IUGR & IUFD

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IUGR IUFD

• DR. SALWA NEYAZI
• CONSULTANT OBSTETRICIAN GYNECOLOGIST
• PEDIATRIC ADOLESCENT GYNECOLOGIST

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IUGR
What is the definition of IUGR?

• lt 10th centile for age ? include normal fetuses
  at the lower ends of the growth curve fetuses
  with IUGR
• This definition is not helpful clinically
• lt 5th centile for age ?
• lt 3rd centile for age ?the most appropriate
  definition but associated with adverse perinatal
  outcome

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What is the deference between IUGR SGA?
SGA ? lt 10th centile for the population, which
means it is at the lower end of the normal
distribution ie. Constitutionally small but have
reached their full growth potential IUGR
?Failure of the fetus to chieve the expected
weight for a given gestation
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What are the causes of IUGR?

• Maternal medical conditions
• Chromosomal anomalies aneuploidy
• Genetic Structural anomalies
• Exposure to drugs toxins

• 1ry placental disease
• Extremes of maternal age
• Low socioeconomic status
• Infections
• Multiple gestation

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Which maternal medical conditions result in IUGR?

• HPT
• PET
• DM with vascular involvement
• SLE
• Anemia
• Sickle cell disease
• Antiphospholipid syndrome
• Renal disease
• Malnutrition
• Inflammatory bowel disease
• Intestinal parasites
• Cyanotic pulmonary disease

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How does the placenta play a role in the
development of IUGR?

• Abnormalities in placental development
  trophoblast
• invasion ?Idiopathic or due to maternal
  disease eg
• SLE, PET, DM, HPT
• Chronic partial abruption
• Placental infarcts
• Placenta previa
• Chorioangioma
• Circumvallate placenta
• Placental mosaicism
• Twin to twin transfusion Syndrome

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What infections result in IUGR?
5-10 of IUGR

• Congenital infections
• CMV
• Rubella
• Herpes
• Vericella zoster
• Toxoplasmosis
• Malaria
• Listeriosis

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Which drugs can result in IUGR?

• Alcohol
• Cigarette smoking 3-4X
• Heroin coccaine
• Methotrexate
• Anticonvulsants
• Warfarin
• Antihypertensives /ß-blockers
• Cyclosporin

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What are the genetic disorders that can result in
IUGR?
Features suspicious of trisomy
15 of IUGR

• Downs syndrome T21
• Trisomy 13,18
• Turner syndrome
• Neural tube defects
• Achondroplasia
• Osteogenisis imperfecta
• Abdominal wall defects
• Duodenal atresia
• Renal agenesis/ Poters S

• Symmetric IUGR
• AFV/ Doppler ?N
• Structural abnormalities
• Maternal age
• Nuchal translucency
• Biochemical screening results

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Why does multiple pregnancy result in IUGR?

• Placental insufficiency /inadequate placental
  reserve to sustain N growth of gt one fetus
• Twin to twin transfusion syndrome
• Anomalies
• ? with higher order gestations
• ? monozygotic twins

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What are the types of IUGR?
1-Symmetric 20

• Proportionate decrease in many organ weights
  including the brain
• Deprivation occurs early
• The fetus is more likely to have an endogenous
  defect that preclude N development
• U/S biometry ? All measurements BPD, FL, AC ? ?

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Types of IUGR
2-Asymmetric IUGR80

• Relative sparing of the brain
• Deprivation occurres in the later half of
  pregnancy
• The infant is more likely to be N but small in
  size due to intrauterine deprivation
• U/S biometry ?BPD, Fl ? N, AC ? ?

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Why IUGR often associated with olighydramnios?

• ? blood flow to the lungs ?? pulmonary
  contribution to amniotic fluid volume
• ?blood flow to the kidneys ??GFR
• ??urine output
• It is present in 80-90 of IUGR fetuses

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How to evaluate a case of IUGR?

• 1-History
• Current preg
• ? LMP, preg test, quickening
• ? APH, abruptio placentae, fetal movements
• Previous obstetric Hx particularly looking for
  IUGR, adverse
• outcome
• Medical Hx connective tissue diseases,
  thrombotic events
• endocrine disorders
• Hx of recent viral illness
• Drug Hx
• Family Hx of congenital abnormalities
  thrombophilias

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EXAMINATION

• Symphysis fundal height in cm gest age in wks
  after 24 wk
• Sensitivity ?46-86 in detecting IUGR
• A difference of more than 2cm requires fetal
  assessment
• Oligohydramnious may be detected on palpation

U/S

• Fetal biometry ?for dating then serial
  measurements
• Anomaly scan
• AF index
• Doppler ?umbilical artery resistance index, MCA
• Repeat tests every1-2 wks

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Invasive fetal testing

• Amniocentesis or placental biopsy/ fetal blood
  sampling ?for karyotyping if aneuploidy is
  suspected
• ?for viral studies if infections suspected
• Caries the risks of ? infection, PROM, Preterm
  labor

Retrospective tests

• Maternal blood tests for ? CMV, Rubella, Toxo
• ?Metabolic disorders
• ?thrombophilia
• Placenta should be sent for HP
• Postmortem examination

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The constitutionally small fetus

• A fetus growing parallel to the lower centiles
  through out preg
• Anatomically N
• AFV ?N
• Doppler ?N
• Slim petite women

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Complications of IUGR

• Maternal complications ?due to underlying disease
• ?? risk of CS
• Fetal complications ?Stillbirth,
  hypoxia/acidosis,
• 
  malformations
• Neonatal complications ?Hypoglycemia,
  hypocalcemia,
• Hypoxia acidosis, hypothermia, meconium
  aspiration ,
• Polycythemia, hyperbilirubinemia, sepsis, low
  APGAR score
• congenital malformations, apneic spells,
  intubation
• sudden infant death syndrome
• Long term complications ?Lower IQ, learning
  behavior
• Problems, major neurological handicap ?seizures,
  cerebral
• Palsy, mental retardation, HPT
• Perinatal mortalility 1.5-2X

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Treatment

• Stop smoking / alcohol
• Bed rest ?? uterine blood flow ?for pt with
  asymmetric IUGR
• Low dose aspirin
• Weekly visits ?attention to FM, SFH, maternal
  wt, BP, CTG,
• AFV
• U/S every 2-4 wks
• BPP
• Contraction stress test
• Delivery ?38 wks or earlier if there is fetal
  compromise
• Glucocorticoids if planing delivery before 34 wks
• Close monitoring in labor/ continuous monitoring
  /scalp PH
• CS may be necessary

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IUFD
Definition dead fetuses or newborns weighing gt
500gm Or gt 20 wks gestation
4.5/ 1000 total births

• Diagnosis
• Absence of uterine growth
• Serial ß-hcg
• Loss of fetal movement
• Absence of fetal heart
• Disappearance of the signs symptoms of
  pregnancy
• X-ray ?Spalding sign
• Roberts sign
• U/S ?100 accurate Dx

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• Maternal 5-10
• Antiphospholipid antibody
• DM
• HPT
• Trauma
• Abnormal labor
• Sepsis
• Acidosis/ Hypoxia
• Uterine rupture
• Postterm pregnancy
• Drugs
• Thrombophilia
• Cyanotic heart disease
• Epilepsy
• Severe anemia
• Unexplained 25-35

Causes OF IUFD

• Fetal causes 25-40
• Chromosomal anomalies
• Birth defects
• Non immune hydrops
• Infections
• Placental 25-35
• Abruption
• Cord accidents
• Placental insufficiency
• Intrapartum asphyxia
• P Previa
• Twin to twin transfusion S
• Chrioamnionitis

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A systematic approach to fetal death is valuable
in determining the etiology

• B-Maternal History
• I-Maternal medical conditions
• VTE/ PE
• DM
• HPT
• Thrombophilia
• SLE
• Autoimmune disease
• Severe Anemia
• Epilepsy
• Consanguinity
• Heart disease
• II-Past OB Hx
• Baby with congenital anomaly / hereditary
  condition
• IUGR
• Gestational HPT with adverse sequele
• Placental abruption
• IUFD
• Recurrent abortions

1-History

• A-Family history
• Recurrent abortions
• VTE/ PE
• Congenital anomalies
• Abnormal karyptype
• Hereditary conditions
• Developmental delay

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1-History

• Specific fetal conditions
• Nonimmune hydrops
• IUGR
• Infections
• Congenital anomalies
• Chromosomal abnormalities
• Complications of multiple gestation

• Current Pregnancy Hx
• Maternal age
• Gestational age at fetal death
• HPT
• DM/ Gestational D
• Smooking , alcohol, or drug abuse
• Abdominal trauma
• Cholestasis
• Placental abruption
• PROM or prelabor SROM

• Placental or cord complications
• Large or small placenta
• Hematoma
• Edema
• Large infarcts
• Abnormalities in structure , length or
• insertion of the umbilical cord
• Cord prolapse
• Cord knots
• Placental tumors

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2-Evaluation of still born infants

• Infant desciption
• Malformation
• Skin staining
• Degree of maceration
• Color-pale ,plethoric
• Umbilical cord
• Prolapse
• Entanglement-neck, arms, ,legs
• Hematoma or stricture
• Number of vessels
• Length
• Amniotic fluid
• Color-meconium, blood
• Volume

• Placenta
• Weight
• Staining
• Adherent clots
• Structural abnormality
• Velamentous insertion
• Edema/ hydropic changes
• Membranes
• Stained
• Thickening

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• Fetal inveswtigations
• Fetal autopsy
• Karyotype
• (spcimen taken from cord
• blood, intracardiac blood,
• body fluid, skin, spleen,
• Placental wedge, or amniotic
• Fluid)
• Fetography
• Radiography

3-Investigations

• Maternal investigations
• CBC
• Bl Gp antibody screen
• HB A1 C
• Kleihauer Batke test
• Serological screening for Rubella
• CMV, Toxo, Sphylis, Herpes
• Parovirus
• Karyotyping of both parents (RFL,
• Baby with malformation
• Hb electrophorersis
• Antiplatelet anbin tibodies
• Throbophilia screening (antithrombin
• Protein C S , factor IV leiden,
• Factor II mutation, , lupus anticoagulant,
• anticardolipin antibodies)
• DIC

• Placental investigations
• Chorionocity of placenta in
• twins
• Cord thrombosis or knots
• Infarcts, thrombosis,abruption,
• Vascular malformations
• Signs of infection
• Bacterial culture for Ecoli,
• Listeria, gp B strpt.

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IUFD complications

• Hypofibrinogenemia ? 4-5 wks after IUFD
• Coagulation studies must be started 2 wks after
  IUFD
• Delivery by 4 wks or if fibrinogen ?lt 200mg/ml

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Psychological aspect counseling

• A traumetic event
• Post-partum depression
• Anxiety
• Psychotherapy
• Recurrence 0-8 depending on the cause of IUFD