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SCREENINGANDTRIAGEOFINTRAUTERINE

GROWTHRESTRICTION (IUGR) INGENERALPOPULATION

ANDHIGHRISKPREGNANCIES: ASYSTEMATICREVIEW

WITHAFOCUSONREDUCTIONOF IUGR RELATED

STILLBIRTHS

BY ANGELINA PUTRI

TUTOR : DR TIGOR SIMANJUNTAK , SPOG

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BACKGROUND

IUGRStillbirth

1. Etology + Risk Factor - overlap2. Patology complex maternal condition,

Placental dysfunction, Hormonal Regulation

3. Prior Delivery

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Definition IUGR Birth weight < 2 SD

SGA Birth weight < persentil 10

30 milion newborn / year IUGR

developing countries 6 x developedcountries

The highest prevelance Asia ( 75 %), Afrika (20

%), America latin (5%)

To prevent complication IUGR Detect the condition

Appropriate survaillance to asses fetal well being + suitableIntervention in case of fetal distress early delivery

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METHOD

1. Search Strategy Literature

Studies evaluating fetal movement monitoring and dopllerultrasound in high pregnancies

Pubmed , Cochare Library, Regional database WHO

Last date of search -->3 rd March 2010

Evaluating

Title and abstract

Reference List

Meta analyses

Other studies

contact authors

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2. INCLUSION /EXCLUSIONCRITERIA

Doppler velocimetry in high risk pregnancies randomized trials and quasi randomized studiesinclusion in the riview

for fetal movement monitoring randomized controlled trials

Quasi randomized

Observational studies

Exclusion utero placental circulation

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3. DATAABSTRACTIONANDVALIDITYASSESMENT

All relevent data abstract on Standardized Excel

Spreadsheet

Asses and grade CHERG adaption of theGRADE technique

The studies are graded high

Moderate

Low

Very low

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4. QUANTITATIVEDATASYNTHESIS

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DELPHIPROCESSFORESTABLISHINGEXPERTCONSENSUS

for generation of effect estimate

for detection IUGR

Maternal BMI screeningSymphysis Fundal Heightmeasurement

Targeted Ultrasound

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RESULT

1. The detection of IUGRMaternal BMI screening effective method of predicting fetal

growth

Symphysis Fundal Height measurement

* inconclusive A cochrane review by Nielson

* cost effective & relatively accurate methode formeasurement of gestational age andsubsequently fetal growth

* cohort study in Pakistan compare SFHmeasurement with LMP to assesing gestationalage

* observational studies from Brazil , 753 womenlow risk sensitivity 86 % for detection SGA

Ultrasonographic routine early and late pregnancies showed no effect

detect abnormal fetal growth

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Maternal anthropometry predict adverse

perinatal outcomes

Detection & management of maternal malnutrition reduce IUGR & related perinatal adverse

outcomes

Balance suplementation protein energy

reduce occurance of SGA by 32 %( a cochrane review by Kramer at al)

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Repeat USG with monitoring of fetal growth bysymphysis-fundal height measurement

appropriate management

reduce perinatal mortality and stillbirth

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SURVEILLANCEOFHIGHRISKPREGNANCIES

1. Fetal movement monitoring

a cluster randomized study by Grant et al.68,654women

fetal counting (Cardiff method)

vs

no instruction to monitor fetal movements

no significant difference in the mean antepartumstillbirth rate per cluster

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A quasi randomized trial by neldom

show significant decline stillbirth

Doppler velocimetry reduction stillbirth by 35 %

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DISCUSSION

Detection and management of IUGR

a. Maternal BMI screening

predict growth of fetus and related occurance

of low birth weight and other perinatal adverseoutcomes

b. Measurement of symphisis fundal height

c. Repeat ultrasound(a-c) + appropriate intervention -

reducing IUGR & stillbirth

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Surveillance of high risk pregnancies

Doppler velocimetry - one of the mostobjection method

Fetal movement counting simple,inexpensive , oldest

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CONCLUSION

There is insufficient evidence to recommend infavor or against fetal movement counting for routineuse for testing fetal well being.

Doppler velocimetry of umbilical and fetal arteriesand appropriate intervention is associated with 29% (95 % CI 2% to 48 %) reduction in perinatalmortality.

Expert opinion suggests that detection and

management of IUGR with the help of maternalBMI, symphysial-fundal height measurement andtargeted ultrasound could be effective in reducingIUGR related stillbirths by 20%.

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