MONITORING FETAL GROWTH. Self - Instruction. Manual. 2nd edition. Monitoring Fetal Growth Self - Instruction Manual 2nd. edition CLAP/WR - PAHO/WHO

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1 Monitoring Fetal Growth Self - Instruction Manual 2nd. edition CLAP/WR - PAHO/WHO MONITORING Self - Instruction 2nd edition Manual FETAL GROWTH Fescina RH De Mucio B Martínez G Alemán A Sosa C Mainero L Rubino M Latin American Center for Perinatology Women & Reproductive Health - CLAP/WR Scientific Publication CLAP/WR

2 Monitoring Fetal Growth Self-Instruction Manual 2 nd edition Fescina RH De Mucio B Martínez G Alemán A Sosa C Mainero L Rubino M Latin American Center for Perinatology Women and Reproductive Health CLAP/WR Familiy and Community Health Pan American Health Organization / World Health Organization

3 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 Pan American Health Organization / World Health Organization - PAHO/WHO 2nd edition Roberto Porro, art design

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5 2 Monitoring Fetal Growth TABLE OF CONTENTS INTRODUCTION 4 FACTORS AFFECTING INTRAUTERINE GROWTH PHYSIOPATHOGENESIS OF INTRAUTERINE GROWTH RESTRICTION DIAGNOSIS DIAGNOSIS OF IUGR WITH KNOWN OR ESTIMATED GESTATIONAL AGE DIAGNOSIS 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 CAPTURE DIFFERENTIAL DIAGNOSIS BETWEEN SYMMETRIC IUGR AND ERROR IN THE ESTIMATION OF GESTATIONAL AGE BY LMP PROPOSALS FOR THE SOUND USE OF THE FETAL GROWTH SURVEILLANCE METHODS OBSTETRIC MANAGEMENT OF INTRAUTERINE GROWTH RESTRICTION 42 EXERCISES USING THE PERINATAL COMPUTING SYSTEM FOR THE ASSESSMENT AND MONITORING OF FETAL GROWTH Pag

6 Monitoring Fetal Growth BIBLIOGRAPHY

7 4 Monitoring Fetal Growth MONITORING FETAL GROWTH INTRODUCTION SELF-INSTRUCTION MANUAL 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,

8 Monitoring Fetal Growth 5 Exercise 1 30 weeks 35 weeks 40 weeks Case A 1800 g g g. Case B 900 g g g P 90 Grams 3000 P Amenorrhea, in weeks Figure 1 Weight by GA curve, showing P10 and P90

9 6 Monitoring Fetal Growth 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. Case C Case D Case E Case F G. A. Weight grs grs grs grs. Rank the case infants. foreign standards developed ignoring certain factors that alter fetal growth and

10 Monitoring Fetal Growth 7 the population, as to warrant changing the reference standards P 90 Gramos 3000 P Amenorrhea in weeks Figure 2 Standards developed by CLAP/WR for neonatal weight by gestational age

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12 Monitoring Fetal Growth 9 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 Severe malnutrition vascular disease, chronic lung disease, mesenchymal diseases b) Risk factors detected during pregnancy Pregnancy-induced hypertension / preeclampsia-eclampsia Antiphospholipid syndrome Anemia Congenital malformations Exposure to teratogens

13 10 Monitoring Fetal Growth c) Environmental and behavioral risk factors 2. Heavy alcohol consumption Excessive consumption of caffeine 4. Drug Addiction Stress

14 Monitoring Fetal Growth 11 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. Early and prolonged harm Late onset harm Acts at the critical period Neurons Yes Long bones Yes Adipositosis Yes Neurons No Long bones No Adipositosis Yes Reduced head cir. Length Weight Normal head circ. Normal length Reduced weight Results Symmetric SGA Asymmetric SGA Growth rate Neurons Long bones Adiposytes Weeks of gestation Figure 3 Critical periods of the different tissues and perinatal outcomes depending on the time of occurrence and the duration of the noxa

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16 Monitoring Fetal Growth 13 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

17 14 Monitoring Fetal Growth 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 in population % History of SGA 14 Smoking habit (10 o +) 26 Multiple pregnancy 1 Pregnancy-induced hypertension 7 Preeclampsia 4 Hemorrhage 2nd trimester 0.5 Weight gain < 8 kg. 16 Oligoamnios 0.5 Relative Risk % Confidence interval 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

18 Monitoring Fetal Growth 15 crown-to-rump length, which has a linear relationship with gestational Weeks Femur P 95 P 50 P 5 D. BP. P 95 P 50 P Central value and confidence limits for estimating gestational age based on the ultrasound measurements of: L.CN P 95 P 50 P 5 Femur length Biparietal D. Ceph.-Buttocks length mm Figure 4. Estimation of gestational age based on the fetal anthropometric measurements using two-dimensional ultrasound. (21)

19 16 Monitoring Fetal Growth 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

20 Monitoring Fetal Growth 17 Kg. 15 P 90 Maternal weight gain P 75 P 50 P 25 P Weeks of amenorrhea Figure 5. Maternal weight gain in Kg by gestational age. Longitudinal prospective study N = 1023 weight measurements. (22) cm 35 P P P sem. Fundal height Figure 6. Fundal height in cm by gestational age. Longitudinal prospective study. N = 1074 measurements. (23)

21 18 Monitoring Fetal Growth Exercise 3 Week Maternal weight (kg.) Weight gain

22 Monitoring Fetal Growth 19 Table II - Maternal weight by height by gestational age (p10-p90). (22)

23 20 Monitoring Fetal Growth 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) of the fundal height of this case. gestational age and maternal height.

24 Monitoring Fetal Growth 21 Exercise 5 A B C D E Gest. age (wk.) Maternal height (cm.) Maternal Weight (kg.) Is maternal weight for height by gestational age appropriate? Yes No If you answered that ladies A, C, and D do not have an appropriate weight KNOWN AND RELIABLE GESTATIONAL AGE Yes No Serial measurements Fundal height Mother s weight Estimation of volume amniotic fluid Investigate risk factors Values < lower limit Oligohydramnios Presence of risk factors No Appropriate fetal growth- low risk antenatal control Yes Confirmation ultrasound using GA-dependent growth indicators Distance curve of fetal abdominal circumference and head circumference. by gestational age Yes Estimation of Gestational age by ultrasound By Crown-to-rump length 8-13 weeks By BPD after 12 weeks By Femur length after 13 weeks Early capture Before 20 weeks Ultrasound after the 3rd trimester using GA independent growth factors Ratio = D i a g n o s i s o f I U G R Ruled out Confirmed No Abd. Circ Femur length Growth rate based on previous value of fetal abdominal circumference C li n ic a l C o m p l e m e n t a r y m et h o d s t e s t i n g See algorithm for the differential diagnosis between symmetric and asymmetric IUGR and management Figure 7. Algorithm for the diagnosis of IUGR

25 22 Monitoring Fetal Growth Head circumference mm P 95 P 50 P 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)

26 Monitoring Fetal Growth 23 Abdominal circumference mm P 50 P Weeks of amenorrhea 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)

27 24 Monitoring Fetal Growth 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 < AGA Sens. P10 % < P Fundal height (AU) 56 % Sp. PPV NPP % % % 91 % 80 % 77 % PLR 6.22 NLR 0.48 Maternal weight gain (GP) < P % 79 % 60 % 72 % FH or GP < P10 < P % 72 % 63 % 82 % Fetal abdominal circumference < P % 100 % 94 % 94 % Biparietal diameter < P % 93 % 67 % 67 % Head circumference < P % 100 % 42 % 42 % Oligoamnios Si No % 98 % 28 % 28 % Appropriate for gestational age Sens: Sensitivity Sp: PPV: Positive Predictive Value PLR:

28 Monitoring Fetal Growth 25 Yes Known gestational age with no doubts No Between P5 and P95 Distance curve of the fetal abdominal circumference Lower than percentile 5 Distance curve of the fetal head circumference or femur length Fetal Abdominal Circumference/ Femur Length ratio P10 < 4.25 P Normal growth or symmetric IUGR Between P5 and P95 Lower than P5 Fetal abdominal circumference growth rate curve based on previous value Increase lower tan expected Increase as expected Normal fetal growth Asymmetric IUGR Symmetric IUGR Normal fetal growth Exercise 6 Figure 10. Algorithm for the differential diagnosis between normal fetal growth and symmetric and asymmetric IUGR. they are formulated. Do not go any further with your reading without complying

29 26 Monitoring Fetal Growth Mrs. ZZ Gestational age Current weight Usual weight Blood pressure Fundal height 34 weeks 62 kg. 53 kg. 120/70 mmhg. 25 cm. Which would be your presumptive diagnosis? Fetus with a normal growth Fetus 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

30 Monitoring Fetal Growth 27 Fetal diagnosis Normal fetal growth IUGR Macrosomic None of the above Fetal abdominal circumference 300 mm 266 mm Recommended Management Proceed with antenatal control for low-risk pregnancy Refer to high risk Special tests to determine IUGR type Oral Glucose Tolerance Test Fetal abdominal circumference 300 mm 266 mm pattern. If you decided to continue with special tests to determine the What other assessment would you order? Measurement of fetal head circumference or Femur length 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

31 28 Monitoring Fetal Growth that you consider correct. Head circumference 320 mm. 290 mm. IUGR Symmetric Asymmetric Exercise 7. What would you do in this case? Check the right answer You would hurry to ask for a test to estimate gestational age You 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

32 Monitoring Fetal Growth 29 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

33 30 Monitoring Fetal Growth 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

34 Monitoring Fetal Growth 31 Fetal abdominal increase at 2 weeks mm Previus value of the abdominal circumference P 90 P 70 P 50 P 30 P 10 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

35 32 Monitoring Fetal Growth 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

36 Monitoring Fetal Growth 33 Symmetric IUGR Asymmetric IUGR Abdominal circumference based on previous value 94 % 61 % Abdominal circumference/femur length ratio 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. XX Maternal height Gestational age Current weight Usual weight Weight gain Blood pressure Fundal height 1.55 m. Unknown 60 kg. Unknown 140/94 mmhg 27 cm. that it is small in size.

37 34 Monitoring Fetal Growth What diagnoses would you suggest? Fetus with a normal growth Macrosomic fetus (large) None of the above Small fetus for < age or IUGR How would you solve this problem? I would estimate gestational age asking about the date of onset of the first fetal movements I would only estimate gestational age by ultrasound I would assess fetal growth with indicators independent from gestational age I would wait without doing anything If you answered fetal growth assessment with independent indicators of gestational age, you are on the right path, and you may continue

38 Monitoring Fetal Growth 35 If the FAC/FL ratio was 4.25, What would be your probable diagnosis? Asymmetric IUGR or fetus with a normal growth IUGR no matter what type Symmetric IUGR or fetus with a normal growth Certainty of fetus with a normal growth Low fetal AC Asymmetric IUGR = = < 4.25 Normal fetal femur length 260 mm Example = = mm Fetus with Normal fetal AC normal = growth Normal fetal femur length = > 4.25 Example = = mm 66 mm

39 36 Monitoring Fetal Growth Low fetal abdominal circumference Symmetric. IUGR = = > 4.25 Low fetal femur length 260 mm Example = = 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 ratio Measure the increase of the FAC based on its previous value Measure the BPD Measure the Head Circumference - you have understood the pathophysiology of fetal growth correctly. Otherwise, value:

40 Monitoring Fetal Growth 37 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.

41 38 Monitoring Fetal Growth 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 B.P.D Head circ. Femur length AC BPD Head circumference Femur length AC Error in the estimation of gestational age Lower than normal and tending to converge Normal Normal Asymmetric IUGR Within normal ranges may occur late Lower than normal and diverging Normal Decreased Symmetric IUGR Lower than normal and diverging Decreased Decreased

42 Monitoring Fetal Growth 39 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. Antenatal low risk control 66 True False General population 14% SGA N = 100 No SGA 86 SGA 14 Test Test - + Intervention is lost Test - 34 False True Prevalence 31% False True False True Intervention P. de d et e c ti ó n Referral for Fundal height < P10 and/or Weight gain < P25 Special exploration P. c o Ultrasound Test + 33 n fi r m at i ó n Aprox. } 35 weeks 37 Fetal abdominal circumf < P5 Figure 12 - Application of different tests to diagnose intrauterine growth

43 40 Monitoring Fetal 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 IUGR Yes NO D I A G N O S I S Yes 11 NO {

44 Monitoring Fetal Growth 41 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

45 42 Monitoring Fetal Growth 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. Beaufils et al. (1985) Wallenburg et al. (1985) Wallenburg et al. (1985) Schiff et al. (1985) Uzan et al. (1985) Sibai et al. (1985) CLASP (1985) 4/48 4/41 4/30 2/34 19/156 69/ /4810 (8.3) (19) (13.3) (5.9) (12) (4.6) (7.7) 13/48 9/23 16/27 6/31 20/73 88/ /4821 (28.8) (39) (59.2) (19.4) (27) (5.8) (8.3) Common Odds ratio 473/6604 (7.1) 553/6542 (8.5) B) Childbirth death according to the different gestational ages. determine the gestational age at which you decide to interrupt pregnancy.

46 Monitoring Fetal Growth 43 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)

47 44 Monitoring Fetal Growth 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. Abdominal circumference P 50 P 5 Area of alarm Zone with high death odds Weeks of amenorrhea Figure 14-Normal pattern of fetal abdominal circumference growth with alarm zone and zone of high probability of death.

48 Monitoring Fetal Growth 45 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

49 46 Monitoring Fetal Growth 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.

50 Monitoring Fetal Growth 47 Your diagnosis is: Symmetric IUGR Asymmetric IUGR Fetus with a normal growth 35 week fetus; GA based on the previous ultrasound Abdominal circumference Head circumference Femur length Reduced amniotic fluid 280 mm (<P5) mm charts and record the course of fetal growth. What is your diagnosis? Symmetric IUGR Asymmetric IUGR Fetus with a normal growth but genetically small not a reduction in the femur length.

51 48 Monitoring Fetal Growth strategy would you suggest? The fetus has been confirmed an asymmetric IUGR. What monitoring strategy would you suggest? Monitoring with biophysical profile of the fetus Monitoring only with fetal eco Doppler Monitoring only with obstetric ultrasound Monitoring only with fetal eco Doppler ultrasound Monitoring with measurement of the fundal height 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 week You 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.

52 Monitoring Fetal Growth 49 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.

53 50 Monitoring Fetal Growth 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,

54 34 Monitoring Fetal Growth 51 Newborn s weight in grams Weeks p10 p P 90 Grams 3000 P Amenorrhea in weeks

55 52 Monitoring Fetal Growth Institution B Selection by variables tool, select the population that meets the following conditions: Singleton pregnancy and Literate mother Five or more antenatal visits program Distribution of a variable and place the Gestational age at birth birth weight as a study

56 Monitoring Fetal Growth 53 for this new target population, we have Newborn s birth weight in grams Weeks p10 p90

57 54 Monitoring Fetal Growth connect them with a dashed line. Institution A Institution B alternatives to calculate percentiles in these cases? Prolonged study Sum with other similar institutions

58 Monitoring Fetal Growth 55 Population of the Institution B Grams Amenorrhea in weeks Yes

59 56 Monitoring Fetal Growth Listing of medical records historias B- certain conditions. In each list, the software displays a document that Institution A,

60 Monitoring Fetal Growth 57 studied. Count how many small for gestational age (SGA) taking as a reference the pattern built with: Grams Amenorrhea in weeks

61 58 Monitoring Fetal Growth diagnosed. Complete the following table with the results obtained Number of SGAs diagnosed Population selected of Institution A Reference pattern Population selected of Institution B CLAP Risk estimations C- Risk estimation used in the following examples is intervals.

62 Monitoring Fetal Growth 59 History of LBW Smoking habit

63 60 Monitoring Fetal Growth Preclampsia Multiple pregnancy

64 Monitoring Fetal Growth 61 Fill in the chart below with the data included in the table Proportion Risk Factors exposed (frequency %) History of LBW Smoking habit Pre-eclampsia Multiple pregnancy Damage: SGA RR 95% Confidence interval PAR % Analyze the picture

65 62 Monitoring Fetal Growth 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

66 Monitoring Fetal Growth 63 First trimester

67 64 Monitoring Fetal Growth Second trimester

68 Monitoring Fetal Growth 65 Third trimester

69 66 Monitoring Fetal Growth Fourth trimester

70 Tendencia en a disminuir en el año SI NO Tasa MNP % o PEG % BPN % Monitoring Fetal Growth 67 Trimester ENM rate %o SGA % LBW % VLBW % MBPN % ENM rate % SGA % LBW VLBW% Tendency to be reduced during the year YES NO

71 68 Monitoring Fetal Growth Answers to the exercises using the perinatal information system for the assessment and monitoring of fetal growth Exercise A - Weight percentiles of Institution A Grams Weeks of amenorrhea Weight percentiles at Institution B Grams Weeks of amenorrhea

72 Monitoring Fetal Growth 69 Grams Weeks of amenorrhea Both patterns are the same Percentile 10 is higher in the selected population Percentile 90 is higher in the selected population The population of Institution A Population selected from Institution B population. Prolonged study Adding the cases with other similar institutions

73 70 Monitoring Fetal Growth Institution B Grams Weeks of amenorrhea Yes Exercise B - Institution A Grams Weeks of amenorrhea

74 Monitoring Fetal Growth 71 Institution B Grams Weeks of amenorrhea Grams Weeks of amenorrhea following as a reference:

75 72 Monitoring Fetal Growth Number of SGAs diagnosed Population selected of Institution A 3 Reference pattern Population selected of Institution B 5 CLAP 4 Exercise C. Risk Factors History of LBW Smoking habit Pre-eclampsia Multiple pregnancy Proportion exposed (frequency %) Exercise D Damage: SGA RR % Confidence interval PAR % Trimester ENM rate %o SGA % LBW % VLBW % ENM rate % SGA % LBW VLBW% Tendency to be reduced during the year YES NO

76 Monitoring Fetal Growth 73 Bibliography investigation and management of the small-for-gestational-age

77 74 Monitoring Fetal Growth a gestational age estimation method. Paediatr Perinat Epidemiol

78 Monitoring Fetal Growth 75

79 76 Monitoring Fetal Growth presenting with decreased fetal movements in late pregnancy. Acta restriction: a mathematical model of the effect of time interval and

80 Monitoring Fetal Growth 77 supplementation for suspected impaired fetal growth. Cochrane administration for suspected impaired fetal growth. Cochrane

81 Monitoring Fetal Growth Self - Instruction Manual 2nd edition ISBN Monitoring Fetal Growth Self - Instruction Manual 2nd. edition CLAP/WR - PAHO/WHO Latin American Center for Perinatology Women & Reproductive Health - CLAP/WR Scientific Publication CLAP/WR