Aim
The aim of this good practice point is to remind staff of the need for repeated risk assessment for FGR throughout pregnancy and the importance of adapting initial plans to new information and events arising throughout pregnancy.
Background
Stillbirth CRE has provided a position statement on the detection and management of women with Fetal Growth Restriction in Singleton Pregnancies as part of the Safer Baby Bundle to reduce stillbirth. This position statement has been endorsed by Australian and New Zealand peak bodies including ACM and RANZCOG.
SCV supports the use of the Safer Baby Bundle of care in Victorian Maternity Hospitals.
Risk assessment for fetal growth restriction
The position statement includes a Risk assessment chart which stratifies women into three risk groups. Each group has a different strategy for detection of FGR.
Women with no risk factors should be screened with symphyseal fundal heights performed at every visit and charted as a visual aid to detection of FGR.
Women with one of the level 2 risk factors should have screening third trimester ultrasounds at 28-30 weeks and 34-36 weeks. Women with two or more level 2 risk factors should be screened more frequently. Strategies may include a third screening ultrasound at 30-32 weeks or there may be sufficient indication for fortnightly growth US.
Women in the level 3 group require serial ultrasound fortnightly from 26-28 weeks.
A finding of static growth or slow growth requires ultrasound assessment of fetal growth and well-being in a timely manner, ideally within 48 hours.
Please see Fetal Growth Restriction (FGR) Care Pathway
Case vignette 1
A 35-year-old woman with an IVF pregnancy and a raised BMI is planned for ultrasound assessment of growth to be performed at 28 weeks and 36 weeks. At her morphology US, a velamentous cord insertion is identified. Her care provider reviews her risk status in view of this information and adds a further US assessment at 34 weeks.
Case vignette 2
A 28-year-old woman is diagnosed with gestational diabetes at 26 weeks gestation. Ultrasound assessment of growth is planned at 30 weeks and 36 weeks gestation. At 34 weeks, slow growth is detected by SFH measurement. A review of the result from the 30 week US showed that the fetus was on the 25th centile at that time. A further growth US is quickly organised and demonstrates and estimated fetal weight on the 8th centile.
Implications for clinical practice
Clinicians must remain alert for additional FGR risk factors which may emerge during pregnancy and be prepared to alter plans for surveillance of fetal well-being as necessary.