gestational-

Fetomaternal Book
Reading
age fetuses: Antenatal and
Intrapartum
Strategies
Presenter:
Dr. Ardelia Bianda

Moderator:
Dr. Hj. Putri Mirani, SpOG (K)
 normal SGA, fetuses that represent (iii)
the lower spectrum of the weight
distribution of the normal population.
intrauterine growth restriction (ii)
(IUGR),fetuses with impaired placental
function; and, by exclusion
abnormal SGA, fetuses whose
smallness is secondary to
(i)
chromosomal, structural or infective
abnormalities;
etiologic and clinical groups
heterogeneous condition that includes several
Small-for-gestationalage (SGA) fetuses is an
For the correct management of
SGA fetuses, the following factors
must be taken into account:
1. Gestational age and fetal maturity: not only
to decide on possible interruption of the
gestation, but also to use the most
appropriate control procedure
2. Basic or associated medical pathology.
3. Type of growth retardation
4. Existence or otherwise of a congenital defect
5. Presence or otherwise of oligohydramnios.
6. Results of fetal control tests.
(cardiotocography, acoustic stimulation test,
fetal movements study, umbilical doppler,
profile, etc)
Primary Prevention
Genuine primary preventive strategies for
SGA include:
smoking cessation programs, antirubella
vaccination,
counseling for prevention of toxoplasmosis,
prenatal diagnosis programs ,
strategies aimed at reducing the number
of multiple pregnancies in women on
assisted reproductive techniques,
primary preventive strategies for pre-
eclampsiamediated IUGR
Secondary Prevention
Secondary prevention is aimed at
detection and treatment of the
Maternal serum screening has proved
preclinical phase
disappointing for IUGR: elevated of aofdisease:
levels alpha-
fetoprotein and human chorionic gonadotrophin
are associated with IUGR but are a very poor
screening test

Doppler evaluation of this vessel

constitutes the most promising
screening method for IUGR.
Since the spectrum of complications caused
by poor trophoblast invasion is
characterized by reduced endothelial
production of prostacyclin and increased
production of thromboxane A2 by platelets
and the enzyme cyclo-oxygenase, which
plays a central role in this
pathophysiological mechanism, can be
inhibited by aspirin.
 Tertiary Prevention
InIUGR minimize the
complications of this disease,
namely, fetal morbidity and
mortality.
Tertiary preventive strategies

those aimed at optimizing

focused on treatment the delivery timing
(therapeutic strategies) (obstetric management
strategies).
 Therapeutic strategies
All the fetal substrates originate from the maternal circulation,
Nutritive
suppleme which means that, in theory, the maternal administration of
food supplements would be the most physiological therapy and
nts to the benefit the fetus.
diet:

The renal and uteroplacentary circulation increases in the

prone position, and especially on the side, as the uterine
Rahia contractility decreases. On the other hand, complete rest
therapy considerably reduces the expenditure of energy, and it is
possible that some energy substrates normally used in
muscular exertion may now be placed at the disposal of the
fetus
There is evidence that insulin levels are markedly increased
Perfusions of in many mothers of fetuses with a low weight for the
dextrose gestational age, especially in the postprandial phase.
and amino Maternal perfusion with solutions of dextrose (or glucose)
acids has been suggested.
 Therapeutic strategies
(1)There is a statistically significant positive correlation between the maternal
Maternal plasma volume and the weights of the fetus and placenta in cases of idiopathic
growth retardation.
hemodiluti (2) Doppler study of IUGR shows that a significant decrease in the resistance
on indices of the uterine artery and the fetal arteries is produced in therapy with
hemodilution.
(3) Maternal hemodilution produces not only an increase in plasma volume but
also reduced viscosity in the blood and an antiaggregant platelet effect in some
colloids
It has been established that the administration of uterus
Betamimeti relaxing betamimetics produces effects beneficial to the
cs uteroplacental flow and the motherfetus exchange and to
the possibilities of postnatal survival

Some experimental studies suggest that chlorpromazine

Sedative dilates the myometrial vessels. It has been suggested that
s this beneficial effect is due to a momentary reduction in
the cerebral consumption of oxygen, which makes it more
resistant to hypoxia.
 Therapeutic strategies
The activation of the processes of coagulation has frequently been described
in cases of fetal growth retardation.
Heparin and
anticoagula Some cases of fetal growth retardation associated with preeclampsia are
nts related to a depletion in the platelet levels in the maternal blood, resulting
from intravascular coagulation in the placenta, which gives rise to a localized
deposit of fibrin and platelets.

uteroplacental perfusion and disturbances in the villous microcirculation are

Acetylsal connected to an imbalance in the production of prostacyclin and
icylic thromboxane.
Acid A host of studies over the last few years have demonstrated that
acetylsalicylic acid at low doses irreversibly inhibits platelet cyclo-
oxygenase, thus reducing thromboxane synthesis but without modifying the
production of prostacyclin (PGI2) of endothelial origin.100
The atrial natriuretic peptide (ANP) is an endogenous peptide with diuretic,
natriuretic and vasodilatory properties. It is synthesized in the right atrium. It
Atrial has been reported that ANP is capable of provoking vasodilatation of the
Natriuretic placental circulation in animals
Peptide
 Therapeutic strategies
Beydoun and coworkers have shown, progesterone
Sexual treatment on ovariectomized rabbits is capable of
Steroids significantly increasing the fetal and placental
weights through hyperplasia

Oxygen is an essential component for fetal growth: a 2040% oxidative

metabolism is required to provide Management of small-for-gestational-age
Oxygen fetuses: antenatal and intrapartum strategies Tertiary prevention the energy
Therapy necessary for fetal growth. In fact, it seems that hypoxemia must be the cause of
the retarded growth observed in mothers who are carriers of hemoglobinopathy,
cyanotic cardiopathy and asthma, or who live at very high altitudes, as occurs in
animals subject to hypobaric hypoxemia.

Various studies have stated that the supply of nutrients to the human
fetus is restricted by growth retardation; autopsies have demonstrated a
Intraamnio decrease in the reserves of glycogen and fat similar to that in
tic undernourished children.
Therapy For this reason, the intra-amniotic injection of amino acids and glucose
has been suggested for attempting to improve the nutrition of the fetus.
 Therapeutic strategies
Direct The direct administration to the stomach or intestine of sheep of
administrati glucose and amino acids by means of a catheter rapidly
on of increased their levels in the fetal blood, and produced an
Nutrients to increase in weight in those fetuses previously experiencing
the fetus delayed growth brought on by a limited maternal diet

This technique attempts to improve uteroplacental blood flow

Intermittent and, as a result, fetal oxygenation
Abdominal
It consists of an adjustable plastic garment on a rigid support
Decompressi
with a decompression mechanism that induces a decrease in
on
the pressure round the maternal abdomen.

Pharmacolo The work of Clark and coworkers in animal experimentation

gy of demonstrates a clear increase in the blood flow in the uterine
Prostacyclin artery after the intra-arterial administration of prostacyclin,
/ although this has not always been confirmed afterwards.
Tromboxane
balance
 Therapeutic strategies
The maternal administration of glyceryl trinitrate (GTN), an
Nitric agent that releases nitric oxide, is capable of improving both
Oxide the uterine and the umbilical circulation; this is verified in
Liberators practice by a significant reduction in the pulsatility indices of
both arteries.

It is theoretically possible that the inhibition of the secreting

Immunolog activity of B lymphocytes or the blocking of the peripheral
ical action of immunoglobulins could occasion an improved fetal
Treatmant outcome in gestations that are complicated by the presence
of antiphospholipid antibodies.

Pharmacol There are four possible pharmacological strategies: the

ogy of avoidance of: (1) increased intercellular calcium; (2)
Cerebral excessive release of amino acid exciters; (3) pathological
Observatio arachidonic acid cascade; and (4) oxygen free radicals.
n
 Obstetrics Management
Strategies
Decisio Although this study did not provide a detailed clinical guidance on
the exact point at which compromised fetuses should be delivered,
n to it stressed the critical importance of delivery timing. Arterial and
Termina venous Doppler parameters, biophysical variables and fetal heart
rate analysis are used for this purpose. In addition, others factors
te such as maternal complications (especially in pre-eclampsia),
Gestati severity of growth restriction, neonatal resources, parental opinion
and, overall, gestational age, complicate the decision-making in
on those fetuses.

The literature reiterates the finding that two-thirds of fetuses with

growth retardation can tolerate the stress of birth perfectly well,
and, therefore, they are delivered by the vaginal route. A cesarean
Elective section should be performed in only one-third of gestations.
Route The decision between induction of the birth or a cesarean section
of Birth must be made on the basis of various criteria, especially: fetal
condition (phase of fetal adaptation to hypoxia, decompensation
phase), special obstetric features (parity, fetal presentation, pelvic
and cervical conditions) and gestational age.
 Obstetrics Management
Strategies

(1) SGA (estimated fetal weight below the 5th centile with normal
cerebroplacental ratio and normal uterine artery Doppler flow):
excluding infectious and genetic causes, the perinatal results are good.
Delivery should only be indicated for obstetrics or maternal factors.
Weekly BPS and fortnightly doppler evaluation should be performed.
(2) IUGR with normal fetal well-being tests (estimated fetal weight
below the 5th centile with abnormal cerebroplacental ratio or uterine
artery Doppler flow): weekly Doppler and BPS 2 times /week should be
performed. Delivery beyond 37 weeks or when pulmonary maturity is
proven could be considered.
Managem (3) IUGR (estimated fetal weight below the 5th centile with abnormal
cerebroplacental ratio or uterine artery Doppler flow) with significant
ent and blood flow redistribution (absent or reversed enddiatolic flow in the
Timing umbilical artery):
a. beyond 34 weeks: deliver
b. between 32 and 34 weeks:
i. REDV: steroids and deliver in 2448 h
ii. AEDV: steroids, daily Doppler and BPS
c. below 32 weeks: steroids, daily Doppler and BPS
(4) IUGR (estimated fetal weight below the 5th centile with abnormal
cerebroplacental ratio or uterine artery Doppler flow) with proven fetal
compromise (persistent increased ductus venosus waveforms
pulsatility, low short-term variability in cardiotocography or
oligohydramnios):
a. beyond 32 weeks: deliver
b. below 32 weeks: hospital admission, steroids, daily Doppler and
BPS/812 h
 Obstetrics Management
Strategies
It must be remembered that the reserves of glycogen and fat are severely
Means of depleted in a fetus with growth retardation, which has a greater or lesser
degree of uteroplacental insufficiency. The hypoxic stress derived from labor
inducing can give rise to a rapid depletion of the scanty fetal reserves. This makes it
Births necessary to establish an anaerobic defense metabolism, with subsequent
metabolic acidosis.
For this reason, the induction of birth must be meticulous and avoid any
hyperstimulation.
labor, whether begun spontaneously or induced, must be controlled by
continuous cardiotocographic monitoring, at first externally and then
Intrapart internally when ervical conditions permit it. Any significant anomalies in the
um findings must be followed up with biochemical control, as in any other high-
risk gestation
Control

Of all the various types of anesthetic procedures, it seems to us that peridural

anesthesia is the most satisfactory in cases of growth retardation. This type of
Obstetric anesthesia avoids the administration of analgesics, anxiolytics and
Anesthesi spasmolytics which are capable of depressing the fetus, and it is particularly
useful in the frequent cases of association of toxemia and fetal growth
a retardation.
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