• Like
IUGR boom&fnd latest
Upcoming SlideShare
Loading in...5
×

IUGR boom&fnd latest

  • 2,962 views
Uploaded on

 

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
  • greatfull info, thanks
    Are you sure you want to
    Your message goes here
No Downloads

Views

Total Views
2,962
On Slideshare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
185
Comments
1
Likes
3

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. IUGR
    (Intrauterine Growth Restriction)
    4th Year Medical Student PCM 34
    Present 17th October ,2011
  • 2. 1
    2
    3
    4
    5
    6
    7
    Definition
    Classification
    Cause
    Diagnosis
    Prevention
    Management
    Long term sequelae
    Contents
  • 3. Definition
    • Failure of normal fetal growth
    • 4. Most common definition
    “ fetus weighing below 10th percentile for GA”
    (SGA)
    • Other definition
    • 5. BW < -2SD for GA
    • 6. BW < 3rd percentile for GA
  • 10th Percentile
  • 7.
  • 8. 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
  • 9. 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
  • 10. Classification
    1.Symmetrical growth restriction
    Intrinsic factor
    Chromosomal abnormalities
    Congenital anomalies
    Intrauterine infection
    LOGO
  • 11. Classification
    1. Symmetrical growth restriction
    • An early insult could result in a relative decrease in cell number and size.
    • 12. chemical exposure
    • 13. viral infection
    • 14. cellular maldevelopment with aneuploidy
    • 15. It may cause a proportionate reduction of both head and body size.
    LOGO
  • 16. LOGO
  • 17. 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
  • 18. Classification
    2.Asymmetrical growth restriction
    Extrinsic factors : uteroplacental insufficiency
    Maternal vascular disease: hypertension
    Multiple gestations
    Placental disease
    Abruption, infarcts
    Abnormal cord insertion, hemangioma
    LOGO
  • 19. Classification
    2.Asymmetrical growth restriction
    • It might follow a late pregnancy insult such as
    • 20. placental insufficiency from hypertension
    • 21. 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
  • 22. 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.
    • 23. 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
  • 24. LOGO
  • 25. Classification
    3. Combine type
    • Asymmetricalsymmetrical
    • 26. Symmetricalasymmetrical
    More morbidities and mortalities
    More long term effects
    LOGO
  • 27. 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.
    • 28. A fetus with symmetrical IUGR how have complication with circulation in late gestational aged, may cause reduction of abdominal circumference.
    LOGO
  • 29. Cause
    Fetal causes
    Maternal causes
    Placental causes
    LOGO
  • 30. Cause
    Fetal causes
    • Infection
    • 31. CMV, Rubella, Toxoplasmagondii – severe IUGR
    • 32. Syphilis, Tuberculosis, Malaria, listeriosis
    • 33. Herpes simplex, chicken pox
    • 34. Chromosomal abnormality
    • 35. Trisomy 18,13 –severe IUGR
    • 36. Trisomy 21
    • 37. Turner syndrome (45,XO), Klinefelter syndrome (47,XXY)
    LOGO
  • 38. Cause
    Fetal causes
    • Congenital anomalies
    • 39. Congenital Heart diseases
    • 40. Anencephaly
    • 41. Renal agenesis, osteogenesisimperfecta
    LOGO
  • 42. Cause
    Maternal causes
    • Maternal malnutrition
    • 43. Poor maternal weight gain
    • 44. Severe anemia
    • 45. Chronic hypoxemia
    • 46. Cardiovascular disease
    • 47. Drugs and teratogens
    • 48. Multiple pregnancy
    • 49. Antiphospholipid antibodies syndrome
  • Cause
    Placental causes
    • Placental infarction
    • 50. Placental abruption
    • 51. Chorioangioma
    • 52. Placenta previa , circumvallate placenta
    • 53. Marginal or velamentous insertion of umbilical cord
  • Cause
    Fetal causes (intrinsic factors)
    Symmetrical IUGR
    Maternal causes Plcental causes
    (extrinsic factors)
    Asymmetrical IUGR
  • 54. Diagnosis
    • Clinical assessment
    • 55. Ultrasonic measurement
    • 56. Doppler velocity
  • Diagnosis
    I. Clinical assessment
    • History for risk factor
    • 57. Socioeconomic factor
    • 58. Smoking , Alcohol , Drugs
    • 59. Previous IUGR pregnancy history
    • 60. Family history : previous IUGR in family
  • Diagnosis
    • Physical examination
    • 61. Uterine fundal height
    • 62. Uterine fundus Pubic symphysis
    • 63. Simple, Safe, Inexpensive for screening
    • 64. 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
    • 65. Uterine fundal height
    • 66. Maternal body weight
    : BW<45 kg or
    : BW increased < 6.5 kg all over pregnancy
  • 67. Diagnosis
    Maternal underlying disease
    Medical condition
    ภาวะขาดสารอาหาร
    โลหิตจางอย่างรุนแรง
    ภาวะขาดออกซิเจนอย่างเรื้อรัง
    โรคไตบางชนิด
    โรคหลอดเลือดในมารดา
    Antiphospholipid antibody syndrome
    Obstetric condition
    ครรภ์แฝด
  • 68. 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) ***
    • 69. Sensitivity 90-100% , Specificity 95% (ดีที่สุด)
    • 70. < 5 thpercentile
    • 71. Biparietal diameter (BPD)
    • 72. Growth curve < 10 th percentile
    • 73. Sensitivity to Symmetrical > Asymmetrical
    • 74. Head-Abdominal circumference ratio (HC/AC ratio)
    • 75. Diagnosis for asymmetrical IUGR
    • 76. HC/AC ratio > 2 SD
  • Diagnosis
    II. Ultrasonic measurement
    • Femur length– abdominal circumference ratio (FL/AC ratio)
    • 77. เป็น age independent index ในทารกที่ GA>20 wks
    • 78. จะมีค่าคงที่เท่าๆกันทุกอายุครรภ์คือ 20-24%
    • 79. ในรายที่ >24% ให้สงสัย IUGR
    • 80. Estimate fetal weight
    • 81. < 10 thpercentile
  • Diagnosis
    II. Ultrasonic measurement
    • Amniotic fluid volume
    • 82. ในภาวะ IUGR จะลดลงเป็นอย่างแรก
    • 83. เกิดจาก renal perfusion ลดลง
    • 84. Vertical pocket ที่ใหญ่ที่สุด ได้ < 1 cm. ถือว่าผิดปกติ
    • 85. การตรวจพบน้ำคร่ำน้อยอย่างเดียว ไม่สามารถวินิจฉัยภาวะ IUGR ได้ต้องร่วมกับการตรวจอื่นๆด้วย
  • 86. < 5th Percentile
  • 87. < 10th Percentile
  • 88. Diagnosis
    III. Doppler velocimetry
    • Abnormal umbilical artery Doppler velocimetry
    • 89. characterized by absent or reversed end-diastolic flow
    • 90. 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
  • 91. Prevention
    • Stop and avoid all of the risk factors
    • 92. Control maternal U/D
    • 93. Antimalarial prophylaxis
    • 94. Correction of nutritional deficiencies
    • 95. Low-dose aspirin prophylaxis
    • 96. Hypertension
    • 97. Prior IUGR history
  • Management
    • Growth restriction near term
    • 98. Prompt delivery
    • 99. Recommend delivery at 34 weeks or beyond if there is clinically significant oligohydramnios
  • Management
    • Growth restriction remote from term
    • 100. No specific treatment
    • 101. 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
  • 102. Long-term sequelae
  • Thank You !