Fundal Height Measurement

Introduce Gardosi Charts
Improve your SGA detection and
reduce IU Fetal Death rates
Dr Alphonse Roex, MD PhD
Senior Consultant O&G,
Northern Adelaide Local
Hospital Network
Senior Lecturer University of
Adelaide
Port Augusta Sat 21 June 2014
What would you prefer?
Key question: is fetus too small and not growing to its
genetic potential - and at risk?
Baby scale: ‘the gold standard’
Just by looking IUGR obvious ‘wasting’
Antenatal care
Is fetus growing at a normal rate = according to
its genetic potential?
• How to estimate fetal growth in a low risk (GP
shared care) population?
• The fetus is ‘hidden’
• Different methods used
1. Clinical ‘laying on hands abdomen’
2. Fundal Height (FH) measurement tape
What should method should we use?
Case
• Primigravida presents at 36+ weeks
• Uneventful pregnancy
Obstetric examination:
• Fetus: longitudinal lie, cephalic presentation
• FHR: 145 bpm
• Fundal Height: 35.5 cm
What is your opinion regarding fetal growth?
Fundal Height Measurement
Fundal Height
measurement:
current SA guideline
Are you a follower?
‘Record measurement’
• What is your next step?
Single FH measurement approach
“The fetus is most likely AGA if
FH = Dates +/-2 cm”
Antenatal detection rates of SGA fetus (25-30%)
FH Chart SA hand held record
Who does actually plot FH in chart?
Our case 36 weeks: serial plot
population based chart
What is your view now about fetal growth?
Our case: serial FH plot
customised chart
What is your view about fetal growth now?
The crux
Compare the
actual FH slope
with the
expected FH slope (print)
Comparing slopes
Example Customised FH Chart
FUNDAL HEIGHT
CM
GESTATION WKS
ULTRASOUND
EST. FETAL WEIGHT
Just one case report ! 
• Show me higher quality evidence
please!
Evidence
1. One cohort trial comparing laying on hands
with plotting on customised chart (level III)
2. One cohort trial comparing non plotting with
plotting on customised chart (level III)
3. No randomised controlled trials (Level II)
Serial plotting FH on Gardosi chart
1. West Midlands UK 1999
• Improved detection of SGA fetus 29.2% vs 47.9%
(OR 2.2; 95% CI 1.1-4.5; p 0.03)
Gardosi J and Francis A. BJOG 1999;106(4):309-17
2. Adelaide Lyell McEwin and Modbury hospitals 2012
• Improved detection rate 24.8% vs 50.6%
(OR 3.1; CI 1.7-5.5; P<0.001 )
Roex et al Aust N Z J Obstet Gynaecol 2012; 52:78-82.
‘Fetal GROW’ guideline NALHN
ANC visit > 24 wks
PLOT FH in Gardosi Chart
FH slope less than
expected?
US Fetal growth
Assess US & Plot EFW in Gardosi Chart
EFW>P10 & US findings 
Back to routine care
and FH plotting
US EFW <P10
URGENT REFERRAL
OBSTETRICAL REVIEW
Example Gardosi Chart -1
Example Gardosi Chart 2
Question
• You have requested and US scan Fetal Growth
for a healthy para 1
• Uneventful pregnancy so far
• US report: Estimated Fetal Weight is 2600
grams at a gestational age of 37+0
• How would you manage?
1. Pakistani lady: 160cm, 49 kg
US at 37+0 wks: EFW of 2500 g
Fetus AGA
2. European lady: 177cm, 78 kg
US at 37 wks: same EFW of 2500g
Fetus SGA
or IUGR?
The crux stillbirth rates
• What has happened in Prof Gardosi’s health
regions were customised charts were first
introduced?
Yearly stillbirth rates in the three regions with high uptake of GROW
training and protocols (‘high uptake’) vs the rest (‘low uptake’), 2008-2012
Gardosi J1, Giddings S, Clifford S, Wood L, Francis A. Association between reduced stillbirth rates in England and
regional uptake of accreditation training in customised fetal growth assessment.
BMJ Open. 2013 Dec 17;3(12):e003942. doi: 10.1136/bmjopen-2013-003942.
West Midlands 2011:
est. 78 fewer stillbirth
Conclusion
Fundal Height=Gest Age ±2
Conclusion Antenatal Detection SGA
• In a low risk population serial plotting of the
Fundal Height on a customised Gardosi chart
combined with using the ‘GROW guideline’ is
the preferred method, until proven otherwise
• Training of all staff paramount
• Happy to provide you with URL and
instruction to upload on your computer for
free. Prof Jason Gardosi 
• Need www connection, windows computer
and printer
• Just email to me:
alphonse.roex@health.sa.gov.au
Questions
Ron Mueck
Background article
• Intrauterine growth restriction: new concepts
in antenatal surveillance, diagnosis and
management Frances Figueras and Jason
Gardosi AJOG 2011:288-296
Non plotting of FH measurements
Questions?
Guideline SGA/IUGR
FH slope less than
expected
If <36 weeks:
US Fetal growth
If >36 weeks:
Consider
Induction of Labour
Plot EFW in Gardosi Chart
EFW <P10
REFERRAL
OBSTETRICAL REVIEW
HC/AC, AFI
Umb. art. Doppler
SGA or IUGR?
•
•
•
Serial US fetal Growth
AFI, Doppler
Increased surveillance
Admit, IOL / LSCS?