Macrosomia and IUGR for undergraduate

1
Macrosomia and Intrauterine Growth
Restriction(IUGR)

• DR Manal Behery
• Zagazig University, 2013

2
Macrosomia
3
Definition

• A fetal weight of more than 4.5 kg at term or
• fetal birth weight gt 90
• percentile for the gestational age..

4
Causes

• Genetic or constitutional
• obese women tend to give
• birth to macrosomic babies.
• Diabetes and prediabetes.
• Post-date (postmaturity).
• Multiparity The first baby is about 100 gm
  smaller than the next.
• Hydrops foetalis.

5
Macrosomia and diabetes

• ¼ th of insulin dependent mothers have Macrosomic
  infants
• Excess growth happens in 3rd trimester.
• GDM mothers have same incidence of Macrosomic
  infants as other diabetics

6
Risk factors

• Excessive maternal weight gain during pregnancy.
  
• Advanced maternal age.
• Male fetus than female.
• Previous macrosomic infant.

7
Diagnosis

• Clinical palpation can give a rough idea.
  Ultrasonography can calculate the fetal weight

8
Hazards

• Prolonged pregnancy
• Cephalopelvic disproportion
• Obstructed labour.
• Shoulder dystocia.
• Meconium aspiration syndrome.
• Nerve and bone injuries.

9
Management

• Proper antenatal care to prevent macrosomia
  and diagnose it before labour commences.
• Cesarean section is the safest for both mother
  and fetus.

10
IUGR
11
Definition !

• IUGR is defined as a fetus that has an estimated
  weight that is less than the 10th percentile for
  its gestational age
• At term, the cutoff birth weight for IUGR is
  2,500 g (5 lb, 8 oz)

12
Growth percentiles for fetal weight versus
gestational age
13
Correlation of birth weight percentile to
perinatal morbdity and mortalility
14
Is small for gestational age (SGA) the same as
IUGR?

• IUGR is used synonymously with small for
  gestational age (SGA) but implies a pathologic
  condition.
• EFW at or below 10th percentile is used to
  identify fetuses at risk
• However a certain number of fetuses at or below
  the 10th percentile just may be constitutionally
  small and not growth restricted
• About one third of all infants weighing less than
  2500 grams at birth have IUGR

15
IUGR VS SGA

• IUGR fetus with birth weight lt10th percentile
  for gestational age due to pathologic process.
• SGA fetus with birth weight lt10th percentile for
  gestational age in the absence of pathologic
  process

16
1. Symmetrical growth restriction

• 20 of IUGR Infants
• proportional decrease in all organs
• HC/AC ratio is normal
• Occurs in early pregnancy Cellular hyperplasia
• Increase risk for long term neurodevelopmental
  dysfunction
• Due to Intrinsic factor
• Chromosomal abnormalities
• Congenital anomalies
• Intrauterine infection

17
2.Asymmetrical growth restriction

• 80 of IUGR Infants
• Increase HC/AC ratio decrease in abdominal
  size
• Brain sparing effects
• Occurs in late pregnancy cellular hypertrophy
• Risk for perinatal hypoxia, neonatal
  hypoglycemia
• Good prognosis
• Due to extrinsic factors Uteroplacental
  insufficiency
• Maternal
  vascular disease hypertension
• Multiple
  gestations
• 
  Placental disease

18
3. Combined type

• Asymmetrical symmetrical
• Symmetrical asymmetrical
• More morbidities and mortalities
• More long term effects

19
Ponderal Index

• Ultrasound criteria for diagnosis of fetal
  malnutrition
• Gestation age independent
• Way of characterizing the relationship of height
  to mass for an individual.
• PI 1000 x
• Typical values are 20 to 25.
• PI is normal in symmetric IUGR.
• PI is low in asymmetric IUGR.

Mass (kgs) Height (cms)
20
Etiology- Overlapping

• ,,

Placental
Maternal
Fetal
21
Fetal causes

• Infection
• CMV, Rubella, Toxoplasma gondii severe IUGR
• Syphilis, Tuberculosis, Malaria, listeriosis
• Herpes simplex, chicken pox
• Chromosomal abnormality
• Trisomy 18,13 severe IUGR
• Trisomy 21
• Turner syndrome (45,XO), Klinefelter syndrome
  (47,XXY)
• Congenital anomalies
• Congenital Heart diseases
• Anencephaly

22
Case 1

• A baby is delivered at 36 WGA via repeat C-
  section
• BW- 2 kg
• HC- lt 10th tile
• Lt- lt 10th tile
• CMV

23
Case 2- What if?
Toxoplasmosis
Rubella
24
Case 3- What if?
Trisomy 18
Turner syndrome
25
Maternal causes

• Maternal malnutrition
• Poor maternal weight gain
• Severe anemia
• Chronic hypoxemia
• Cardiovascular disease
• Drugs and teratogens
• Multiple pregnancy
• Antiphospholipid antibodies syndrome

26
Case 4

• Infant is delivered at 38 weeks to mom who
  presents with headaches and epigastric pain
• BW 2.1 kg
• HC 50thtile
• Lt 30thtile

Pre-eclampsia/ HELLP
27
Case 5- What if?

• Mom with no prenatal care delivers undiagnosed
  twins at EGA 34 weeks

Discordant twins
28
Case 6- What if?

• An infant is delivered at 42 weeks via c- section
  due to NRHTs after induction
• Post dates

- decreased subcutaneous fat - skin
desquamation - wizened facies - large
AF(diminished membranous bone formation) -
meconium staining
29
Placental causes

• Placental infarction
• Placental abruption
• Chorioangioma
• Placenta previa , circumvallate placenta
• Marginal or velamentous insertion of umbilical
  cord

30
Cause

• Fetal causes (intrinsic factors)
• Symmetrical IUGR

• Maternal causes Plcental causes
• (extrinsic factors)
• Asymmetrical IUGR

31
IUGR
Symmetric IUGR Asmmetric IUGR
Small symmetrically. Head is larger than abdomen.
Ponderal index is normal. Ponderal index is low.
Normal head-abdomen ratio. High head-abdomen ratio.
Genetic, infections. Placental vascular insufficiency.
Complicated neonatal course. Benign neonatal course if complications are treated adequately.
32
Diagnosis

• Clinical assessment
• Ultrasonic measurement
• Doppler velocity

33
History for risk factor

• Teen age
• High altitude
• Socioeconomic factor
• Smoking , Alcohol , Drugs
• Previous IUGR pregnancy history
• previous IUGR in family

34
Signs

• Seldom elicited before 28 weeks of gestation
• Failure of fetus and uterus to grow at the normal
  rate over a 4 week period
• Uterine fundal height should be at least 2cm less
  than expected for the length of gestation
• Poor maternal weight gain
• Diminished fetal movements.

35
Physical examination

• Uterine fundal height
• Uterine fundus ? Pubic symphysis
• Simple, Safe, Inexpensive for screening
• Between 18 and 30 weeks,
• the uterine fundal height in centimeters
  coincides with weeks of gestation.
• If the measurement is more than 2 to 3 cm from
  the expected height or lt 1oth percentile from
  normal curve, inappropriate fetal growth may be
  suspected

36
Errors in Fundal Height Estimation

• Inter-observer variations
• Obese patients
• Transverse lie
• Multiple gestation
• Polyhydramnios / Oligohydramnios
• Uterine fibroids

37
Ultrasonic measurement

• Initial U/S at 16 to 20 weeks to establish
  gestational age and identify anomalies and
  repeated at 32 to 34 weeks to evaluate fetal
  growth

38

• Ultrasonography BiometryThe measurements most
  commonly used to measure and follow fetal growth
  are

Biparietal Diameter
Head circumference
Head Circumference
Femur Length
Abdominal Circumference
Clic here
Ratio - Head circumference to the abdominal
circumference (HC/AC) .
39
Amniotic Fluid Index

• Mild IUGR Normal amniotic fluid
• Severe IUGR Oligohydramnios (AFI is 5)
  Incidence 40
• On ultrasonography - a pocket of fluid lt 1cm is
  diagnosed as oligohydramnios.

40

• The amniotic fluid index is obtained by summing
  the largest cord-free vertical pocket in each of
  the four quadrants of an equally divided uterus.

41
Abnormal umbilical artery Doppler velocimetry

• characterized by absent or reversed end-diastolic
  flow
• associated with fetal growth restriction

1. Normal velocimetry pattern with an S/D ratio of
   lt30.
2. The diastolic velocity approaching zero reflects
   increased placental vascular resistance.
3. During diastole, arterial flow is reversed
   (negative S/D ratio), which is an ominous sign
   that may precede fetal demise

42
(No Transcript)
43
An IUGR infant is at risk for

• Hypothermia?
• Hypoglycemia?
• Or
• Hypocalcemia?

• decreased subcutaneous fat, increased surface-
  volume ratio, decreased heat production
• decreased glycogen stores/ glycogenolysis/
  gluconeogenesis
• increased metabolic rate
• deficient catecholamine release
• Associated with perinatal stress, asphyxia,
  prematurity

44
Management

• Prepregnancy to prevent it by identifying risk
  factors and treat as necessary (e.g. improve
  nutrition intake, stop smoking or alcohol, ASA in
  APA syndrome, and Heparin in thrombophilias)
• Antepartum identify risk factors that can be
  changed. Fetal surveillance by ultrasound (BPP)
  and fetal heart monitoring (Non-Stress Test). To
  decide on timing and mode of delivery.

45
Growth restriction near term

• Prompt delivery
• Recommend delivery at 34 weeks or beyond if there
  is clinically significant oligohydramnios

46
Growth restriction remote from term

• No specific treatment
• If diagnosed in prior to 34 weeks, and amnionic
  fluid volume and fetal surveillance are normal
• ? Observation is recommended
• screening for toxoplasmosis,herpes,rubella,CMV
  and others
• ? Specific treatment(causes of IUGR) and
  supportive care
• If severe IUGR or bad obstetric conditions
• ? Terminate pregnancy should be considered

47
IUGR- Outcome

• Neurodevelopment
• etiology and adverse event dependent
• lower intelligence, learning/ behavioral
  disorders, neurologic handicaps
• symmetric, chromosomal disorders, congenital
  infections--- poorer outcome
• school performance influenced by social class

48
Case study
49
Case

• SW a16 years old G1 P00 presented early for
  prenatal care
• PMH None
• PSH None
• Allergies None
• Medications Prenatal vitamins
• Social Hx Tobacco 1ppd x gt 5 years, No illicit
  drug use
• B average in high school and good support system
• Lives in Denver, HIGH ALTITUDE
• Poor nutrition

50

• She followed up regularly and had an
  uncomplicated 1st trimester..
• At 18 weeks fundal height measured 17 cm
• At 22 weeks fundal height measured 20 cm
• At 24 weeks fundal height measured 21 cm
• At this point I am worried about IUGR with this
  sluggish growth.
• Although we do not use fundal height to diagnose
  IUGR, it can be a clue to a developing problem.

• A fundal height that lags by more than 3 cm or is
  increasing in disparity with the gestational age
  may signal IUGR.
• A lag of 4 cm or more certainly suggests growth
  restriction.
• The size of the uterus should be assessed at
  each prenatal visit.

51

• So now we have increasing concern over her poor
  fundal height. What other risk factors for IUGR
  does AMY have?

A) Teen B) Poor nutrition C) Poor abdominal girth
growth D) High altitude E) Smoker F)All of the
above ANSWER F
52
Maternal weight Gain

• Decreased maternal weight gain is a relatively
  insensitive sign of IUGR baby

53
Risk Factors of IUGR

• With all these risk factors, poor weight gain,
  and an inadequate fundal height
• What would you do to further evaluate for
  potential IUGR?
• 1)Consult OB now
• 2) Get an ultrasound
• 3) Do an NST
• 4) Continue to watch one more week
• ANSWER 2

54
The result of 32 wks US

• Commentsa single intrauterine pregnancy. No
  obvious fetal anatomic abnormalities were seen.
  Not all malformations of the above mentioned
  organ systems can be detected by ultrasound.
• There is an overall growth lag of two weeks, with
  the head and abdomen lagging three weeks.
• Amniotic fluid is lower limits of normal
  measuring 8.5 cm . S/D ratio is slightly
  elevated. She declined amniocentesis.Recommend
  follow up growth in three weeks. This appointment
  was scheduled today

55
History of Present Illness

• That was her ultrasound at 24 weeks. You repeat
  it at 27 weeks 3 week growth lag and AFI 8.5
• Repeat US at 30 weeks normal growth since last
  US 15 day lag AFI 10.5
• Repeat US at 32 weeks EFW 9 AFI 5.9

Is this IUGR? What do you do now?
56
She has an overall 3 week lag and an EGW 12 at
32 weeks. Is this IUGR?

• A) Yes ,any growth lag is IUGR
• B)Yes any EFWltl15 is IUGR
• C)No ,too early to diagnose IUGR
• D) No, IUGR is EGW overall lag 4 weeks

ANSWER C
57
IUGR is usually not detectable before 32-34
weeks (maximal fetal growth). But it must be
suspected earlier
Signs rarely occur before 28 weeks of gestation
58
What is Intrauterine Growth Restriction (IUGR)?

• A fetus with IUGR often has an estimated fetal
  weight associated with which of the following?
• A) Abdominal circumference is below 5th
  percentile
• B) Abdominal circumference is below the 2.5th
  percentile
• C) Less than the 5th percentile for its
  gestational age
• D) Less than the 10th percentile for its
  gestational age
• ANSWER D

59

• What is one of the pathologic Maternal/Placental
  causes for IUGR?

• Gestational Diabetes
• Hypertension
• Obesity
• Hyperemesis Gravidarum
• ANSWER B

60
Which of the following is not a pathologic FETAL
cause for IUGR?
B)Cleft lip/palate
A)Trisomy 21
D)CMV infection
C)Congenital heart disease
ANSWER B
61
Does SW have symmetrical or asymmetrical IUGR?
A)Asymmetrical
B) Symmetrical
Answer B
62
Comments of the ultrasound at 32 weeks. It
reads

• A complete detailed scan of a single intrauterine
  pregnancy was performed. Noobvious fetal
  anatomic abnormalities were seen. Not all
  malformations of theabove mentioned organ
  systems can be detected by ultrasound. There is
  an overallgrowth lag of two weeks, with the head
  and abdomen lagging three weeks. Amnioticfluid
  is lower limits of normal measuring 5.9 cm . S/D
  ratio is slightlyelevated.

63
How else can IUGR be diagnosed in addition to a
lt10 weight for gestational age?

• A) US
• B) Inadequate Maternal Weight gain
• C) Non-reassuring NST
• D) Fundal Height

ANSWER A
64
So SW has had a 32 wk US with EFW 10 and AFI
6.9. What is your next step?
B)No further US needed
A)Repeat US in 8 weeks
ANS C
C)Repeat US in 4 weeks
D)Transfer to OB
65
Yes! Correct Answer Repeat US in 3-4 weeks

• Repeat US at 35 weeks
• Comments
• A repeat ultrasound of this single intrauterine
  pregnancy was performed. EFW is in the less than
  10th percentile in growth.
• Amniotic fluid is within normal limits for this
  gestation.
• Umbilical artery dopplers performed and S/D
  ratio is
• normal.
• Recommendations include
• 1. follow up ultrasound in 1 week for AFI and
  dopplers
• 2. follow-up ultrasound in 2 weeks for growth
• 3. NST testing twice weekly.

66
SW is in your office to review the results. You
explain the results and schedule her for an
ultrasound next week and the week after. Any
other advice for her?
Click for advice
1. Rest as much as possible- she does not work
and is out of school.
2. Perform daily kick counts.
3. She will need weekly visits with biweekly
NSTs.
She asks you Why so many ultrasounds? What do
you tell her?
67

• You tell herUltrasound measurement of the
  fetus is the gold standard for assessing fetal
  growth.
• AND
• We need to follow the amount of fluid around the
  baby as well. If it is too low, we will need to
  deliver your baby early.

Click here.
Click here next
68
When should we (Family Practice) Transfer care to
the Obstetricians?

• A)Whenever you are unsure or uncomfortable with
  the situation
• B)Definite need for C-Section
• C)Worsening fetal status
• D)Severe/worsening Maternal Disease
• E)Unsure of IUGR etiology
• F)All of the above

Answer F
69
Which of the following may we see after the birth
of a baby with IUGR?

• Decreased oxygen levels
• Meconium aspiration
• Hypoglycemia
• Difficulty maintaining normal body temperature
• Polycythemia
• Stillbirth
• All of the Above

ANSWER G
70
Case Close

• SW remained on the family practice service
  because she remained stable and her biweekly BPP
  and NST were reassuring.
• In the 36th week, she was found to have
  oligohydramnios by US ? AFI 3.2 along with IUGR
  EFW lt 10
• Pt was at this time transferred to OB for care.
• She was already known to them because we
  consulted them at the first signs of IUGR.
• Amniocentesis was done to ensure fetal lung
  maturity and she was induced soon there after.
• Patient vaginally delivered a baby with Downs
  Syndrome
• No other complications at birth

71
Thank you