \/>\ncan be improved.<br \/>\n00:37<br \/>\nIn section three,<br \/>\n00:38<br \/>\nwe talk about the management<br \/>\n00:39<br \/>\nand section four, we round off<br \/>\n00:41<br \/>\nwith a summary of the points<br \/>\n00:43<br \/>\nwhich we find could have been<br \/>\n00:44<br \/>\nbetter in this article.<br \/>\n00:45<\/p>\n<p>00:49<br \/>\nSGA is defined as a field birth<br \/>\n00:51<br \/>\nweight of less than 10%<br \/>\n00:53<br \/>\nof the total population.<br \/>\n00:54<br \/>\nAnd that is confirmed<br \/>\n00:55<br \/>\nby ultrasound.<br \/>\n00:57<br \/>\nOther sources have advocated<br \/>\n00:58<br \/>\nthe use of 5% or 3%.<br \/>\n01:01<br \/>\nBut basically it is an arbitrary<br \/>\n01:03<br \/>\ncutoff point at the moment,<br \/>\n01:04<br \/>\nwhereas IUGR,<br \/>\n01:06<br \/>\nIntrauterine growth restriction,<br \/>\n01:07<br \/>\nis basically any condition<br \/>\n01:09<br \/>\nany in-utero condition,<br \/>\n01:11<br \/>\nwhich restricts the growth<br \/>\n01:12<br \/>\nof the fetus<br \/>\n01:13<br \/>\nto its full predicted age.<br \/>\n01:15<br \/>\nThe causes can be broadly<br \/>\n01:16<br \/>\nclassified as maternal,<br \/>\n01:18<br \/>\nplacental, or fetal.<br \/>\n01:19<br \/>\nAnd on the slide,<br \/>\n01:20<br \/>\nyou&#8217;ll see some examples.<br \/>\n01:22<br \/>\nCurrent definitions tend to use<br \/>\n01:24<br \/>\nthese terms<br \/>\n01:25<br \/>\nquite interchangeably and more<br \/>\n01:27<br \/>\naccurate<br \/>\n01:27<br \/>\nuse would say that IUGR is part<br \/>\n01:32<br \/>\nof SGA<br \/>\n01:33<br \/>\nand this is the basis<br \/>\n01:34<br \/>\nfor the author&#8217;s paper<br \/>\n01:36<br \/>\nin which he goes about trying<br \/>\n01:38<br \/>\nto challenge<br \/>\n01:38<br \/>\nthese current definitions.<br \/>\n01:39<\/p>\n<p>01:43<br \/>\nThe author goes on to say<br \/>\n01:44<br \/>\nthat the term should be distinct<br \/>\n01:46<br \/>\nand should define them<br \/>\n01:47<br \/>\ndifferently as such<br \/>\n01:48<br \/>\nbecause this definition does not<br \/>\n01:49<br \/>\nmake a distinction among infants<br \/>\n01:51<br \/>\nwho are constitutionally small,<br \/>\n01:53<br \/>\ngrowth restricted small,<br \/>\n01:54<br \/>\nand not small birth, growth<br \/>\n01:56<br \/>\nrestricted relative<br \/>\n01:57<br \/>\nto their potential.<br \/>\n01:58<br \/>\nAs an example, as many as 70%<br \/>\n02:00<br \/>\nof fetuses who way<br \/>\n02:01<br \/>\nbelow the 10th percentile<br \/>\n02:02<br \/>\nfor gestational age are small<br \/>\n02:04<br \/>\nsimply<br \/>\n02:05<br \/>\nbecause the constitutional<br \/>\n02:06<br \/>\nfactors such as female, sex,<br \/>\n02:07<br \/>\nor maternal ethnicity, perry,<br \/>\n02:10<br \/>\nor BMI.<br \/>\n02:11<br \/>\nThey are not at high risk<br \/>\n02:12<br \/>\nof perinatal mortality<br \/>\n02:13<br \/>\nand morbidity<br \/>\n02:14<br \/>\nbut<br \/>\n02:15<br \/>\nunder the current definitions,<br \/>\n02:16<br \/>\nthey would be defined as IUGR.<br \/>\n02:19<br \/>\nOne further point is that if you<br \/>\n02:22<br \/>\ngo by the 10% criteria for small<br \/>\n02:24<br \/>\nfor gestational age,<br \/>\n02:26<br \/>\nif you take it for,<br \/>\n02:28<br \/>\nlet&#8217;s say, this country and then<br \/>\n02:29<br \/>\nyou go to another country,<br \/>\n02:31<br \/>\nyou might find<br \/>\n02:32<br \/>\nthat<br \/>\n02:32<br \/>\nunder the same classification<br \/>\n02:33<br \/>\nyou could end up with 23%&#8211; one<br \/>\n02:35<br \/>\nof the papers that we cited.<br \/>\n02:38<br \/>\nSo obviously there needs to be<br \/>\n02:42<br \/>\nfew changes in definition.<br \/>\n02:44<br \/>\nNow on the diagram,<br \/>\n02:45<br \/>\nyou&#8217;ll see three<br \/>\n02:48<br \/>\ndifferent examples of how<br \/>\n02:49<br \/>\na fetus could be classified.<br \/>\n02:51<br \/>\nThe first example is the fetus<br \/>\n02:53<br \/>\nis not small, but it is growth<br \/>\n02:54<br \/>\nrestricted.<br \/>\n02:55<br \/>\nFor example, it<br \/>\n02:56<br \/>\nis possible for a fetus<br \/>\n02:56<br \/>\nto be growth restricted,<br \/>\n02:57<br \/>\nbut not be in the less than 10%<br \/>\n02:59<br \/>\nof estimated fetal weight.<br \/>\n03:02<br \/>\nOn the other hand, a fetus could<br \/>\n03:04<br \/>\nbe just constitutionally small<br \/>\n03:06<br \/>\nbecause of, let&#8217;s say,<br \/>\n03:07<br \/>\nparental factors<br \/>\n03:08<br \/>\nor other factors,<br \/>\n03:09<br \/>\nsuch as sex or ethnicity.<br \/>\n03:13<br \/>\nFinally, you could always have<br \/>\n03:14<br \/>\na fetus that is both growth<br \/>\n03:16<br \/>\nrestricted and small<br \/>\n03:17<br \/>\nand the author says that this<br \/>\n03:19<br \/>\ncalls for a need for better<br \/>\n03:21<br \/>\ndefinitions.<br \/>\n03:21<\/p>\n<p>03:25<br \/>\nFinally, the author goes on<br \/>\n03:26<br \/>\nto summarize his suggestions,<br \/>\n03:28<br \/>\nlike how you see on the page<br \/>\n03:30<br \/>\nhere.<br \/>\n03:31<br \/>\nThe main thing is he still<br \/>\n03:33<br \/>\ndecides to stick with just two<br \/>\n03:35<br \/>\ndefinitions<br \/>\n03:36<br \/>\nfor this current problem<br \/>\n03:37<br \/>\nthat we have.<br \/>\n03:40<br \/>\nSo then he gives examples of how<br \/>\n03:42<br \/>\nthese definitions can still<br \/>\n03:43<br \/>\nwork.<br \/>\n03:43<br \/>\nFor example CMV can still<br \/>\n03:45<br \/>\nbe relatively easy classified<br \/>\n03:47<br \/>\nas IUGR still.<br \/>\n03:49<br \/>\nHe admits that there will be<br \/>\n03:50<br \/>\ndifficulty with some definition,<br \/>\n03:52<br \/>\nsuch as aneuploid fetus.<br \/>\n03:56<br \/>\nYou might think that it might be<br \/>\n03:57<br \/>\neasily classified as SGA,<br \/>\n03:59<br \/>\nbut the problem is aneuploid<br \/>\n04:01<br \/>\nfetuses are also correlated<br \/>\n04:03<br \/>\nwith dis-functional placentas.<br \/>\n04:05<br \/>\nYou could say that that is<br \/>\n04:06<br \/>\nbecause of the aneuploidia<br \/>\n04:07<br \/>\nitself and therefore you could<br \/>\n04:09<br \/>\nclassify it as IUGR.<br \/>\n04:10<br \/>\nSo the question is, do you<br \/>\n04:12<br \/>\nclassify it as just SGA<br \/>\n04:14<br \/>\nby itself or do you classify it<br \/>\n04:16<br \/>\nin the middle right<br \/>\n04:17<br \/>\nthere as SGA superimposed IUGR.<br \/>\n04:21<br \/>\nAnd this is one of the critiques<br \/>\n04:23<br \/>\nthat we have of this paper,<br \/>\n04:24<br \/>\nis<br \/>\n04:24<br \/>\nthat<br \/>\n04:24<br \/>\nunder the current definitions<br \/>\n04:25<br \/>\nyou do run into a lot<br \/>\n04:26<br \/>\nof problems.<br \/>\n04:27<br \/>\nAnd the main thing is things<br \/>\n04:29<br \/>\nwhich are even harder<br \/>\n04:31<br \/>\nto classify,<br \/>\n04:31<br \/>\nsuch as fetal alcohol syndrome.<br \/>\n04:33<\/p>\n<p>04:36<br \/>\nIt can&#8217;t easily be classified<br \/>\n04:38<br \/>\nunder the current definitions<br \/>\n04:39<br \/>\nthat we have.<br \/>\n04:40<br \/>\nAnd we&#8217;re surprised<br \/>\n04:41<br \/>\nbecause there are<br \/>\n04:42<br \/>\nother classification systems<br \/>\n04:45<br \/>\ncurrently in use.<br \/>\n04:46<br \/>\nAnd we&#8217;d like to propose one<br \/>\n04:48<br \/>\nwhich is probably better<br \/>\n04:49<br \/>\nthan the current suggestions<br \/>\n04:53<br \/>\nby the author.<br \/>\n04:53<\/p>\n<p>04:57<br \/>\nRather than looking at just<br \/>\n04:59<br \/>\nthe size of a fetus<br \/>\n05:00<br \/>\nor its possible causes,<br \/>\n05:01<br \/>\nwe feel that there might be<br \/>\n05:04<br \/>\nbetter definitions in existence.<br \/>\n05:07<br \/>\nFor example, one which looks<br \/>\n05:09<br \/>\nat also how likely the fetus<br \/>\n05:12<br \/>\nwill benefit from ante natal<br \/>\n05:14<br \/>\nintervention<br \/>\n05:14<br \/>\nand whether or not<br \/>\n05:16<br \/>\ntheir outcomes are modifiable.<br \/>\n05:19<br \/>\nBy doing this, we can avoid<br \/>\n05:21<br \/>\nsubjecting fetuses<br \/>\n05:22<br \/>\nto unnecessary interventions.<br \/>\n05:26<br \/>\nSo the diagram to your right,<br \/>\n05:27<br \/>\nyou see that of all this year&#8217;s<br \/>\n05:28<br \/>\nfetuses,<br \/>\n05:29<br \/>\n40% are healthy small fetuses,<br \/>\n05:32<br \/>\nmeaning that they are<br \/>\n05:32<br \/>\nconstitutionally small,<br \/>\n05:34<br \/>\nas well as 20% of SGA fetuses<br \/>\n05:38<br \/>\nare intrinsically small, which<br \/>\n05:39<br \/>\nmeans either they have CMV<br \/>\n05:42<br \/>\ninfections, fetal alcohol<br \/>\n05:44<br \/>\nsyndrome, or a neuploidy.<br \/>\n05:47<br \/>\nBy classifying it like this,<br \/>\n05:50<br \/>\nwe are taking a more<br \/>\n05:51<br \/>\nclinical approach<br \/>\n05:52<br \/>\nand we&#8217;re saying<br \/>\n05:53<br \/>\nthat these fetuses do not need<br \/>\n05:56<br \/>\nintervention.<br \/>\n05:58<br \/>\nAnd we feel that this is<br \/>\n05:59<br \/>\na better approach to OB\/GYN<br \/>\n06:02<br \/>\npractice.<br \/>\n06:05<br \/>\nAnd finally the 40%,<br \/>\n06:07<br \/>\nthe darker 40% that you see<br \/>\n06:08<br \/>\nthere,<br \/>\n06:09<br \/>\nwhich is growth restricted<br \/>\n06:12<br \/>\nSGA, now we&#8217;ve identified them<br \/>\n06:15<br \/>\nas possibly benefiting<br \/>\n06:17<br \/>\nfrom intervention and therefore<br \/>\n06:19<br \/>\nwe are no longer concerned<br \/>\n06:21<br \/>\nwhether or not FAS should be<br \/>\n06:23<br \/>\nclassified as SGA or IUGR.<br \/>\n06:26<br \/>\nWe are just sure that it is not<br \/>\n06:27<br \/>\nlikely to benefit<br \/>\n06:28<br \/>\nfrom intervention<br \/>\n06:29<br \/>\nand we will not intervene.<br \/>\n06:31<\/p>\n<p>06:34<br \/>\nMoving on, we will now talk<br \/>\n06:35<br \/>\nabout current issues<br \/>\n06:38<br \/>\nin screening methods.<br \/>\n06:40<br \/>\nFor example, we talk about how<br \/>\n06:42<br \/>\nto screen for fetal growth<br \/>\n06:44<br \/>\nabnormalities,<br \/>\n06:45<br \/>\nthe current practices,<br \/>\n06:47<br \/>\nthe accuracy of final height<br \/>\n06:48<br \/>\nmeasurements<br \/>\n06:49<br \/>\nand ultrasound and finally<br \/>\n06:50<br \/>\nthe challenges in terms<br \/>\n06:51<br \/>\nof antenatal testing, doppler<br \/>\n06:53<br \/>\nultrasound,<br \/>\n06:54<br \/>\nand timing of delivery.<br \/>\n06:55<\/p>\n<p>06:57<br \/>\nFor the remainder<br \/>\n06:58<br \/>\nof this presentation<br \/>\n07:00<br \/>\nSGA will be referred<br \/>\n07:01<br \/>\nto as those fetuses which we do<br \/>\n07:07<br \/>\nnot feel<br \/>\n07:08<br \/>\nwould benefit from intervention<br \/>\n07:09<br \/>\nwhile IUGR are those that will<br \/>\n07:11<br \/>\nbe, for the sake of simplicity.<br \/>\n07:14<br \/>\nNow moving on, the author&#8217;s<br \/>\n07:15<br \/>\nsuggestions to improve<br \/>\n07:18<br \/>\nthe screening methods<br \/>\n07:19<br \/>\nare quite effective.<br \/>\n07:21<br \/>\nYou see on your screen,<br \/>\n07:22<br \/>\nthere are<br \/>\n07:22<br \/>\nseveral different factors which<br \/>\n07:24<br \/>\nplay a part in an SGA or IUGR<br \/>\n07:26<br \/>\nfetus, things<br \/>\n07:27<br \/>\nsuch as maternal age, height,<br \/>\n07:29<br \/>\nweight, paternal height<br \/>\n07:32<br \/>\nand weight,<br \/>\n07:32<br \/>\nrace, ethnicity, so on, so<br \/>\n07:34<br \/>\nforth.<br \/>\n07:35<br \/>\nThese all play a part<br \/>\n07:36<br \/>\nin determining whether or not<br \/>\n07:38<br \/>\na fetus is classified as SGA<br \/>\n07:40<br \/>\nor IUGR.<br \/>\n07:41<br \/>\nNow the author makes<br \/>\n07:43<br \/>\na strong point in saying<br \/>\n07:44<br \/>\nthat if we are able to account<br \/>\n07:46<br \/>\nfor these factors,<br \/>\n07:48<br \/>\nthen we are better<br \/>\n07:49<br \/>\nable to arrive at growth curves<br \/>\n07:51<br \/>\nwhich are more<br \/>\n07:51<br \/>\npredictive<br \/>\n07:53<br \/>\nof percentile estimates.<br \/>\n07:56<br \/>\nAnd by doing so,<br \/>\n07:57<br \/>\nwe will be able to tell<br \/>\n08:00<br \/>\nwhether or not intervention is<br \/>\n08:01<br \/>\nlikely to benefit outcome.<br \/>\n08:03<\/p>\n<p>08:06<br \/>\nWe&#8217;d also like to add<br \/>\n08:07<br \/>\nthat the recent literature is<br \/>\n08:08<br \/>\nin agreement with the author&#8217;s<br \/>\n08:10<br \/>\nviewpoints.<br \/>\n08:11<br \/>\nThere have been several studies<br \/>\n08:13<br \/>\ntrying to incorporate all<br \/>\n08:15<br \/>\nthese different predictive<br \/>\n08:17<br \/>\nvalues into some sort<br \/>\n08:19<br \/>\nof algorithm.<br \/>\n08:21<br \/>\nThe idea is one day we&#8217;ll<br \/>\n08:22<br \/>\nbe able to enter all<br \/>\n08:23<br \/>\nthe patients particulars<br \/>\n08:25<br \/>\ninto a computer, and it will be<br \/>\n08:27<br \/>\nable to say whether or not<br \/>\n08:29<br \/>\nthe fetus is indeed SGA or IUGR.<br \/>\n08:32<\/p>\n<p>08:36<br \/>\nI will not discuss<br \/>\n08:37<br \/>\nabout the management<br \/>\n08:38<br \/>\nof SGA\/IUGR.<br \/>\n08:39<br \/>\nI<br \/>\n08:40<br \/>\nIf SGA\/IUGR is suspected,<br \/>\n08:42<br \/>\nthe author suggested performing<br \/>\n08:44<br \/>\nantenatal testing, which<br \/>\n08:46<br \/>\nincludes non-stress tests<br \/>\n08:48<br \/>\nand biophysical profile.<br \/>\n08:50<br \/>\nThe biophysical profile in turn<br \/>\n08:51<br \/>\nincludes fetal movement, tone,<br \/>\n08:54<br \/>\nbreathing, AFI, and fetal heart<br \/>\n08:56<br \/>\nrate.<br \/>\n08:57<br \/>\nIn addition, the author also<br \/>\n08:59<br \/>\nsuggests performing<br \/>\n09:00<br \/>\nserial ultrasound growth scans<br \/>\n09:02<br \/>\nas a form<br \/>\n09:03<br \/>\nof fetal and anatomic survey,<br \/>\n09:06<br \/>\nas well as doppler blood flow<br \/>\n09:07<br \/>\nstudies<br \/>\n09:08<br \/>\nto assess the amount of blood<br \/>\n09:09<br \/>\nflow to the fetus.<br \/>\n09:11<br \/>\nThese suggestions are in line<br \/>\n09:13<br \/>\nwith the current literature.<br \/>\n09:14<br \/>\nHowever when we did a literature<br \/>\n09:16<br \/>\nsearch, there are studies that<br \/>\n09:18<br \/>\nalso support fetal karyotyping<br \/>\n09:20<br \/>\nto screen for karyotypes types<br \/>\n09:22<br \/>\nsuch as Trisome 21 and 18,<br \/>\n09:24<br \/>\nwhich may lead<br \/>\n09:25<br \/>\nto anatomical defect<br \/>\n09:26<br \/>\nin the fetus and has SGA\/IUGR.<br \/>\n09:31<br \/>\nIn addition, another study<br \/>\n09:32<br \/>\nsuggested performing<br \/>\n09:33<br \/>\nmaternal serum examination<br \/>\n09:35<br \/>\nfor infection<br \/>\n09:36<br \/>\nsuch as corneal immunitis.<br \/>\n09:37<\/p>\n<p>09:42<br \/>\nAs part of antepartum<br \/>\n09:44<br \/>\nmanagement, other literatures<br \/>\n09:45<br \/>\nhave suggested repeating<br \/>\n09:46<br \/>\nultrasounds one to two times<br \/>\n09:48<br \/>\na week if normal,<br \/>\n09:49<br \/>\nbut more frequently if result is<br \/>\n09:51<br \/>\nabnormal.<br \/>\n09:52<br \/>\nAnother studies suggests<br \/>\n09:53<br \/>\nthat glucocorticoids be given<br \/>\n09:55<br \/>\nto the mother for preterm<br \/>\n09:56<br \/>\ngestations<br \/>\n09:57<br \/>\nto aid in fetal maturity.<br \/>\n09:59<br \/>\nAnd of course, should the cause<br \/>\n10:01<br \/>\nof SGA be found, treatment<br \/>\n10:03<br \/>\nshould be given to the mother<br \/>\n10:04<br \/>\nimmediately.<br \/>\n10:05<br \/>\nFor example, control<br \/>\n10:06<br \/>\nof hypertension in the mother,<br \/>\n10:09<br \/>\nand treatment of CMV<br \/>\n10:10<br \/>\nwith antiviral hyperimmuno<br \/>\n10:12<br \/>\nglobulin therapy.<br \/>\n10:14<\/p>\n<p>10:17<br \/>\nThere is, however,<br \/>\n10:18<br \/>\nan important question that<br \/>\n10:19<br \/>\nremained<br \/>\n10:20<br \/>\nelusive to obstetricians<br \/>\n10:21<br \/>\neven to today.<br \/>\n10:23<br \/>\nThe key question is, how will<br \/>\n10:25<br \/>\nthe neonate do<br \/>\n10:26<br \/>\nat a current gestation age<br \/>\n10:27<br \/>\nversus what is the ongoing risk<br \/>\n10:29<br \/>\nover the next week and outcome<br \/>\n10:31<br \/>\nif he achieves another week<br \/>\n10:32<br \/>\nof gestation.<br \/>\n10:33<br \/>\nThere is however<br \/>\n10:34<br \/>\nlittle consensus<br \/>\n10:35<br \/>\nabout the optimal time<br \/>\n10:36<br \/>\nof delivery of the fetus.<br \/>\n10:38<br \/>\nThis is partly<br \/>\n10:39<br \/>\ndue to the insufficient evidence<br \/>\n10:41<br \/>\nfrom randomized control trial.<br \/>\n10:42<\/p>\n<p>10:45<br \/>\nIf we guess to the delivery<br \/>\n10:47<br \/>\ntiming of fetus<br \/>\n10:47<br \/>\nin the setting of SGA,<br \/>\n10:50<br \/>\nthe author did however mention<br \/>\n10:51<br \/>\nsome determinants that could<br \/>\n10:52<br \/>\nassist obstetricians into making<br \/>\n10:54<br \/>\na delivery decision.<br \/>\n10:56<br \/>\nFor example, the author<br \/>\n10:57<br \/>\nsuggested doppler ultrasound<br \/>\n10:58<br \/>\nscanning, particularly looking<br \/>\n11:00<br \/>\nat the umbilical artery<br \/>\n11:01<br \/>\nas a determinant<br \/>\n11:02<br \/>\nfor the decision<br \/>\n11:03<br \/>\nto deliver a fetus.<br \/>\n11:05<br \/>\nAs you can see from the chart<br \/>\n11:06<br \/>\nhere, should the ultrasound scan<br \/>\n11:09<br \/>\nshow normal blood flow,<br \/>\n11:11<br \/>\nthe author suggested<br \/>\n11:12<br \/>\nongoing fetal assessment<br \/>\n11:14<br \/>\none to two times per week<br \/>\n11:15<br \/>\nand expected management<br \/>\n11:17<br \/>\nto achieve fetal maturity.<br \/>\n11:19<br \/>\nHowever if there is<br \/>\n11:20<br \/>\nabnormal blood flow,<br \/>\n11:21<br \/>\nsuch as reverse end-diastolic<br \/>\n11:22<br \/>\nblood flow, the author suggested<br \/>\n11:25<br \/>\ndelivery<br \/>\n11:25<br \/>\nat any viable gestation age.<br \/>\n11:28<br \/>\nIf the abnormal blood flow is<br \/>\n11:30<br \/>\nin the form of increased<br \/>\n11:32<br \/>\nsystolic or diastolic ratio<br \/>\n11:34<br \/>\nor absent diastolic blood flow<br \/>\n11:36<br \/>\nand the fetus is at least 24<br \/>\n11:38<br \/>\nto 25 weeks gestational age,<br \/>\n11:41<br \/>\nthe author suggested<br \/>\n11:42<br \/>\nexpectant measurement in view<br \/>\n11:43<br \/>\nof high risk and more<br \/>\n11:45<br \/>\nfrequent evaluation<br \/>\n11:46<br \/>\nis indicated.<br \/>\n11:49<br \/>\nIf the gestation age is more<br \/>\n11:50<br \/>\nthan 25 weeks, the author<br \/>\n11:52<br \/>\nsuggested weighing the risk<br \/>\n11:53<br \/>\nand benefits of delivering<br \/>\n11:55<br \/>\nthe fetus.<br \/>\n11:56<\/p>\n<p>11:59<br \/>\nThe author also suggested<br \/>\n12:00<br \/>\namniotic fluid index<br \/>\n12:02<br \/>\nas a determinant<br \/>\n12:03<br \/>\nfor the delivery timing.<br \/>\n12:05<br \/>\nAlthough the AFI is<br \/>\n12:06<br \/>\na crude measurement of mid<br \/>\n12:08<br \/>\nto long term placental function,<br \/>\n12:09<br \/>\nthe author suggests earlier<br \/>\n12:10<br \/>\ndelivery of fetus,<br \/>\n12:12<br \/>\nif oligohydramnios in a setting<br \/>\n12:14<br \/>\nof suspect IUGR.<br \/>\n12:16<br \/>\nIn addition, there is also<br \/>\n12:17<br \/>\na study that the auto quoted<br \/>\n12:18<br \/>\nthat suggested<br \/>\n12:19<br \/>\nthat every extra week<br \/>\n12:20<br \/>\nof intrauterine maturation<br \/>\n12:22<br \/>\nfor the fetus<br \/>\n12:23<br \/>\nput twice the risk<br \/>\n12:24<br \/>\nof stillbirth.<br \/>\n12:25<br \/>\nTherefore, the recent benefit<br \/>\n12:27<br \/>\nof delaying delivery<br \/>\n12:28<br \/>\nmay be complicated<br \/>\n12:29<br \/>\nwith an increased risk<br \/>\n12:30<br \/>\nof stillbirth,<br \/>\n12:31<br \/>\nand this is an important factor<br \/>\n12:33<br \/>\nfor all obstetricians<br \/>\n12:34<br \/>\nto take note.<br \/>\n12:34<\/p>\n<p>12:37<br \/>\nThis is a list<br \/>\n12:38<br \/>\nof relevant literatures<br \/>\n12:39<br \/>\nthat we found on Pat Net.<br \/>\n12:41<br \/>\nBasically, there are<br \/>\n12:41<br \/>\nmany different studies that<br \/>\n12:43<br \/>\nattempted to scrutinize<br \/>\n12:44<br \/>\nthe different factors that may<br \/>\n12:45<br \/>\nimprove the outcome of the fetus<br \/>\n12:47<br \/>\nin the setting of SGA.<br \/>\n12:49<br \/>\nFor example, there was a study<br \/>\n12:51<br \/>\nthat suggested<br \/>\n12:52<br \/>\nevery single intrauterine day<br \/>\n12:54<br \/>\nimproved the survival of fetus<br \/>\n12:55<br \/>\nby 1% to 2%<br \/>\n12:57<br \/>\nbetween the gestational age<br \/>\n12:58<br \/>\nof 26 to 29 weeks.<br \/>\n13:00<br \/>\nHowever, the issue is that there<br \/>\n13:02<br \/>\nis no breakthrough study that<br \/>\n13:04<br \/>\nhas sufficient evidence to guide<br \/>\n13:05<br \/>\nthe delivery of SGA fetus.<br \/>\n13:08<br \/>\nThis is perhaps attributed<br \/>\n13:09<br \/>\nto the difficulty of performing<br \/>\n13:10<br \/>\nrandomized controlled trial<br \/>\n13:11<br \/>\nin this area.<br \/>\n13:12<\/p>\n<p>13:15<br \/>\nWe did however manage to find<br \/>\n13:17<br \/>\nan author that tried to use<br \/>\n13:18<br \/>\nseveral parameters<br \/>\n13:19<br \/>\nsuch as abdominal,<br \/>\n13:20<br \/>\ncircumference, growth rate,<br \/>\n13:22<br \/>\nbiophysical profiling<br \/>\n13:24<br \/>\nto classify the severity<br \/>\n13:26<br \/>\nof IMGR.<br \/>\n13:27<br \/>\nIn this study,<br \/>\n13:28<br \/>\nHarman and Baschat basically<br \/>\n13:30<br \/>\nused parameters as mentioned<br \/>\n13:31<br \/>\nearlier to stratify fetus<br \/>\n13:33<br \/>\nin IUGR setting into five<br \/>\n13:35<br \/>\ndifferent gradings for which<br \/>\n13:36<br \/>\neach grading had a suggested<br \/>\n13:38<br \/>\ncourse of action to be taken.<br \/>\n13:40<br \/>\nFor example, scenario one<br \/>\n13:42<br \/>\nis the least severe<br \/>\n13:43<br \/>\nand therefore expected<br \/>\n13:44<br \/>\nmanagement is advice, where<br \/>\n13:46<br \/>\nas scenario five is the most<br \/>\n13:47<br \/>\nsevere<br \/>\n13:48<br \/>\nand has delivery as soon<br \/>\n13:49<br \/>\nas possible is advised.<br \/>\n13:51<br \/>\nWe feel that perhaps such a<br \/>\n13:53<br \/>\ngraduated approach to IUGR<br \/>\n13:55<br \/>\nmay be helpful to assist<br \/>\n13:57<br \/>\nobstetricians in judging<br \/>\n13:58<br \/>\nthis issue.<br \/>\n13:58<\/p>\n<p>14:01<br \/>\nFinally, I would like to provide<br \/>\n14:03<br \/>\na summary of critique<br \/>\n14:04<br \/>\nfor this article.<br \/>\n14:05<br \/>\nThe author did point<br \/>\n14:06<br \/>\nout several important points.<br \/>\n14:08<br \/>\nFor example, he recognized<br \/>\n14:09<br \/>\nthe importance to differentiate<br \/>\n14:11<br \/>\nbetween SGA and IUGR,<br \/>\n14:12<br \/>\nand also proposed delineation<br \/>\n14:14<br \/>\nand better academic definitions<br \/>\n14:16<br \/>\nbetween SGA and IUGR.<br \/>\n14:18<br \/>\nIn addition, he also attempted<br \/>\n14:20<br \/>\nto normalize measurements based<br \/>\n14:21<br \/>\non multiple factors<br \/>\n14:22<br \/>\nsuch as parents height, weight,<br \/>\n14:24<br \/>\nethnicity to remove confounding<br \/>\n14:26<br \/>\nvariables in the diagnosis<br \/>\n14:27<br \/>\nof IUGR.<br \/>\n14:29<br \/>\nHowever, there are areas where<br \/>\n14:31<br \/>\nthe author failed to discuss as<br \/>\n14:32<br \/>\nwell.<br \/>\n14:33<br \/>\nFor example, although he did<br \/>\n14:34<br \/>\nmention key management steps<br \/>\n14:35<br \/>\nof SGA, he omitted discussion<br \/>\n14:38<br \/>\non categorization, profiles,<br \/>\n14:40<br \/>\nand graduated management steps<br \/>\n14:42<br \/>\nbased on BPP and doppler<br \/>\n14:44<br \/>\nultrasound,<br \/>\n14:45<br \/>\nas well as antepartum management<br \/>\n14:47<br \/>\nmeasures.<br \/>\n14:48<br \/>\nIn addition, although he did<br \/>\n14:50<br \/>\ndiscuss the dilemma<br \/>\n14:50<br \/>\nbetween prematurity<br \/>\n14:51<br \/>\nand stillbirth,<br \/>\n14:53<br \/>\nhe did not suggest<br \/>\n14:53<br \/>\na clear framework on handling<br \/>\n14:55<br \/>\nthe issue, thusly he did you not<br \/>\n14:57<br \/>\nmention<br \/>\n14:58<br \/>\nabout the important randomized<br \/>\n14:59<br \/>\ntrials that has been done so far<br \/>\n15:01<br \/>\nand the inconclusive results<br \/>\n15:02<br \/>\nfrom these trials.<\/p>\n<p><\/div>\n","protected":false},"excerpt":{"rendered":"<p>Duration 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