SMALL FOR GESTATIONAL AGE

INTRODUCTION
- Fetal growth is dependent on genetic, placental and maternal factors.
- Fetal growth restriction is the second leading cause of perinatal morbidity and mortality.
ASSESSING FETAL GROWTH
HISTORY
PHYSICAL EXAM
USES OF ULTRASOUND
- Mothers age
a) General Exam
- Diagnosis and confirmation
- Accuracy of LMP
b) Obstetrical Exam
of viability in early pregnancy
date
Uterine Fundal Height
- Determination of gestational
- Infections during
- Obtaining serial uterine fundal height
age and assessment of fetal
pregnancy
measurements.
size
- Multiple
- The Mcdonalds rule in pregnancy is a
- Intrauterine or Ectopic
pregnancy
rough determination of fetal age in weeks
pregnancy.
- ANC and visits,
Uterus size: by pelvic examination in the
- Multiple pregnancy
Supplements
first trimester and subsequent antenatal
- Diagnosis of fetal
- Past obs. Hx, Past visits.
abnormalities
Med Hx, Drug Hx,
Misleading in: Full bladder, obesity, deep
- Placental localization
Family Hx,
masses, uterine fibroids & multiple
- Assessment of fetal wellSocioeconomic Hx. pregnancy
being
DETERMINATION OF GA AND ASSESSMENT OF GROWTH
UP TO 13TH WEEKS GA
FROM 16 24 WEEKS GA
CROWN-RUMP LENGTH
BIPARIETAL DIAMETER
HEAD CIRCUMFERENCE
FEMUR LENGTH
(CRL)
(BPD)
(HC)
(FL)
From Crown to
The transverse width Not affected by the
- Better than BPD
shape of the head.
in accuracy and
Coccyx (Rump)
of the head at its
timing.
(longitudinal axis).
widest (the distance
- Accurate only
Accurate up to 14
between the parietal
when the image
bones eminence of
wks (1st TM).
shows two blunted
the skull).
It is the most
ends of the femur.

Accurate
up
to16-24
accurate
wks.
parameter.
Accuracy of +/- 7
Accuracy of +/- 5
days.
days from the GA.
It is affected by the
shape of the head.

FETAL VIABILITY
Detection of :
Gestational sac (45wks)
Yolk sac (5wks)
Embryo (5-6wks)
Visible heart beat
(6wks).

ABDOMINAL
CIRCUMFERENCE (AC)
Made at the widest
points in the
abdomen.
Most accurate
single predictor of
fetal weight.

SMALL FOR GESTATIONAL AGE (SGA)

Small for gestational age is defined as a fetal birth weight below the 10 th centile for the stated gestational age.
The incidence of SGA fetuses is 5-10%
CONSTITUTIONAL
(70%)
SGA

PREMATURITY (10%)
INTRAUTERINE
GROWTH
RESTRICTION (20%)

SYMMETRICAL IUGR
(20%)
ASYMMETRICAL IUGR
(80%)

A] CONSTITUTIONALLY SMALL FETUS

Unfortunately, it can be concluded that a fetus is constitutionally small only after pathologic processes have
been excluded.
Therefore, identification of a constitutionally small infant is usually made in retrospect, after the infant is born.
Causes (Multifactorial): Race, Geographical area, Sex (M>F), Maternal age, Maternal weight and height,
Socioeconomic status

B] INTRA-UTERINE GROWTH RESTRICTION

Failure of the fetus to achieve its growth potential
INCIDENCE
TYPES
3 - 10 % of all pregnancies.
Symmetrical growth restriction: fetus whose entire body is
proportionally small. (20%)
20 % of stillborns are growth retarded.
Asymmetrical growth restriction: Decrease in subcutaneous fat and
9 - 27 % have anatomic and/or genetic
abdominal circumference with relative sparing of head circumference
abnormalities.
and femur length. (80%)
Perinatal mortality is 8 - 10 times higher for
these fetuses.
CAUSES OF IUGR
MATERNAL
MATERNAL
FETAL
FETAL PATHOLOGICAL
PLACENTAL CAUSES
PHYSIOLOGICAL
PATHOLOGICAL CAUSES
PHYSIOLOGICAL
CAUSES
CAUSE
CAUSES
Multiple pregnancy Uteroplacental
Genetic disorders
Placental
Genetic Factors:
blood flow:
(Achondroplasia,
insufficiency
Short stature
Race, ethnicity,
- PET/eclampsia
Russell
silver
synd)
(most imp in 3rd
Younger or older
nationality
trimester)
Chromosomal
age (<15 and >45) - chronic renovascular
sex (male weigh
anomalies:
Anatomic
Low socioeconomic disease
150 -200 gm
- Chronic HTN
Chromosomal
deletions
problems:
class
more than
Maternal malnutrition
Trisomies
13,18
&
21
Multiple
infarcts
Primiparity
female)
Aberrant
cord
Maternal hypoxemia

Congenital
Grand multiparity
Parity
insertions
Hemoglobinopathies
malformations:
Low pregnancy
(primiparous,
- Umbilical
- High altitudes
Ex: Anencephaly, GI
weight
weigh less than
vascular thrombosis
atresia, Potters
Drugs
Previous h/o
subsequent
& hemangiomas
syndrome, and
preterm IUGR baby - Cigarettes, alcohol,
siblings)
- Premature
pancreatic agenesis.
heroin, cocaine
placental
separation
- Teratogens,
Fetal Cardiovascular
- Small Placenta
antimetabolites and
anomalies
therapeutic agents such
Congenital Infxn:
as trimethadione,
mainly TORCH.
warfarin, phenytoin.
Inborn error of
Chronic illness (DM,
metabolism:
renal failure, cyanotic
- Transient neonatal
heart disease etc.)
diabetes

- Galactosemia
- PKU
DIAGNOSIS
History, Physical examination, Investigations
Ultrasound
Abdominal circumference is the single most
effective parameter for predicting fetal weight
because its reduced in both symmetrical &
Asymmetrical IUGR .
In the presence of normal head and femur
measurements, abdominal circumference (AC)
measurements of less than 2 standard deviations
below the mean appear to be a reasonable cutoff to
consider a fetus asymmetric.
COMPLICATIONS
ANTENATAL
NEONATAL
Metabolic changes 1- Related to hypoxia and
acidosis:
(acidosis etc).
a- Meconium aspiration.
Oligohydramnios
b- Persistent fetal
(80%)
circulation.
Abnormal fetal
c- Hypoxic ischemic
heart patterns.
encephalopathy.
Abnormal Doppler
2- Metabolic: Hypoglycemia,
studies.
HypoCa, Hypothermia,
IUFD
Hyperviscocity syndrome
INTRAPARTUM
3- Related to the etiology:
Abnormal CTG.
a- Chromosomal
Fetal death.
abnormalities.
Meconium stained
b- Infection.
liquor.
c- Congenital anomalies.
incidence of
instrumental and
caesarean
deliveries.

Asymmetrical growth restriction : BPD is normal in the 3rd

trimester , whereas ratio of HC/AC is abnormal .
Symmetrical growth restriction : HC/AC may be normal .
Amniotic fluid volumes ( oligohydramnios is associated with
IUGR) .
Umbilical artery & fetal artery dopplar assessments : increased
resistance is associated with a greater risk of IUGR as pregnancy
progresses.

PRE-PREGNANCY
Modify lifestyle
habits.
Detect and
treat medical
disorders.

MANAGEMENT
ANTEPARTUM
Regular antenatal care.
Serial fetal growth assessment.
Serial fetal wellbeing assessment
1- Biophysical profile
2- Computerized CTG
3- Umbilical artery Doppler
Timing of delivery.
Mode of delivery.

Time & Mode of delivery governed by: Maternal

age, Past obs. History, GA, Fetal well being,
Status of cervix, Availability of direct
monitoring during labor (Ex: scalp PH
sampling).
Mode of Delivery
Cesarean delivery without a trial of labor:
1. in the presence of evidence of fetal distress
2. for traditional obstetrical indications for
cesarean delivery

 Induction of labor
Continuous heart rate monitoring and scalp pH
monitoring optimize success of vaginal delivery