Eduovisual
Pregnancy, Childbirth & Puerperium
Intrauterine growth restriction: workup and surveillance
— Symmetric (20–30%): Head and body proportionally small. Suggests early insult — aneuploidy (trisomy 13, 18, 21, triploidy), congenital infection (CMV, toxoplasmosis, rubella, Zika), teratogen exposure.
— Asymmetric (70–80%): Head sparing with reduced AC ("brain-sparing"). Suggests late uteroplacental insufficiency — preeclampsia, chronic hypertension, smoking, autoimmune disease.
— Fundal height lags >3 cm behind gestational age after 20 weeks (in patients without obesity or fibroids).
— Maternal risk factors: chronic HTN, pregestational diabetes with vasculopathy, SLE/APS, prior FGR or stillbirth, smoking, substance use, low pre-pregnancy BMI, advanced maternal age, ART pregnancy, multiple gestation.
— Placental risk factors: previa, abruption history, single umbilical artery, velamentous cord insertion.
Board pearl: Severe FGR = EFW <3rd %ile is, by itself, sufficient diagnosis regardless of Dopplers — these fetuses always need formal antenatal surveillance.
— Dating accuracy: Confirm EDD by first-trimester CRL ultrasound (most accurate). LMP-based dating is unreliable; redating after 22 weeks is generally not permitted by ACOG.
— Prior obstetric history: Prior FGR (recurrence risk ~20%), prior stillbirth, preeclampsia, preterm birth, recurrent pregnancy loss.
— Maternal medical history: Chronic HTN, type 1/2 diabetes (especially with end-organ disease), CKD, SLE, antiphospholipid syndrome, cyanotic heart disease, severe anemia, hyperthyroidism, IBD.
— Medications/teratogens: Warfarin, antiepileptics (valproate, phenytoin), methotrexate, ACEi/ARBs, chemotherapy.
— Social: Tobacco (dose-dependent reduction in birthweight ~200 g), alcohol, cocaine/methamphetamine, opioids, cannabis. Ask non-judgmentally.
— Nutritional: Pre-pregnancy BMI, gestational weight gain, food insecurity, bariatric surgery history.
— Infectious: Recent febrile illness, rash, cat exposure (toxoplasmosis), daycare/child exposure (CMV), travel (Zika), TB risk.
— Decreased fetal movement (late, ominous sign).
— Headache, visual changes, RUQ pain (preeclampsia overlap).
— Vaginal bleeding (abruption risk).
Key distinction: Constitutionally small fetus → small mother, small father, normal Dopplers, growth tracking along its own curve. Pathologic FGR → maternal/placental risk factors, falling off the growth curve, abnormal Dopplers, or oligohydramnios.
Step 3 management: When a 3-cm lag is found, the next best step is ultrasound for EFW, AFI, and umbilical artery Doppler — not repeat fundal height in two weeks.
— Fundal height: From symphysis pubis to top of fundus in cm; from 20–36 weeks should approximate gestational age ± 2 cm. A lag of ≥3 cm triggers ultrasound. Caveats: obesity, fibroids, multiple gestation, polyhydramnios, malpresentation reduce reliability.
— Blood pressure: Screen for new-onset HTN or preeclampsia at every visit. SBP ≥140 or DBP ≥90 on two occasions ≥4 h apart = gestational HTN; add proteinuria, thrombocytopenia, transaminitis, Cr ≥1.1, pulmonary edema, or neurologic symptoms = preeclampsia.
— Weight trajectory: Poor maternal weight gain correlates with FGR.
— Edema, hyperreflexia, RUQ tenderness: Suggest preeclampsia.
— Uterine tenderness, bleeding: Concern for abruption.
— Fetal heart tones by Doppler — establish viability, rate (110–160), variability impressionistically.
— Leopold maneuvers: Assess size, lie, presentation, and amniotic fluid impression (fetus feels "tight" with oligohydramnios).
— Fetal movement counting ("kick counts") after 28 weeks — 10 movements in 2 hours is reassuring.
— Biometry: BPD, HC, AC, FL → composite EFW (Hadlock formula).
— AC <10th %ile is the most sensitive single biometric marker for FGR.
— Amniotic fluid: Single deepest pocket (SDP) <2 cm or AFI <5 cm = oligohydramnios — a sign of redistribution away from fetal kidneys.
— Placental morphology: Thickened, echogenic, infarcts.
Board pearl: AC lag is the earliest and most sensitive biometric sign of asymmetric FGR — the liver shrinks first as glycogen stores deplete.
CCS pearl: On the CCS interface, after identifying fundal-height lag, order in this sequence: OB ultrasound (biometry + AFI) → umbilical artery Doppler → maternal BP and urine protein. Schedule follow-up before advancing the clock.
— Review the earliest ultrasound (ideally first-trimester CRL). If dating is uncertain, FGR cannot be confidently diagnosed.
— Measure BPD, HC, AC, FL; calculate EFW (Hadlock).
— Diagnosis: EFW or AC <10th %ile for GA.
— Repeat in 2–4 weeks to assess interval growth; do not repeat sooner (measurement error exceeds true growth).
— The cornerstone surveillance tool in FGR. Reflects placental vascular resistance.
— Normal → continued diastolic forward flow.
— Abnormal progression: elevated S/D ratio → absent end-diastolic flow (AEDF) → reversed end-diastolic flow (REDF).
— UA Doppler is the only modality shown to reduce perinatal mortality in FGR.
— BP, urine protein/creatinine ratio, CBC, comprehensive metabolic panel, LDH, uric acid → preeclampsia screen.
— HbA1c if diabetes suspected.
— TORCH-directed testing only if indicated: CMV IgM/IgG with avidity, toxoplasma IgM/IgG, syphilis RPR, Zika if exposure, parvovirus if hydrops.
— Antiphospholipid antibodies (lupus anticoagulant, anti-cardiolipin, anti-β2-glycoprotein I) if recurrent FGR, prior fetal loss, or thrombosis.
— Drug screen if clinically indicated.
Step 3 management: "Best initial test" after a lagging fundal height = obstetric ultrasound with biometry, AFI, and umbilical artery Doppler. TORCH "panels" are obsolete — order targeted serologies based on exposure.
Key distinction: UA Doppler abnormalities predict outcome and guide delivery timing; biometry alone establishes diagnosis.
— Measures fetal cerebral vascular resistance. In hypoxia, fetal cerebral vessels vasodilate → decreased MCA pulsatility index (PI) <5th %ile = "brain-sparing."
— Cerebroplacental ratio (CPR) = MCA PI / UA PI; low CPR predicts adverse outcome even when UA Doppler is normal — useful in late-onset (≥32 wk) FGR where UA Doppler is often normal.
— Reflects fetal cardiac function. Absent or reversed a-wave indicates impending cardiac decompensation and acidemia — strongest predictor of stillbirth in early-onset FGR.
— FGR is early-onset (<32 wk), severe (<3rd %ile), symmetric, or accompanied by structural anomalies, polyhydramnios, or soft markers.
— Options: diagnostic amniocentesis with chromosomal microarray (CMA) — preferred over karyotype (detects copy-number variants, ~6% additional yield).
— Consider cell-free DNA only as screening; not diagnostic.
— Amniotic fluid PCR for CMV if maternal seroconversion or imaging suggestive (echogenic bowel, intracranial calcifications, ventriculomegaly).
Board pearl: Ductus venosus a-wave reversal = the latest and most ominous Doppler change before fetal demise in early-onset FGR — drives delivery before 32 weeks despite prematurity.
Key distinction: Early-onset FGR (<32 wk) follows the UA → MCA → DV cascade; late-onset FGR (≥32 wk) is detected better by CPR and MCA, often with normal UA Doppler.
— Gestational age at onset: Early-onset (<32 wk) vs late-onset (≥32 wk) — different surveillance and delivery thresholds.
— Severity: EFW 3rd–10th %ile vs <3rd %ile.
— Doppler status: Normal UA → AEDF → REDF; MCA PI; DV a-wave.
— Amniotic fluid: Normal vs oligohydramnios.
— Comorbidities: Preeclampsia, diabetes, multiple gestation.
— EFW 3rd–10th %ile, normal Dopplers, normal AFI:
– Weekly or twice-weekly NST or BPP, UA Doppler every 1–2 weeks, growth every 3–4 weeks.
– Deliver at 36 0/7 – 37 6/7 weeks.
— EFW <3rd %ile (severe FGR), Dopplers normal:
– Twice-weekly surveillance.
– Deliver at 37 0/7 weeks.
— Elevated UA S/D (>95th %ile) with normal end-diastolic flow:
– Surveillance 1–2×/week.
– Deliver 37 0/7 weeks.
— Absent end-diastolic flow (AEDF):
– Hospitalize, daily surveillance, antenatal corticosteroids if <34 wk, magnesium for neuroprotection <32 wk.
– Deliver at 34 0/7 weeks.
— Reversed end-diastolic flow (REDF):
– Inpatient management.
– Deliver at 30 0/7 weeks (after steroids/Mg).
— Abnormal DV (absent/reversed a-wave) or spontaneous decels: Deliver regardless of GA after viability with steroids if time permits.
Step 3 management: Memorize the delivery timing ladder — 37 / 37 / 34 / 30 for FGR 3rd–10th / <3rd / AEDF / REDF.
Board pearl: Late preterm steroids (between 34 0/7 and 36 6/7) are recommended when delivery is anticipated within 7 days and the patient has not previously received them.
— Bed rest: Not recommended; increases VTE risk without proven benefit.
— Maternal oxygen therapy: Not standard.
— Nutritional supplementation, zinc, calcium, fish oil: No demonstrated benefit for established FGR.
— Sildenafil (STRIDER trial): Showed potential neonatal harm (pulmonary hypertension); do not use.
— Heparin/LMWH: Not indicated for FGR alone; reserve for confirmed antiphospholipid syndrome or VTE.
— Smoking cessation: Single most impactful modifiable factor — counsel at every visit (5 A's). Nicotine replacement preferred over continued smoking if needed.
— Substance use treatment: MAT for opioid use disorder; alcohol cessation.
— Optimize chronic disease: Tight BP control (target <140/90; labetalol, nifedipine, methyldopa); glycemic control (A1c <6.5%); SLE quiescence.
— Adequate nutrition and food security referrals (WIC).
— Low-dose aspirin 81 mg daily starting 12–28 weeks (ideally before 16 wk) in patients at high risk for preeclampsia (and thus FGR) — chronic HTN, pregestational DM, CKD, autoimmune disease, prior preeclampsia, multifetal gestation, or ≥2 moderate risk factors.
— USPSTF Grade B recommendation.
— Aspirin does not treat established FGR.
— Betamethasone 12 mg IM ×2 doses 24 h apart between 24 0/7 and 33 6/7 weeks when delivery anticipated within 7 days.
— Late preterm (34 0/7–36 6/7) single course if not previously given.
Board pearl: The "drug" that prevents FGR is low-dose aspirin started before 16 weeks in high-risk patients — but it does nothing once FGR is established.
— Nonstress test (NST): Reactive = ≥2 accelerations of 15 bpm × 15 sec in 20 min (≥32 wk); 10×10 if <32 wk. Reassuring of acute fetal well-being.
— Biophysical profile (BPP): NST + 4 ultrasound components (movement, tone, breathing, AFV); each 0 or 2, max 10. 8–10 reassuring; 6 equivocal; ≤4 deliver. Oligohydramnios alone (AFV 0) often prompts delivery near term.
— Modified BPP: NST + AFI; commonly used.
— Contraction stress test: Rarely used; positive (late decels with ≥50% contractions) is concerning.
— UA Doppler weekly for mild FGR; 2×/week or daily for AEDF; daily inpatient for REDF.
— Add MCA and DV when UA is abnormal or for late-onset FGR.
— AEDF or REDF, abnormal DV, recurrent late decels, severe preeclampsia, oligohydramnios with FGR remote from term.
— Continuous EFM in labor — FGR fetuses tolerate labor poorly.
— Anticipate higher rate of cesarean for non-reassuring tracing.
— Neonatology at delivery — anticipate hypoglycemia, hypothermia, polycythemia, meconium aspiration.
— Cord gases at delivery for documentation.
— Placental pathology sent for all FGR deliveries — informs future pregnancy counseling.
CCS pearl: When managing FGR with AEDF on the CCS: admit to L&D antepartum unit, betamethasone ×2, magnesium sulfate (if <32 wk), daily UA Doppler + NST, BP/urine protein, neonatology consult, plan delivery at 34 0/7 weeks — advance the clock in small increments.
Board pearl: Send the placenta to pathology in every FGR case — findings (infarcts, villous maldevelopment, malperfusion) guide recurrence risk and future aspirin prophylaxis.
— Risk of FGR rises with creatinine and proteinuria. Cr >1.4 or proteinuria >1 g/day markedly increases FGR, preeclampsia, and preterm birth.
— Co-manage with nephrology; control BP (avoid ACEi/ARB — switch preconception to labetalol or nifedipine).
— Earlier and more frequent growth scans (every 3 wk from 24–28 wk).
— Target BP <140/90 (CHAP trial supports treatment threshold).
— Low-dose aspirin from 12–16 wk.
— Baseline labs (Cr, urine protein/Cr, LFTs, uric acid, platelets, LDH) at entry to pregnancy to differentiate superimposed preeclampsia later.
— Cholestasis of pregnancy, autoimmune hepatitis, or cirrhosis → FGR risk. Ursodeoxycholic acid for cholestasis; monitor bile acids; deliver by 36–37 wk if bile acids ≥100 µmol/L.
— Cyanotic congenital heart disease (uncorrected TOF, Eisenmenger) → severe FGR risk due to chronic hypoxemia.
— Maternal pulmonary hypertension carries ~30% maternal mortality — counsel against pregnancy.
— SLE/APS: Aspirin + prophylactic LMWH (APS), hydroxychloroquine for SLE through pregnancy.
— Active lupus nephritis confers high FGR risk; aim for ≥6 months quiescence preconception.
— Pregestational DM with vasculopathy (retinopathy, nephropathy) → FGR (not macrosomia). White class F, R, T.
— Tight glycemic control (A1c <6.5%, fasting <95, 1-hr postprandial <140).
Key distinction: Diabetes without vascular disease → macrosomia; diabetes with vasculopathy → FGR. Same disease, opposite fetal phenotype.
Step 3 management: A pregnant patient on lisinopril for chronic HTN → switch immediately to labetalol/nifedipine; ACEi in 2nd/3rd trimester causes fetal renal dysgenesis, oligohydramnios, and FGR.
— Discordance = (larger EFW − smaller EFW) / larger EFW. Significant at ≥20%.
— Selective FGR (sFGR) in monochorionic twins is distinct from dichorionic; classified by UA Doppler pattern (Type I normal, Type II persistent AEDF/REDF, Type III intermittent AEDF/REDF) — refer to MFM.
— TTTS must be excluded in MC twins with size discrepancy (look at amniotic fluid: poly/oli sequence).
— Surveillance every 2 weeks for MC twins from 16 wk; every 4 wk for DC twins from 24 wk.
— Delivery timing varies: uncomplicated DCDA 38 wk, MCDA 36 wk; earlier with FGR.
— Higher FGR risk from nutritional competition (still-growing mother), late prenatal care, smoking, low SES.
— Aggressive prenatal care engagement, nutritional support (WIC), confidentiality balanced with mandatory reporting laws.
— Higher rates of chronic HTN, diabetes, placental insufficiency, and aneuploidy → increased FGR risk.
— Offer aneuploidy screening; consider aspirin if additional preeclampsia risk factors.
— Independent risk factor for FGR even in singletons.
— Population-based curves may misclassify; customized growth charts (maternal height, weight, parity, ethnicity) reduce false positives in constitutionally small fetuses and false negatives in larger mothers. ACOG accepts either approach.
— Tobacco (200 g birthweight reduction), cocaine (vasoconstriction, abruption), opioids (FGR + NAS), alcohol (FGR + FAS).
— Screen universally with validated tools (4 P's, CRAFFT).
Board pearl: In monochorionic twins, intertwin growth discordance + AEDF/REDF in the smaller twin = selective FGR Type II/III — urgent MFM referral; expectant management risks demise of both twins via shared circulation.
— Stillbirth: Risk rises sharply with severity; FGR accounts for ~30% of unexplained stillbirths. REDF carries weekly stillbirth risk ~10%.
— Oligohydramnios: Cord compression, meconium aspiration risk.
— Iatrogenic prematurity: From delivery for fetal indications.
— Non-reassuring fetal tracing (late decels, minimal variability) → emergency cesarean.
— Meconium aspiration syndrome.
— Cord compression.
— Hypoglycemia (low glycogen stores) — check glucose at 30 min and hourly.
— Hypothermia (low subcutaneous fat).
— Polycythemia/hyperviscosity (chronic hypoxia drives erythropoiesis) → jaundice, stroke risk.
— Hypocalcemia.
— Necrotizing enterocolitis (especially with AEDF/REDF — gut hypoperfusion in utero).
— Pulmonary hemorrhage, persistent pulmonary hypertension.
— Respiratory distress syndrome if preterm.
— Neurodevelopmental delay, cerebral palsy (especially if abnormal DV).
— Learning disabilities, behavioral issues.
— Short stature (most catch up by age 2; ~10% remain short — GH therapy may be considered).
— Type 2 diabetes, hypertension, coronary artery disease, metabolic syndrome, obesity — fetal programming from intrauterine undernutrition.
— Preeclampsia, abruption, postpartum hemorrhage, postpartum depression after adverse outcome.
Board pearl: Necrotizing enterocolitis risk is elevated in neonates born after AEDF/REDF — counsel neonatology team and use cautious feeding advancement.
Key distinction: Symmetric FGR neonates have worse neurodevelopmental outcomes (early insult affecting brain); asymmetric FGR neonates more often catch up with brain sparing.
— Early-onset FGR (<32 wk).
— Severe FGR (<3rd %ile).
— Abnormal UA Doppler (elevated S/D, AEDF, REDF).
— Suspected aneuploidy or congenital infection.
— Multiple gestation with FGR or discordance.
— Maternal comorbidity (SLE, APS, severe CKD, cyanotic CHD).
— AEDF or REDF.
— Abnormal ductus venosus.
— Severe oligohydramnios with non-reassuring testing.
— Co-existing severe preeclampsia, HELLP, or suspected abruption.
— Patient unable to comply with frequent outpatient surveillance or remote from care.
— Repetitive late decelerations or recurrent variable decelerations with minimal variability.
— BPP ≤4.
— Reversed ductus venosus a-wave.
— Spontaneous prolonged decelerations.
— Maternal indications: eclampsia, HELLP, abruption, uncontrolled severe-range BP, pulmonary edema.
— Anticipated delivery <34 wk, EFW <1500 g, or severe FGR — antenatal counseling regarding NICU course, anticipated complications, survival data by GA/weight.
— Patients with high-risk comorbidities; neuraxial planning if thrombocytopenia or anticoagulation.
CCS pearl: In a CCS case with FGR + new-onset severe-range BP at 33 wk → admit, IV labetalol or hydralazine for BP control, magnesium sulfate for seizure prophylaxis, betamethasone, continuous fetal monitoring, MFM consult, plan delivery within 24–48 h depending on stability.
Step 3 management: REDF = inpatient management, period. Do not send home regardless of gestational age between viability and 30 weeks.
— Small parents, normal Dopplers, normal AFV, growth tracks along its own (lower) percentile, no maternal risk factors. Not pathologic.
— LMP-based dating overestimates EDD when ovulation is late (irregular cycles). First-trimester CRL is gold standard; cannot redate after 22 wk if early ultrasound exists.
— Reduces fundal height; ultrasound disambiguates.
— Aneuploidy: Trisomy 13, 18, 21 (T18 most associated with severe symmetric FGR), triploidy, Turner syndrome.
— Structural anomalies: Skeletal dysplasias, cardiac anomalies, gastroschisis.
— Congenital infection: CMV (most common; periventricular calcifications, echogenic bowel, ventriculomegaly), toxoplasmosis, rubella, syphilis, Zika (microcephaly), parvovirus (hydrops).
— Confined placental mosaicism: Detected on CVS/amnio; placenta abnormal, fetus normal karyotype.
— Symmetric FGR + early onset + anomalies → chase aneuploidy and infection (amnio + CMA + CMV PCR).
— Asymmetric FGR + late onset + maternal HTN → placental insufficiency, focus on Doppler surveillance.
Key distinction: "Small baby" on ultrasound is not automatically pathologic — you must integrate Dopplers, AFV, anatomy, dating, and parental size before labeling FGR.
Board pearl: Trisomy 18 presents classically as early symmetric FGR + polyhydramnios + clenched hands + choroid plexus cysts + congenital heart disease + horseshoe kidney.
— Chronic hypertension, preeclampsia (the #1 acquired cause of FGR), gestational HTN.
— Chronic kidney disease, lupus nephritis.
— Antiphospholipid syndrome (recurrent miscarriage, FGR, preeclampsia, stillbirth).
— SLE — especially with active disease or anti-Ro/La.
— Pregestational diabetes with vasculopathy.
— Severe hyperthyroidism.
— Phenylketonuria (untreated maternal PKU).
— Cyanotic CHD, severe asthma with chronic hypoxemia, severe anemia.
— High-altitude residence (chronic hypoxia).
— Tobacco (most common modifiable cause).
— Alcohol, cocaine, methamphetamine, opioids.
— Teratogens: warfarin, antiepileptics, ACEi/ARB, chemotherapy.
— Severe undernutrition, eating disorders, bariatric surgery malabsorption, food insecurity.
— Placenta previa, abruption, placental infarction, chronic abruption.
— Velamentous cord insertion, single umbilical artery, marginal cord insertion.
— Chorioangioma, circumvallate placenta.
— Confined placental mosaicism.
— CMV (most common), toxoplasmosis, rubella, syphilis, varicella, Zika, HIV (less if treated), parvovirus B19, TB, malaria.
Board pearl: CMV is the single most common congenital infection and the most common infectious cause of FGR — suspect with periventricular calcifications, echogenic bowel, ventriculomegaly, hyperechoic kidneys, hepatosplenomegaly.
Step 3 management: A patient with prior FGR + prior preeclampsia at <34 wk + recurrent miscarriages → test antiphospholipid antibodies. If positive on two occasions ≥12 wk apart → next pregnancy gets aspirin + prophylactic LMWH.
— Continue BP monitoring; postpartum preeclampsia can occur up to 6 weeks after delivery. Continue antihypertensives if needed.
— Magnesium for 24 h post-delivery if preeclampsia with severe features.
— VTE prophylaxis (mechanical ± pharmacologic) — pregnancy and delivery are prothrombotic states.
— Lactation support — FGR/preterm infants benefit especially from breast milk (NEC reduction).
— Review results: maternal vascular malperfusion, villitis of unknown etiology, fetal vascular malperfusion, infectious placentitis — each informs recurrence counseling.
— 2-week BP check if hypertensive disorder.
— 6-week comprehensive postpartum visit — BP, mood (EPDS screening), contraception, breastfeeding, glucose tolerance if GDM.
— Long-term: women with preeclampsia/FGR have 2× lifetime cardiovascular disease risk — counsel on lipid screening, BP monitoring, lifestyle modification; consider as ASCVD risk enhancer.
— Recurrence risk for FGR ~20%; for severe early-onset, higher.
— Interpregnancy interval ≥18 months optimal.
— Preconception optimization: Smoking cessation, BP control, diabetes control, weight optimization, autoimmune disease quiescence ≥6 months.
— Next pregnancy aspirin 81 mg starting 12 wk if preeclampsia/FGR history.
— Early dating ultrasound, early growth ultrasounds (24, 28, 32, 36 wk).
— Glucose monitoring first 24 h.
— Growth tracking — most catch up by 2 years.
— Neurodevelopmental follow-up through age 2 minimum; school-age assessment if early-onset/severe FGR.
— Pediatric BP, BMI, glucose monitoring through life (DOHaD).
Step 3 management: Every patient with FGR pregnancy gets a 6-week postpartum visit explicitly addressing CV risk, future-pregnancy aspirin plan, and contraception choice supporting an 18-month interval.
— Mild FGR (3rd–10th %ile, normal Dopplers): Growth q3–4 wk; UA Doppler q1–2 wk; NST/BPP 1–2×/week from 32 wk; deliver 36 0/7–37 6/7 wk.
— Severe FGR (<3rd %ile): Twice-weekly surveillance; deliver 37 0/7 wk.
— Elevated S/D: Surveillance 1–2×/week; deliver 37 wk.
— AEDF: Daily inpatient surveillance; steroids; deliver 34 wk.
— REDF: Inpatient, daily DV Doppler; deliver 30 wk.
— Explain FGR vs constitutional smallness.
— Discuss surveillance plan and what will trigger admission/delivery.
— Review fetal kick counts — call for <10 movements in 2 hours.
— Warning signs: vaginal bleeding, decreased movement, headache/visual changes, RUQ pain, severe edema.
— Smoking cessation: 5 A's (Ask, Advise, Assess, Assist, Arrange); offer nicotine replacement therapy.
— Nutrition: balanced diet, prenatal vitamins; food insecurity → WIC, social work referral.
— High-risk pregnancy is associated with anxiety and depression — screen with PHQ-9/EPDS; refer to behavioral health.
— Discuss thresholds for delivery, NICU course, viability if <25 wk.
— Use family meetings with neonatology for periviable cases.
— Record EFW, Doppler indices, AFI, NST/BPP score at each visit.
— Document delivery plan and triggers in the chart for cross-coverage.
Board pearl: Kick counts are a free, validated tool — instruct patients in the third trimester (especially FGR) to perform daily; decreased movement is often the earliest patient-detected sign of compromise.
CCS pearl: On CCS, after each surveillance ultrasound, re-schedule the next one before advancing the clock — missing surveillance intervals lowers your management score.
— Shared decision-making with neonatology regarding resuscitation, antenatal steroids, magnesium, cesarean for fetal indication.
— Document parental wishes; use gestational age- and weight-specific outcome data (e.g., NICHD calculator).
— Recognize parental autonomy: at 22 wk, intervention is optional; by 25 wk, generally recommended.
— Discuss maternal risks of cesarean for fetal indication vs neonatal risks of expectant management.
— Document risks/benefits/alternatives in language patient understands; use interpreter services if non-English-speaking — never family members.
— Substance use in pregnancy: State laws vary — some mandate reporting to child protective services; some require treatment referral only. Know your state. Counsel without coercion; punitive reporting discourages prenatal care and worsens outcomes.
— Suspected intimate partner violence: most states do not mandate reporting for competent adults; provide resources (national DV hotline).
— High-risk FGR patients transferring from community OB to MFM or to a tertiary center for delivery require closed-loop communication: send records, Doppler images, delivery plan; confirm receipt.
— At delivery, explicit handoff to neonatology of FGR-specific risks (hypoglycemia, polycythemia, NEC).
— Black patients have higher FGR and stillbirth rates partly from systemic racism, access barriers, and undertreatment of pain/hypertension — actively counter implicit bias; ensure aspirin is offered when indicated.
— Sildenafil for FGR — STRIDER trial halted for fetal harm; reminds us not to use unproven therapies even when desperate.
— Standardized growth chart use, structured Doppler reporting, and explicit delivery-timing protocols reduce variability and missed diagnoses.
Step 3 management: A pregnant patient with FGR admits to smoking — counsel, document, offer cessation resources/NRT, do not threaten CPS reporting unless your state law mandates it for tobacco (it does not in any US state); maintain therapeutic alliance.
Board pearl: When asked "which Doppler finding mandates delivery regardless of GA after viability?" — answer is reversed ductus venosus a-wave (or spontaneous late decelerations).
Step 3 management: When the answer choices include "bed rest," "maternal oxygen," "sildenafil," "heparin (without APS)," or "TORCH panel" — none of these is correct.
Board pearl: If gestational age does not match physical exam by ≥3 cm, the first action is always ultrasound — not redating, not reassurance.
Fetal growth restriction is EFW or AC <10th %ile (or <3rd %ile = severe) most commonly from placental insufficiency, diagnosed and surveilled with serial biometry plus umbilical artery Doppler, prevented in high-risk patients by aspirin started before 16 weeks, and delivered on a tiered schedule (37 / 37 / 34 / 30 weeks for mild / severe / AEDF / REDF) with antenatal steroids and magnesium where applicable.
Board pearl: "Small for gestational age" is a statistical label; fetal growth restriction is a pathologic diagnosis requiring surveillance, timed delivery, and recurrence-risk counseling.
Step 3 management: Never accept "bed rest," "sildenafil," "maternal O₂," or "empiric heparin" as a treatment — delivery is the only cure, aspirin is the only proven prevention, and umbilical artery Doppler is the only modality that reduces perinatal mortality.