Foetal Growth Restriction- The list of medical diseases which can cause a small neonate

A)                     Is the prevalence of FGR on the rise?? How to elicit the medical history in detail which might have caused FGR? How best to confirm and tackle FGR??

Confirmation and detail evaluation of medical history is an art by itself more so in elderly pregnant woman and who clinically seems to you a bit sick. Quite often some albeit minor long standing medical disorders may be the etiology of  FGR and we falsely attribute such cases as placental diseases or idiopathic .Unfortunately some medical diseases or even combination f diseases in a single pregnant woman  are not  disclosed by the concerned woman more so if in Law is present in the consulting room. Possibly some of you have such experience of facing similar cases in your practice life.

Here are some tips:--Dating is certain by early USG, but  surprisingly one finds that foetal weight is less at third trimester:  Put in such situation  one is in dilemma:--Is it FGR with moderate risk of IUFD ?? Or is it SGA foetus with minimal risk of IUD ??? What to do?? What is the etiology of FGR in an well to do family??   

SGA-. The woman concerned is a booked case can recollect LMP with fair degree of accuracy and her periods were regular.--In  such cases where EFW is < 10centile  as many as 70% of such weight lagging foetus  (which appears to be < 10 centile)  at early third trimester ) will be constitutionally  SGA-. These foetus are  not to be termed as FGR  and there will be uniformly decreased diameters all over the body- i.e. all biometric measurement . Such foetus when born even at term may not   catch up growth velocity in postpartum   and there should not be any feeling of guilt / deficiency in ANC service rendered by you.

. In our country as many as 30 % only will be  FGR(IUGR) and in rest 30% of foetus who fall below <10 percentile of underweight   foetus will be really FGR but -with good outcome if born alive. ).

Be it SGA/ FGR : What will be the Plan for  onward management: - To again look for any anomaly even in booked cases which might have been missed in earlier scan  2) Any soft marker for aneuploidy- in USG then to àavoid CS. 3) To exclude diligently if any demonstrable / overt medical  disease which may yield to  FGR foetus : Such diseases are about 19 in number : e.g.  1) PIH & 2) hypertensive disorders,3)  Anaemia, 4) uncontrolled DM, 5) Smoking, 6) COPD, 7) Drug abuse, 8) alcohol, 9) epilepsy 10) Renal diseases . 11) B asthma, 12) SLE, 13) Irritable Bowels Syndrome ( who are in long term high fiber diet, Anticholinergics drugs like hyoscine / Dicyclomine) , 13) Inflammatory Bowel diseases ( be it Celiac disease or Ulcerative diseases- These women are often subjected to repeated  colonoscopy/ sigmoidoscopy even in pregancy period and are treated long term with  Sulphasalazine/ meafazine, high dose F acid, oral steroids /rectal steroids suppositories Azothiaprine & sometimes Anti-TNF agents like INFLIXMAB/ ADALINUMAB etc) , 14) Thalassaemia, 15)  ITP, 16) Hypothyroid states, 17) those who are on psychiatric medications 18) Heart disease 19)  parathyroid disorders & 20) Renal transplant cases . etc   

-Any case no etilogy could be ascertained for FGR then one should institute some empirical Tr.:- Rest,  nutritious diet, Folic Acid, Proteins, Antioxidants, Vasodilators (sildenafil) , Progesterone support to prevent PTL  5) ACS ( steroid coverage)  6)  Weekly/ Fortnightly monitoring  by clinical & USG 7) to deliver as appropriate guided by DFMC, CTG, USG Doppler & AFI and growth velocity. Cerebro placental Ratio is currently one of te major tool which is being currently used increasingly to plan elective CS/induction,NICU facility will help to salvage the neonate if born preterm,.