INTRAUTERINE GROWTH RESTRICTION

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INTRAUTERINE GROWTH RESTRICTION

• By
• DR NOSHABA RAFIQ
• M.B.B.S M.C.P.S F.C.P.S.

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DEFINITION OF IUGR

• Fetus whose estimated weight is
• less than 10th percentile for its gestational
  age.
• Abdominal circumference is less than 2.5th
  percentile.
• Incidence 10 percent of all pregnancies.

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Fetal weight percentiles throughout gestation
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Risk of IUGR Babies

• Still birth 15 fold increase risk
• Intra-partum hypoxia
• Neonatal risk
• Sepsis
• Hypoglycemia
• RDS
• Hypothermia
• Meconium Aspiration
• Haematological disorders
• Seizers in first 24 hours
• Malformations

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contd

• 4. Impaired Neurodevelopment
• Long term neuromotor dysfunction
• Poor school performance
• Deficits in academic achievements
• 5. Complications in Adult Life
• Obesity
• Diabetes Mellitis
• Hypertension
• Cardio-vascular disease

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Classification of IUGR

• Symmetrical growth restriction fetus whose
  entire body is proportionally small.
• Incidence 20
• Asymmetrical growth restriction Decrease in
  subcutaneous fat and abdominal circumference with
  relative sparing of head circumference and femur
  length.
• Incidence 80

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ETIOLOGY

• Maternal Causes of IUGR
• Chronic Illnesses (e.g. cystic fibrosis, CHD,
  renal failure, haemoglobinopathies, APS)
• Nutrition (e.g. anorexia nervosa and bulimia)
• Smoking
• Alcohol
• Drug Abuse (e.g. Cocaine, amphetamines, betal
  chewing)

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contd

• Infections (e.g. vaginal bacteria, specially M.
  hominis, U. urealyticum, T. vaginalis and
  bacteroides group).
• Endocrine disorders (e.g. diabetic nephropathy,
  hyperthyroidism, addisons disease).

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Placental Causes of IUGR

• Uteroplacental insufficiency
• Unexplained
• Preeclampsia
• Elevated maternal AFP
• 2. Fetoplacental insufficiency
• Single Umbilical Artery
• Velamentous insertion of cord
• Placental Haemangioma
• 3. Abnormal Placentation
• Abruptioplacentae
• Placenta Previa
• Placenta Accretia

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Fetal Causes of IUGR

• Normal Small Fetus (Constitutionally small fetus)
• 2. Infection
• CMV
• Toxoplasmosis
• Rubella
• Herpes
• Malaria
• Syphilis

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contd

• 3. Fetal Abnormality
• Chromosomal (Trisomy, 13,18 and 21, deletions or
  tripliody)
• Structural (Gastroschisis, e.g. anencepholy)
• 4. Multiple Gestation

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DIAGNOSIS OF IUGR

• 1. History
• Previous infant with growth restriction
• Decreased fetal movements
• Medical disorders
• Drugs
• Poor nutrition
• Adverse factors, e.g. bleeding
• 2. Clinical Examination
• Poor maternal weight gain
• Fundal height lag
• Reduced amount of liquour
• Clinical assessment of small fetus

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contd

• HC/AC ratio or FL/AC ratio
• Estimated Fetal weight
• 4. Growth Velocity
• Serial measurements of AC or EFT
• 5. Invasive Investigation
• Karyotyping
• Screening for congenital infections

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Doppler Ultrasound

• Umblical Artery
• S/D ratio
• Resistance index
• Pulsatility index
• Middle Cerebral Artery
• Venous Doppler
• Reversal of blood flow in IVC, DV and UV at the
  end of diastole

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MANAGEMENT

• Accurate dating is mandatory
• Symmetric or Asymmetric IUGR
• Assymmetric rule out chromosomal abnormalities
  and congenital infections.
• 3. General Management
• Treat maternal disease
• Stop substance abuse
• Good nutrition
• Bed Rest
• Maternal hyperoxygenation

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ANTENATAL SERVEILLANCE

• Growth scans every 3 weeks
• Daily fetal movement profile
• NST twice weekly
• BPP weekly if NST is abnormal
• Umblical artery Doppler study every 2 to 3 weeks.
  
• Oxytocin challenge test if NST is abnormal or BPP
  is lt8

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DELIVERY CONSIDERATIONS

• Antenatal steroids To promote fetal lung
  maturity if gestational age less than 34 weeks.
• Delivery gt 32 weeks If antenatal test results
  are abnormal.
• Antenatal test results reassuring continue fetal
  surveillance and delivery at term, if fetal
  growth is noted.
• If no fetal growth or severe oligohydramnios
  assess fetal lung maturity. Deliver if lungs are
  mature otherwise, reassess after 1 week.
• Abnormal antenatal test results at less than 32
  weeks of gestation, each case must be considered
  individually.

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LABOR AND DELIVERY

• Continuous fetal monitoring during labor.
• Delivery in hospital, capable of providing
  intensive neonatal care.
• Amnioinfusion non-reassuring fetal response, low
  amniotic fluid index and meconium stained liquor.
• Caesarean Section Detoriating fetal status.

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THANK YOU