APGO U wise questions
Topics:
- Intrauterine growth restriction
- How to assess growth restriction (what measures, parameters, etc)
- How to monitor baby after growth restriction is detected
- How to treat said baby - answer
Baby's weight (EFW = "estimated fetal weight) is < 10th percentile. Diagnosis? - answer
Intrauterine growth restriction
Types of intrauterine growth restriction? - answer*Symmetric* - All parts of body are
small
*Asymmetric* - Only trunk and limbs small (head is normal)
What causes symmetrical intrauterine growth restriction? - answer- Congenital disease
- Aneuploidies
(think: intrinsic to baby)
What causes asymmetrical intrauterine growth restriction? - answer- Placental
insufficiency
- Maternal disease
(think: extrinsic to baby)
All causes of intrauterine growth restriction? - answer- Congenital
- Aneuploidies
- Uteroplacental insufficiency
- Maternal disease
When the EFW < 10th percentile, what's the NBS? - answer(1) Confirm by measuring
*fetal biometry* using *ultrasound*.
(2) Amniotic fluid volume: *oligohydramnios*
(3) Umbilical artery *systolic to diastolic* ratio doppler ultrasound
(4) Non stress test
What are the parts of a *fetal biometry*? - answerThis includes
(1) Head circumference
(2) Abdominal circumference
(3) Biparietal length
(4) Femur length
What does amniotic fluid volume show in IUGR? - answerLow volume
*oligohydramnios*
,What does umbilical artery doppler show in IUGR? - answerUmbilical artery
systolic:diastolic ratio *increases*
Workup for IUGR? - answer(1) Determine percentile for EFW
(2) Confirm w/ fetal biometry, amniotic fluid level, umbilical artery ratio, non stress test
What to do once IUGR is diagnosed? - answer(1) Antenatal testing (keep monitoring
before birth)
-OR-
(2) Deliver (induce labor)
IUGR is diagnosed. NBS is antenatal testing. What is this antenatal testing? - answer(1)
Non-stress test (NST) - look at fetal heart tone when fetus is moved
(2) Biophysical profile - ultrasound (Fetal movement), fetal heart tones, breathing,
amniotic fluid index (not amniocentesis)
Continue until delivery
How does an NST work (opposed to contraction stress test)? - answerThe NST is
based on the principle that when the fetus moves, its heartbeat normally accelerates.
The NST assesses fetal health through monitoring accelerations of the heart rate in
response to the baby's own movements.
When to induce labor in IUGR patient? - answerWhen IUGR is severe:
- 36 weeks gestation or greater (viable)
- Oligohydramnios
- Abnormal umbilical artery Doppler studies.
What are the (5) conditions associated with IUGR? - answer"CHAMP"
C - congenital anomalies
H - hypoglycemia, hypothermia
A - asphyxia
M - meconium aspiration
P - polycythemia
Is IUGR associated with polyhydramnios or oligohydramnios? - answerOligohydramnios
What causes polyhydramnios? - answer(1) Produce too much amniotic fluid -
hyperglycemia
(2) Don't remove enough amniotic fluid by swallowing - CNS problem (anencephaly), GI
problem (esophageal atresia, duodenal atresia), diaphragmatic hernia, muscular
disease
,A baby with IUGR will develop what diseases later? - answerFetal growth restriction is a
significant risk factor for the subsequent development of:
- Cardiovascular disease
- Chronic hypertension
- Chronic obstructive lung disease
- Diabetes
What is *macrosomia*? - answerBirth weight at or above the 90th percentile for
gestational age.
What causes *macrosomia*? - answerEnhanced growth potential
Abnormal maternal glucose homeostasis - diabetic mother;
Underestimation of fetal age
What are the problems for macrosomia babies with diabetic moms (gestational
diabetes)? - answer- Higher chance of death: neonatal morbidity, due to birth trauma
such as shoulder dystocia and brachial plexus injury.
- Severe hypoglycemia
- Neonatal jaundice.
- Neonatal acidosis
(hypoglycemia, hypocalcemia, polycythemia, hyperbilirubinemia, polyhydramnios,
shoulder dystocia/macrosomia, pre eclampsia)
Note: gestational diabetes is NOT associated with increased risk of congenital
anomalies.
A 36-year-old G1 began prenatal care at eight weeks gestation. At that time, the
gestational age was confirmed by a transvaginal ultrasound. She is now at 36 weeks
gestation. Her previous medical history reveals hypertension for eight years and class F
diabetes for five years (baseline proteinuria = 1 g). She smokes one half-pack of
cigarettes per day. On examination at 32 weeks gestation, her fundal height was 29 cm.
At 33 weeks, biometry was consistent with 31-3/7, EFW 1827g, 25th percentile. Today,
ultrasound reveals limited fetal growth over the past three weeks. Biometry is consistent
with 31-5/7, EFW 1900 g, <10th percentile. What is the most likely etiology of the
intrauterine growth restriction in this case?
A. Genetic factors
B. Congenital anomaly
C. Tobacco use
D. Uteroplacental insufficiency
E. Perinatal infection - answerD. There is substantial evidence from experimental
animal studies that suggests that alterations in uteroplacental perfusion affect the
growth and status of the fetus, as well as the placenta. This patient has significant
medical diseases that are affecting her vasculature and, ultimately, limiting the substrate
, availability to the fetus with resultant uteroplacental insufficiency. The vascular disease
is evidenced by retinopathy and proteinuria. The other choices above may all result in
fetal growth restriction; however, they are not the most likely etiology in this clinical
scenario.
A 36-year-old G1 with type 1 diabetes is diagnosed with intrauterine growth restriction at
33 weeks gestation. What is the most appropriate next step in management?
A. Amniocentesis
B. Immediate delivery
C. Weekly ultrasounds to assess fetal growth
D. Antenatal testing of fetal well-being
E. Observation - answerD
Once intrauterine growth restriction is detected, the fetus needs to be evaluated
periodically for evidence of well-being until delivery is deemed necessary. This will
result in once or twice weekly testing, depending on the modality of assessment that is
being used. Testing includes: non-stress test (NST), where the fetal heart beat is
recorded over a period of at least 30 minutes while looking for accelerations with fetal
movement, and the biophysical profile, which includes an ultrasound evaluation of fetal
movement, fetal tone, amniotic fluid and breathing. NSTs should be performed twice
weekly with at least a weekly AFI. The BPP may be performed weekly. Ultrasound for
fetal growth is not useful if more frequent than every two weeks. An amniocentesis for
fetal lung maturity can be considered at more advanced gestational age.
A 36-year-old female G1 presents for her prenatal care visit at 35 weeks gestation. She
has good dating criteria that were confirmed by a first trimester ultrasound. Her previous
medical history is positive for hypertension and type 2 diabetes. You have been
following fetal growth with serial ultrasounds. At this visit, ultrasound reveals limited fetal
growth over the past three weeks. Biometry is consistent with 32-5/7, EFW 2175 g,
<10th percentile. What is the most appropriate next test indicated in the management of
this patient?
A. Amniotic fluid volume, umbilical artery Doppler systolic: diastolic ratio, non-stress test
B. Daily fetal kick counts with follow up ultrasound to reassess fetal growth in one week
C. Amniocentesis for fetal lung maturity
D. Twice daily fetal kick counts with delivery at 37 weeks gestation
E. None, delivery is indicated - answerA. When a pregnancy is complicated by fetal
growth restriction, various fetal physiologic parameters require assessment. In growth-
restricted pregnancies, oligohydramnios is frequently found. This finding is presumably
due to reduced fetal blood volume, renal blood flow and urinary output. Chronic hypoxia
is responsible for diverting blood flow from the kidney to organs that are more critical
during fetal life. The significance of the amniotic fluid volume with respect to fetal
outcome has been well documented. Ninety percent of patients with oligohydramnios
delivered growth restricted infants. These infants experienced a high rate of fetal
compromise. The systolic/diastolic (S/D) ratio of the umbilical artery is determined by
Doppler ultrasound. An increase in the S/D ratio reflects increased vascular resistance.
Topics:
- Intrauterine growth restriction
- How to assess growth restriction (what measures, parameters, etc)
- How to monitor baby after growth restriction is detected
- How to treat said baby - answer
Baby's weight (EFW = "estimated fetal weight) is < 10th percentile. Diagnosis? - answer
Intrauterine growth restriction
Types of intrauterine growth restriction? - answer*Symmetric* - All parts of body are
small
*Asymmetric* - Only trunk and limbs small (head is normal)
What causes symmetrical intrauterine growth restriction? - answer- Congenital disease
- Aneuploidies
(think: intrinsic to baby)
What causes asymmetrical intrauterine growth restriction? - answer- Placental
insufficiency
- Maternal disease
(think: extrinsic to baby)
All causes of intrauterine growth restriction? - answer- Congenital
- Aneuploidies
- Uteroplacental insufficiency
- Maternal disease
When the EFW < 10th percentile, what's the NBS? - answer(1) Confirm by measuring
*fetal biometry* using *ultrasound*.
(2) Amniotic fluid volume: *oligohydramnios*
(3) Umbilical artery *systolic to diastolic* ratio doppler ultrasound
(4) Non stress test
What are the parts of a *fetal biometry*? - answerThis includes
(1) Head circumference
(2) Abdominal circumference
(3) Biparietal length
(4) Femur length
What does amniotic fluid volume show in IUGR? - answerLow volume
*oligohydramnios*
,What does umbilical artery doppler show in IUGR? - answerUmbilical artery
systolic:diastolic ratio *increases*
Workup for IUGR? - answer(1) Determine percentile for EFW
(2) Confirm w/ fetal biometry, amniotic fluid level, umbilical artery ratio, non stress test
What to do once IUGR is diagnosed? - answer(1) Antenatal testing (keep monitoring
before birth)
-OR-
(2) Deliver (induce labor)
IUGR is diagnosed. NBS is antenatal testing. What is this antenatal testing? - answer(1)
Non-stress test (NST) - look at fetal heart tone when fetus is moved
(2) Biophysical profile - ultrasound (Fetal movement), fetal heart tones, breathing,
amniotic fluid index (not amniocentesis)
Continue until delivery
How does an NST work (opposed to contraction stress test)? - answerThe NST is
based on the principle that when the fetus moves, its heartbeat normally accelerates.
The NST assesses fetal health through monitoring accelerations of the heart rate in
response to the baby's own movements.
When to induce labor in IUGR patient? - answerWhen IUGR is severe:
- 36 weeks gestation or greater (viable)
- Oligohydramnios
- Abnormal umbilical artery Doppler studies.
What are the (5) conditions associated with IUGR? - answer"CHAMP"
C - congenital anomalies
H - hypoglycemia, hypothermia
A - asphyxia
M - meconium aspiration
P - polycythemia
Is IUGR associated with polyhydramnios or oligohydramnios? - answerOligohydramnios
What causes polyhydramnios? - answer(1) Produce too much amniotic fluid -
hyperglycemia
(2) Don't remove enough amniotic fluid by swallowing - CNS problem (anencephaly), GI
problem (esophageal atresia, duodenal atresia), diaphragmatic hernia, muscular
disease
,A baby with IUGR will develop what diseases later? - answerFetal growth restriction is a
significant risk factor for the subsequent development of:
- Cardiovascular disease
- Chronic hypertension
- Chronic obstructive lung disease
- Diabetes
What is *macrosomia*? - answerBirth weight at or above the 90th percentile for
gestational age.
What causes *macrosomia*? - answerEnhanced growth potential
Abnormal maternal glucose homeostasis - diabetic mother;
Underestimation of fetal age
What are the problems for macrosomia babies with diabetic moms (gestational
diabetes)? - answer- Higher chance of death: neonatal morbidity, due to birth trauma
such as shoulder dystocia and brachial plexus injury.
- Severe hypoglycemia
- Neonatal jaundice.
- Neonatal acidosis
(hypoglycemia, hypocalcemia, polycythemia, hyperbilirubinemia, polyhydramnios,
shoulder dystocia/macrosomia, pre eclampsia)
Note: gestational diabetes is NOT associated with increased risk of congenital
anomalies.
A 36-year-old G1 began prenatal care at eight weeks gestation. At that time, the
gestational age was confirmed by a transvaginal ultrasound. She is now at 36 weeks
gestation. Her previous medical history reveals hypertension for eight years and class F
diabetes for five years (baseline proteinuria = 1 g). She smokes one half-pack of
cigarettes per day. On examination at 32 weeks gestation, her fundal height was 29 cm.
At 33 weeks, biometry was consistent with 31-3/7, EFW 1827g, 25th percentile. Today,
ultrasound reveals limited fetal growth over the past three weeks. Biometry is consistent
with 31-5/7, EFW 1900 g, <10th percentile. What is the most likely etiology of the
intrauterine growth restriction in this case?
A. Genetic factors
B. Congenital anomaly
C. Tobacco use
D. Uteroplacental insufficiency
E. Perinatal infection - answerD. There is substantial evidence from experimental
animal studies that suggests that alterations in uteroplacental perfusion affect the
growth and status of the fetus, as well as the placenta. This patient has significant
medical diseases that are affecting her vasculature and, ultimately, limiting the substrate
, availability to the fetus with resultant uteroplacental insufficiency. The vascular disease
is evidenced by retinopathy and proteinuria. The other choices above may all result in
fetal growth restriction; however, they are not the most likely etiology in this clinical
scenario.
A 36-year-old G1 with type 1 diabetes is diagnosed with intrauterine growth restriction at
33 weeks gestation. What is the most appropriate next step in management?
A. Amniocentesis
B. Immediate delivery
C. Weekly ultrasounds to assess fetal growth
D. Antenatal testing of fetal well-being
E. Observation - answerD
Once intrauterine growth restriction is detected, the fetus needs to be evaluated
periodically for evidence of well-being until delivery is deemed necessary. This will
result in once or twice weekly testing, depending on the modality of assessment that is
being used. Testing includes: non-stress test (NST), where the fetal heart beat is
recorded over a period of at least 30 minutes while looking for accelerations with fetal
movement, and the biophysical profile, which includes an ultrasound evaluation of fetal
movement, fetal tone, amniotic fluid and breathing. NSTs should be performed twice
weekly with at least a weekly AFI. The BPP may be performed weekly. Ultrasound for
fetal growth is not useful if more frequent than every two weeks. An amniocentesis for
fetal lung maturity can be considered at more advanced gestational age.
A 36-year-old female G1 presents for her prenatal care visit at 35 weeks gestation. She
has good dating criteria that were confirmed by a first trimester ultrasound. Her previous
medical history is positive for hypertension and type 2 diabetes. You have been
following fetal growth with serial ultrasounds. At this visit, ultrasound reveals limited fetal
growth over the past three weeks. Biometry is consistent with 32-5/7, EFW 2175 g,
<10th percentile. What is the most appropriate next test indicated in the management of
this patient?
A. Amniotic fluid volume, umbilical artery Doppler systolic: diastolic ratio, non-stress test
B. Daily fetal kick counts with follow up ultrasound to reassess fetal growth in one week
C. Amniocentesis for fetal lung maturity
D. Twice daily fetal kick counts with delivery at 37 weeks gestation
E. None, delivery is indicated - answerA. When a pregnancy is complicated by fetal
growth restriction, various fetal physiologic parameters require assessment. In growth-
restricted pregnancies, oligohydramnios is frequently found. This finding is presumably
due to reduced fetal blood volume, renal blood flow and urinary output. Chronic hypoxia
is responsible for diverting blood flow from the kidney to organs that are more critical
during fetal life. The significance of the amniotic fluid volume with respect to fetal
outcome has been well documented. Ninety percent of patients with oligohydramnios
delivered growth restricted infants. These infants experienced a high rate of fetal
compromise. The systolic/diastolic (S/D) ratio of the umbilical artery is determined by
Doppler ultrasound. An increase in the S/D ratio reflects increased vascular resistance.
