When to induce in a case of FGR?? Should we terminate the pregancy as soon as there is detection of FGR??

When to induce in a case of FGR?? Should we terminate the pregancy as soon as there is detection of FGR??

We know that an increased S/D ratio in the umbilical artery   is evident in Doppler. But it is equally true that increased S/D ratio in the umbilical artery   is a definite indicating    of increasing   fetal   compromise and should be taken with great concern.   But the question is  how  do we react after diagnosing   Foetal Growth Restriction to avert intra uterine Foetal death??  The degree of hypoxia is best judged by Doppler studies of various fetoplacental vessels.  In fact Doppler studies are superior method than BPP methods like (NST.CTG, BPS) . It is agreed that in comparison to above mentioned biophysical methods like NST  or BPS  umbilical artery Doppler   studies has better  ability to predict poor perinatal   outcome in IUGR   fetuses . An increased S/D ratio in the umbilical artery   is indicative   of increasing   fetal   compromise and should bd taken with great concern . But by that one should not jump on induction or CS as soon as  a patient   exhibit with raised S/ D ratio of Umbilical Artery. Such cases may be followed by &    monitored   with serial Doppler  studies till :

1.  37  weeks maturity

2.  Absent or  reversed diastolic flow

3.  Reversal of Doppler   velocities in ductus venosus   during atrial contraction.

4.  Umbilical    venous   pulsations

Abnormal    NST   or BPP Management   of IUGR is summarized in Flow charts Doppler  Velocimetry ( MA, MCA  & DV) –A) Normal à wait at 37  week then   delivery   . But if EDF   of Umbilical artery is less along with   oligohydramnios à then delivery > 34 weeks.

   

Group    II – SGA Doppler Normal , AFI  -- > 37 weeks – Deliver  < 37 weeks Monitor  with Modified  BPP weekly  biometry  and Doppler  2 weekly . – BPP and Doppler   normal deliver   at 37 weeks – If any of the above abnormal   -Counsel and deliver .

Step I:àSuspect FGR when: -   AC/ EFW < 10^th percentile – Then proceed for Umbilical artery   Doppler – 1) If  Normal Doppler –& AFI normal  then classify her as Phase l- No risk     factors . But if the foetal wt (EFW)  is    3-10   percentile – then a) rescan    at 2-4 weeks-Fetal growth low and AFI low   - An increased S/D ratio in the umbilical artery   is indicative   of increasing   fetal   compromise. A patient   with raised S/ D ratio  can be  monitored   with serial Doppler  studies till 37  weeks maturity

1.  Absent or  reversed diastolic flow

2.  Reversal of Doppler   velocities in ductus venosus   during atrial contraction.

3.  Umbilical    venous   pulsations :

Phase :ll  – Fetal   growth   normal and AFI normal   - Routine  follow up  , An increased S/D ratio in the umbilical artery   is indicative   of increasing   fetal   compromise. A patient   with raised S/ D ratio  can be  monitored   with serial Doppler  studies till AFI reduced 2.  Raised S/D  ratio 3.  Absent   or reversal diastolic flow  

Phase III : Insist not only on Doppler  Velocimetry of Umbilical only. Also concentrate on  , MCA  & DV –

A) If all are normal à and gest age is > 34 weeks then also  follow up with NST, AFI, Growth chart and Doppler weekly  à Objective is to carry her up to wait at 37 week then   delivery   . But if EDF (End Diastolic Flow velocity wave form)    of Umbilical artery  is less along with   oligohydramnios à then delivery > 34 weeks.

  B) But if there is functional deterioration of foetus with features of intrauterine hypoxia when gest age below  < 34 weeks –Then we are at thick soup. We have to hospitalize her and rely mainly on Doppler of Umbilical,   MCA   , and venous Doppler of both Umbilical veins & Ductus venosus. And induce accordingly before 34 weeks occasionally.   

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Phase : IV - SGA and absent or reversed EDF Options  A:--If above 34 weeks –1) Admit and deliver   if > 34 weeks  2)  Options  B If gets age is  < 34 weeks but  > 32 weeks then also àadmission, steroids and NST   8 hourly—Deliver after  48 hours but  immediate delivery may be warranted  provided  a) NST  nonreassuring or b)  spontaneous  decelerations  are evident  or  c) umbilical  venous pulsations or     reversal of flow in ductus   venosus .  3)  Options  C :-If get age is  < 32 weeks steroids Explain  fetal risk  NST- BD:   BPP- daily::   Doppler – biweekly  - a. ) If NST, BPP, % Doppler are normal continue monitoring   till 32 weeks   -à- deliver.  B) If get age is < 32 weeks but If NST, BPP, & Doppler are abnormal   offer delivery after explaining fetal prognosis