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Radiology
Fetal Growth Restriction
Built from Obstetric Imaging
What’s inside
12 sections · 135 slides
Overview
- What this deck covers
The basic idea
Growth potential, and what it means to fall short of it
- A fetus that never reaches its own potential
- Small for gestational age is a number, not a diagnosis
- Why it matters before birth
- Why it matters after birth
How normal growth is supplied
Building the placental supply line, and what it delivers
- Preparation starts before the embryo implants
- The route blood takes to reach the placenta
- The supply line, step by step
- Spiral artery remodelling turns a hose into a river
- 10x
- What actually crosses to the fetus
- Where that blood goes inside the fetus
- The placenta takes its own cut first
- Three compartments have to mature in step
How common it is
Ten percent by definition -- and why the true figure is slippery
- How often does it happen?
- What pushes the numbers up or down
- Twins and preterm babies are hit hardest
Why it happens
Maternal, placental and fetal causes -- and how often each matters
- Three places the problem can sit
- Maternal causes -- the supply side
- Smoking, drugs and alcohol
- It tends to happen again
- Placental insufficiency, the commonest mechanism
- How placental failure becomes small size
- Placental structure and placental genetics
- Confined placental mosaicism and chromosome 16
- Fetal causes -- infection
- Fetal causes -- whole chromosomes
- Fetal causes -- single genes and methylation
- When the bones give the clue
- How to read the risk factor table
- Risk Factors for Fetal Growth Restriction
- Risk Factors for Fetal Growth Restriction (continued)
- Risk Factors for Fetal Growth Restriction (continued)
- Risk Factors for Fetal Growth Restriction (continued)
- Risk Factors for Fetal Growth Restriction (continued)
- Risk Factors for Fetal Growth Restriction (continued)
Making the diagnosis
Dates first, then measurements, then which definition you follow
- Clinical screening: history and fundal height
- Everything rests on knowing the dates
- Why the last menstrual period is not enough
- When ACOG says to revise the due date
- Reading the redating rules
- What the growth scan measures
- Abdominal circumference and weight percentile charts
- What to notice on a serial growth chart
- The trouble with one-size-fits-all charts
- Why Hadlock is still the recommended formula
- Early onset versus late onset
- Severity predicts the outcome
- The old symmetric versus asymmetric split
- The United States definition
- The international definition: early onset
- The international definition: late onset
- Two definitions, two different trade-offs
- What to do once FGR is diagnosed
- Checking the amniotic fluid
Doppler
Four vessels, and the story they tell as the placenta fails
- What Doppler is actually measuring
- Four vessels, four questions
- How a Doppler waveform gives its indices
- Numbers and yes-or-no signs
- Uterine artery Doppler: what should happen
- Normal uterine artery flow in pregnancy
- When the uterine artery transition fails
- Uterine artery notching
- Umbilical artery Doppler: what it looks at
- Normal umbilical artery flow
- What happens when the placenta develops badly
- The umbilical artery deteriorates in order
- Rising umbilical artery resistance
- Absent end-diastolic flow in the umbilical artery
- Reversed end-diastolic flow in the umbilical artery
- Which index should you use?
- What abnormal umbilical Doppler means clinically
- Why the test is weaker in late-onset disease
- Middle cerebral artery: the fetus protects its brain
- How to record the middle cerebral artery properly
- Normal middle cerebral artery flow
- Brain sparing in the middle cerebral artery
- The physiology behind brain sparing
- Cerebroplacental ratio: redistribution in one number
- What the PORTO trial showed about CPR
- Should cerebroplacental ratio be used to screen?
- Where cerebroplacental ratio actually sits today
- Ductus venosus: the fetal express lane
- Normal ductus venosus flow
- When the fetal heart starts to struggle
- Reversed a-wave in the ductus venosus
- What an abnormal a-wave warns you about
- The TRUFFLE study
- The caveat on ductus venosus
Differential diagnosis
Before you call it growth restriction, rule out the mimics
- Is it really growth restriction?
- Low fluid: think about ruptured membranes too
- How Doppler helps the differential
Management before birth
No cure, so the whole question becomes when to deliver
- There is no treatment that makes the fetus grow
- What does help
- Aspirin: for pre-eclampsia, not for FGR alone
- So what is management actually for?
- The monitoring toolkit
- The guidelines do not agree
- Common ground between the guidelines
- The non-stress test
- Computerised cardiotocography
- How often to test
- Why reversed flow means admission
- The biophysical profile
- Why the biophysical profile works
- What a biophysical profile score predicts
- The argument about BPP in growth restriction
- Deciding when to deliver
- Doppler changes outcomes, but guidelines differ
- How to read the delivery timing table
- Delivery Timing Recommendation Differences Between the Society of Maternal-Fetal Medicine and the International Society of Ultrasound in Obstetrics and Gynecology
- Delivery Timing Recommendation Differences Between the Society of Maternal-Fetal Medicine and the International Society of Ultrasound in Obstetrics and Gynecology (continued)
- Notes on that table
After birth
What growth restriction leaves behind, in the first days and for life
- What decides the newborn's outcome
- Immediate metabolic problems
- Brain and nervous system
- Other organ systems
- Infection and long-term disease
- The Barker hypothesis
What to take away
The points the referring clinician needs, and the classic signs
- For the referring physician: dating and diagnosis
- For the referring physician: testing
- For the referring physician: management
- Classic signs
- Key points
References
The chapter's own reference list
- References
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- Suggested reading
- Obstetric Imaging: Fetal Diagnosis and Care, 2nd Edition