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    Intrauterine Growth Restriction

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    rajaeas
    This document discusses intrauterine growth restriction (IUGR). [1] It defines IUGR as birth weight below the 10th percentile for gestational age. [2] It classifies IUGR into symmetrical and asymmetrical types based on timing of insult. Symmetrical IUGR involves all organs and has a worse prognosis, while asymmetrical IUGR spares the brain and has better prognosis. [3] Causes include placental, maternal, fetal, and unknown factors. Diagnosis involves ultrasound and Doppler assessments of fetal size and blood flow. Complications include immediate risks like hypoglycemia as well as long term risks. Management aims to support fetal growth and optimize delivery timing based on surveillance.

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    Intrauterine Growth Restriction

    Uploaded by

    rajaeas
    42 views26 pages
    This document discusses intrauterine growth restriction (IUGR). [1] It defines IUGR as birth weight below the 10th percentile for gestational age. [2] It classifies IUGR into symmetrical and asymmetrical types based on timing of insult. Symmetrical IUGR involves all organs and has a worse prognosis, while asymmetrical IUGR spares the brain and has better prognosis. [3] Causes include placental, maternal, fetal, and unknown factors. Diagnosis involves ultrasound and Doppler assessments of fetal size and blood flow. Complications include immediate risks like hypoglycemia as well as long term risks. Management aims to support fetal growth and optimize delivery timing based on surveillance.

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    This document discusses intrauterine growth restriction (IUGR). [1] It defines IUGR as birth weight below the 10th percentile for gestational age. [2] It classifies IUGR into symmetrical and asymmetrical types based on timing of insult. Symmetrical IUGR involves all organs and has a worse prognosis, while asymmetrical IUGR spares the brain and has better prognosis. [3] Causes include placental, maternal, fetal, and unknown factors. Diagnosis involves ultrasound and Doppler assessments of fetal size and blood flow. Complications include immediate risks like hypoglycemia as well as long term risks. Management aims to support fetal growth and optimize delivery timing based on surveillance.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    42 views26 pages

    Intrauterine Growth Restriction

    Uploaded by

    rajaeas
    This document discusses intrauterine growth restriction (IUGR). [1] It defines IUGR as birth weight below the 10th percentile for gestational age. [2] It classifies IUGR into symmetrical and asymmetrical types based on timing of insult. Symmetrical IUGR involves all organs and has a worse prognosis, while asymmetrical IUGR spares the brain and has better prognosis. [3] Causes include placental, maternal, fetal, and unknown factors. Diagnosis involves ultrasound and Doppler assessments of fetal size and blood flow. Complications include immediate risks like hypoglycemia as well as long term risks. Management aims to support fetal growth and optimize delivery timing based on surveillance.

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    INTRAUTERINE GROWTH

    RESTRICTION
    Synopsis

    • Definition
    • Incidence
    • Classification of IUGR
    • Etiology
    • Pathophysiology
    • Diagnosis
    • Complications
    • Management
    DEFINITION

    Fetal growth restriction (FGR) is present when birth weight is below


    the 10th precentile of the average for the gestational age or birth
    weight less than 2 SD.
    INCIDENCE

    • FGR comprises about ⅓rd of LBW babies.


    • Incidence among term babies: 2-8%
    • Incidence among post term babies: 15%
    CLASSIFICATION

    Symmetrical IUGR: a.k.a Type 1 IUGR


    • Insult early in pregnancy in the phase of cellular hyperplasia
    • Total cell number is less.
    • Most common cause : structural or chromosomal abnormalities or
    congenital infections (TORCH)
    • Pathological process is intrinsic , so it involves all organs including head.
    • Reduced Abdominal circumference, Head circumference, BPD, Femur
    length and weight
    • Has a bad prognosis
    CLASSIFICATION

    Asymmetrical IUGR a.k.a Type 2 IUGR


    • Occurs late in pregnancy, usually 32-34 wks ( during stage of Cellular hypertrophy)
    • Reduction in size of cells (number of cells are normal)
    • Most commonly due to maternal diseases extrinsic to the fetus.
    • Alteration in fetal size is due to reduced uteroplacental blood flow or reduction in
    nutrient and oxygen transfer to baby or due to reduction in placental size
    • Has a brain sparing effect. (HC, BPD are normal)
    • Abdominal circumference and weight is reduced
    • Femur length and crown rump length is normal
    • Has a better prognosis
    DIFFERENCES B/W TYPE 1 AND 2 IUGR
    DIFFERENCES B/W EARLY & LATE ONSET IUGR
    ETIOLOGY

    Maternal Causes
    • Constitutional:
    • Small woman
    • Slim, Low BMI
    1. Maternal genetic and racial predisposition.
    • Maternal undernutrition
    • Maternal diseases:
    1. Anemia
    2. PIH
    3. Chronic renal disease
    4. Heart disease ( NYHA class 3/4)
    5. Connective tissue diseases
    6. Thrombotic diseases
    7. Diabetes with vasculopathy or PIH.
    • Toxins: like alcohol, smoking, cocaine, heroin, drugs
    ETIOLOGY

    Fetal causes:
    Structural anomalies
    • Chromosomal anomalies: like triploidy, aneuploidy or trisomies.
    Common anomalies- Trisomy 13, 18, 21 and Turner’s syndrome
    Infection: like TORCH agents or Malaria
    • Multiple gestation – due to mechanical hinderance to growth and excessive fetal demands.
    Placental causes:
    • Placental insufficiency
    • Abnormal placentation: like placenta previa, abruption, circumvallate placenta, infaction and
    mosaicism
    • Calcifications.
    Unknown: The cause for IUGR remains unknown in about 40% of cases
    PATHOPHYSIOLOGY

    • Reduced availablity of nutrients to the fetus.


    • Reduced utilisation of nutrients by the fetus.
    • Depending of the time of insult, brain cell size or cell number is
    reduced.
    • Liver glycogen is reduced
    • Oligohydramnios present due to reduced contribution to amniotic
    fluid by kidneys and lungs, because of reduced blood flow.
    • Increased risk of hypoxia and acidosis which may lead to IUD.
    DIAGNOSIS

    It is first mandatory to find the correct gestational age

    PREDICTIVE FACTORS:
    • Maternal risk factors.
    • Reduced BMI
    • Less weight gain during pregnancy
    • Low level of 1st trimester PAPP-1 value
    • Abnormal uterine artery Doppler value (notching) at 20-24 wks
    • Fetal echogenic bowel on USG
    DIAGNOSIS

    CLINICAL FEATURES
    • Lag in symphysiofundal height of 3 or more cm on serial measurement.
    • Maternal weight gain remains stationary or at times falls during the 2nd
    half of pregnancy
    • Abdominal girth values remains stationary or falls on serial measurement.
    DIAGNOSIS

    ULTRASOUND FINDINGS:
    • HC/AC ratio:
    • Normally, as pregnancy advances AC (abdominal circumference) increases ,
    so HC/AC value decreases
    • In asymmetric IUGR, AC value reduces and so HC/AC value increases
    • In symmetry IUGR, both HC( head circumference) and AC value is reduced ,
    so HC/AC value remains normal.
    • FL/AC ratio:
    • Femur length(FL)/ AC ratio normally is 22 from 21 wks to term.
    • FL is normal in asymmetric IUGR , AC is reduced, so FL/AC is increased
    (>23.5)
    • Amniotic fluid Volume:
    • Single deepest vertical pocket (SDVP) <1cm suggests IUGR
    • Amniotic fluid index (AFI) <5 indicates oligohydramnios
    DIAGNOSIS

    ULTRASOUND DOPPLER PARAMETERS:


    • Uterine artery: Presence of diastolic notch- suggests incomplete invastion
    of trophoblasts to spiral arteries. Also predicts preeclampsia
    • Umbilical artery:
    • Reduced end diastolic velocity
    • Absent or reversed end diastolic flow
    • Increased S/D ratio (systolic/ diastolic ratio)
    DIAGNOSIS

    ULTRASOUND DOPPLER PARAMETERS:


    • Middle cerebral artery Doppler: Reduced S/D ratio ( increased diastolic
    flow)
    DIAGNOSIS

    ULTRASOUND DOPPLER PARAMETERS:


    • Ductus venosus Doppler: Shows reduced flow in ductus venosus

    Normal wave form:


    DIAGNOSIS

    Abnormal ductus venosus wave forms:


    1. Reduced flow in atrial systole:

    2. Reversal of blood flow in atrial systole:

    3. Reversal of blood flow in atrial systole and ventricular diastole:


    COMPLICATIONS

    IMMEDIATE:
    Asphyxia, bronchopulmonary dysplasia, RDS
    • Hypoglycemia due to low liver glycogen
    • Meconium aspiration syndrome
    • Microcoagulation leading to DIC
    • Hypothermia
    • Pulmonary hemorrhage
    • Polycythemia, Anemia, thrombocytopenia
    • Hyperviscosity/ thrombosis
    • Necrotising enterocolitis
    • Intraventricular hemorrhage
    • Electrolyte abnormalities ( low Calcium and potassium, high phosphate)
    • Multiorgan failure
    • Increased perinatal mortality and morbidity
    COMPLICATIONS
    LATE:
    • Neurological retardation, intellectual disabilities
    • Increased risk of metabolic syndrome in adult life
    • Altered orexigenic mechanisms leading to increased appetite and reduced
    satiety
    • Low number of nephrons- causing renal vascular hypertension

    Asymmetric IUGR- old man look


    MANAGEMENT

    • Constitutionally small fetus: no intervention


    • Symmetrical FGR: look for the cause ( no effective therapy in majority of cases)
    • Regular fetal well being should be assessed.
    • Baby should be preferably placed in a NICU after birth.
    • Same protocol conducted in management of preterm babies to be followed after birth.

    GENERAL:
    • Adequate bedrest in left lateral position
    • Correct malnutrition- 300 extra kcal to be taken
    • Appropriate therapy for the cause of FGR
    • Avoid tobacco, alcohol.
    • Maternal hyperoxygenation- 2.5L/min
    • Low dose aspirin (50mg daily) if h/o thrombosis, hypertension, or recurrent IUGR present.
    • Maternal volume expansion to improve placental prefusion.
    MANAGEMENT

    ANTEPARTUM EVALUATION:
    USG: every 3-4 wks to assess BPD, HC, AC, fetal weight, AFI
    • Fetal well being: kick count, NST, biophysical profile.
    • Doppler ultrasound parameters
    MANAGEMENT

    TIMING OF DELIVERY:
    Optimum time for delivering: 34-37 wks
    • Pregnancy > 37wks: Delivery should be done
    • Pregnancy <37 wks:
    • Uncomplicated/ mild IUGR: Pregnancy continued till 37 wks , then delivery done
    • Severe IUGR: delivery planned based on fetal surveillance reports.
    • Delivery done if lung maturity achieved (L:S ratio >= 2)
    • If lung maturity not achieved, betamethasone given if <34 wks
    • If delivery should be done before 32 wks, magnesium sulphate given to mother for fetal
    neuroprotection
    • Fetus with aneuploidy or cong. Infections have poor outcome irrespective of gestational
    age and time of delivery.
    MANAGEMENT

    METHODS OF DELIVERY:
    • Low rupture of membranes followed by oxytocin is done when
    pregnancy is beyond 34 wks with favourable cervix and head deep in
    pelvis. PGE2 can be given if cervix not favourable.
    • Intrapartum monitoring by clinical and blood sampling necessary to
    detect Intrapartum asphyxia.
    • Cesarean delivery without trial of labour done when risk of vaginal
    delivery is more.
    MANAGEMENT PROTOCOL FOR FGR
    THANK YOU

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