· Web viewNorth West Regional Guideline for the Detection and Management of Fetal Growth...

North West Regional Guideline for the Detection and

Management of Fetal Growth Restriction

This guideline is for use in conjunction with the North West eFGR Integrated Care Pathway

Version 1.1August 2019

Document Control

OwnershipRole ContactDocument authorsDesignation:

Ed Johnstone Suzanne ThomasNW FGR Network Chairs

Emma IngramAcademic Clinical Lecturer

[email protected]@mft.nhs.uk

[email protected]

Project Manager GMEC SCN [email protected]

Version controlTitle The North West Regional Guideline for the Detection and Management of

Fetal Growth Restriction

Version V1.1 02/08/2019

Supersedes New document

Endorsement processRatification Signed off by the North West FGR Group on 25/01/2019

Date of ratification GMEC SCN Maternity Steering Group on 15/02/2019

Application All Staff Circulation Issue Date: 22/03/19

Circulated by [email protected] Review Date: 22/03/2021

Responsibility of: North West FGR Network

Date placed on the Intranet:Please enter your EqIA Registration Number here:

Acknowledgements

document.docx Issue Date 02/08/2019 Version 1.1

Status Final Review Date 02/08/2021 Page 1 of 41

mailto:[email protected]




I would like to thank the members of the North West FGR Group for their enthusiasm, commitment and contribution to the development of this North West Fetal Growth Restriction Guideline.

I would also like to acknowledge and thank the families who gave their time and experience to create this guideline; together we are committed to driving better outcomes for babies across our region.

Ed Johnstone Consultant Obstetrician/Senior Lecturer in Obstetrics and Fetal MedicineChair of the North West FGR Group



Contents

1 Introduction 3

2 Detail of the Guideline 3

2.1 Risk assessment for FGR and management of women at the booking appointment

2.2 Antenatal management

2.3 Delivery planning

2.4 Postnatal management

2.5 Communication and Documentation

3 Equality, Diversity and Human Rights Impact Assessment 9

4 Consultation, Approval and Ratification Process 9

Appendix 1: Abnormal Fundal Height (FH) Measurement pathway 10

Appendix 2: SGA Management Pathway 11

Appendix 3: NW Early Onset FGR Integrated Care Pathway 12

Appendix 4: Risk assessment, surveillance pathway and management of FGR 38

Appendix 5: Reference ranges for uterine artery mean pulsatility index at 11 – 41 weeks of gestation 39

Appendix 6: Reference range for serial measurements of umbilical artery Doppler indices in the second half of pregnancy 40

References 41



1 Introduction

Up to 40% of ‘unexplained’ stillbirths are small for gestation age (SGA) and thought to have suffered fetal growth restriction (FGR sometimes known as IUGR) (Gardosi et al, 2005). In addition, these infants are at increased risk of perinatal hypoxia and acidaemia, operative delivery, neonatal encephalopathy and cerebral palsy (Ribbert et al. 2005, Jacobsson et al 2008).

Not all babies who are SGA (<10th centile birth weight) will have FGR, but the lower the centile the higher the chance that FGR will be present. The management strategies within this guideline recognise this and stratify patients according to risk. This approach aims to increase identification of high-risk pregnancies whilst at the same time reducing unnecessary investigations and iatrogenic deliveries in lower risk women.

2 Detail of the Guideline

2.1 Risk assessment for FGR and management of women at the booking appointment

Women should be screened at booking and throughout pregnancy for the identification of risk factors for SGA (see Appendix 4). Birth weight centiles for previous babies should be calculated using an appropriate individualised birth weight centile calculator, for example https://icc.growservice.org/754731/

2.1.1 These centiles must be documented in the antenatal booking proforma in addition to those generated on the customised growth chart.

Women with singleton pregnancies and no evidence of diabetes should be assigned to one of 4 groups below at their booking visit:

Please refer to section 2.2 Antenatal Management for detail on the management of these groups

1. Women at low risk of SGA or FGR No identifiable risk factors for SGA or FGR at booking appointment

2. Women at moderate risk of SGA or FGR Previous SGA (BW centile 3rd -<10th) Previous stillbirth (>/=10th centile) Current cigarette smoker (any number of cigarettes, does not

include women who vape) Drug misuse



https://urldefense.proofpoint.com/v2/url?u=https-3A__icc.growservice.org_754731_&d=DwMFAg&c=bMxC-A1upgdsx4J2OmDkk2Eep4PyO1BA6pjHrrW-ii0&r=_PhHIbttY6k7xeuw0iEH2fNwq9tY4pgJyz8K1RShtWQ&m=-jJ9f6xUZPStEjJBXeHdZf-Zq8WMQXIuaJn5QMLK7EA&s=eXESqR_h1eQd-BcYRVIUSVBObKG9vdXAuNWVy5z7jD8&e=

Women aged >40 at booking

3. Women at high risk of SGA or FGRHistory (obstetric or medical) of: Maternal medical conditions (for example chronic kidney disease,

hypertension, autoimmune disease (SLE, APLS), cyanotic congenital cardiac disease)

Previous FGR (<3rd centile) Hypertensive disease in a previous pregnancy Previous Stillbirth (<10th centile)

Or current pregnancy risk factors developing <24 weeks: PAPPA < 0.415 MoM Echogenic bowel Significant heavy bleeding in the 1st or 2nd trimester Evolving gestational HT or pre-eclampsia > 20 weeks

4. Women unsuitable for assessment of fetal growth by Fundal Height measurement BMI ≥ 35kg/m2 Multiple fibroids

2.1.2 Women who stop smoking before week 15 of pregnancy reduce their risk of SGA to the same as a non-smoker (McGowan et al, 2009). In the absence of any additional risk factors these women do not require growth scans in pregnancy.

2.1.3 In women who meet the following criteria:

Previous baby with a birthweight centile less than the 3rd centile & delivered less than 34 weeks due to FGR or

Previous history of pre-eclampsia

Aspirin should be prescribed 150mg once a day (at night) from 8 weeks of pregnancy until 36 weeks (Rolnik et al, 2017). Low molecular weight heparin (LMWH) should not be routinely prescribed in the absence of other risk factors, please refer to the Thromboprophylaxis in Pregnancy and the Puerperium Guideline / name of local guideline.



2.2 Antenatal management

Following assessment of FGR risk women should be managed according to appendix 2. Further details of this management are provided below.

2.2.1 Women who are at low risk of SGA or FGR

Fundal height (FH) should be measured and plotted on a customised growth chart at every scheduled antenatal appointment from 26-28 weeks of pregnancy. Only practitioners who have successfully completed the Perinatal Institute E-Learning programme (annually) should undertake assessment of fetal growth by fundal measurement.

Where the FH is less than the 10th centile at the first plot or there is slowing or static velocity on the customised chart and fetal movements are normal, the woman must be seen, within 72 hours, for ultrasound scan of fetal growth, LV and umbilical artery Doppler (UAD) (See Appendix 1). Where movements are reduced the woman must be seen in: insert name of local service here

on the same day where they should have a computerised CTG performed and ultrasound scan of fetal growth, LV and umbilical artery Doppler (UAD) arranged for the next working day (See Appendix 1).

2.2.2 Women at moderate risk of FGR

Women at moderate risk of FGR should have assessment of fetal growth by the measurement of fundal height from 26-28 weeks of pregnancy until the commencement of ultrasound assessment of fetal growth at 32 weeks gestation. Ultrasound assessment of fetal growth, umbilical artery Doppler assessment and LV must start at 32 weeks gestation and be repeated every 3-4 weeks but must not exceed 4 weeks until delivery. The scan should be reviewed by an appropriately trained person (sonographer / Midwife / Midwife Ultrasound Practitioner / Clinician). The continuation of fundal height measurements is not required once the woman is on a scan pathway. See Appendix 1 & Appendix 2 for the management of abnormal findings.

2.2.3 Women at high risk of FGR

Women at high risk of FGR should have Uterine Doppler Artery Doppler (UtAD), Umbilical Artery Doppler (UAD) and assessment of fetal growth by ultrasound at 20-24 weeks gestation. Women will be assigned a “positive” screen if they have the following: EFW <10th centile, either uterine artery PI>95th centile for gestation (use Gomez chart; Appendix 5) or uterine artery notching.



Follow up will be arranged 2-6 weekly depending on the findings. Some units may wish to assess placental biometry in conjunction with uterine artery dopplers in recognition that small placental size (<10cm diameter) is associated with FGR (Kingdom, 2018) and may constitute a positive screen finding. Women with none of these features (negative screen) should be seen for ultrasound assessment of fetal growth at 32 weeks gestation (previous FGR) and from 36 weeks gestation (low PAPP-A).

2.2.4 Women unsuitable for assessment of fetal growth by fundal height measurement

Women in whom FH measurement is not possible due to either high BMI or multiple fibroids show undergo ultrasound assessment of fetal growth from 32 weeks’ gestation 3-4 weekly until delivery.

2.2.5 Management of women when SGA/FGR is detected

If the woman is less than 28 weeks’ gestation and the estimated fetal weight when plotted on the customised growth chart is less than the 5th centile, discussion should take place with the Consultant on call within 24 hours regarding a plan of care, and the woman should also be referred to insert name of local service here (see Appendix 2).

Women diagnosed with SGA or FGR (<5th centile) should be managed in accordance with Appendix 2 and if <32 weeks the NW eFGR integrated care pathway should be commenced (go to: https://www.england.nhs.uk/north-west/gmec-clinical-networks/our-networks/maternity/resources/) (Appendix 3).

At every antenatal visit / attendance all women must be asked about the pattern of fetal movements and advised to report any decrease or cessation of fetal movements and immediately contact: insert name of local service here

In the presence of absent/reversed end diastolic flow in UAD at less than 32 weeks a Fetal Medicine assessment should be sought within 24 hours. This assessment should include a repeat umbilical artery Doppler assessment, ductus venosus Doppler assessment and a review of fetal growth.

Antenatal steroids should not be administered before this assessment has occurred. If assessment is not available within 24 hours then a computerised CTG should be performed. If computerised CTG criteria are met then delivery can be postponed until a fetal medicine opinion is obtained at the next possible opportunity. If computerised CTG criteria are not met then a review of which component this is dependent on should take place by a senior obstetrician. If the component is STV then refer to NW eFGR integrated care



https://urldefense.proofpoint.com/v2/url?u=https-3A__www.england.nhs.uk_north-2Dwest_gmec-2Dclinical-2Dnetworks_our-2Dnetworks_maternity_resources_&d=DwMGaQ&c=bMxC-A1upgdsx4J2OmDkk2Eep4PyO1BA6pjHrrW-ii0&r=_PhHIbttY6k7xeuw0iEH2fHiUZ_5NGz8sAhGTsdtuIc&m=gdQT90lG0SsBD16NH4GAWbcwjEPdfwpI8kGLOCcwWrY&s=2LQj_aV_6VYZDSVFnz2s_9g4z9Q15mqGjJm0OEayExA&e=


pathway (go to: https://www.england.nhs.uk/north-west/gmec-clinical-networks/our-networks/maternity/resources/) (Appendix 3). If the cCTG does not meet the criteria on another component then the decision regarding whether to proceed to delivery or repeat the cCTG is the responsibility of the obstetrician caring for the patient.

In the presence of absent/reversed end diastolic flow in UAD >/=32 weeks delivery should occur as soon as is safely possible following the administration of steroids.

Antenatal steroids - All women with FGR and planned for delivery at less than 35+6 weeks must receive a single course of antenatal steroids. Two doses of betamethasone/dexamethasone 12mg given intramuscularly, or two doses of dexamethasone 12mg intramuscularly, should be given 12-24 hours apart. Choice depends upon the stock available. These are unlicensed indications for these medications but are commonly used within practice. See also Preterm Labour Guidelines.

Inpatient monitoring - Inpatient monitoring should be reserved for women with FGR at less than 32 weeks with absent/reversed end diastolic flow in whom delivery is anticipated.

2.3 Delivery planning

If delivery when EFW<1.8kg or <35 weeks is planned due to FGR then the availability of neonatal care should be identified prior to induction or caesarean delivery. If no facilities are available, arrangements can be made for transfer, but only if there is a normal computerised CTG and / or a normal Ductus venosus a-wave (if <32 weeks) prior to this occurring. Where this is not the case women must be delivered locally with ex-utero neonatal transfer as needed. The NW eFGR Integrated care pathway should be followed (go to: https://www.england.nhs.uk/north-west/gmec-clinical-networks/our-networks/maternity/resources/) (Appendix 3).

For women <34 weeks’ gestation, delivery should usually be by planned caesarean section 24 hours after antenatal steroids. At least 4 hours prior to caesarean section a magnesium sulphate loading dose and infusion should be offered to all women between 24+0 and 29+6 weeks of pregnancy, and considered for women between 30+0 and 33+6 weeks of pregnancy. This has been shown to reduce the incidence of cerebral palsy in high risk pre-term infants (RCOG, 2011). The NW eFGR integrated care pathway should be followed (go to: https://www.england.nhs.uk/north-west/gmec-clinical-networks/our-networks/maternity/resources/) (Appendix 3).



https://www.england.nhs.uk/north-west/gmec-clinical-networks/our-networks/maternity/resources/

https://www.england.nhs.uk/north-west/gmec-clinical-networks/our-networks/maternity/resources/





2.3.1 For women >34 weeks’, timing of delivery depends on the estimated fetal weight centile, growth velocity and the whole clinical picture.

Infants with likely FGR (<3rd centile EFW) should be delivered at 37 weeks.Infants with SGA at moderate risk of FGR (5th -<10th centile) should be delivered at 39 weeks. Infants with slowed or static growth defined as <280g change over 2 weeks (140g per week, 20g per day from 34 weeks) should be induced no later than 37 weeks. Infants with abnormal dopplers or MDVP <2cm should be reviewed by a consultant obstetrician and delivery planned (see Appendix 2).

2.4 Postnatal management

2.4.1 An individual birth weight centile must be calculated for every baby (live born/ stillborn / multiples) at birth, this must be documented on the neonatal record and in the child’s personal health record (red book)

2.4.2 Any low-risk woman who delivers a baby with a birth weight less than the 3rd

centile and <32+6 weeks must be offered a follow up postnatal appointment within:

insert name of local service here

At this time any potentially identifiable risk factor for FGR in future pregnancies will be discussed. Scientific data supporting a causal association between either methylenetetrahydrofolate reductase (MTHFR) polymorphisms or other common inherited thrombophilias and adverse pregnancy outcomes, such as recurrent pregnancy loss, severe preeclampsia and IUGR, are lacking. Specific testing for antiphospholipid antibodies, when clinically indicated, should be limited to lupus anticoagulant, anticardiolipin antibodies and beta 2 glycoprotein antibodies.

See also the guideline for Hypoglycaemia prevention and Thermoregulation following Birth for neonatal care planning.

2.5 Communication and Documentation

All women with learning disabilities, visual or hearing impairments or those whose first language is not English must be offered assistance with interpretation where applicable, and where appropriate a telephone interpreter must be used. It is paramount that clear channels of communication are maintained at all times between all staff, the women and their families. Once any decisions have been made/agreed, comprehensive and clear details must be given to the woman thereby confirming the wishes of the women and



their families. The contents of any leaflet issued must be explained in full at the time it is issued. All communication difficulties (including learning difficulties) and language barriers must be addressed as outlined in the previous paragraph at the time the leaflet is issued.

Ensure the provision and discussion of information of the risks and benefits with women during the antenatal, intrapartum and postnatal periods.

Staff should aim to foster a culturally sensitive care approach in accordance with the religious and cultural beliefs of the parents and families in our care.

3 Equality, Diversity and Human Rights Impact Assessment

The EqIA score fell into low priority; no significant issues in relation to equality, diversity, gender, colour, race or religion are identified as raising a concern.

4 Consultation, Approval and Ratification Process

This guideline has been approved and ratified in accordance with the agreed process. Refer to Guideline for the Introduction or Re-approval of a Clinical Guideline for Obstetric Practice.



Appendix 1: Abnormal Fundal Height (FH) Measurement pathway



1st FH plot below 10th centile or slowed / static growth on FH on customised growth chart

Refer for CTG & USS (growth, liquor & UAD) immediately

Normal pattern of fetal movementsReduced fetal movements

Refer for USS (growth, liquor & UAD).To be seen within 72 hours

See Appendix 2: SGA Management

Pathway

EFW within normal range

Continued with planned care

USS findings

EFW 5-<10th/

EFW <5th/Absent EDF

Appendix 2: SGA Management Pathway



Appendix 3: NW Early Onset FGR Integrated Care Pathway

North West RegionalEarly Onset FGR

Integrated Care Pathway

This integrated care pathway is for use in the management of FGR pregnancies diagnosed before 32 weeks’ gestation.

Version 1.0March 2019

Booklet to be kept with handheld notes



Document ControlOwnershipRole ContactDocument authorsDesignation:

Ed Johnstone Suzanne ThomasNW FGR Network Chairs

Emma IngramAcademic Clinical Lecturer

[email protected]@mft.nhs.uk

[email protected]

Project Manager GMEC SCN [email protected] Version control

Title The North West Regional Pathway for the Detection and Management of Fetal Growth Restriction

Version V1.0 22/03/2019

Supersedes New document

Endorsement processRatification Signed off by the North West FGR Group on 25/01/2019

Date of clinical endorsement

GMEC SCN Maternity Steering Group on 15/02/2019

Application All Staff Circulation Issue Date: 22/03/19

Circulated by [email protected] Review Date: 22/03/2021

Responsibility of: North West FGR Network

Date placed on the Intranet:

Please enter your EqIA Registration Number here:

Acknowledgements

I would like to thank the members of the North West FGR Group for their enthusiasm, commitment and contribution to the development of this North West eFGR Integrated Care Pathway.

I would also like to acknowledge and thank the families who gave their time and experience to create this guideline; together we are committed to driving better outcomes for babies across our region.

Ed Johnstone Consultant Obstetrician/Senior Lecturer in Obstetrics and Fetal MedicineChair of the North West FGR Group







Patient Identifier and Demographics

Surname

First Name

Hospital No.

Date of Birth

Address

Contact Tel No

Consultant

GP Name

GP Address

Interpreter required Y/N

Language

Partners Name

Local Unit

Local Contact Name

Local Contact No.



Communication, Principles and Management

Communication Principles Management

With parents; Ensure privacy Diagnosis of eFGR

- answer questions openly and honestly

Involve both parents where appropriate

NW eFGR referral

- if you do not know the answer say so and find someone who can answer the question

Use empathic and unambiguous language

Counselling at Diagnosis

Respect culture and religious beliefs

Investigations after diagnosis

With colleagues; Provide written information Neonatal Counselling

- provide relevant and consistent advice

Allow time for decision making Delivery Discussion: Conservative vs. Active

Pregnancy Surveillance:

Repeat information Active management

Conservative management

cCTG

Promote continuity of care and carer

Gestational Age based Indications for Delivery

Delivery Indication Algorithm

Involve experienced staff Visits

Inform relevant care providers Scan reports

Co-ordinate referrals Information for Parents

Postnatal Care and Investigations

Plan for future pregnancies

Accountability Sheet

Signature Print Designation



Information on Fetal Growth Restriction

We understand that being told that your baby has Fetal Growth Restriction (FGR) and will be born prematurely is devastating. Living with the uncertainty of a positive birth outcome is a highly anxious time. You may feel alone and that you don’t know anyone else who this has happened to. We care for many women who have pregnancies complicated by FGR, we will support you and your family and answer your questions.

FGR is sometimes also IUGR (Intrauterine Growth Restriction), both terms refer to a condition where the baby is much smaller than expected. This is because the baby’s growth has slowed down and can eventually stop. Please be reassured that in most cases nothing you have done, or could have done differently, has caused this to happen.

There is a lot of information to take in at your first appointment and everything can feel very uncertain. It is normal to feel confused, scared and anxious after being told that your baby has growth restriction. We will give you more information at each appointment and together we will take your pregnancy scan by scan.

You may be faced with making a very difficult decision about how to proceed with your pregnancy, only you can decide what is best for you and your family. This can be very challenging but the team caring for you will support you, you can ask as many questions as needed.

Living with FGR will have an emotional impact on you and your family, there is no right way to feel, use the support around you including the team caring for you.

These things can help: Write down any questions as they come into your head – there are no silly questions

and we understand that this is all new to you. You can call your named midwife if you have any questions or bring them to your next appointment.

Some of the things we need to explain are quite complicated and we apologise if we don’t always explain properly the first time we try. Please feel free to ask us to explain anything again, as many times as you need.

We can provide a letter for your employer and your partner’s employer to explain that you will need to attend the hospital frequently for additional appointments and that your baby will be born prematurely.

If you are coming to the hospital 3 or more times a week we can help with parking or travel expenses.



Baby’s movementsIt is important to be aware of your baby’s pattern of movements and to inform the maternity unit caring for you immediately if you notice any change in the pattern.

Other sources of information & supportIt is natural that you will want to find out as much as possible about FGR and how it will affect you and your baby; however, some of the information available on the internet can be very frightening and isn’t always accurate. Please ask the team caring for you if you have any questions.

Organisations that you may find helpful:

Tommy’s – The Baby Charity

www.Tommys.org.uk Helpline: 0800 0147800

Provide evidence based, expert and user-led, accessible pregnancy information to support expectant parents in understanding what they can do to support a safe and healthy pregnancy.

ARC Antenatal Choices and Results

www.arc-uk.org Helpline: 0845 0772290

Support for parents whose baby is diagnosed with a fetal abnormality in pregnancy

Bliss for babies born sick or premature

www.bliss.org.uk Helpline: 0808 010322

Family support helpline offering guidance and support for expectant parents of premature and sick babies

Words you may hear used;

Fetal Growth Restriction (FGR): where baby is much smaller than expected due to slow growth in the womb, the baby may eventually stop growing all together.

Intrauterine Growth Restriction (IUGR): where baby is much smaller than expected due to slow growth in the womb, the baby can eventually stop growing all together.

Doppler: Doppler ultrasound measures the movement of blood in vessels. The blood flow is often measured in several places to monitor baby’s wellbeing in the womb, changes in these measurements can indicate when it may be time for baby to be born, this is usually earlier than expected.

Umbilical Artery Doppler (UAD): measurement of blood flow through baby’s umbilical cord



Middle Cerebral Artery Doppler (MCA): measurement of blood flow through an artery in baby’s brain.

Ductus Venous (DV): blood vessel connecting the umbilical vein to the baby’s heart. Can be used as an assessment of baby’s wellbeing in certain circumstances.

Uterine Artery Doppler: the measurement of blood flow through your uterine arteries which are the main blood vessels that supply blood to your womb (or uterus). The presence of a ‘notch’ in one or both uterine arteries represents an abnormal waveform and suggests that there may be a problem with the blood supply to the placenta.Liquor Volume or Amniotic Fluid Index: the measurement of the water also known as liquor or amniotic fluid surrounding your baby.Computerised CTG: An assessment of baby’s heart rate over a period of time to check baby’s wellbeing. Neonatal Intensive Care Unit (NICU): a specialist unit providing intensive care for sick or premature newborn babies

________

A diagnosis of an eFGR infant is an emotionally and physically demanding time for families. Being cared for and having access to a known /dedicated team can be helpful for families. It is helpful for families to have the ability to contact their dedicated team directly:

Named Midwife Contact No

Named Consultant Contact No.

Regional Centre information Directions/Map

Car parking exemption or assistance with travel expenses

Information / permit given _____/_____/_____ (date)

Offer a letter of support for employers explaining the increased frequency of appointments and early delivery. Letter provided_____/_____/_____(date)



Diagnosis checklist for this NW eFGR Integrated Care Pathway

Needs to meet criteria 1 AND either criteria 2 or 3

1. Gestation at diagnosis: before 31+6 weeks

AND

2. Estimated Fetal Weight <3rd centile or Abdominal Circumference <3rd centile

OR

3. Estimated Fetal Weight (EFW) < 10th centile with Umbilical Artery Doppler PI> 95th centile or Absent or Reversed End Diastolic Flow

Initial Ultrasound report



Managing an eFGR pregnancy and when to refer

Once diagnosed, eFGR pregnancies require regular maternal and fetal assessment and appropriate postnatal care including:

ultrasound measurement of fetal growth ultrasound Doppler measures of the Ductus Venosus (DV) computerised CTG (cCTG) tertiary (level 3) NICU facilities

Counselling at Diagnosis

Discussion of possible cause/pathology;• Placental• Chromosomal• Infection• Constitutional

Survival Statistics (General Information)

Based on eFGR cases managed through St Mary’s Hospital since June 2009, 71% of eFGR pregnancies end in a live birth, and 29% unfortunately end in a stillbirth. Of those born alive, 23% die in the days or months following delivery.

Survival rates for infants alive at the start of labour, less than the 10th centile

The figures below are based on work that was performed in the late 1990s1 , and updated figures are awaited. Neonatal care has advanced greatly over the past 20 years and more premature babies are surviving now than previously2, therefore we would expect the updated figures to be better than those quoted here.

Gestation at delivery Predicted survival

1 Draper E., Manktelow B., Field D., James D. Prediction of survival for preterm births by weight and gestational age: retrospective population based study. BMJ 1999; 319:1093-10972 Moore T., Hennessy E.M., Myles J., Johnson S.J., Draper E.S., Costeloe K.L., Marlow N. Neurological and developmental outcome in extremely preterm children born in England in 1995 and 2006: the EPICure studies. BMJ 2012; 345:e7961



(alive at the start of labour)

<26 weeks 43%

28 weeks 63%

30 weeks 86%

32 weeks 93%

Discussion regarding viability thresholds



Investigations

Chromosomal abnormalities: FGR secondary to chromosomal abnormalities is more common if; structural abnormalities are identified, 1st/2nd trimester screening for aneuploidy is high risk, or if Doppler abnormalities are absent in severe FGR. This will obviously have consequences for the likely postnatal prognosis of the child. Chromosomal abnormalities can be tested for by amniocentesis, the principle risk of this test is miscarriage (which is nationally 1% above the background rate for that gestation).

Infection: FGR secondary to infection is more common in cases with; associated fetal abnormalities (especially of the fetal brain), where FGR is occurs before 23 weeks or where there has been a history compatible with maternal infection. Test for Toxoplasma, Rubella, Cytomegalovirus (CMV). In the case of equivocal results, it can be helpful to check the IgM and IgG status on the stored booking serum sample.

Maternal conditionsFGR is frequently associated with preeclampsia and therefore a BP and urine dipstick should be performed at every visit. Where proteinuria is present, quantify using urinary protein creatinine ratio (confirm absence of infection and repeat if between 30 – 50mg/mmol). Consider the possibility of underlying renal disease or chronic hypertension.

Test Date Offered Date Accepted Result (Date)

Amniocentesis

TORCH/CMV

uPCR

sFlt/PlGF test (if available)

Discussion of appropriate investigation with parents

Date ______________________________________________________

Name ______________________________________________________

Designation _________________________________________________



Neonatology Counselling

A detailed discussion regarding anticipated care on NICU, potential complications and prognosis would usually be provided by a neonatology consultant or member of the NICU team.

Offered

Accepted / Declined (delete as appropriate)

Documentation of neonatal discussion:

Date ______________________________________________________________Name ______________________________________________________________Designation ______________________________________________________________

Neonatal Tour offered YES/NO

Date & Time arranged: __________________________________________________



Delivery Discussion

Discussion regarding viability thresholds (when weight EFW<500g and gestation<26 weeks)

Pregnancy Management options;

Conservative Management Monitoring at a frequency requested by parents Induced vaginal delivery when intrauterine death occurs

Active Management Regular surveillance (maternal and fetal) Pre-delivery management – steroids & magnesium sulphate Delivery by Caesarean section A duration of stay on NICU Risk of Stillbirth or Neonatal Death

Termination of Pregnancy

Further delivery details discussed

Date ______________________________________________________________Name ______________________________________________________________Designation ______________________________________________________________



Surveillance of the FGR Fetus & Maternal Monitoring

Active Management

The suggested frequency of monitoring (see figure 1, page 16) represents the recommended surveillance for women with eFGR affected pregnancies following active management and EFW>450g at 28+0 weeks or >500g at 26+0 weeks.

This surveillance pathway is based on optimizing the timing of delivery for the fetus. However, many of these eFGR pregnancies will be due to preterm preeclampsia and as such may warrant more frequent monitoring of BP and blood tests for maternal disease surveillance.

Maternal Surveillance

Maternal wellbeing should be assessed at every visit (symptoms, BP and urine). Once proteinuria is confirmed (PCR >50mg/mmol with a negative MSSU) protein quantification does not need to be repeated, and should not be used as a measure of deterioration. If pre-eclampsia is diagnosed/suspected, then blood tests should be performed twice weekly and BP should be maintained within a target of 130-150/80-100mmHg. If the fetal condition is stable prior to 32 weeks, antihypertensive medication should be increased to control BP rather than triggering delivery. A diagnosis of pre-eclampsia does not mandate delivery before 34 weeks unless;

thrombocytopenia (platelets <100 x109/L) abnormal renal function (new onset Creatinine >100mmol/L) abnormal liver function (ALT/AST > double normal unit range) severe hypoalbuminaemia (albumin <15g/L) severe or increasing proteinuria is

not an indication to deliver in isolation

A diagnosis of pre-eclampsia should not prompt steroid administration unless there is a maternal or fetal indication for delivery (see flow chart, page 21).

In women with pre-existing hypertensive or renal disease, thresholds for BP and blood test abnormalities may need to be adjusted, and LMWH considered if proteinuria >300mg/mmol, in these cases tertiary centre input may helpful.

Where possible AN appointments and scanning should be combined to minimise attendances and pregnancies should be supervised/co-ordinated by a named provider in your Local eFGR Network Centre. It may be necessary to offer inpatient stay if attending the appointments is logistically difficult or at maternal request.



Fig 1: Frequency of monitoring* if UAD PI returns to <95th centile then surveillance can be stepped down to 1-2 weekly assessment.

Conservative management

If the estimated fetal weight is <500g before 26+0 weeks’ gestation, or <450g at 28+0 weeks’ gestation or above, the chances of healthy survival of the infant is remote. Conservative management (as below) is advocated, except where after detailed counselling of the parents (including neonatal counselling) the parents wish for active management. In these situations, please follow the care plan.

Conservative management includes;

Maternal assessment for the early diagnosis of conditions related to eFGR such as pre-eclampsia (blood pressure and urine)

Weekly scan for viability Estimate fetal weight weekly to assess whether viable weight has been

achieved (not to assess growth trajectory) Dopplers may be recorded for counselling purposes, but not to instigate

delivery Not for cCTG



1-2 weekly assessment Ultrasound - UAD and MPD EFW (every 2 weeks) Maternal Assessment - BP & urinalysis

eFGR UAD EDF with PI<95th centile

Twice per week assessment* Ultrasound - UAD and MPD (+/- cCTG) EFW (every 2 weeks) Maternal Assessment - BP & urinalysis

eFGR with UAD EDF with PI>95th centile

Three times per week assessment (Mon/Wed/Fri) Ultrasound - UAD, DV and MPD EFW (every 1-2 weeks) cCTG if change in Dopplers or reduced FMs Maternal Assessment - BP & urinalysis

eFGR with absent EDF in UAD

Alternate day assessment Ultrasound - UAD, DV and MPD EFW (every 1-2 weeks) cCTG Maternal assessment - BP & urinalysis

eFGR with reversed EDF or changing fetal Dopplers (DV

PI> 95th centile )

Daily assessment Maternal Assessment - BP & urinalysis cCTG

eFGR awaiting delivery

Not for delivery for fetal reasons

Computerised CTG (cCTG)

cCTG calculated STV is based on the Dawes–Redman algorithm, and is the only objective measure of fetal heart rate that has been validated against invasive testing in fetal hypoxemia and acidemia. Simple visual interpretation of a regular CTG may not be sufficiently informative or sufficiently objective to provide reassurance about the fetal condition. cCTG will also detect repetitive fetal heart-rate decelerations.

cCTG assessment should be performed until Dawes-Redman criteria met, or for a maximum of 60 minutes. The machine first evaluates for criteria at 10 minutes and repeats this analysis every 2 minutes. The cCTG can be stopped once the Dawes-Redman criteria have been met. If the cCTG continues to the full 60 minutes, it will report ‘CRITERIA NOT MET’ and give a justification. In these eFGR pregnancies, if the calculated STV value is above the specified safety net criteria for that gestation (>2.6ms if <29 weeks, or >3.0 at 29 weeks and beyond) CTG monitoring can be discontinued. A cCTG STV below the gestation safety net is a trigger to prepare for delivery.

All cCTGs should be considered in relation to the gestation and clinical situation.

cCTG may fail to meet criteria for a number of reasons beyond STV (see table below). In these situations, consider a repeat cCTG or obstetric consultant review.

Dawes Redman CRITERIA NOT MET codes: 1. Basal Heart Rate outside normal range (110 – 160) 2. Large decelerations 3. No episodes of high variation 4. No movements and fewer than 3 accelerations 5. Baseline fitting is uncertain 6. Short-term variation is less than 3ms 7. Possible error at end of the record 8. Deceleration at the end of the record 9. High-frequency sinusoidal rhythm 10. Suspected sinusoidal rhythm 11. Long-term variation in high episodes below acceptable level 12. No accelerations



Should there be spontaneous repeated unprovoked decelerations which may warrant a plan for delivery the cCTG should be repeated after a 1-hour break. If the spontaneous repeated unprovoked decelerations persist, discuss with the named care provider or the Obstetric Consultant on-call for Delivery suite. In the presence of accelerations, smaller decelerations are of uncertain significance and should not trigger delivery, particularly without fetal lung maturation. Observation of continuous CTG tracing over a 24-hour period has shown that before 32 weeks, both normal and FGR babies show decelerations, but these do not seem to have any immediate bearing on the pregnancy outcome.

The use of cCTG in eFGR is based on the TRUFFLE randomised controlled trial3-4. In TRUFFLE the frequency of cCTG assessment was not specified. cCTG should be performed if there is a further deterioration in fetal wellbeing or maternal concern, such as;

Reduced fetal movements New oligohydramnios Increase in Ductus Venosus (DV) PI

3 Ganzevoort W, Mensing Van Charante N, Thilaganathan B, Prefumo F, Arabin B, Bilardo CM et al. How to monitor pregnancies complicated by fetal growth restriction and delivery before 32 weeks: post hoc analysis of TRUFFLE study. Ultrasound Obstet Gynecol 2017;49:769-7774 Wolf H, Arabin B, Lees C, Oepkes D, Prefumo F, Thilaganathan B et al. Longitudinal study of computerized cardiotocography in early fetal growth restriction. Ultrasound Obstet Gynaecol 2017;50:71-78



Gestational Age Indication for Delivery

If decision is made for ACTIVE MANAGEMENT a plan for delivery should be made on maternal condition or if delivering on fetal grounds based gestational specific criteria, please see algorithm (page 21).

If there are concerns regarding maternal condition which indicate a consistent deterioration justifying preterm delivery this should ALWAYS override the fetal wellbeing assessment. Approximately 1 in 3 eFGR pregnancies will be delivered on maternal grounds, most commonly preeclampsia.

On meeting a criterion for delivery in the algorithm;

1. Admit2. IM Dexamethasone or Betamethasone 12mg (two doses 12 hours apart) for fetal lung

maturity3. Aim for delivery 12 - 24 hours after 2nd dose of corticosteroids4. Delivery is usually by Caesarean section (<34 weeks with abnormal UAD PI or

absent/reversed EDF)5. Inform Delivery Unit to arrange Magnesium Sulphate (below 34 weeks’ gestation) to be

given for at least 4 hours prior to delivery6. Inform NICU co-ordinator 7. Inform Consultant on-call 8. Consider transfer out if delivery is delayed by more than 24 hours

The closer to birth the corticosteroids are given, the greater the benefit to the infant; in particular steroid-delivery intervals >7 days are associated with reduced benefit from steroid administration5. Review of data from 100 cases of early onset FGR from the Manchester Placenta Clinic since 2009 has shown a median interval from UAD absent EDF to delivery of 17 days (only 9 delivered within 24hours, and 71 infants delivered after more than 7 days). Thus, antenatal steroids should not be administered without a plan to deliver in the next 48 hours. There is also evidence that there is benefit in giving antenatal steroids for fetal lung maturation even if delivery cannot be delayed to receive a full course of treatment6.

If the umbilical artery EDF remains present, pregnancies with EFW <5th centile should be delivered by 37 weeks (see SGA guidelines). In these pregnancies induction of labour may be appropriate.

5 Wilms FF, Vis JY, Pattinaja DA, Kuin RA, Stam MC, Reuvers JM et al. Relationship between the time interval from antenatal corticosteroid administration until preterm birth and the occurrence of respiratory morbidity. Am J Obstet Gynecol 2011;205(1):49.e1-76 Norman M, Piedvache A, Borch K, Drasbek Huusom L, Edstedt Bonamy A, Howell EA et al. Association of short antenatal corticosteroid administration-to-birth intervals with survival and morbidity among very preterm infants. Results from the EPICE cohort. JAMA Pediatr 2017;17(7)678-698



Using the indication for delivery algorithm (page 21)• orange boxes represent scans• green boxes represent cCTG assessment, the safety net STV value changes at 29

weeks’ gestation • if in any arm you end at a red ‘Plan to deliver’ box, then corticosteroids should be

given and delivery occur within 24-48 hours.



Delivery Indication by Gestation at the Time of Assessment Algorithm



Visit Record

Date Gestation BP

Urine FMs FM Discussed

Date Gestation BP


Date Gestation BP


Date Gestation BP


Date Gestation BP




Date Gestation BP


Date Gestation BP


Date Gestation BP


Date Gestation BP


Date Gestation BP




Scan Reports



Maternal Postnatal Discharge Check list

Please ensure that the placenta is sent for histopathology

Maternal Discharge Date ___________________________________________

Placental Histology sent

Discharge letter to GP sent

Postnatal fasting glucose performed

Blood pressure on discharge ___________________________________________

PN antihypertensive treatment required

Medication/Dose ____________________________________________________

Discussion regarding weight optimisation (if applicable)

Discussion regarding contraception

Additional notes



Follow up Visit Prompt List

This visit is usually with the named consultant 6-8 weeks following delivery.

Visit Date __________________________________________________________

Baby’s Name _________________ Gestation Delivered ___________ LB/SB/NND

Observations: BP ______________ Urine _____________

Investigation Results

Karyotype __________________________

Placental Pathology __________________.

Thrombophilia screen (if indicated by placental histology)__________________________

Final Diagnosis

Plan for Future Pregnancy

Pre-conception (via GP) Folic Acid Optimising Hypertension Optimising Weight Optimising HbA1c

Who to contact when pregnant: ________________________________________________

At Consultation Folic Acid Aspirin 150mg (from 8 weeks) Optimising Hypertension Serial Ultrasound Scan from ________ weeks’ gestation Uterine artery Doppler at 20-24 weeks’ gestation

Other _____________________________________________________________________________________________________________________________________________



FGR Research

We are always trying to find out more about the cause of FGR and develop tests and treatments to improve outcomes for women and their babies. This is done through carefully designed research. You may be asked to take part in research at some point during your pregnancy or afterwards. You do not have to take part in any of the research studies offered to you, your care will not be affected if you choose not to or decide that you want to withdraw from a study.



Appendix 4: Risk assessment, surveillance pathway and

management of FGR



Appendix 5: Reference ranges for uterine artery mean pulsatility

index at 11 – 41 weeks of gestation

Gómez, O (2008). Reference ranges for uterine artery mean pulsatility index at 11 – 41 weeks of gestation. Ultrasound Obstet Gynaecol, 32: 128 – 132. DOI:10.1002/uog.5315. Published online 6th May 2008.



Appendix 6: Reference range for serial measurements of umbilical

artery Doppler indices in the second half of pregnancy

Percentile

Gestation (wk) 2.5th 5th 10th 25th 50th 75th 90th 95th 97.5th

19 0.97 1.02 1.08 1.18 1.30 1.44 1.57 1.66 1.74

20 0.94 0.99 1.04 1.14 1.27 1.40 1.54 1.62 1.70

21 0.90 0.95 1.00 1.10 1.22 1.36 1.49 1.58 1.65

22 0.87 0.92 0.97 1.07 1.19 1.32 1.46 1.54 1.62

23 0.84 0.89 0.94 1.04 1.15 1.29 1.42 1.50 1.58

24 0.81 0.86 0.91 1.00 1.12 1.25 1.38 1.47 1.55

25 0.78 0.83 0.88 0.97 1.09 1.22 1.35 1.44 1.51

26 0.76 0.80 0.85 0.94 1.06 1.19 1.32 1.41 1.48

27 0.73 0.77 0.82 0.92 1.03 1.16 1.29 1.38 1.45

28 0.71 0.75 0.80 0.89 1.00 1.13 1.26 1.35 1.43

29 0.68 0.72 0.77 0.86 0.98 1.10 1.23 1.32 1.40

30 0.66 0.70 0.75 0.84 0.95 1.08 1.21 1.29 1.37

31 0.64 0.68 0.73 0.82 0.93 1.05 1.18 1.27 1.35

32 0.62 0.66 0.70 0.79 0.90 1.03 1.16 1.25 1.32

33 0.60 0.64 0.68 0.77 0.88 1.01 1.14 1.22 1.30

34 0.58 0.62 0.66 0.75 0.86 0.99 1.12 1.20 1.28

35 0.56 0.60 0.64 0.73 0.84 0.97 1.09 1.18 1.26

36 0.54 0.58 0.63 0.71 0.82 0.95 1.07 1.16 1.24

37 0.53 0.56 0.61 0.69 0.80 0.93 1.05 1.14 1.22

38 0.51 0.55 0.59 0.68 0.78 0.91 1.04 1.12 1.20

39 0.49 0.53 0.57 0.66 0.76 0.89 1.02 1.10 1.18

40 0.48 0.51 0.56 0.64 0.75 0.87 1.00 1.09 1.17

41 0.47 0.50 0.54 0.63 0.73 0.85 0.98 1.07 1.15

Acharya, G et al (2005). Reference ranges for serial measurements of umbilical artery Doppler indices in the second half of pregnancy. Am J Obstet Gynecol, Mar; 192(3): 937-44



References

Bujold, E et al. (2010) “Prevention of Preeclampsia and Intrauterine Growth Restriction With Aspirin Started in Early Pregnancy: A MetaAnalysis.” Obstetrics & Gynecology 116(2:1): 402-414.

Gardosi, J et al. (2005) “Classification of stillbirth by relevant condition at death (ReCoDe): population based cohort study.” BMJ 331(7525): 1113-7.

Jacobsson, B et al. (2008) “Cerebral palsy and restricted growth status at birth: population-based case-control study” BJOG 115(10): 1250-5.Kingdom J, (2018) A placenta clinic approach to the diagnosis and management of fetal growth restriction. December 2017. American Journal of Obstetrics and Gynecology 218(2S).

McCowan LME. (2009) Spontaneous preterm birth and small for gestational age infants in women who stop smoking early in pregnancy: prospective cohort study. BMJ 2009;338:1081–2009

Magann EF, Sanderson M, Martin JN, Chauhan S (2000) The amniotic fluid index, single deepest pocket, and two-diameter pocket in normal human pregnancy, Am J Obstet Gynecol. Jun;182(6):1581-8.

Ribbert, LS et al. (1993) “Prediction of fetal acidaemia in intrauterine growth retardation: comparison of quantified fetal activity with biophysical profile score.” Br J Obstet Gynaecol 100(7): 653-6.

Rolnik et al (2017) Aspirin versus Placebo in Pregnancies at High Risk for Preterm Preeclampsia. N engl j med 377;7 nejm.org August 17, 2017

Royal College of Obstetricians and Gynaecologists Scientific Advisory Committee (2011) Magnesium sulphate to prevent cerebral palsy following preterm birth (Opinion Paper 29). London: RCOG.



· Web viewNorth West Regional Guideline for the Detection and Management of Fetal Growth...

Documents

Transcript of · Web viewNorth West Regional Guideline for the Detection and Management of Fetal Growth...