Must know for O& G specialist and also Pediatricians..

1. By,
Dr. Debasis patro
PG student 1st yr
Guided by Asso Prof Dr. PRAVAKAR MISHRA

2. Definition
 GROWTH : Net increase in size/ mass of tissues OR
multiplication of cells OR increase in intracellular
substance .
 DEVELOPMENT :Maturation of function e.g.:
maturation and myelination of Nervous system and
indicates acquisition of variety of skills .

3. Definition
 SGA(Small for gestation age ) – Weight less than 10
th percentile for gestation age or Birth weight less than
2 SD from mean.
 Almost 40 % of term still births and 63 % of preterm
still births are SGA.
 IUGR – It is a condition in which a fetus is unable to
achieve its genetically determined potential size &
represents a deviation and reduction in expected fetal
growth .

5.  2 types of IUGR:
 ASYMMETRICAL :weight is more affected
than length with “ HEAD SPARRING “ pattern.
 It is due to maternal factors such as Pre eclampsia ,
chronic Htn .
 Occurs due to insult mostly in 3rd trimester .
 SYMMETRICAL: Weight, length and HC are affected
at birth.
 It is due to factors intrinsic to the fetus e.g.:
chromosomal anomaly , congenital infection , IEM.
 Occurs due to insult in 1st trim .

6. Factors affecting fetal growth
(A) GENETIC : 40 % contribution . e.g Tall parents have
tall children and obese parents have obese children;
ENVIRONMENTAL : 60 % CONTRIBUTION
(B) SEX: Boys have a good growth compared to girls .
(C) HORMONES : Fetus secretes T4 from 12th week of
gestation .
Insulin has a imp role in tissue accretion and
differentiation.
Glucocorticoids help in prepartum maturation of
organs .

7.  (D)FETAL GROWTH FACTORS:
 Secreted by fetal tissue &act by autocrine/paracrine
mechanism.
 Most imp is IGF –I & IGF – II(Insulin like growth
factor).
 GROWTH PROMOTING-
EGF( Epidermal growth factor ), TGFα(Transforming
growth factor ) , PDGF( Platelet derived growth factor
) , FGF( Fibroblast like growth factor) , NGF ( Nerve
growth factor).
 GROWTH INHIBITING-
TGFβ, MIS (Mullerian inhibiting substance ), Inhibin.

8.  1st cause of IUGR is chromosomal anomaly. 2nd is
Malformations .
 (E) PLACENTAL FACTORS:
Fetal weight is directly proportional to placental weight
at term.
Other changes in placenta :-
 1. Total vilious surface area increases.
 2. Diffusion distance decreases.
 3. Fetal capillaries dilates.
 4. Resistance in feto-placental vasculature falls.

9. Clinical conditions a/s with reduced placental size
(and subsequent ↓ fetal size)
 Maternal vascular diseases
 Uterine anomalies (Fibroids , structural abnormality )
 Placental infarcts.
 Abnormality in cord insertions ( vilamentous or battledore )
 Abnormality of placentation .
-Multiple gestations with limited space ( Placenta previa )
-Monochorionic twins due to sharing of vasculature “TWIN
TWIN TRANSFUSION SYNDROME” leading to growth
restriction .
 High altitude –IUGR babies with have lower adominal
circumference .

10. MATERNAL FACTORS
 H/o mother’s own fetal and childhood growth.
 Maternal antenatal under nutrition – m/c cause of
IUGR in developing countries as compared to maternal
smoking and alcoholism in developed ones.
 Micro nutrients like zinc and Vit C has a role in growth.
 Adequacy of iron stores should be ensured before
pregnancy rather than trying to correct the deficiency
state.

11.  Age :- teenage or elderly.
 Parity :- nulliparous mother- high risk for SGA
 Obstetric complications– PIH, Pre-ecclampsia, GDM
 Chronic systemic illness – CRF, CHF, Anemia of
chronic diseases.
 TORCH infections during pregnancy- All girls must
receive Rubella and Tetanus vaccines.

12. STAGES OF GROWTH & DEVELOPMENT
 PRENATAL:
Embryo- from day of fertilization to 9 weeks.
Fetus- 9 weeks to birth .
Perinatal – 22 weeks to 7 days after birth.
POSTNATAL:
Neonatal- First 4 weeks or 28 days of life.
Infancy- First year of life.
Toddler- 1- 3 year.
Preschool – 3-6 yr
School age – 6 – 12 yr

13. Screen clipping taken: 11/2/2015, 7:28 PM

14. NERVOUS SYSTEM DEVELOPMENT

15. Fetal growth assessment
 (I) FETAL MATURITY:
Human gestation averages 280 days( 40 wks)
& EDD is calculated by adding 9 months and 7 days
to LMP or 266 days (38 weeks) from time of
ovulation.
TERM is defined as 37 wks to 42 wks of gestation.
 (II) PHYSICAL EXAMINATION:
Pelvic examination at 8-10 wks of gestation
can accurately date the pregnancy by assessing the
height of uterine fundus from pubic symphysis.

17.  Uterine height averages 20 cms at 20 weeks and 28
cms at 28 weeks of gestation in absence of obesity ,
polyhydramnios, fibroid and twin preg.
 It becomes unreliable after 28 weeks .
 (III) RADIOLOGICAL EXAM(obsolete now):
Distal femoral epiphysis is usually present
at 36 weeks and proximal tibial epiphysis by 40 weeks
of gestation.
Thus absence of distal femoral epi indicates
PREMATURITY and presence of proximal one denotes
MATURITY.

18. (IV) ULTRASONOGRAPHY:
-Transvaginal – is safer in 1st trim of preg
Helpful in detection of
a. Gestation sac at 5 wks
b. Yolk sac at 5 wks .
c. Fetal pole at 6 wks .
d. cardiac activity at 6 wks .
- Transabdominal –
B-Mode for basic imaging.
M-Mode for mapping the movement of
structures over time .

19.  1st TRIMESTER USG- Crown rump length
(CRL)=sitting height.
Crown heel length(CHL)=Standing height.
 HASSE’s Rule to calculate the age of fetus
 In 1st 5 months of gestation –
Age in months=square root of CHL.
• In 2nd half of preg:
Age in months =CHL/5.
• AT 9 weeks CRL is 6cms and Weight is 10 gms.
• At 37 wks CRL is 35cms and weight is 3250 gms .
• Done to confirm intrauterine preg, fetal viablity, fetal
number , gestation age, examine maternal pelvis and
organs.

20. 2nd AND 3RD TRIMESTER USG:
Broadly classified into 3 types
1. Basic / standard examination (Level I)
2. Specialized (Detailed ) (Level II)
3. Limited (Level III) .
LEVEL I SCAN is done –fetal number & viability.
placental location .
Amniotic volume .
To R/o Pelvic mass.
To R/o Gross fetal malformation
To examine Umblical cord.
NB: Fetal C:T ratio >0.5 is a indicator of α Thalassemia and
development of Hydrops.

21.  If the patient has past h/o of fetal anomaly or Level I
scan suggest any abnormality then proceed level II.
LEVEL II SCAN is done at 18 to 20 weeks of gestation.
Basically done to R/o any fetal abnormality.
LEVEL III scan is done prior to any invasive procedure
such as Amniocentesis.
Indication : Uncertain LMP.
Uterine size larger /smaller than expected.
Maternal Disease (HTN,DM,CVD)
Family H/o genetic abnormality.
Suspected Fetal Growth disturbance.

23.  (V) AMNIOTIC FLUID ANALYSIS:
Up to 12 wks – ultra filtrate of plasma.
12 – 20 wks – Transudate of fetal skin.
> 20 wks – fetal urine.
Ph is 7-7.5
It lacks fibrinogen so no clotting .
Max AF is at 28 wks(1000ml) .
There after it decreases. At 40 wks it is 800 ml . At
42 wks it is 200ml.

24. POLYHYDRAMNIOS
o AFI >24(N=8-24).
o Deep vertical pocket>8.
o Total vol>2L.
o MCC of mild is
IDIOPATHIC.
o MCC of mod-severe is
cong anomaly( MC is
GIT>Nervous )
OLIGOHYDRAMNIOS
o AFI<5
o Deep pocket<2.
o Total vol<200ml.
o MCC is Idiopathic.
o Mc Cong anomaly is
Renal agenesis.
o Tetrad of early oligo-
1. Facial cleft defect.
2. Limb deformity.
3. Pul hypoplasia.
4. IUGR.

26. SURFACTANT STUDY:
 Appearance of surfactant in fetal lung is related to
maturity( protection of HMD).
 It is made of phospholipids , dipalmitoyl lecithin or
phosphatidyl choline synthesized by Type II Alveolar
cells.
 Starts secretion at 24 wks of gestation and appears in
amniotic fluid at 32 wks- 35 wks due to ciliary action of
respiratory mucosa.
 Lecithin and sphingomyelin are in equal conc upto
34 wks i.e. L:S ratio is 1:1. After this lecithin level rises
so at 35 wks L:S ratio is 2:1 which indicates maturity.
 In RDS it is < 1.5:1.

27. SHAKE TEST/BUBBLE STABILITY TEST:
Undiluted AF and its various saline dilutions are
taken in a test tube and shaken for 15 secs with
equivalent vol of 95% ethanol. The tubes are allowed
to stand for 15 mins and the test is read as Positive if a
complete ring of bubbles persists at the meniscus .
Positive shake test in dilutions of 1:2 or more correlates
well with mature L/S ratio and absence of HMD.
Optical density at 650 nm: values of 0.15 or more
correlates well with maturity.
In mother with DM it is phosphatidyl glycerol
which is the most reliable test.

28. SHAKE TEST

29.  AMNIOTIC FLUID CREATININE
- MOSTLY DERIVED FROM FETAL URINE.
- increasing level reflects mature renal function.
- Cr value of 2 mg/dl or more is indicative of
gestation age of 37 wks .
• AMNIOTIC FLUID CYTOLOGY
- Lipid containing epithelial cells from sebaceous
gland of fetal skin are shed into fluid.
- it is stained with 0.1% nile blue sulfate or
hematoxylin eosin .

30. AMNIOTIC FLUID BIOCHEMICAL SCREEN
(A) ALPHA FETO PROTEIN:
• It is a glycoprotein produced by yolk sac then fetal liver as
preg advances.
• As it is HMW protein , it crosses the placenta.
• Maternal serum AFP (MSAFP) at 16 wks is 25ng/ml and it
increases by 15% till 30 wks.
• ELEVATED LEVELS are due to FETAL cause ( Open NTD ,
Multiple preg , Exstrophy of bladder, exomphalos &
gastroschisis, Meckel’s syndrome, Sacrococcygeal
teratoma, Cystic hygroma) and MATERNAL cause ( low
weight , Maternal disease like HCC, viral hepatitis and SLE)
.

31.  LOW MSAFP level :
- Fetal aneuploidy ( Down’s ,Edward’s)
- overestimated gestation.
- Molar pregnancy.
- DM.
(B) HUMAN CHORIONIC GONADOTROPIN (HCG):
• Helps in maintenance of corpus luteum upto 8 wks
• Initially produced by trophoblastic cells and later by
placental synctiotrophoblast.
• Exponential increase upto 8 wks followed by a gradual
decline and then plateau phase begins at 20 wks .
• Comes back to normal level after 3-4 wks of delivery .

32.  Interpretation :
- 20 IU is required to give a Positive report.
- Critical value to view gestation sac in TVS is 1000-
2000.
- for viable intrauterine preg βhcg increases by 66 %.
- If <66% or plateau it is Ectopic preg.
- if it falls further it is nonviable fetus
(C )UNCONJUGATED ESTRIOL:
Produced by fetal adrenal gland is handled by
placenta and conjugated by fetal liver.
Helpful in Down’s syndrome screening.

33. Down’s syndrome screening
1st TRIMESTER SCREENING:
 Dual test- βhcg increases and Preg a/s plasma
protein A (PAPPA) decreased. Usually done in 9-
13wks.
 Combine test- (HCG+PAPPA) +Age >35 yrs + Nuchal
transluceny
2nd TRIMESTER SCREENING( 15 – 22WKS):
• Triple test- HCG increased and AFP+ESTRIOL
decreases .
• Quadrapule test is Triple test +increased Dimeric
Inhibin A (DIA)

34.  Ultra sonography done at 11- 20 wks shows Nuchal
folds >4mm thick, Double bubble in abdomen , short
femur , clinodactyly , macroglossia ,renal pyelactasis .
 In Echocardiography of fetus – atrioventricular canal
defects
 When 3 maternal serum markers are abnormal the
validity for detection of down’s syndrome goes above
60 % .
 Suspicion of Trisomy 18 can be made by strawberry
shaped head , choroid plexus cyst, facial cleft ,
micrognathia , exomphalos & abnormality of hands
and feets .

35. PRENATAL CYTOGENETICS:
CHORIONIC VILIOUS SAMPLING:
 Done at 9-12 wks (Transcervical ) and 12wks ( Trans
abdomen is safer ).
 Fetal loss is 3-5%.
AMNIOCENTESIS:
 Done at 16-18 wks .
CORDOCENTESIS :
 DONE AFTER >18 WKS.
 Indicated for Hematological indices , Intrauterine
infections and cytogenetic study.

36.  Fetal karyotyping done with CVS & Cord blood is available
© 72hrs and in amniotic fluid 2 -3 wks.
 CVS not done <9 wks due to development of Limb defects
and oromandibular defects.
Diseases amenable to prenatal diagnosis :
 Autosomal dominant- NF , PKD , Huntington’s disease,
Myotonic dystrophy.
 Autosomal recessive – β Thalassemia, SCA , Hb E , IEM
(Phenylketonuria ), CF, α-1 AT def , Wilson’s , CAH, Spinal
muscular atrophy.
 X LINKED recessive – Hemophilia A &B , Duchenne

37. NESTROF TEST:
 Naked eye single tube red cell osmotic fragility test.
 To detect carrier status of β Thalassemia in parents.
 2ml each of freshly prepared 0.36% buffered saline &
DW(control) are taken in 2 tubes. 20 μl of maternal
blood is added and mixed and kept for 5mins.
Hemolysis is compared by holding them against a
blackline drawn in white background.
 In Normal the black line will be visible .
 In Thalasemia the RBC resist hemolysis so black line is
not visible. So TEST is POSITIVE. Then proceed for Hb
indices, HbF and HbA2 by electrophoresis /HPLC. If
abnormal prenatal cytogenetic study should be carried
out in fetus.

39. FISH:
 Fluorescent in situ hybridization.
 Uses fetal cells in maternal circulation .
 Used for detecting chromosomal abnormality
including both numerical & microdeletion .
 also used for detection of carrier state in Duchene or
Becker muscular dystrophy in females whose male
relatives have a known specific gene deletion.
 Other Mutation analysis technique: Restriction
enzyme studies , PCR, Trinucleotide repeats, RFLP.
 PCR is helpful in IEM , muscular dystrophy , Fragile X
syndrome.

40. FETAL ECHOCARDIOGRAPHY:
 Family h/o CHD.
 Diabetic mother.
 Intrauterine infection.
 Exposure to teratogens.
 Non immune hydrops fetalis.
 Unexplained polyhyramnios.
 Screening in case of abnormal fetal scan.
 Helpful is assessment of fetus in Non stress test and
oxytocin challenge test.

41. ASSESSMENT OF FETAL WELLBEING
(A) Fetal activity record( Count to Ten ):
• Quickening is perceived durning 3rd trim.
• Count is done usually after a meal starting at 9 am.
• If count is < 10 / Hr for 2 consecutive day she should
consult.
(B) HPL( HUMAN PLACENTAL LACTOGEN):
• Best indicator of placental functioning.
• Level less than 4 μg/ml after 30 wks is a/s with fetal
jeopardy.

42. (C )ESTRIOL:
 Best indicator of integrity of both fetus & placenta as
fetal adrenal precursor (DHEA) is converted to Estriol
by placenta.
 A decline of more than 30% in serial plasma level or in
24 hr urine assay is a indication of Fetal distress.
(D) NONSTRESS MONITORING:
Fetus is considered “REACTIVE” if 2 or more
acceleration of HR by 15 or more for 15 secs in a/s with
fetal movement in a 20 min recording.
If it is “NON REACTIVE” then we proceed to
OXYTOCIN TEST.

43. (E) OXYTOCIN CHALLENGE TEST:
 Access the integrity of uteroplacental unit. Uterine
contraction are induced by oxytocin and their effects
on FHR is monitored.
 In fetal hypoxia ,FHR begins to decelerate 15 – 20 secs
after contraction and doesn’t return to baseline even
after cessation of contraction(LATE DECELERATION)
 EARLY DECELERATION is benign & it is due to
compression of fetal head.
 VARIABLE DECELERATION implies cord
compression.
 C/I in Placenta previa and High risk preg.

44. (F)FETAL BIOPHYSICAL PROFILE:
 Most accurate and noninvasive method to asses well
being of fetus by USG.
 5 variables – Posture
 - Fetal breathing movements.
 - Gross body movements.
 - Reactive FHR.
 - Amniotic fluid volume(AFI).
 Normal score is 2. abnormal is 0.
 Score of >7 is Normal fetus .
 Score of 4 means baby should be delivered
immediately.

45. Screen clipping taken: 11/9/2015, 12:45 AM

46. (G) DOPPLER VELOCIMETRY STUDIES of umbilical
and uterine artery.
 Absence of umbilical artery end diastolic flow and
reversal of umbilical artery end diastolic flow are
ominous.
(H)FETAL SCALP BLOOD SAMPLING:
 Done transvaginally with help of Amnioscope in
vertex presenting fetus when membranes are ruptured
& cervix is dilated.
 If Ph<7.15 it indicates fetal hypoxemia.
 C/I in Hbs Ag+ve and HIV + mother.

47. THANK YOU