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IUGR boom&fnd latest
 

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    IUGR boom&fnd latest IUGR boom&fnd latest Presentation Transcript

    • IUGR
      (Intrauterine Growth Restriction)
      4th Year Medical Student PCM 34
      Present 17th October ,2011
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      Definition
      Classification
      Cause
      Diagnosis
      Prevention
      Management
      Long term sequelae
      Contents
    • Definition
      • Failure of normal fetal growth
      • Most common definition
      “ fetus weighing below 10th percentile for GA”
      (SGA)
      • Other definition
      • BW < -2SD for GA
      • BW < 3rd percentile for GA
    • 10th Percentile
    • Classification
      Campbell and Thoms (1977) described the use of the sonographically determined head-to-abdomen circumference ratio (HC/AC) to differentiate growth-restricted fetuses.
      Symmetrical IUGR (type I)
      Asymetrical IUGR (type II)
      Combined type
    • Classification
      1.Symmetrical growth restriction
      20 % of IUGR Infants
      proportional decrease in all organs
      HC/AC ratio is normal
      Occurs inearly pregnancy : cellular hyperplasia
      Increase risk for long term neurodevelopmental dysfunction
    • Classification
      1.Symmetrical growth restriction
      Intrinsic factor
      Chromosomal abnormalities
      Congenital anomalies
      Intrauterine infection
      LOGO
    • Classification
      1. Symmetrical growth restriction
      • An early insult could result in a relative decrease in cell number and size.
      • chemical exposure
      • viral infection
      • cellular maldevelopment with aneuploidy
      • It may cause a proportionate reduction of both head and body size.
      LOGO
    • LOGO
    • Classification
      2.Asymmetrical growth restriction
      75 % 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
      LOGO
    • Classification
      2.Asymmetrical growth restriction
      Extrinsic factors : uteroplacental insufficiency
      Maternal vascular disease: hypertension
      Multiple gestations
      Placental disease
      Abruption, infarcts
      Abnormal cord insertion, hemangioma
      LOGO
    • Classification
      2.Asymmetrical growth restriction
      • It might follow a late pregnancy insult such as
      • placental insufficiency from hypertension
      • Resultant diminished glucose transfer and hepatic storage would primarily affect cell size and not number, and fetal abdominal circumference which reflects liver size would be reduced.
      LOGO
    • Classification
      • Such somatic growth restriction is proposed to result from preferential shunting of oxygen and nutrients to the brain, which allows normal brain and head growth, so-called brain sparing.
      • The fetal brain is normally relatively large and the liver relatively small. Accordingly, the ratio of brain weight to liver weight during the last 12 weeks, usually about 3 to 1, may be increased to 5 to 1 or more in severely growth-restricted infants.
      LOGO
    • LOGO
    • Classification
      3. Combine type
      • Asymmetricalsymmetrical
      • Symmetricalasymmetrical
      More morbidities and mortalities
      More long term effects
      LOGO
    • Classification
      3. Combine type
      • A fetus with asymmetrical IUGR might confront with cause of IUGR until cannot be compensated with brain sparing effect, may cause restriction of head circumference.
      • A fetus with symmetrical IUGR how have complication with circulation in late gestational aged, may cause reduction of abdominal circumference.
      LOGO
    • Cause
      Fetal causes
      Maternal causes
      Placental causes
      LOGO
    • Cause
      Fetal causes
      • Infection
      • CMV, Rubella, Toxoplasmagondii – 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)
      LOGO
    • Cause
      Fetal causes
      • Congenital anomalies
      • Congenital Heart diseases
      • Anencephaly
      • Renal agenesis, osteogenesisimperfecta
      LOGO
    • Cause
      Maternal causes
      • Maternal malnutrition
      • Poor maternal weight gain
      • Severe anemia
      • Chronic hypoxemia
      • Cardiovascular disease
      • Drugs and teratogens
      • Multiple pregnancy
      • Antiphospholipid antibodies syndrome
    • Cause
      Placental causes
      • Placental infarction
      • Placental abruption
      • Chorioangioma
      • Placenta previa , circumvallate placenta
      • Marginal or velamentous insertion of umbilical cord
    • Cause
      Fetal causes (intrinsic factors)
      Symmetrical IUGR
      Maternal causes Plcental causes
      (extrinsic factors)
      Asymmetrical IUGR
    • Diagnosis
      • Clinical assessment
      • Ultrasonic measurement
      • Doppler velocity
    • Diagnosis
      I. Clinical assessment
      • History for risk factor
      • Socioeconomic factor
      • Smoking , Alcohol , Drugs
      • Previous IUGR pregnancy history
      • Family history : previous IUGR in family
    • Diagnosis
      • 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 < 1oth percentile from normal curve, inappropriate fetal growth may be suspected
    • Diagnosis
      I. Clinical assessment
      • Physical examination
      • Uterine fundal height
      • Maternal body weight
      : BW<45 kg or
      : BW increased < 6.5 kg all over pregnancy
    • Diagnosis
      Maternal underlying disease
      Medical condition
      ภาวะขาดสารอาหาร
      โลหิตจางอย่างรุนแรง
      ภาวะขาดออกซิเจนอย่างเรื้อรัง
      โรคไตบางชนิด
      โรคหลอดเลือดในมารดา
      Antiphospholipid antibody syndrome
      Obstetric condition
      ครรภ์แฝด
    • Diagnosis
      II. 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
    • Diagnosis
      II. Ultrasonic measurement
      • Abdominal circumference (AC) ***
      • Sensitivity 90-100% , Specificity 95% (ดีที่สุด)
      • < 5 thpercentile
      • Biparietal diameter (BPD)
      • Growth curve < 10 th percentile
      • Sensitivity to Symmetrical > Asymmetrical
      • Head-Abdominal circumference ratio (HC/AC ratio)
      • Diagnosis for asymmetrical IUGR
      • HC/AC ratio > 2 SD
    • Diagnosis
      II. Ultrasonic measurement
      • Femur length– abdominal circumference ratio (FL/AC ratio)
      • เป็น age independent index ในทารกที่ GA>20 wks
      • จะมีค่าคงที่เท่าๆกันทุกอายุครรภ์คือ 20-24%
      • ในรายที่ >24% ให้สงสัย IUGR
      • Estimate fetal weight
      • < 10 thpercentile
    • Diagnosis
      II. Ultrasonic measurement
      • Amniotic fluid volume
      • ในภาวะ IUGR จะลดลงเป็นอย่างแรก
      • เกิดจาก renal perfusion ลดลง
      • Vertical pocket ที่ใหญ่ที่สุด ได้ < 1 cm. ถือว่าผิดปกติ
      • การตรวจพบน้ำคร่ำน้อยอย่างเดียว ไม่สามารถวินิจฉัยภาวะ IUGR ได้ต้องร่วมกับการตรวจอื่นๆด้วย
    • < 5th Percentile
    • < 10th Percentile
    • Diagnosis
      III. Doppler velocimetry
      • Abnormal umbilical artery Doppler velocimetry
      • characterized by absent or reversed end-diastolic flow
      • associated with fetal growth restriction
      Normal velocimetry pattern with an S/D ratio of <30.
      The diastolic velocity approaching zero reflects increased placental vascular resistance.
      During diastole, arterial flow is reversed (negative S/D ratio), which is an ominous sign that may precede fetal demise
    • Prevention
      • Stop and avoid all of the risk factors
      • Control maternal U/D
      • Antimalarial prophylaxis
      • Correction of nutritional deficiencies
      • Low-dose aspirin prophylaxis
      • Hypertension
      • Prior IUGR history
    • Management
      • Growth restriction near term
      • Prompt delivery
      • Recommend delivery at 34 weeks or beyond if there is clinically significant oligohydramnios
    • Management
      • 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
    • Long-term sequelae
      • Type 2 DM
      • Atherosclerosis
      • Hypertension
      • Heart diseases
      • Cerebral palsy
      • Learning deficits
    • Thank You !