CLAP/WR - PAHO/WHO MONITORING FETALCLAP/WR - PAHO/WHO Self - Instruction Manual 2011 1586.02 Fescina...

MONITORING

FETAL

GROWTH

Mon

itori

ng F

eta

l G

row

th S

elf

- I

nst

ruct

ion

Man

ual

2n

d. ed

itio

nC

LA

P/W

R -

PA

HO

/WH

O

Self - Instruction

Manual

2011

1586.0

2

Fescina RHDe Mucio BMartínez GAlemán ASosa CMainero LRubino M

Scientific Publication CLAP/WR 1586.02

2nd edition

Latin American Center for PerinatologyWomen & Reproductive Health - CLAP/WR

Monitoring FetalGrowth

Self-InstructionManual

2nd edition

Fescina RHDe Mucio BMartínez GAlemán ASosa C

Mainero LRubino M

Latin American Center for PerinatologyWomen and Reproductive Health CLAP/WR

Familiy and Community HealthPan American Health Organization / World Health Organization

www.clap.ops-oms.orghttp://new.paho.org/Clap

4. Data Systems

I. CLAP/WR

any changes made to the text, plans for new editions, and reprints and translations already

the expression of any opinion whatsoever on the part of the Secretariat of the Pan American Health Organization concerning the status of any country, territory, city or area or of its

others of a similar nature that are not mentioned. Errors and omissions excepted, the names of

interpretation and use of the material lies with the reader. In no event shall the Pan American

Latin American Center for Perinatology/ Women and Reproductive Health - CLAP/WR PanAmerican Health Organization / World Health Organization - PAHO/WHO

http://new.paho.org/clap http://perinatal.bvsalud.org/

2nd edition

Roberto Porro, art design

2 Monitoring Fetal Growth

Latin American Center for Perinatology - Women and Reproductive Health CLAP/WR

TABLE OF CONTENTSPag

INTRODUCTION 4FACTORS AFFECTING INTRAUTERINE GROWTHPHYSIOPATHOGENESIS OF INTRAUTERINE GROWTH RESTRICTIONDIAGNOSIS

DIAGNOSIS OF IUGR WITH KNOWN OR ESTIMATED GESTATIONAL AGEDIAGNOSIS OF IUGR WHEN THE GESTATIONAL AGE IS EITHER UNRELIABLE OR UNKNOWN IN PREGNANT WOMEN CAPTURED LATE FOR CONTROL

DIFFERENTIAL DIAGNOSIS BETWEEN A FETUS WITH APPROPRIATE GROWTH AND IUGR WITH UNCERTAIN LMP AND LATE CAPTUREDIFFERENTIAL DIAGNOSIS BETWEEN SYMMETRIC IUGR AND ERROR IN THE ESTIMATION OF GESTATIONAL AGE BY LMPPROPOSALS FOR THE SOUND USE OF THE FETAL GROWTH SURVEILLANCE METHODSOBSTETRIC MANAGEMENT OF INTRAUTERINE GROWTH RESTRICTION

42

EXERCISES USING THE PERINATAL COMPUTING SYSTEM FOR THE ASSESSMENT AND MONITORING OF FETAL GROWTH

3Monitoring Fetal Growth


24

42

BIBLIOGRAPHY



MONITORING FETAL GROWTH

SELF-INSTRUCTION MANUAL

INTRODUCTION

uneventful cell division and growth, yielding a full-term term infant with full

neonates considered “healthy” on the grounds that they are the product of

For practical clinical purposes, a fetus is considered to have an intrauterine

In a strict sense, it is important to consider that:

a normal child with a low growth potential.

indeed a growth restriction that led it to go, for instance,



Exercise 1

Case A Case B30 weeks35 weeks40 weeks

1800 g.2300 g.3000 g.

900 g.1900 g.2800 g.

5000

4000

3000

2000

1000

Gra

ms

P90

P10

Amenorrhea, in weeks25 27 29 31 33 35 37 39 41

Figure 1 – Weight by GA curve, showing P10 and P90



not provide an accurate estimation of the proportion of small for gestational age

Exercise 2

Let us review the concepts of SGA and LBW. Try to locate the 4 values listed below in Figure 1.

infants.

foreign standards developed ignoring certain factors that alter fetal growth and

G. A. Weight Rank thecase

Case CCase DCase ECase F

35373939

2600 grs.2300 grs.2800 grs.3350 grs.



the population, as to warrant changing the reference standards.

5000

4000

3000

2000

1000

Gra

mos

P90

P10

Amenorrhea in weeks25 27 29 31 33 35 37 39 41

Figure 2 – Standards developed by CLAP/WR for neonatal weight by gestational age



FACTORS AFFECTING INTRAUTERINE GROWTH

differentiation, and it leads to the development of organs and tissues in charge of complex and interrelated functions.

at which they are detected: a) Preconception risk factors,

c) Environmental and behavioral risks

a) Preconception risk factors

2.

4. Severe malnutrition

vascular disease, chronic lung disease, mesenchymal diseases

b) Risk factors detected during pregnancy

2.

4. Pregnancy-induced hypertension / preeclampsia-eclampsiaAntiphospholipid syndromeAnemia

Congenital malformations

Exposure to teratogens



c) Environmental and behavioral risk factors

2. Heavy alcohol consumptionExcessive consumption of caffeine

4. Drug Addiction

Stress



PHYSIOPATHOGENESIS OF INTRAUTERINE GROWTH RESTRICTION

In the latter, the asymmetric growth is due to insults that appear in the third

the various tissues, i.e., tissues present their hyperplasia at different times of

so-called critical period.

AdiposytesNeurons Longbones

Early andprolonged harm

Late onset harm

Acts at the critical period

15 20 25 30 35 40Weeks of gestation

Gro

wth

rat

e

Results

Reduced head cir.

“ Length

“ Weight

Symmetric SGA

Normal head circ.

Normal length

Reduced weight

Asymmetric SGA

Neurons

Long bones

Adipositosis

Yes

Yes

Yes

Neurons

Long bones

Adipositosis

No

No

Yes

Figure 3 – Critical periods of the different tissues and perinatal outcomes depending on the time of occurrence and the duration of the noxa



DIAGNOSIS

of technological complexity, and that are generally found in specialized facilities.

monitoring of fetal growth for the entire population of pregnant women,

of resources.

diagnosis, and thus decide what level of complexity is appropriate for that delivery.

For this reason, instead of a scoring system, we recommend using a list



time the pregnant woman is captured for antenatal care.

Table 1- Risk factors in a Latin American population (Brazil, Argentina and Uruguay)

Risk Factor Frequency inpopulation %

RelativeRisk

95% Confidenceinterval

History of SGASmoking habit (10 o +) Multiple pregnancy Pregnancy-induced hypertension PreeclampsiaHemorrhage 2nd trimester Weight gain < 8 kg. Oligoamnios

1426174

0.5160.5

1.51.63

1.42.11.62.12.9

1.1 - 2.71.1 - 2.22.0 - 3.41.2 - 1.71.9 - 3.21.2 - 2.71.3 - 3.51.7 - 5.0

Calculation of gestational age

the duration of pregnancy and properly evaluate fetal growth, we will

as an approximation to the time of ovulation and therefore, the time

in addition, this date also coincides with the clinical examination of the

An alternative method used is the clinical estimation of gestational age



crown-to-rump length, which has a linear relationship with gestational

105

9

13

17

21

25

29

33

37

41

16 22 28 34 40 46 52 58 6470 76 82 88 94 100 mm

Weeks

Femur

D. BP.

L.CN P95P50P5

P95

P50

P5

P95

P50

P5

Central value and confidence limits for estimating gestational age based on the ultrasound measurements of:

Femur length Biparietal D. Ceph.-Buttocks length

Figure 4. Estimation of gestational age based on the fetal anthropometric measurements using two-dimensional ultrasound. (21)



DIAGNOSIS OF IUGR WITH KNOWN OR ESTIMATED GESTATIONAL AGE

with decreased fetal movements, oligohydramnios, low maternal weight

relation to the duration of pregnancy.

Although there is no compelling evidence regarding the use of fundal

with the measurement of the fundal height, the diagnosis should always



Mat

ern

al

wei

gh

t g

ain

Kg.15

13

16 20 24 28 32 36 40

11

9

7

5

3

10

Weeks of amenorrhea

P90

P75

P50

P25

P10

Figure 5. Maternal weight gain in Kg by gestational age. Longitudinal prospective study N = 1023 weight measurements. (22)

P90P50

P10

3533312927252321191715131197

13 15 17 19 21 23 25 27 29 31 33 35 37 39 sem.

cm

Fund

al h

eigh

t

Figure 6. Fundal height in cm by gestational age. Longitudinal prospective study. N = 1074 measurements. (23)



Exercise 3

Week Weight gain Maternal weight (kg.)

1624273234

58.761.562.563.063.5



Table II - Maternal weight by height by gestational age (p10-p90). (22)



gain curve for that case.

You will see that the curve of the case studied crosses it and falls under percentile

Exercise 4

Week Fundal height (cm)

1624273234

1421232425

of the fundal height of this case.

gestational age and maternal height.



Exercise 5

Maternal height (cm.)

MaternalWeight (kg.)

Is maternal weight for height by gestational age appropriate?

Gest. age (wk.)

ABCDE

Yes No5358465567

154160150156162

2720183136

If you answered that ladies A, C, and D do not have an appropriate weight

KNOWN AND RELIABLE GESTATIONAL AGE

Serial measurements

Confirmation ultrasound using GA-dependent

growth indicators

Appropriate fetal growth- low risk antenatal control

D i a g n o s i s o f I U G RRuled out

See algorithm for the differential diagnosis between symmetric and asymmetric IUGR and management

Confirmed

Estimation of Gestational age by

ultrasound

Ultrasound after the 3rd trimester using –GA independent

growth factors

Fundal heightMother’s weightEstimation of volume amniotic fluidInvestigate risk factors

Values < lower limitOligohydramniosPresence of risk factors

Distance curve of fetal abdominal circumference and head circumference by gestational age

By Crown-to-rump length 8-13 weeksBy BPD after 12 weeksBy Femur length after 13 weeks

Early captureBefore 20 weeks

.

Abd. CircFemur length

Growth rate based on previous value of fetal abdominal circumference

Ratio =

Clinical

testing

Complementary

methods

Yes

Yes

No

Yes No

No

Figure 7. Algorithm for the diagnosis of IUGR



370350

330310

290

270

250

230

210

190170

150130

110

90

70

14 16 18 20 22 24 26 28 30 32 34 36 38 40

Head circumference

mmP95

P50

P5

Weeks of amenorrhea

Figure 8 - The fetal head circumference measurements in the symmetric growth restriction (- - - ) fall early (24 weeks) below normal limits (percentile 5), while in the asymmetric restriction (.....) measurements usually remain within normal limits. (15)



mm.3903703503303102902702502302101901701501301109070

15 17 19 21 23 25 27 29 31 33 35 37 39Weeks of amenorrhea

Abd

omin

al c

ircum

fere

nce

P50

P5

Figure 9 - The fetal abdominal circumference falls below the normal range (percentile 5) around 32 weeks in the types of restrictions, so this measure is the most sensitive indicator. In the case of symmetric restrictions (- - - ), its fall occurs later than the asymmetric restrictions of the head circumference (24 weeks) (.....). (15)



Table III-Effectiveness of fundal height, maternal weight gain, fetal abdominal circumference, fetal head circumference, BPD and oligoamnios measured by ultrasonography to predict SGA (24)

Measured Variable <P10

Sens.%

Sp.%

PPV%

NPP%

PLR NLRAGA

Maternal weight gain (GP)

FH or GP

Biparietal diameter

Oligoamnios

Head circumference

Fetal abdominal circumference

Fundal height (AU)

50 %

75 %

67 %

28 %

42 %

94 %

56 %

79 %

72 %

93 %

98 %

100 %

100 %

91 %

60 %

63 %

67 %

28 %

42 %

94 %

80 %

72 %

82 %

67 %

28 %

42 %

94 %

77 %

2.38

2.68

9.57

14.0

100

100

6.22

0.63

0.35

0.35

0.73

0.58

0.06

0.48< P10

< P25

< P25< P10

< P5

< P5

< P5

SiNo

2016

1818

279

342

2412

1521

1026

553

1246

1642

058

454

058

157

Appropriate for gestational age

Sens: Sensitivity

Sp:

PPV: Positive Predictive Value

PLR:



Known gestational age with no doubts

Distance curve of the fetal abdominal circumference

Between P5 and P95

Between P5 and P95 Lower than P5

Lower than percentile 5

Distance curve of the fetal head circumference or femur length

Normal fetal growth

Normal fetal growth

Asymmetric IUGR Symmetric IUGR

Increase lower tan expected

Increase as

expected

Fetal abdominal circumference growth rate curve based

on previous value

Normal growthor symmetric IUGR

Fetal Abdominal Circumference/ Femur Length ratio

P10 < 4.25 P10 4.25

NoYes

Figure 10. Algorithm for the differential diagnosis between normal fetal growth and symmetric and asymmetric IUGR.

Exercise 6

they are formulated. Do not go any further with your reading without complying



Mrs. ZZGestational ageCurrent weight Usual weight Blood pressure Fundal height

34 weeks62 kg.53 kg.120/70 mmHg.25 cm.

Which would be your presumptivediagnosis?

Fetus with a normal growthFetus with a growth restriction Macrosomic fetus (large) None of the above

Assuming you can order tests to confirm the diagnosis, which would you ask?Fetal abdominal circumference (ultrasound) Maternal abdominal circumference Biparietal diameter (ultrasound) None of the above

What diagnosis would you suggest and what would you do if the measurement



Fetal diagnosis Normal fetal growth IUGRMacrosomicNone of the above


300 mm 266 mm

Recommended ManagementProceed with antenatal control for low-risk pregnancyRefer to high riskSpecial tests to determine IUGR type Oral Glucose Tolerance Test


300 mm 266 mm

pattern. If you decided to continue with special tests to determine the

What other assessment would you order?

or Femur lengthMeasurement of fetal head circumference

Growth rate curves according to previous value

Measurement of mother’s height

Measurement of estriol levels

If you chose the fetal head circumference and femur length, the decision was correct. Otherwise, you should read the diagnostic algorithm to differentiate



that you consider correct.

Head circumference 320 mm. 290 mm.

IUGRSymmetric Asymmetric

Exercise 7.

What would you do in this case? Check the right answerYou would hurry to ask for a test to estimate gestational ageYou would not worry until the last trimester because it is then that it is important to know it

If you answered that you would wait until the last trimester, see the diagnostic



Choose the parameter you consider most important for the cases in which you need to estimate gestational age:

Choose the parameter you consider most important when you need to estimate gestational age Crown-Rump Length (CRL) or biparietal diameter (BPD)or femur length according to the size of the fetus

Amniotic fluid test

Measurement of the fetal abdominal fluid

Measurement of fundal height

length, you can continue.

Let us assume that the gestational age was properly estimated, that pregnancy

What tests would you order?

Calculation of the FAC/Femur Length ratio

Measurement of the biparietal diameter

None of the above

FL ratio, later on in the text we will see that the effectiveness of this procedure



DIAGNOSIS OF IUGR WHEN THE GESTATIONAL AGE IS EITHER UNRELIABLE OR UNKNOWN IN PREGNANT WOMEN CAPTURED LATE FOR CONTROL

you should use growth indicators that do not depend on gestational age.

Growth rate patterns based on the earlier value

one must refer directly to the ultrasound, as the measurement of the

Exercise 8

Case A



Feta

l abd

omin

al in

crea

se a

t 2 w

eeks

40

80 100 120 140 160 180 200 220 240 260 280 300 320 340

35

30

25

20

15

10

5

0

Previus value of the abdominal circumference

mm.

P90

P70

P50

P30

P10

Figure 11: Growth rate of fetal abdominal circumference based on an

Case B

Repeat the exercise with the following values:

2nd ultrasound measurement of Fetal AC



The fetal abdominal circumference /femur length ratio

Another method to assess fetal growth independent of gestational age

circumference growth rate has a higher sensitivity for the diagnosis

value and a new ultrasound examination. If the expected increase is normal, the diagnosis is that of a fetus with normal growth. If, however, the increase is less than expected, we are facing a growth restriction,

Sensitivity for the diagnosis of intrauterine growth restriction in case of uncertain gestational age and late recruitment



Symmetric IUGRAsymmetric IUGR

Abdominalcircumference

based on previous value

Abdominalcircumference/Femur

length ratio94 %61 %

46 %74 %

Exercise 9

DIFFERENTIAL DIAGNOSIS BETWEEN A FETUS WITH APPROPRIATE GROWTH AND IUGR WITH UNCERTAIN LMP AND LATE CAPTURE

For this exercise you will use the algorithms for the differential diagnosis

as they are formulated. You should not go any further in your reading

Mrs. XXMaternal heightGestational ageCurrent weightUsual weightWeight gainBlood pressureFundal height

1.55 m.Unknown 60 kg.Unknown 140/94 mmHg27 cm.

that it is small in size.



What diagnoses would you suggest?Fetus with a normal growthMacrosomic fetus (large)

Small fetus for < age or IUGRNone of the above

How would you solve this problem?I would estimate gestational age asking about the date of onset of the first fetal movements

I would assess fetal growth with indicators independent from gestational age

I would wait without doing anything

I would only estimate gestational age by ultrasound

If you answered fetal growth assessment with independent indicators of gestational age, you are on the right path, and you may continue



If the FAC/FL ratio was 4.25,What would be your probable diagnosis?

Asymmetric IUGR or fetus with a normal growthIUGR – no matter what type

Certainty of fetus with a normal growthSymmetric IUGR or fetus with a normal growth

Asymmetric IUGR = = < 4.25Low fetal AC

Normal fetal femur length

Example = = 3.94260 mm

66 mm

Fetus withnormal = growth

= > 4.25Normal fetal AC

Normal fetal femur length


66 mm



Symmetric. IUGR = = > 4.25Low fetal abdominal circumference

Low fetal femur length


54 mm

What test would you order to establish the differential diagnosis between a fetus with a normal growth and an asymmetric IUGR,

two situations that require a radically different management?Measure the FAC/FL ratioMeasure the increase of the FAC based on its previous value

Measure the Head CircumferenceMeasure the BPD

- you have understood the pathophysiology of fetal growth correctly. Otherwise,

value:



DIFFERENTIAL DIAGNOSIS BETWEEN SYMMETRIC IUGR AND ERROR IN THE ESTIMATION OF GESTATIONAL AGE BY LMP

symmetric growth restriction and an error in the estimation of gestational

circumference

the growth rate

an appropriate growth. Conversely, if the increase is less than

distance curves and growth rates.



Table IV-Behavior of fetal growth when there is an error in the estimation of gestational age by LMP and asymmetric and symmetric growth restriction

CURVES

At a distance Growth rate based on a previous value

BPDHead circumference Femur length

AC

NormalNormal

Normal Decreased

DecreasedDecreased

B.P.DHead circ. Femur length

AC

Error in the estimation of gestational age

Lower than normal and tending to converge

Lower than normal and diverging

Asymmetric IUGR

Symmetric IUGR

Within normal ranges may occur late

Lower than normal and diverging



PROPOSALS FOR THE SOUND USE OF THE FETAL GROWTH SURVEILLANCE METHODS

weight gain at each antenatal care visit.

shown that routine ultrasounds do not improve the detection of intrauterine growth restriction when compared with the scan performed in cases where there is a change in clinical parameters.

General population 14% SGAN = 100

No SGA86

SGA14 TestTest +

Test +Test -

- -

True

11

False

23+ +

True

63

False

3

True

10

False

0 + +

True

23

False

1

- -

-

Prevalence 31%

3466

24 10

Antenatal low risk control

Intervention is lost Intervention

P.dedetectión

Fundal height< P10and/or

Weight gain< P25

Referral forSpecial exploration

P.confirmatión

Ultrasound

Fetalabdominal

circumf < P5

3335 weeks37

Aprox. }

Figure 12 - Application of different tests to diagnose intrauterine growth



Table V - Diagnosis of IUGR using risk factors, fundal height and

maternal weight gain as a screening procedure, and

with a 14% prevalence of IUGR

NO

0 11

89

100

86

86

Yes

Yes 11

3

14

NO

DIAGNOSIS

IUGR

{



OBSTETRIC MANAGEMENT OF INTRAUTERINE GROWTH RESTRICTION

A) Antenatal management

others.

In the case of hypertensive women, the administration of low doses of

of prostacyclin, with a predominance of the latter over the former, thus



Table VI - Table VI: Prevention of the birth of small for gestational age infants with low-dose aspirin. The common odds ratio (summary measurement of the results of the 7

administration. This protective effect of aspirin would reduce the SGA likelihood by 20% (between 10% and 30%)

Therapy (%) (%) Odds ratio (95% confidence internval)Contr.

4/48Beaufils et al.

Wallenburg et al.

Wallenburg et al.

Schiff et al.

Uzan et al.

Sibai et al.

CLASP

CommonOdds ratio

4/41

4/30

2/34

19/156

69/1505

37/4810

473/6604

(8.3)(1985)

(1985)

(1985)

(1985)

(1985)

(1985)

(1985)

0.08

0.09

0.03

0.05

0.18

0.56

0.79

0.71

0.24

0.37

0.11

0.26

0.37

0.78

0.92

0.81

10.01 100.1

0.77

1.41

0.36

1.29

0.73

1.08

1.06

0.92

(19)

(13.3)

(5.9)

(12)

(4.6)

(7.7)

(7.1)

13/48

9/23

16/27

6/31

20/73

88/1519

401/4821

553/6542

(28.8)

(39)

(59.2)

(19.4)

(27)

(5.8)

(8.3)

(8.5)

B) Childbirth

death according to the different gestational ages.

determine the gestational age at which you decide to interrupt pregnancy.



If one has special resources to monitor fetal health, in addition to

course of development, especially once the corrective measures have

In preterm pregnancies, if the assessment of fetal vitality shows a fetus in good conditions and the ultrasound shows that the fetus is growing, pregnancy should go on. Otherwise if lung maturity and will interrupt pregnancy. If the fetal lung has not synthesized surfactant, its synthesis

IUGR**

*

No

No

Figure 13-Flow chart showing the stepwise diagnostic decisions in case of IUGR. (2)



accurate parameter at this point to indicate the termination of pregnancy

growing, delaying the termination of pregnancy is associated with and increased fetal mortality. Conversely, the interruption of pregnancy does not worsen the neonatal prognosis.

strict monitoring of fetal growth.

P50

P5

Abdominal circumference

3903703503303102902702502302101901701501301109070

15 17 19 21 23 25 27 29 31 33 35 37 39 41Weeks of amenorrhea

Area ofalarm

Zone with high death odds

Figure 14-Normal pattern of fetal abdominal circumference growthwith alarm zone and zone of high probability of death.



ultrasound assessments evaluating the fetal measurements and functional

Serial ultrasound studies are an essential tool for monitoring fetal well-

the contrary, it recovers its growth pace and exceeds the lowest level in the normal patterns, succeeding to catch-up or recuperating growth.

termination of pregnancy.

useful information. Changes in the values of the different indices employed

this compensatory mechanism is missing, or when the resistance of the



is a vascular disease in the mother.

associated with severe fetal compromise such as acidosis and hypoxia

having completed their validation process, which limits their scope and the

C) During labor

In cases where the plan is to have a vaginal delivery, one must consider that these fetuses show a high incidence of acute fetal distress, especially

clinical monitoring of the fetal heart rate and uterine contractions during

Exercise 10

value is consistent with the earlier ultrasound.



Symmetric IUGRYour diagnosis is:

Asymmetric IUGR Fetus with a normal growth

35 week fetus; GA based on the previous ultrasound Abdominal circumference 280 mm (<P5)

31969 mm

Head circumferenceFemur lengthReduced amniotic fluid

charts and record the course of fetal growth.

Symmetric IUGRWhat is your diagnosis?

Asymmetric IUGRFetus with a normal growth but genetically small

not a reduction in the femur length.



strategy would you suggest?

The fetus has been confirmed an asymmetric IUGR. What monitoring strategy would you suggest?

Monitoring with biophysical profile of the fetusMonitoring only with fetal eco Doppler

Monitoring only with fetal eco Doppler ultrasoundMonitoring with measurement of the fundal height

Monitoring only with obstetric ultrasound

If your answer was to monitor with eco Doppler and ultrasound your choice

and an echo Doppler and you schedule a visit.

You decide

Schedule a new follow-up visit in 1 weekYou would admit her to rest at the hospital to promote the fetal catch up Terminate pregnancy

If you opted for termination of pregnancy, you have made the right decision.



EXERCISES USING THE PERINATAL COMPUTING SYSTEM FOR THE ASSESSMENT AND MONITORING OF FETAL GROWTH

several options to assess and monitor fetal growth.

Weight by gestational age

uses the program “Distribution of a variable”.

“Selection by variables”.



program “Distribution of a variable” we put “Gestational age at birth” as “birth weight”

institution A:

In the previous window, as we position ourselves at each gestational age,



34

5000

4000

3000

2000

1000

Gra

ms

P90

P10

Amenorrhea in weeks25 27 29 31 33 35 37 39 41

Newborn’s weight in grams

Weeks p10 p90



Institution B “Selection by variables” tool, select the population that meets the following conditions:

Singleton pregnancy and

Literate motherFive or more antenatal visits

program “Distribution of a variable” and place the “Gestational age at birth” “birth weight” as a study



for this new target population, we have

Weeks p10 p90

Newborn’s birth weight in grams



connect them with a dashed line.

Institution A Institution B

alternatives to calculate percentiles in these cases?

Prolonged study Sum with other similar institutions



Population of the Institution B

Yes

Amenorrhea in weeks

Gra

ms



Listing of medical records historiasB-certain conditions. In each list, the software displays a document that

Institution A,



studied. Count how many small for gestational age (SGA)

taking as a reference the pattern built with:

Amenorrhea in weeks

Gra

ms



diagnosed.

Complete the following table with the results obtained

Reference patternPopulation selected

of Institution A Population selected

of Institution B CLAP

Number of SGAs diagnosed

Risk estimations

C- “Risk estimation” used in the following examples is

intervals.



History of LBW

Smoking habit



Preclampsia

Multiple pregnancy



Fill in the chart below with the data included in the table

Damage: SGAProportion exposed

(frequency %)Risk Factors RR PAR

%History of LBW

95% Confidence interval

Smoking habitPre-eclampsiaMultiple pregnancy

Analyze the picture

…………………………………………………………………………………...

..................................................................................................................

…………………………………………………………………………………...

..................................................................................................................



Basic statistics

D- “Key Indicators Report” program provides the main indicators of perinatal care and gives a clear overview of some characteristics of the population served and the outcomes of the care provided.

On the “Basic Statistics”Rate, while in the “Newborn”

“Selection by Dates”



First trimester



Second trimester



Third trimester



Fourth trimester



Trimester ENM rate %o SGA %1234

LBW % VLBW %

Tendencia en a disminuir en el añoSI NO

T a s a MNP %o

PEG %

BPN %

M B P N %

YES NOENM rate %

SGA %LBW

VLBW%

Tendency to be reducedduring the year



Answers to the exercises using the perinatal information system for the assessment and monitoring of fetal growth

Exercise A - Weight percentiles of Institution A

Weight percentiles at Institution B

Gra

ms

Gra

ms

Weeks of amenorrhea

Weeks of amenorrhea



Both patterns are the samePercentile 10 is higher in the selected populationPercentile 90 is higher in the selected population

The population of Institution APopulation selected from Institution B

population.

Prolonged studyAdding the cases with other similar institutions

Gra

ms

Weeks of amenorrhea



Institution B

Yes

Exercise B -

Institution A

Gra

ms

Weeks of amenorrhea

Gra

ms

Weeks of amenorrhea



Institution B

following as a reference:

Gra

ms

Weeks of amenorrhea

Gra

ms

Weeks of amenorrhea



Reference patternPopulation selected

of Institution A Population selected

of Institution B CLAP

453Number of SGAs diagnosed

Exercise C.

Damage: SGAProportion exposed

(frequency %)Risk Factors RR PAR

%History of LBW

95% Confidence interval

Smoking habitPre-eclampsiaMultiple pregnancy

13.6312.4713.6018.61

1.942.392.053.11

1.58 - 2.372.17 - 2.631.74 - 2.412.68 - 3.61

3.1717.444.514.73

Exercise D

Trimester ENM rate %o SGA %1234

4.43.55.15.0

5.56.26.15.5

8.38.98.78.5

1.11.31.11.3

LBW % VLBW %

YES NOENM rate %

SGA %LBW

VLBW%

Tendency to be reducedduring the year



Bibliography

investigation and management of the small-for-gestational-age



a gestational age estimation method. Paediatr Perinat Epidemiol



presenting with decreased fetal movements in late pregnancy. Acta

restriction: a mathematical model of the effect of time interval and



supplementation for suspected impaired fetal growth. Cochrane

administration for suspected impaired fetal growth. Cochrane

www.clap.ops-oms.org

Monitoring

Fetal

Growth

Self - InstructionManual

Mon

itori

ng F

eta

l G

row

th S

elf

- I

nst

ruct

ion

Man

ual

2n

d. ed

itio

nC

LA

P/W

R -

PA

HO

/WH

O

ISBN 978-92-75-13228-9

http://perinatal.bvsalud.org/

1586.0

2

Scientific Publication CLAP/WR 1586.02 2011

2nd edition

Latin American Center for PerinatologyWomen & Reproductive Health - CLAP/WR

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