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A
Foreign. Welcome to the first of what is meant to be recurrent periodic episodes called the Quickie. No, we're not getting rid of our regular format. That will continue. Our regular episodes typically are about 25 to 30 minutes ago, much more into depth. But I decided to have periodic episodes just to relay some quick information out, maybe something we see in practice or something that comes out in print as a quick reminder or as a quick heads up about something in clinical practice as it affects women's health and OB gyn. All right, so I told Michael, maybe we should do these little quick episodes. And he said, oh, let's call it the quickie. Yeah, baby. All right, now it just got creepy, so I think I've set it up enough. This is meant to be, again, a interspersed between our regular episodes. We're not getting rid of our regular format, but every once in a while we'll throw out a quickie as a quick reminder of something in print or in the media. So, Michael, thank you for the very catchy idea to our producer for calling this the Quickie.
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B
Oh, my.
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A
And now that I've set it up enough, we'll be right back.
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B
Oh, my.
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A
This is Dr. Chapas, OBGYN Clinical Pearls no Spin podcast. Well, ladies and gentlemen, this is our first quickie.
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B
Oh, my.
- [02:01]
A
And in this episode, we're gonna cover the the little discrepancy with FGR in terms of management versus diagnosis. All right, very quickly. Again, it's just a quickie, but for this we have two main pieces of reference. The first is ACOG Committee Opinion 831. And then the other is ACOG's Practice Bulletin 2. Now, 227 is a one on Fetal Growth Restriction, and Committee Opinion 831 is medically indicated late preterm and early term deliveries. Okay. Nothing new. We've covered both of those in the past. However, as a quick reminder, as a quick quickie, remember that fetal growth restriction, according to SMFM and the college, is either diagnosed by an abdominal circumference under 10 percentile for gestational age or an estimated fetal weight of under the 10th percentile for gestational weight. It's not one it's not. And the other it's or. All right, so either abdominal circumference or estimated fetal weight. Now here's what happens. We had in the clinic recently, in our high risk clinic, we had a patient with a fetal growth restriction diagnosis because the abdominal circumference was 6% and she was 38 weeks. Right. So she's FGR based on abdominal circumference, but the EFW was 16%. Guys, so there's a discrepancy here. All right, so the estimated fetal weight is normal. It's above 10th percentile, but the abdominal circumference was 6%. So that is a diagnosis of FGR, because it doesn't have to be both of them. It's one or the other. We know this. That's nothing new. That's straight out of Practice Bulletin 227, which says the diagnosis of fetal growth restriction is either an abdominal circumference under the 10th percentile or. Or Hadlock composite EFW under the 10th percentile. So either one gets it. All right, now remember, as we've talked about before, abdominal circumference will be the first thing that lags as the baby's fat stores are depleted, as glycogen stores in the liver become less, as growth restriction happens as a pathological process, and then the total EFW will show up as lagging. Right. So it's kind of like ferritin and H and H or anemia. Ferritin drops flu first. That's the first marker. And then with time, if nothing happens or corrects, the patient will have a low H and H as iron deficiency anemia. Same thing with abdominal circumference. That typically is the first marker to be off. So in this patient, who was 38 weeks, she definitely had a diagnosis of FGR based on abdominal circumference, but the total EFW is normal. So the question was this. Well, so while we have the diagnosis, that's not a question is how do we do management? Then, because she's 38 weeks, she's FGR. But. But the EFW is normal. It's 16th percentile. So that's the little disconnect, and that's why we're doing this as a quickie. When you find an abdominal circumference under the 10th percentile, you flag that chart as that is a FGR child. That means that over 32 weeks, that child is going to have surveillance and should have additional umbilical artery dopplers, because that is how management will be guided. Right.
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D
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E
MGLIS Lebricizumab LBKZ a 250mg per 2ml injection is a prescription medicine used to treat adults and children 12 years of age and older who weigh at least 88 pounds or 40 kilograms with moderate to severe eczema, also called atopic dermatitis, that is not well controlled with prescription therapies used on the skin or topicals, or who cannot use topical therapies. Ebglis can be used with or without topical corticosteroids. Don't use if you're allergic to ebglis. Allergic reactions can occur that can be severe. Eye problems can occur. Tell your doctor if you have new or worsening eye problems. You should not receive a live vaccine when treated with ebglis. Before starting ebglis, tell your doctor if you have a parasitic infection.
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Ask your doctor about eglis and visit eglis.lilly.com or call 1-800-lilyrx or 1-800-545-5979.
- [06:44]
A
So an abdominal circumference automatically gets a flag in the air and says, hey, I'm fgr. However, for delivery timing, delivery timing is based only on two things, the estimated fetal weight and its percentage based on the norm and or on the Doppler studies. Okay, so even though this child had an abdominal circumference of under the 10th percentile, which earned it a diagnosis of FGR, you could actually go until 38 or 39 weeks as a delivery plan because the percentage of the fetal weight was normal. So in this case we said, yeah, she can actually hold off for 39 weeks. I wouldn't go past that because of the abdominal circumference, but 39 weeks is reasonable even though the child has a diagnosis of FGR. So if we go back to ACOG's committee opinion on medically indicated late preterm and early term deliveries, again, that's committee opinion number 83 1. It's very clear there that for growth restriction that is isolated with an estimated fetal weight between the third and the 10th percentile, you can get up to 38 weeks in zero to 39 weeks in zero for induction. Now, don't go after that 39 weeks. You should pretty much get out because the abdominal circumference does give the child a diagnosis of fgr. In other words, something is going on. So inducing at 39 weeks is reasonable. Okay, but you don't have to go before even though the child is fgr. My point is, while the diagnosis can be made by abdominal circumference, the delivery planning is based on EFW percentages and or on the Doppler studies. So very quickly, as a recap, remember EFW for growth restriction, that's between 3 and 10th percentile, you can get up to 38 to 39%. And if the EFW is normal, meaning above the 10 percentile, etcetera, just do a regular induction at 39 weeks. Now, if the estimated fetal weight is under the third percentile, then ACOG says you can make the diagnosis, or the case rather for delivery at 37 weeks and or whenever you find it after that. So if the fetal weight is under the third percentile, meaning severe growth restriction, be out at 37, it then defaults to the Doppler studies. So if you have an elevated SD ratio, which is one of the first things that happens, that's the pulsativity index, right? That or. Or a resistance index that's greater than the 95th percentile. That's the first marker that's thrown off with Doppler studies. Then deliver at 37 weeks. Of course, if there is absent end diastolic flow, you can get out at 33 or 34 weeks. And with reversal flow, you can get out at 30 to 32 weeks because that's a very poor prognostic factor. My point is this did cause confusion in our clinic because. Wait, she's growth restricted. It's 6% based on the abdominal circumference. And that is true. That diagnosis does not go away. But delivery management is only based on EFW percentile and. Or the umbilical artery Doppler studies. Okay, so that's a little disconnect like you're going to get. You're going to allow an FGR child to go up to 39 weeks, surely, because you can even do that if the EFW is between 3rd and 10th percentile, where delivery is allowed between 38 up to 39 and 0. But if it's greater than the 10th percentile, even though the abdominal circumference is under 10%, you can get out at 39 weeks. I probably wouldn't go past that because, again, the abdominal circumference is showing you something, but it's totally okay at 39 weeks in that scenario. So, again, guys, this was just a very quick one called our quickie because we wanted to make the distinction between abdominal circumference diagnosis versus efw, which is for management. So abdominal circumference gets the flag if you find that antepartum. You know, during prenatal care, they get surveillance, they get serial growth for ultrasound, and they get umbilical artery dopplers. But the final decision for delivery is not based on abdominal circumference. It's based on EFW and umbilical artery dopplers. Podcast family, this wraps up our quickie.
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Oh, my God.
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And we'll see you next time on the Clinical Pearls no Spin podcast. Michael, let's take it home. This is Dr. Chapa's ob gyn clinical pearls no spin podcast.