 Hi, I'm going to talk on Feetal Growth Distriction and Management. So we'll discuss the management work, the stage-based management as well as the management which is proposed in the recent ISWA guidelines in August 2020. So we are worried about FGR for Feetal Growth Retardation because we know that there can be a lot that are associated Feetal Mobilities and there can also be a mortality. There is a subset of FGR which is known as severe early onset FGR where typically at a very early stage we see an FGR and usually you have a secondary cause like genetic causes, Feetal Infection, Anomalies. This is a different group and we are not going to discuss this. What we are going to discuss is what we see in day-to-day practice. So the first clue that something is going wrong with this fetus comes up when you identify a small fetus. So first step is to identify a small fetus and let us see how to do that. Now once we have identified a small fetus we need to differentiate between what is known as an HGA or small for gestational age fetus versus an FGR or a fetal growth restriction. We need to look at what time we have picked it up whether it is early or late. We will come to that a little later. Once you have diagnosed something as an HGR and FGR we need to look at some parameters to follow this fetal to judge their well-being and then finally based on all these findings we need to have some management decisions which can be either what are known as stage based management for an early onset FGR or recently we can follow these work guidelines which were published in August 2020. So we can say that a fetus is appropriate for gestational age when it is within the normal limits. That means typically if you plot a graph and the growth pattern is well within the 50th percentile we know that that is appropriate for gestational age. On the other hand a small for gestational age fetus or a small fetus is one which is basically shows a weight which is below the 10th percentile for all practical purposes whereas an FGR fetus is one that has not achieved its growth potential. So as compared to an appropriate gestational age typically when you see the weight is gone below the 10th percentile for that gestational age then we know that we first label this as a small fetus. But we need to understand that of all fetile whose weight is less than 10th percentile almost 70% are what are known as HGA or small for gestational age and they do not have any additional risk operating into mobility and mortality as compared to those which show weight which is appropriate for gestational age and they are very often labeled to as a true HGA or constitutionally small fetus whereas 30% of fetus whose weight is below 10th percentile are what are known as FGRs or true fetal growth restrictions. So we will see how to differentiate between these two also. Now being constitutionally small is nothing abnormal. I mean we know that our external affairs minister, respected Sismar Swaraj Ji was constitutionally small as compared to the US external affairs minister but she was very very efficient. So being constitutionally small is nothing wrong. So HGA as we said we define as a fetus whose weight is less than 10% time but it is otherwise healthy with relatively low risk of very little mobility and mortality. That means all other findings are known as ultrasonic especially Doppler is all normal. Whereas an FGR is a fetus whose now this is a recent classification of course it published in 2019 recent definition. So FGR is a fetus whose abdomen perimeter or the weight is below 3rd percentile. So we are not talking about 10th we are talking about 3rd percentile or a fetus whose abdomen perimeter or weight is below 10th percentile associated with an abnormal Doppler. This abnormal Doppler can either be neutron artery on the right-hand side or the fetal umbilical artery or the central artery also. And recently one more thing which has been added is a drop in the percentiles of more than 2 quartiles either in the abdomen perimeter or weight. What we mean by that is suppose a fetus is at 75th percentile and you will see that a fetus has gone to 20th percentile. So 20th percentile is well above 3rd or 10th percentile but there has been a drop of almost 2 quartiles from 75 percentile and this is abnormal and we can classify this as a growth restricted fetus. So just to summarize an HGI is a fetus whose weight is below 10th percentile FGR is a fetus whose weight is below 3rd percentile or a weight below 10th percentile with an abnormal Doppler or a drop in the weight or the AC by more than 2 quartiles in a significant scale. So that is how an HGI fetus shows on the graph. It typically is low but it maintains its graph whereas an FGR fetus as you go shows a further drop in the weight on the abdomen perimeter as we go towards later on gestational age. Now so far we have identified HGI and FGR. Now we need to differentiate between two phenotypes of FGR that is an early onset FGR and an late onset FGR and it is very important to differentiate between them because both of them behave differently as far as outcome and prognosis is concerned and this difference between early onset and late onset FGR is based on the time of onset or when you diagnose and for all practical purposes now we take 32 weeks gestation as a cutoff between early onset FGR and a late onset FGR that means if you have picked up something before 32 weeks it is early onset if you have picked up an FGR after 32 weeks it is late onset FGR. So just to come back to the definitions because now we have put up this criteria of 32 weeks gestation we can say an early onset FGR is a fetus where we have picked up something for growth friction before 32 weeks of gestation the abdomen perimeter or weight is below third percentile or as we said there is an abnormality like an absent end diastolic flow or we have an abdomen perimeter or weight below tenth percentile as we said associated with either uterinary abnormality or an abnormality. Whereas a late onset FGR is something which we pick up after 32 weeks gestation again if the abdomen perimeter or the weight is below third percentile we have a straight forward diagnosis or at least two of the three criteria that means the weight or the abdomen perimeter below tenth percentile or with at least two of the three that means this with either an abnormal CPR or an umbilical artery abnormality or the AC or AFW crossing more than two quartiles so we have already talked about all this it is just putting things together so why the difference what is the difference between early onset FGR and late onset FGR so typically as we said early onset FGRs are diagnosed before 32 weeks of gestation generally they would require delivery by 37 weeks of gestation we cannot wait too long they are easy to identify because the biometric is florid and you can easily pick it up but they are difficult to manage because a good number of them are premature they suffer from chronic hypoxia and therefore they have a better tolerance for hypoxia since the process of hypoxia has been going on for quite some time they are tolerant to hypoxia they constitute to almost 30% of all growth restriction fetus and a good number of them have an early onset pre-ethylampsia and therefore they are picked up very easily or we are on uterine artidopola and we are suspicious about this when we see an abnormal uterine artidopola whereas the late onset FGRs as we said are diagnosed after 32 weeks of gestation very often at term they are difficult to identify because very often the Doppler features are not florid as we will see later on they have a poor tolerance to hypoxia they are not used to hypoxia and they can constitute to almost 50% of unexplained near term steel birds which are supposed to be because of late onset FGR which have not been identified so this is very important and we have a lot of responsibility here to almost about 70 to 80% of all FGRs and the association with late onset pre-ethylampsia is very low and therefore the detection rate is very very poor now the difference between early onset FGR and late onset FGR is like a Sherpa going to the Mount Everest and one of us who has never gone to the mountain going to even the forget about the mountain it is going to the base camp of Mount Everest we would get sick immediately because we are not used to hypoxia because the Sherpa is used to hypoxia and therefore there are stories of Sherpa climbing the Mount Everest without even an oxygen so this is an early onset FGR they are used to hypoxia this is late onset FGR if the fetus is not used to hypoxia and therefore a slight change in oxygen can actually basically cause a lot of problems so now what we have done so far is we have picked up HGA and FGRs we have picked up early onset and late onset now we need to find out how well the fetus is doing inside is it quite comfortable inside the change in utero environment or is it showing some signs of distress that ok things are not too bad I want to come on early and for this of course we now are going to depend heavily on Doppler ok and of course other things like biophysical profile etc so we know that FETA react differently to progressive hypoxia at different gestational age and Doppler is probably the best non-implicit method to evaluate fetal circuitry change which can either be adaptive or reactive so when we talk of Doppler we know that on the maternal side we have uterine arteries and on the fetal side we have the umbilical artery, the MCA and of course we can take the CP ratio now of the ductus as well as the aortic isthmus so let us see how different vessels help us basically the uterine arteries and the umbilical arteries give us an idea about the utropacetin function ok whereas on the other hand the MCA the ductus phenosis as well as the aortic isthmus they give us an idea about fetal cardiovascular adaptation and they give us an idea about the changes which happen progressively from hypoxia to acedemia so let us see how we utilize each of these vessels now there are some indices which show a chronic deterioration for example umbilical artery or MCA whereas some of the indices like typically ductus phenosis show something is going acutely wrong so this also we need to keep in mind when we take decisions so when we talk of early oxidative GR we know that early oxidative GR is typically associated with a vascular disorder to the abnormalities of tertiary venous vessel most of these are associated with inappropriate trophoblastic invasion of the spiral arteries and therefore the typical change in the uterine artery from high resistance to a low resistance flow does not happen which is of course because of inadequate trophoblastic invasion and this can be easily picked up by looking at the uterine artery P.I so what we are typically looking at is the uterine artery P.I at different gestational ages and trying to find out if it is more than 90 percent time for that particular gestational age and we know that this is associated with placental insufficiency and maternal vascular malperfusion of the placental so typically therefore it is very important to look at uterine artery top left both in the first as well as in the second trimester what is the technique we can do transseptominal as well as trans vaginal we go to the midline from the midline we go along, go to the sites identify the iliac artery iliac artery and then identify the uterine artery as it processes so typically we can sample it in an area where the uterine artery is straight it can be about 1 centimeter downstream as per the guidelines or wherever you get a good section of uterine artery but do not go too peripheral to look at branches of uterine artery and then of course we look at the spectral waveform and calculate the PI now it is very important to understand that we now look at only the mean PI that means we take the mean from both sides usually the machine will do it for us and we do not look at other things like pleiastolic notching and other ratios which have been described in the past and of course for each gestational age we need to find out the percentile but for all practical purposes if the mean PI is above 2.3 in the first trimester or above 1.4 in the second trimester that is considered as high and these are figures which are very easy to remember okay so let us come to the umbilical artery so uterine arteries once they are abnormal we are alert that okay we need to keep a close watch on this particular pregnancy now the umbilical artery is basically a progressive increase in the umbilical artery tells us that there is a progressive reduction in the placental surface area which is available for gas and nutrient exchange and increase fetal after load resistance we talk about this term after load later and we know very well that this is associated with placental vascular insufficiency which ultimately will be reflected in an absent end vascular flow or a reverse end vascular flow so we know that normal placenta is quite fluffy which allows easy exchange of nutrition whereas a disease placenta looks something like this and offers a lot of resistance and does not allow easy exchange of nutrition so when we look at umbilical artery we are looking at a PI which is again more than 95 percentile and umbilical artery is both diagnostic as well as prognostic diagnostic because we saw earlier that in the definition of FGR also we used an abnormal umbilical artery as one of the criteria okay but we need to remember that in late onset FGRs the placental disease is very mild and umbilical Doppler is normal in most of the cases so we will come to this point a little later now when do we sample umbilical artery typically we know that when we sample it close to the fetus or when we sample it close to the placenta and there can be a little variation in the in the values which you take and therefore the ISWA guidelines in 2013 which were published for standardizing Doppler techniques said that for the sake of simplicity and consistency you can measure the umbilical artery in a free chord flow so we know that typically once more than 30 percent of the placenta gets disease and this is reflected in the umbilical artery as a high resistance or in a worse case even as a reversal of flow so that's a normal umbilical artery that's an abnormal umbilical artery showing absent diastolic flow and that is even more abnormally showing reversal of diastolic flow telling us that there is a high resistance the middle simple artery is a surrogate for hypoxia so we know that whenever there is hypoxia that is what is known as a brain as a sparing effect so what happens is the moment the oxygen tension in the oxygen there is hypoxia there are some chemo receptors in the aortic isthmus which basically pick up this hypoxia and they modulate in such a way that basically more blood goes to the brain this is classically known as a brain sparing effect and this is basically mediated by vasodilatation of the cranial vessels and this vasodilatation of course once there is dilatation there is increase there is less resistance once there is less resistance there is increased diastolic flow and the PI will definitely go down so that's a normal MCA showing a fairly high resistance and with vasodilatation we get higher diastolic flow and a very high diastolic flow with a fall in the PI so typically in the umbilical arteries we are looking at an increased PI more than 90 percentile whereas in an MCA we are looking at a PI falling below the fifth percentile for that particular gestational age but now we know so first of all let us see how the technique of the MCA so typically MCA is easy because you just take a good BPD keep a probe which is as much parallel to the blood flow as possible because this is one vessel which can actually make it parallel to your ultrasound beam and then of course we try to interrogate as close to its origin you should not go too far off in this proximal one third angle correction is very important so that you get a very crisp waveform and then you take the waveform in the medial cerebral artery so typically when you are interested in velocities like in this case in this patient who had an RH incomplete in compatibility it is very important to do an angle correction typically when you want to measure the pixie study velocity we would do it manually but when we want to do an PI we can do it with auto trace which is available on almost all the machines so that is a normal MCA and that is an abnormal MCA showing a higher diastolic flow but now we know that instead of looking at the LCA PI it is much better to look at what is known as cerebral placenta ratio that means you take a ratio of MCA PI and compare it with the umbilical artery PI and we know very well that individually the umbilical artery PI or MCA PI are not altered the CP ratio can get altered first and it is now considered as a very very sensitive criteria as compared to only umbilical artery PI then we come to ductus venosis ductus venosis is a vessel which is very close to the right side of the heart and therefore it reflects what is happening to the right side of the heart so typically we look at the ductus venosis we can look at it both in longitudinal plane and transverse plane it is easy to identify as we see later basically that is the umbilical vein and typically where the ductus starts the umbilical vein suddenly narrows down it almost is like one third of its size and therefore at this point as we know that as blood goes through a narrow channel there is high velocities there is aliasing and that is reflected in this altered color here and typically we like to sample it at its narrow point or at the point of maximum aliasing so that is the umbilical vein that is the umbilical vein ductus venosis on V mode that is the ductus venosis on color we can see that there are low saturated colors in the ductus venosis it is basically an anomhazone and that is the sort of a waveform which you get in the ductus venosis so in the ductus venosis we have this sort of a waveform we have the first systole which is known as S-ray then we have a second peak which is known as a D-peak which is because of an early diastole and then we have the A-wave which is because of the right atrial contraction so but what we need to understand is that persistently the ductus venosis always shows a forward flow in one direction and therefore what ductus venosis reflects is what is happening in the right side of the heart there is this amount of systole the early diastole and the most important is the atrial contraction so basically again in ductus you can now take various values P, PI, you can take SA and various other ratios what is important to understand is whatever you take is that the ductus venosis or typically the A-wave in the ductus venosis gives us a good idea about right ventricular preload so what do we mean by preload preload is the volume of blood in the ventricles at the end of the diastole like for example if you have a normally functioning heart and the ventricle is able to contract adequately and push the blood out during this story then during diastole there is a lot of scope for the blood to come in so in the early phase of diastole we have passive blood coming in from the right atrium and in the late stage of diastole when the right atrium contracts we have more blood coming into the right ventricle but when there is hypoxia when the muscles of the heart becoming weak they are not able to contract adequately then there is a lot of stagnant blood remaining in the right ventricle and therefore when there is this it is time for the right atrium to push blood into the right ventricle it is not able to do that because there is already blood there and therefore where does this blood go it has to go somewhere and therefore it typically would find its way in a reverse direction and this is reflected in the ductus venosis as an a-wave touching the baseline or sometimes a-wave going on the other side of the baseline so with a decreased compliance of the heart with increasing hypoxia we can see that the alien goes on falling down comes to the baseline or sometimes goes on the other side of the baseline so an abnormal ductus venosis like this not only tells us that there is not only a fetal hypoxia but now there is fetal acidemia and the fetus is impending cardiac failure or it already is in failure and we need to deliver it out as soon as possible so over a period of time we know that this is one of the strongest single Doppler parameter to predict fetal death or a poor outcome so it is a very very important criteria but we do not want to wait that late we do not want to see things which are disastrous so we want to pick up things earlier and therefore one more vessel which was proposed is the aortic isthmus basically aortic isthmus is this area in the aorta just after the left subcutaneous artery so what is very peculiar about this area is in a fetal life typically during the cisteri the blood from the left ventricle would go basically through the aortic isthmus in this direction forward direction whereas because of the ductus the blood from the right ventricle during the cisteri would go in an opposite direction whereas during the diastere what decides the direction of the blood flow in the in this region of the aortic isthmus is the resistance both the systemic resistance as well as the central resistance or the resistance in the brain so basically a lot of factors are going to affect the blood flow in the aortic isthmus and therefore this has become a very very important sort of area to look at what is happening all over so typically we sample the aortic isthmus just beyond the subcutaneous artery left subcutaneous artery this can be done in a longitudinal plane we can identify the subcutaneous artery and then look at this relatively narrow area and then take a sample or we can take a three vessel trachea view which all of us are familiar with and look at the aortic isthmus just at the apex of the V and we can take the waveform in the aortic isthmus at this point also so typically aortic isthmus flows a forward flow but as things become bad and especially with redistribution we can see that there can be an upset dastrolyph flow or they can have a reversal of flow in the aortic isthmus in this part now this reverse component is not good in the sense that it tells us that sort of a not good blood or bad that is reaching the fetal brain and once a fetus has this again the prognosis can be bad and we can pick this up even before the ductus venousis becomes abnormal so that is a normal aortic isthmus and that is an abnormal aortic isthmus with a reversal of flow now the recent guidelines we swap 2020 guidelines besides the Doppler also show that it is very important to look at the biophysical profile scoring so over years we were told that we no longer do biophysical scoring we no longer do manic scoring but what we need to understand is we need not look at each and every value and give scores but while you are doing a Doppler it is a good idea to keep a watch on the fetal gross body movements the tone as well as the respiratory movement because you get an idea about how well the baby is doing inside whether it is looking like a sick baby so even if you do not measure or score it as such we can always keep a watch on the fetus but now the recent guidelines also tell us that it may be a better idea to look at biophysical scoring recent guidelines also give a lot of importance to cardiotochography and the short term variations which you could think of but we do not do cardiotochography in India and therefore we need to depend heavily on Doppler and the guidelines also mention that. The guidelines also talk of new biochemical markers like for example SFN T1 to BLGF ratio which can predict a short term deaclampsia in the sense that if this is abnormal then it is likely that the patient will have a deaclampsia in the coming weeks 1 or 2 weeks so let us see some examples here we have a fetus whose weight is at 4th percentile so less than 10 percentile but the Doppler and the CPR and everything is normal so we label this as a small for gestational age fetus so what do we do in an age fetus typically we need to keep a watch we just cannot leave it alone we definitely need to keep a watch and we try and deliver them typically at around 38 weeks of gestation and not beyond 39 weeks of gestation so most of the age fetus do well, we need to follow them fortnightly with all the Doppler parameters but some of them could have problems during labor and therefore we need to keep a close watch even during labor that is for small for gestational age fetus so what we now need to do is we have looked at various parameters of Doppler we have also looked at the biophysical profile and maybe you have done an NST if you do not have a CCTG and what we need to do now is put everything together and sort of interpret things together we cannot just look at umbilical artery okay and say okay now do this and that we need to put all our parameters together and come to a management decision so now we can do this management decisions in two ways one is using what is known as a stage based management protocol which was made popular by Platypus and we can also use the new management protocols which have been published in August 2020 there is not a very significant difference between them I will show you the difference between them in a later stage so let us first talk about stage based management which was made popular by Platypus so typically here he divides them into four stages stage one is where there is a mind placental resistance and that is reflected typically as an altered intra-RTPR and CAPI or a CPR a serial placental resistance where typically we have absent dastry flow in the umbilical artery or reversal of flow in the oorticismas serial hemodynamic adaptation typically when there is a reversal of flow in the umbilical artery in the dastry or the A wave in the ductus reaches the baseline but does not go beyond the baseline and stage 4 where there is a high suspicion of acidosis where the ductus venosis shows A wave reversal so these are the four stages this should be the stage 2 which were made popular by Platypus so let us see some examples here we have a 30 weeks gestation weight is below 10% and so now you are alert is it HG or FGR but we see that the intra-RTPI is high and we can also see that the umbilical artery PI is high so we know that this is stage 1 FGR so typically what do we do in stage 1 FGR we need to keep a close watch typically every week to see if things are going well and if everything goes well then we can induce labor at 30 weeks of gestation and of course but we need to keep a close watch on the fetus even in the labor so let us see second example here we have a 30 weeks gestation weight is less than 3rd percentile less than 3rd means already FGR so we are not talking of HGA any longer but then now we need to see how well the fetus is doing inside we need to stage it so what do we see here we see umbilical artery showing acidosis flow so straight away we are in stage 2 FGR so what do we do in stage 2 FGR we need to keep a close monitoring on the fetus we need to monitor twice the week and typically Gandapas recommended that we should deliver them around 34 weeks of gestation let us see another example now we have a 26 weeks again the weight is less than 3rd percentile so straight away FGR now we need to stage it so we look at Doppler what does Doppler show it shows reversal of flow in the diastolic umbilical artery and the A name in the duct is stretching the baseline but not going on the other side so this become a stage 3 FGR name C again you can see that there is a very high diastolic flow with the fall in the PI so in stage 3 FGR now we need to be even more careful and we need to monitor every 24 hours and 48 hours and in this case we should deliver even if the fetus has reached 30 weeks of gestation with the above findings which we discussed about and now the fetus may not be able to take the burden of stress of a leba and therefore it is recommended to do a C section now let us go to another case here it is 27 weeks gestation and the weight is less than 2nd percentile so straight away FGR now we need to stage it so we look at Doppler and what does Doppler show it shows everything that means umbilical artery reversal very high diastolic flow in the MCA but the ductus venous shows a pulsatile waveform with the A wave reversal so once we say A wave reversal that means it is a stage 4 FGR now we are worried not only of hypoxia we are worried about fetal acidosis and we know that there is a high risk of fetal death so now monitoring is absolutely short term just 12 to 24 hours still maybe you can give steroids and as per Gatakma's guideline even if you have reached each 26th of gestation we can deliver at a tertiary center by C section because for them 26 weeks is a good enough maturity some of our ICUs do equally well as well so here is a classical example of stage 4 umbilical artery showing reversal of diastolic flow if you look at aortic isthmus in the aortic arch you can see this transient reversal which is of course seen on a spectral waveform and the ALM in the ductus venous again shows reversal of flow yeah that is a aortic isthmus and ductus venous is showing reversal of regale so that is again a stage 4 and we would like to give the speakers so now this stage based management is good only for early onset FGR because an early onset FGR shows a classical progressive topical changes that means your alteration in the MC and umbilical artery coming up first then of course we have changes coming up in the aortic isthmus then we can have apsin endastolic flow or reversal of flow in the umbilical artery and finally we have ductus venous abnormally so this cascade of event is very typical of early onset FGR and should be used typically only for early onset FGR and of course in a late stage you can have an abnormal NST so we do not have CCTG but we can definitely have an NST in our center it is a very very useful tool so basically just to summarize as far as the stage based management is concerned we have 4 stages depending upon the topical finding stage 1 we need to do a weekly follow up and deliver at 37 weeks stage 2 follow up twice a week deliver at 34 weeks stage 3 very close monitoring may be daily deliver at 30 weeks and once stage 4 deliver anytime typically anytime after 26 weeks in the station so the recent guidelines of ISWAG actually as I said give a lot of importance to CCTG and biophysical profile besides of course Doppler but there is most significant change we have again it says that if you have ALM reversal going ALM going at or below baseline if you are anywhere between 26 weeks to 28 weeks deliver as far as umbilical arteries are concerned it says if you have a reversal of flow in the umbilical artery and you are anywhere between 30 and 32 weeks deliver and if you have an absent diastolic flow in the umbilical artery and you are anywhere between 32 and 34 weeks deliver so I have just put the stage based management system and the recent guidelines of ISWAG together and as you can see there are very significant changes it is a matter of just few weeks here and there so here he is talking about 26 weeks here they are talking about a range between 26 to 29 weeks almost 26 to 28 weeks similarly with umbilical artery showing absent diastolic flow here we are talking of a range between 32 weeks and 32 to 34 weeks and here of course sorry so if you have an umbilical artery reversal of an diastolic flow then you should deliver as per the ISWAG guidelines at 32 weeks but even 30 weeks is good enough and if you have absent diastolic flow and you have reached 34 weeks you should deliver or even anywhere between 32 weeks and 34 weeks so there is not a very significant change in the management strategies between stage based management and the ISWAG guidelines now we come to late onset FGR so as we said this particular thing like stage based management is good for early onset FGR but when we come to late onset FGR we need to have a different criteria and we need to be more alert so we said earlier that late onset FGR is far more common than early onset FGR it represents a failure of the fetus to reach its potential at term the placental disease is very mild and this results from less immaturity rather than inadequate trophomastic imaging as we saw and therefore the umbilical artery doctors can be unaffected and this is the main difference between early onset and the late onset FGR so we typically suspect late onset FGR when the individual growth curve slows down at a later stage or there is an increase in the C2-AC ratio at a later stage and we know that at term the fetal brain requires more oxygen and therefore the first hemodynamic alteration in the presence of amoxia is an alteration in the MCAPI and we also saw that instead of looking at only MCAPI altered cerebral placental ratio is much more sensitive as compared to an MCAPI so here is an example of a late onset FGR at 30-35 weeks the H2-AC ratio is altered and the cerebral placental ratio is very low 0.6 telling us that is fetal hypoxia so what is also very important in late onset FGR when you are monitoring is the fall in the CPR here for example within a matter of one or two weeks there is a fall in the CPR as compared to the first ultrasound and this is again very, very important to pick up so the late onset FGRs lack a natural history as we said they do not show that cascade of events which are typical of an early onset FGR and suddenly there can be rapid deterioration which can be utilized to a severe brain damage and therefore we need to be very alert and pick it up at the right time and one of the best tools to for surveillance as far as late onset FGR is concerned is an MCA Doppler and a cerebral placental ratio of course biophysical profile and LST are also important and if you have a CCTG then you can use that as well. So what is the SWAG guideline that what is the recommendation so basically for the late onset FGR the delivery should be based on biophysical assessment as well as of course material indications so if you have a spontaneous repeated persistent unprovoked fetal heart rate distillation or an NSC that is one indication, if you have a very bad biophysical profile that can be another indication, material indications like of course TA, eclampsia and help you do not wait to look at what your doctor is showing or obstetrics emergencies or an umbilical artery showing absent or reversed as to be flow. So typically as per the SWAG guidelines for the late onset FGR if you have reached 36 weeks to 38 weeks and if the umbilical artery PI shows a high resistance or of course if the abdomen perimeter or the weight is below 30% and you can deliver if you have reached 38 to 39 weeks and you see that there is an altered cellular blood flow or with no CPR then again you need to deliver and then of course because it is a late onset FGR one can always try and induce for labor instead of going for a C-section but during labor it is very important to look at a fetal heart rate. As far as late onset FGR is concerned we know that there can be there is always a risk of neurocombinative dysfunction later on in life as well so we need to be alert about that as well. So but we need to understand that the stage based protocol or the guidelines of ISWA there can be nothing rigid about it we need to individualize each case we need to look at a maternal condition as of course as been discussed and each case has to be individualized and his decision and for each fetus is going to be separated. So how can we use all this in practice? The first thing we can always do is do a good uterine artery Doppler in the first and the second trimester so that you are aware that something is going to rank and you go wrong and you can predict a possible FGR coming up. The second thing you need to do is establish gestational age because all the percentiles in weight are basically based on establishing the correct gestational age at an early stage. So after you have established gestational age subsequently fetal biometry is very very important in the correct manner so that you pick up weight which is falling below the 10th or the 3rd percentile so growth charts are very very important and finally of course we need to do a good Doppler and again we need to look at percentile charts. We need to understand that there is no effective intratrain treatment when it comes to FGR so what is important is early diagnosis, good surveillance and optimizing the time of delivery and Doppler is again going to be a very important tool. Now Gratacos has this online sort of an app where you can enter all your findings of Doppler as well as the biometry and then the app tells us at what stage we are and what is recommended for the sake of management. The new guidelines have this flow charts within them you can very well use them but as I said that we cannot be very rigid about such apps or such flow charts each case has to be individualized but this gives us a rough both the system that is the stage management as well as the new swap guideline gives us a good idea about what you should be doing in practice but each case has to be individualized that is very important. There is a lot of optimize between the risk to the fetus versus an actinogenic pre-material that means you should not deliver too early because each day in-utero is important for the fetus but if the fetus is showing signs of distress then of course we need to have an early delivery. So what is very important is to understand all the Doppler findings and pick up things in the right time and the fetus shows any indication that it needs to it will be more comfortable outside that we need to decide on that. Thank you so much for your kind attention.