FGR

Question 1

What are the common causes of FGR?

Answer 1

• Infections, chromosome, drugs, structural anomalies
• Maternal medication conditions
  o Collagen vascular-renal disease, hypertension, APS, thrombophilias
• Idiopathic (60%)
  o Decreased uteroplacental blood flow (50%)
  o Decreased fetoplacental blood flow (40%)
  o Abnormal gas exchange (i.e. villitis) (10%)  > 32 weeks gestation

Long term health problems
- Coronary heart disease
- Hypertension
- Insulin-resistance syndrome

Question 2

What are the hormonal fetal findings on FGR (based on PUBS studies)

Answer 2

• Hormonal Findings:
  o Increased cortisol (increased adrenal blood flow)
  o Decreased ACTH (negative feedback or reduced placental size)
  o Long term effects: hypertension – due to loss of vessel wall elasticity
• Lipid metabolism:
  o Hypertriglycidemia
   Lipolysis
   Increased synthesis
   Decreased utilization
   Long term outcomes  coronary heart disease
• Amino acid metabolism
  o Decreased essential amino acids
  o Variable levels of nonessential amino acids
  o Increased ratio of nonessential to essential amino acids
  o Long term effects: nutrition/physical development
• Hematology Findgs:
  o Erythroblastemia
  o Macrocystosis
  o Thrombocytopenia
  o Platelet dysfunction
• Metabolic findings:
  o Hypoglycemia (poor placental perfusion/transport)
  o Hypoinsulinemia (pancreatic beta cell dysfunction?)
  o Long term effects: DM II, insulin resistance syndrome

Question 3

What are the types of dopplers used in FGR?

Answer 3

Question 4

What were the findings of the GRIT study

Answer 4

GRIT Study: RCT of timed delivery with
- 1) delivery in 48 hours after abnormal Doppler
- 2) delivery after abnormal Doppler and FHR abnormal
- Neurologic outcomes slightly higher in delayed delivery group; no difference at age 6-13 years of age

Question 5

What are the interpretations of different dopplers used in FGR?

Answer 5

Doppler:
- Uterine artery Doppler sensitivity for PEC = 50%
o Sensitivity for IUGR = 60%
o Predicts better severe (maternal) disease
- MCA: measure PI
o Diastolic component increases; PI will decrease
o Adaptation by increasing blood flow to brain
- Venous system: DV, IVC, UV
o Absent or reversed A wave is abnormal
o Interval to decels/fetal death  1 week
- Placenta not working  redistribute to brain  1st or 2nd?
- In serial evaluations, some fetuses develop ischemic brain lesions before development of abnormal venous Doppler exams or abnormal FHR/FBPs
- Not all IUGR fetuses follow same pattern of deterioration
- 30% Dopplers measurements become abnormal in a predictable manner
- Umbilical artery and MCA detected 88% of all adverse outcomes
- Predictors of stillbirth
o 2nd trimester – deterioration of UA, DV; followed by abnormal BPP
o 3rd trimester – MCA-PI decline; 75% not anticipated by BPP; late stillbirth