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Impaired fetal growth
Matthews Mathai
Training in Reproductive= Health Research
Gene= va 2006
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Outline
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Terms and definitions
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Factors influen= cing size at birth
•Problems associ= ated with impaired fetal growth and their significance
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Diagnosis <= /span>
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Management =
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Prevention
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Terms and Definitions
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Commonly used terms
•Prematurity
 •Low birthweight (LBW)
 •Small for gestational age (SGA)
•Intrauterine gr= owth restriction (IUGR)
<= span style=3D'visibility:hidden'>•
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Prematurity
•Should refer to functional immaturity of organ systems <= /div>
–= E.g. Respiratory immaturity
•<= /span>When is functional maturity achieved?
•“Preterm” refers to relation to chronological age
–= Refers to gestation less than 37 weeks
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Low birthweight (LBW)
•All inf= ants weighing less than 2500 g at birth
•Does not consider gestational age
•Different problems included in the same group
–Small a= nd average sized preterm infants
–Small s= ized term infant
•Proxy indicator = for growth restriction and prematurity
•VLBW &l= t; 1500g; ELBW < 1000 g
•
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Small for gestational age (SGA)
•Smaller than expected for given gestational age
•<= /span>How much smaller?
–= Less than 10th centile =
–= Less than 5th centile =
–= Less than – 2 SD
•<= /span>Synonyms
–<= /span>Small for dates (SFD), Light for dates (LFD)
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Intrauterine growth restriction
•Restriction or slowing of the rate of intrauterine fetal growth
•<= /span>Not synonymous with SGA
•<= /span>Demonstration of slowing of growth rate
–
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Factors influencing size a= t birth
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Size at birth
•Size at birth depends on = ;
–Gestation at birth
–Fetal growth rate
–=
•A baby may be small at birth because
–It was born earlier than nor= mal, or
–Its rate of intrauterine gro= wth was slower than normal, or
–It had impaired growth and w= as born early
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Factors influencing growth
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Fetal
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Placental <= /span>
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Maternal
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Environmental
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Fetal factors
•<= /span>Abnormal karyotype
–= Trisomies
•<= /span>Fetal sex
–= Male fetuses heavier by 100-150 g
•<= /span>Genetic influences
–= Parental size
–= Ethnic group
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Placental factors
•<= /span>Placental infections
–= Malaria, syphilis
•<= /span>Placental infarction
•<= /span>Placentation
–Later born babies are 100-150 g heavier than first born babies
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Maternal factors
•<= /span>Maternal size
–= limiting effects
–adjusting birthweight centiles for maternal height
•<= /span>Maternal illness
•<= /span>Nutrition
–= Anaemia
–= Malnutrition
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Environmental factors
•<= /span>Altitude
–= Lower birthweight at higher altitudes
•<= /span>Tobacco abuse
–= Active smoking
–= Passive smoking
–= Tobacco chewing
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Environmental factors
•<= /span>Cooking fuels
–= Coal, wood, animal dung
–= Poor ventilation
–= Carbon monoxide inhalation
•<= /span>Other heavy manual work
–= Agriculture
–= Carrying water
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Problems associated with <= /span>impaired fetal growth
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•Low birthweight babies are approximately 20 times more likely to die than heavier = babies •Goal of reducin= g low birthweight incidence by at least one-third between 2000 a= nd 2010 is a major goal in “A World Fit for Children” (UN 2002)=
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Morbidity
•Immediate
–Increased risk of suspected fetal distress
–Increased risk of interventions
–Increased risk of problems a= fter birth
•Hypoglycemia, hypothermia, p= oor feeding
•Medium to long term
–Learning disabilities
–Increased risk of hypertensi= on, heart disease, diabetes
•
•=
–= =
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Birthweight & early neonatal mortality – Vello= re 2001
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Birthweig= ht and perinatal mortality
<= span class=3DBB style=3D'position:absolute;left:-3.78%'>•Birthweight < 5th centile OR 5.6
<= span class=3DBB style=3D'position:absolute;left:-3.78%'>•Birthweight 5th - 10th centile OR 2.8
<= span class=3DBB style=3D'position:absolute;left:-3.78%'>•Birthweight 10th – 15th centile OR 1.9
<= span style=3D'visibility:hidden'>•
•Growth rate in third trimester is a better predict= or of intrapartum problems and immedi= ate perinatal outcomes than estima= tes of fetal size
<= span style=3D'visibility:hidden'>• =
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Diagnosis
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Clinical methods
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Identification = of risk factors
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Maternal weight gain
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Abdominal palpation
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Tape measuremen= ts =
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Laboratory methods
•<= /span>Biochemical methods
•<= /span>Ultrasound
–= Routine vs selective use
–= Fetal biometry
–= Biophysical score
–= Cardiotocography
–= Doppler
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Birthweight standa= rds
•Cross sectional data on birthweight and gestation
•<= /span>Graph of birthweight against gestation
•<= /span>Cut off levels for classification
–= 10th and 90th=  centile <= /span>
–= Small, appropriate and large for gestation =
•
•
•
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Population based standards
•<= /span>Hospital births
•Physiological and pathological factors influencing size at birth
–Misclassification if appropriate adjustments are not made
•<= /span>Ethnic composition
•<= /span>Accuracy of gestation
•<= /span>Growth and preterm births
•
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Antenatal clinical estimation
•Possible everywhere but requires training and experience
•<= /span>Abdominal palpation
•<= /span>Tape measurements of fundal height
–Widely used for assessing fetal growth and size
–Insufficient evidence from only randomized trial
•
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Ultrasound based standards
•<= /span>Hospital based
•<= /span>Mostly cross-sectional studies
•<= /span>Measurements include
–= Head size (BPD, HC)
–= Abdominal circumference
–= Femur length
•<= /span>Weight estimation
•<= /span>Interval growth measurements 
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Ultrasound based standards
•<= /span>Equations for estimation of fetal weight
–= Hadlock equations commonly used
•<= /span>Rossavik model
–= Early estimate of fetal growth rate
–Project fetal weight at birth based on growth <= span style=3D'position:absolute;top:62.5%;left:14.04%;width:79.96%;height:6.0%'= >rate
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Population based or individualised <= span style=3D'position:absolute;top:12.75%;left:5.99%;width:88.2%;height:8.5%'>= standards for fetal growth?
•<= /span>Physiological factors
–= Size of the mother
–= Birth order
–= Sex
–= Ethnicity
•Adjustments made while interpreting size at birth
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Individua= lise
•<= /span>For physiological factors
•Computer generated graph (Gardosi et al)
•Higher antenatal detection of small for dates (48% vs 24%; OR 2.2, 95% CI 1.3-1.5)
•<= /span>OR for stillbirth in small for dates by
–= Individualised graph 6.1 (95% CI 5.0-7.5) <= /div>
–= Standard graph 1.2 (95% 0.8-1.9)
•
•
•
• =
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Management
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Management options
•NO EVIDENCE = OF BENEFIT
•= Bed rest in hospital
•= Hormone therapy
•= Betamimetic therapy
•= Antihypertensive therapy
•= Nutrient supplementation
•= Maternal oxygen administration <= /div>
•= Plasma volume expansion
•= Routine ultrasound
•= Cardiotocography
•= Biophysical scoring
•
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Possible benefit
•<= /span>Delivery at the appropriate time
–Will the baby survive better in the uterus or outside it ?
•= Nursery facilities
•= Costs of treatment
•<= /span>Reducing birth asphyxia
–= Mode of delivery?
–
• =
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Beneficial interventions -1 =
•Doppler ultrasound for deciding on the time of delivery
–= Fewer inductions OR 0.83 (0.74-0.93)
–= Less hospital admissions OR 0.56 (0.43-0.72)
•Corticosteroids prior to preterm delivery
–= Less RDS OR 0.53 (0.44-0.63)
–= Less IVH OR 0.48 (0.48-0.75)
–<= /span>Fewer neonatal deaths OR 0.60 (0.48-0.75)
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Beneficial interventions - 2 =
•<= /span>Amnioinfusion in labour
–= Less FHR decelerations RR 0.54 (0.43-0.68)
–Less CS for suspected fetal distress RR 0.35 (0.24-0.52)
–= Nursery stay > 3 days RR 0.40 (0.26-0.62)
------=_NextPart_01C64E9F.732D8F10 Content-Location: file:///C:/1809C636/Impaired_fetal_growth_Mathai_2006_files/slide0074.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Impaired fetal growth - Matthews Mathai
Prevention
------=_NextPart_01C64E9F.732D8F10 Content-Location: file:///C:/1809C636/Impaired_fetal_growth_Mathai_2006_files/slide0075.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Impaired fetal growth - Matthews Mathai
Beneficial effect
•Smoking cessation
–LBW RR 0.81 (0.70-0.94) =
–Preterm births RR 0.84 (0.72-0.98)
–Mean birthweight increase 33= g (11-55g)
•Balanced energy and protein = supplementation
–Less SGA RR 0.68 (0.56-0.84)
•Treatment of asymptomatic bacteriuria
–LBW/Preterm RR 0.60 (0.45-0.= 80) =
------=_NextPart_01C64E9F.732D8F10 Content-Location: file:///C:/1809C636/Impaired_fetal_growth_Mathai_2006_files/slide0050.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Impaired fetal growth - Matthews Mathai
Summary
•= Impaired fetal growth is associated w= ith increased perinatal morbidity and mor= tality and incre= ased risks in later life
•= Diagnosis is made by demonstrating sl= owing of growth over a peri= od of time using appropriate standards for fetal size
•<= /span>There are few beneficial intervention= s that = improve fetal growth
•<= /span>Delivery at the appropriate time with skilled  = newborn care is the key to improved n= ewborn = survival
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SlideObj.style.visibility=3D"visible" if( fTrans ) SlideObj.filters.revealtrans.Play() } function MakeNotesVis()=20 { if( !IsNts() ) return false=20 SlideObj.style.display=3D"none" nObj =3D document.all.item("NotesObj") parent.SetHasNts(0) if( nObj ) {=20 nObj.style.display=3D"" parent.SetHasNts(1) } return 1 } function ChkAutoAdv() { if(SldHasTrans()) SlideObj.onfilterchange=3DAutoAdv else AutoAdv() } function AutoAdv() { if(!IsWin("PPTSld") || !gUseSldTimings )return var sld=3DGetCurSld() if( (sld.mAdvDelay>0) && !parent.IsFramesMode() ) setTimeout("parent.GoToNextSld()",sld.mAdvDelay) } function GetObj(id) { if(g_supportsPPTHTML) return document.all(id); else return document.getElementById(id); } function SldHasTrans() { return SlideObj.style.filter !=3D ""; } function GetSldId() { return sId=3Dlocation.href.substring(location.href.la= stIndexOf('/')+1) } function HideMenu() { if( frames["PPTSld"] && PPTSld.document.all.item("ctx= tmenu") && PPTSld.ctxtmenu.style.display!=3D"none" ) { PPTSld.ctxtmenu.styl= e.display=3D'none'; return true } return false } function IsWin( name ) { return window.name =3D=3D name } function IsNts() { return IsWin("PPTNts") } function IsSldOrNts() { return( IsWin("PPTSld")||IsWin("PPTNts") ) } function SupportsPPTAnimation() { return( navigator.platform =3D=3D "Win32"= && navigator.appVersion.indexOf("Windows")>0 ) } function SupportsPPTHTML() { var appVer=3Dnavigator.appVersion, msie=3DappVer.indexOf("MSIE "), ver=3D0 if( msie >=3D 0 ) ver=3DparseFloat( appVer.substring( msie+5, appVer.indexOf(";",msie) ) ) else ver=3DparseInt(appVer) return( ver >=3D 4 && msie >=3D 0 ) } function _RSW() { if( !g_supportsPPTHTML || IsNts() || ( !g_scaleInFrame && (!IsWin("PPTSld") || !parent.IsFullScrMode()) ) ) return var padding=3D0; if( IsWin("PPTSld") && parent.IsFramesMode() ) padding=3D6 cltWidth=3Ddocument.body.clientWidth-padding cltHeight=3Ddocument.body.clientHeight-padding factor=3D(1.0*cltWidth)/g_origW if( cltHeight < g_origH*factor ) factor=3D(1.0*cltHeight)/g_origH newSize =3D g_origSz * factor if( newSize < 1 ) newSize=3D1 s=3DSlideObj.style s.fontSize=3DnewSize+"px" s.posWidth=3Dg_origW*factor s.posHeight=3Dg_origH*factor s.posLeft=3D(cltWidth-s.posWidth+padding)/2 s.posTop=3D(cltHeight-s.posHeight+padding)/2 if( g_scaleHyperlinks ) ScaleHyperlinks( factor ) } function _InitAnimations() { animRuntimeInstalled =3D ''+document.body.localTime !=3D 'undefined'; isFullScreen =3D (window.name =3D=3D "PPTSld") && !parent.IsFramesMode(); g_animUseRuntime =3D g_showAnimation && animRuntimeInstalled && !(isFullSc= reen && parent.IsSldVisited()); if( g_animUseRuntime ) { collSeq =3D document.all.tags("seq"); if( collSeq !=3D null ) { for(ii=3D0;ii numSlds ) gSldJumpIdx =3D numSlds; if ( gSldJumpIdx >=3D 0 ) { if ( gSldJumpIdx =3D=3D 0 ) gSldJumpIdx =3D 1; var jumpTo =3D parseInt(gSldJumpIdx); gSldJump =3D 0; gSldJumpIdx =3D ""; win.GoToSld( parent.GetSldList().mList[jumpTo-1].mSldHref ) } } } function _KDH() { if( event.keyCode =3D=3D 8 ) { event.returnValue =3D 0; parent.GoToPrevSld(); } } function DocumentOnClick() { if( IsNts() || parent.HideMenu() ) return; if( ( g_allowAdvOnClick && !parent.IsFramesMode() ) || (event && (event.keyCode=3D=3D32) ) ) parent.GoToNextSld(); } var g_supportsPPTHTML =3D SupportsPPTHTML(), g_scaleInFrame =3D 1, gId=3D""= , g_bgSound=3D"", g_scaleHyperlinks =3D false, g_allowAdvOnClick =3D 1, g_showInBrowser = =3D 0, gLoopCont =3D 0, gUseSldTimings =3D 1; var g_showAnimation =3D g_supportsPPTHTML && SupportsPPTAnimation() && ( (w= indow.name=3D=3D"PPTSld" && !parent.IsFramesMode()) || g_showInBrowser );va= r g_animManager =3D null; var g_animUseRuntime =3D false; var g_animItemsToHide, g_animInteractiveItems, g_animSlideTime; var g_animMainSequence =3D null; var ENDSHOW_MESG=3D"End of slide show, click to exit.", SCREEN_MODE=3D"Fram= es", gIsEndShow=3D0, NUM_VIS_SLDS=3D40, SCRIPT_HREF=3D"script.js", FULLSCR_= HREF=3D"fullscreen.htm"; var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO= tlTxtExp =3D 0, gHasNarration =3D 0, gOtlOpen =3D true window.gPPTHTML=3DSupportsPPTHTML() var gMainDoc=3Dnew Array(new hrefList("slide0001.htm",1,-1,1),new hrefList(= "slide0002.htm",1,-1,1),new hrefList("slide0007.htm",1,-1,1),new hrefList("= slide0009.htm",1,-1,1),new hrefList("slide0010.htm",1,-1,1),new hrefList("s= lide0011.htm",1,-1,1),new hrefList("slide0012.htm",1,-1,1),new hrefList("sl= ide0013.htm",1,-1,1),new hrefList("slide0006.htm",1,-1,1),new hrefList("sli= de0003.htm",1,-1,1),new hrefList("slide0014.htm",1,-1,1),new hrefList("slid= e0015.htm",1,-1,1),new hrefList("slide0016.htm",1,-1,1),new hrefList("slide= 0017.htm",1,-1,1),new hrefList("slide0018.htm",1,-1,1),new hrefList("slide0= 019.htm",1,-1,1),new hrefList("slide0008.htm",1,-1,1),new hrefList("slide00= 78.htm",1,-1,1),new hrefList("slide0064.htm",1,-1,1),new hrefList("slide003= 4.htm",1,-1,1),new hrefList("slide0035.htm",1,-1,1),new hrefList("slide0066= .htm",1,-1,1),new hrefList("slide0067.htm",1,-1,1),new hrefList("slide0068.= htm",1,-1,1),new hrefList("slide0025.htm",1,-1,1),new hrefList("slide0026.h= tm",1,-1,1),new hrefList("slide0030.htm",1,-1,1),new hrefList("slide0028.ht= m",1,-1,1),new hrefList("slide0069.htm",1,-1,1),new hrefList("slide0029.htm= ",1,-1,1),new hrefList("slide0048.htm",1,-1,1),new hrefList("slide0049.htm"= ,1,-1,1),new hrefList("slide0070.htm",1,-1,1),new hrefList("slide0071.htm",= 1,-1,1),new hrefList("slide0072.htm",1,-1,1),new hrefList("slide0076.htm",1= ,-1,1),new hrefList("slide0077.htm",1,-1,1),new hrefList("slide0074.htm",1,= -1,1),new hrefList("slide0075.htm",1,-1,1),new hrefList("slide0050.htm",1,-= 1,1)); /********************************************* Frameset functions These functions control slide navigation and state of the frameset. **********************************************/ function FullScrInit() { g_allowAdvOnClick =3D GetCurSld().mAdvOnClk document.body.style.backgroundColor=3D"black" document.oncontextmenu=3Dparent._CM; document.onkeydown =3D _KDH; document.ondragstart=3DCancel document.onselectstart=3DCancel self.focus() } function Redirect( frmId ) {=09 var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId() if(idx>=3D0) str=3Dstr.substr(1); if( window.name !=3D frmId && ( sId !=3D str) ) { obj =3D GetObj("Main-File") window.location.href=3Dobj.href+"#"+sId return 1 } return 0 } var MHTMLPrefix =3D CalculateMHTMLPrefix();=20 function CalculateMHTMLPrefix() { if ( document.location.protocol =3D=3D 'mhtml:') {=20 href=3Dnew String(document.location.href)=20 Start=3Dhref.indexOf('!')+1=20 End=3Dhref.lastIndexOf('/')+1=20 if (End < Start)=20 return href.substring(0, Start)=20 else=20 return href.substring(0, End)=20 } return ''; } function GetTags(base,tag) { if(g_supportsPPTHTML) return base.all.tags(tag); else return base.getElementsByTagName(tag); } function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP= refix+GetHrefObj( gCurSld ).mNtsHref ) } function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() } function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() } function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() } function SetHasNts( fVal ) { if( gHasNts !=3D fVal ) { gHasNts=3DfVal UpdNavPane() } } function ToggleOtlText() { gOtlTxtExp=3D!gOtlTxtExp UpdOtlPane() } function ClearMedia() { // Clear any sounds playing before launching another browser window. Other= wise, // in fullscreen mode, you'll continue to hear the sound in the frames mod= e. if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0; } function FullScreen() {=20 if ( PPTSld.g_animUseRuntime ) PPTSld.document.body.pause(); ClearMedia(); var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF = : FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref; if(PPTNav.event.ctrlKey) { var w =3D (window.screen.availWidth * 1.0) / 2.0 var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top= =3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } else { win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } } function ToggleVNarration() { rObj=3DPPTSld.document.all("NSPlay") if( rObj && !PPTSld.g_animUseRuntime ) { if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) ) rObj.Play() else if( rObj.playState =3D=3D 2 ) rObj.Pause() else return; } else if( PPTSld.g_animUseRuntime ) { narObj =3D PPTSld.document.all("narrationID") if( narObj ) narObj.togglePause() } } function GetCurSldNum() { =20 obj=3DGetHrefObj(gCurSld) if( obj.mOrigVis =3D=3D 1 ) return obj.mSldIdx else =20 return gCurSld } function GetNumSlds() { =20 if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 ) return GetSldList().mNumVisSlds; else return GetSldList().mList.length } function GetSldNum( href ) { for(ii=3D0; ii 1 ) PopSldList(); else if( !IsFramesMode() ) { if( gLoopCont ) GoToFirst() else EndShow() } } function GoToPrevSld() { ii=3DgCurSld-1 if( ii > 0 ) { obj=3DGetHrefObj(ii) while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) ) obj=3DGetHrefObj(--ii) if( ii =3D=3D 0 ) ii=3D1 GoToSldNum(ii) } } function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) } function GoToLast() { ii=3DGetSldList().mList.length if( ii !=3D gCurSld ) GoToSld( GetHrefObj(ii).mSldHref ) } function GoToSldNum( num ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue obj =3D GetHrefObj( num ) obj.mVis=3D1 gPrevSld=3DgCurSld gCurSld =3D num; PPTSld.location.replace(MHTMLPrefix+obj.mSldHref) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function GoToSld( href ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue GetHrefObj( GetSldNum(href) ).mVis=3D1 PPTSld.location.replace(MHTMLPrefix+href) } function SldUpdated( id ) { if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return gPrevSld=3DgCurSld gCurSld=3DGetSldNum(id) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) } function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO= bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) } function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) } function CloseWindow() { if( HideMenu() ) return; =09 var event =3D PPTSld.event; if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D= =3D32 || event.type=3D=3D"click" ) ) window.close( self ); CatchNumKeys( self, event ); } function Unload() { gIsEndShow=3D0; } function SetupEndShow() { gIsEndShow=3D1; PPTSld.document.body.scroll=3D"no"; PPTSld.document.onkeypress=3DCloseWindow; PPTSld.document.onclick=3DCloseWindow; PPTSld.document.oncontextmenu=3D_CM; } function EndShow() { if( IsFramesMode() ) return if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue doc=3DPPTSld.document var dir =3D doc.body.dir if( dir !=3D "rtl" ) dir =3D "ltr"; doc.open() doc.writeln('


' + ENDSHOW_MESG + '

') doc.close() } function SetSldVisited(){ GetSldList().mList[gCurSld-1].mVisited=3Dtrue } function IsSldVisited(){ return GetSldList().mList[gCurSld-1].mVisited } function hrefList( sldHref, visible, advDelay, advClk ) { this.mSldHref=3D this.mNtsHref =3D sldHref this.mOrigVis=3D this.mVis =3D visible this.mVisited=3D false this.mAdvDelay=3D advDelay this.mAdvOnClk=3D advClk } function SldList(arr,curSld,fEnd) { this.mCurSld =3D curSld; this.mList =3D new Array(); var idx =3D 1; for(ii=3D0;ii 0) { PushSldList(sldList,fEnd); gCurSld =3D 1; } else if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue } function PushSldList(arr,fEnd) { var ii =3D gSldStack.length; gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd); GoToSld( gSldStack[ii].mList[0].mSldHref ); } function PopSldList() { if (gSldStack[gSldStack.length-1].fEndShow) EndShow() else { gCurSld =3D gSldStack[gSldStack.length-1].mCurSld; gSldStack[gSldStack.length-1] =3D null; gSldStack.length--; var sldList =3D gSldStack[gSldStack.length-1]; GoToSld( sldList.mList[gCurSld - 1].mSldHref ); } } var custShowList=3Dnew Array(); /********************************************* Navigation button implementation There are 2 types of buttons: ImgBtn, TxtBtn implemented as function objects. They share a similiar interface so the event handlers can call SetActive, for example, on a button=20 object without needing to know exactly=20 what type of button it is. **********************************************/ //---------------------------------- function ImgBtn( oId,bId,w,action ) //---------------------------------- { var t=3Dthis t.Perform =3D _IBP t.SetActive =3D _IBSetA t.SetInactive=3D _IBSetI t.SetPressed =3D _IBSetP t.SetDisabled=3D _IBSetD t.Enabled =3D _IBSetE t.ChangeIcon =3D null t.UserAction =3D action t.ChgState =3D _IBUI t.mObjId =3D oId t.mBorderId=3D bId t.mWidth =3D w t.mIsOn =3D t.mCurState =3D 0 } function _IBSetA() { if( this.mIsOn ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _IBSetI() { if( this.mIsOn ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0=20 } } function _IBSetP() { if( this.mIsOn ) { obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 ) obj.style.posLeft+=3D1; obj.style.posTop+=3D1 } } function _IBSetD() { =20 obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 ) obj.style.posTop=3D0=20 } function _IBSetE( state ) { var t=3Dthis GetObj( t.mBorderId ).style.visibility=3D"visible" if( state !=3D t.mIsOn ) { t.mIsOn=3Dstate if( state ) t.SetInactive() else t.SetDisabled() } } function _IBP() { var t=3Dthis if( t.mIsOn ) { if( t.UserAction !=3D null ) t.UserAction() if( t.ChangeIcon ) { obj=3DGetObj(t.mObjId) if( t.ChangeIcon() ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth else obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth } t.SetActive() } =20 } function _IBUI( clr1,clr2,nextState ) { var t=3Dthis SetBorder( GetObj( t.mBorderId ),clr1,clr2 ) obj=3DGetObj( t.mObjId ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj= .style.posTop t.mCurState=3DnextState return obj } //----------------------------------------- function TxtBtn( oId,oeId,action,chkState ) //----------------------------------------- { var t=3Dthis t.Perform =3D _TBP t.SetActive =3D _TBSetA t.SetInactive=3D _TBSetI t.SetPressed =3D _TBSetP t.SetDisabled=3D _TBSetD t.SetEnabled =3D _TBSetE t.GetState =3D chkState t.UserAction =3D action t.ChgState =3D _TBUI t.mObjId =3D oId t.m_elementsId=3D oeId t.mIsOn =3D 1 } function _TBSetA() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gHiliteClr,gShadowClr,0,0 ) } function _TBSetI() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) } function _TBSetP() { if( this.mIsOn ) this.ChgState( gShadowClr,gHiliteClr,1,1 ) } function _TBSetD() { =20 this.ChgState( gFaceClr,gFaceClr,0,0 ) this.mIsOn =3D 0 } function _TBSetE() { var t=3Dthis if( !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) else t.ChgState( gShadowClr,gHiliteClr,1,1 ) t.mIsOn =3D 1 } function _TBP() { var t=3Dthis if( t.mIsOn ) {=20 if( t.UserAction !=3D null ) t.UserAction() if( !t.GetState ) return if( t.GetState() ) t.SetPressed() else t.SetActive() } =20 } function _TBUI( clr1,clr2,lOffset,tOffset ) { SetBorder( GetObj( this.mObjId ),clr1,clr2 ) Offset( GetObj( this.m_elementsId ),lOffset,tOffset ) } function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle= ft } function SetBorder( obj, upperLeft, lowerRight ) { s=3Dobj.style; s.borderStyle =3D "solid" s.borderWidth =3D 1=20 s.borderLeftColor =3D s.borderTopColor =3D upperLeft s.borderBottomColor=3D s.borderRightColor =3D lowerRight } function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] } function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() } function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() } function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() } function BtnOnUp() { b=3DGetBtnObj() if( b !=3D null ) b.Perform() else Upd() } function GetNtsState(){ return parent.gNtsOpen } function GetOtlState(){ return parent.gOtlOpen } function GetOtlTxtState(){ return parent.gOtlTxtExp } function NtsBtnSetFlag( fVal ) { s=3Ddocument.all.item( this.m_flagId ).style s.display=3D"none" if( fVal ) s.display=3D"" else s.display=3D"none" } function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etActive() } function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etInactive() } function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etPressed() } function _BSetA_BorderImg() {=20 b =3D gBtnArr[this.mBorderId]=20 if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _BSetI_BorderImg() {=20 b =3D gBtnArr[this.mBorderId] if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0 } } var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"= THREEDFACE" var gBtnArr =3D new Array() gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan= e,GetOtlState ) gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt= lPane,GetOtlState ) gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN= tsPane ) gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg; gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg; gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.= ToggleNtsPane,GetNtsState ) gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To= ggleNtsPane,GetNtsState ) gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n= b_prevBorder",30,parent.GoToPrevSld ) gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n= b_nextBorder",30,parent.GoToNextSld ) gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent= .FullScreen ) gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa= rent.FullScreen,null ) gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border; gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent= .FullScreen,null ) gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border; gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice= ","nb_voiceBorder",18,parent.ToggleVNarration ) gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT= xt","nb_otlTxtBorder",23,parent.ToggleOtlText ) gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts" gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState /********************************************* Context menu implementation _CM() is the function that's hooked up to the oncontextmenu event. Once we're asked to show the menu, we first build it by creating DIVs on-the-fly. Then we position it=20 within the screen area so it doesn't get clipped. 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window.event.returnVa= lue=3Dfalse } function Highlight() { ChangeClr("activecaption","threedhighlight") } function Deselect() { ChangeClr("threedface","menutext") } function Perform() { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) e.Action() else PPTSld.event.cancelBubble=3Dtrue } function ChangeClr( bg,clr ) { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) { e.style.backgroundColor=3Dbg e.style.color=3Dclr } } function M_HasPrevSld() { return( parent.HasPrevSld() ) } function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() } function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();= PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() } function M_True() { return true } function M_End() { window.close( self ) } function CreateMenuItem( node,text,action,eval ) { var e=3DCreateItem( node ) e.type=3D"menuitem" e.Action=3Daction e.IsActive=3Deval e.innerHTML=3Dtext if( !e.IsActive() ) e.style.color=3D"threedshadow" e.onclick=3DPerform e.onmouseover=3DHighlight e.onmouseout=3DDeselect s=3De.style; 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charset="windows-1252" Impaired fetal growth - Matthews Mathai ------=_NextPart_01C64E9F.732D8F10 Content-Location: file:///C:/1809C636/Impaired_fetal_growth_Mathai_2006_files/outline.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252"
 No= tes
Slide Show
Outline
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