Intra uterine growth retardation


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Intra uterine growth retardation

  2. 2. Definition • It is said to be present in babies with birth wt less than 10th percentile of the average for the gestational age in weeks . • SGA -metabolic and nutritional problems • PRETERM CHILD -Organ immaturity
  3. 3. • LBW < 2.5 KG, • VLBW < 1.5 KG, • ELBW < 1.0 KG • Growth-restricted pregnancies are often complicated by a high rate of antepartum and intrapartum fetal distress and the need for cesarean delivery. • Infants who are small for their gestational dates are predisposed to low APGAR scores, low cord pH, intraventricular hemorrhage, necrotizing enterocolitis, hypoglycemia, hypocalcemia, and polycythemia.
  4. 4. TYPES OF IUGR • small and healthy with normal ponderal index • true IUGR A. SYMMETRICAL IUGR • damage in phase of cellular hyperplasia Early pregnancy damage B. ASYMMETRICAL IUGR damage in phase of cellular hypertrophy » Late pregnancy damage
  5. 5. MECHANISM OF IUGR • endothelial damage—decreased blood supply.—IUGR • morphological damage –decreased utilization of nutrients and O2—IUGR
  6. 6. ETIOLOGY OF IUGR • Fetal cause : 1. genetic disorders 2. immunological disorders 3. infection • 4. metabolic • • Feto maternal unit cause : ANAEMIA, CVD, HT, DM, CRF Substance abuse (smoking, • alcohol, drugs), thrombophilia • Environmental cause : multiple gestation,teenage pregnancy,ut anomalies,LSES
  7. 7. DIAGNOSIS OF IUGR • HISTORY : 1. previous history of IUGR • 2. medical history 3. drugs and drug abuse • 4. malnutrition • 5. PRESENT FACTORS DURING PREGNANCY; • (APH,early pregnancy bleeding,maternal preeclampsia) • • EXAMINATION : clinical palpation and Serial measurements of SFH, • • Maternal weight gain,AC
  8. 8. INVESTIGATION A. ULTRASONOGRAPHY • • • • 1. 2 3. 4. 5. 1st trimester USG for dating HC/AC Ratio TCD PLACENTAL ASSESSMENT BPP • 6. DOPPLER ULTRASOUND VELOCIMETRY. B. CTG TRACING NST----Reactive/Non Reactive •
  9. 9. INVESTIGATION C. BIOCHEMICAL MARKERS • Elevated levels of MSAFP and hcg level in 2nd trimester s/o abnormal placentation • Increased urokinase type antigen and sTNF-R2 s/o severe pih in later pregnancy.
  10. 10. MANAGEMENT Identification and treatment of underlying cause Bed rest in left lateral position Adequate balance diet Avoidance of smoking ,tobacco and alcohol Low dose Aspirin 75mg/day to be started in early pregnancy • infusion of i.v aminoacids • Mode of delivery according to age of viability and fetal surveillance during antenatal period • • • • •
  11. 11. DFMC : three counts each of one hour(3 sessions) X4 Interpretation: < 10 movement in 12 hrs/<3 movement in 3 hrs NST : Test is valuable to identify fetal wellness rather than fetal illness • Interpretation : 2 or more accelerations of more than 15 beats per minute above baseline and longer than 15 seconds in duration in 20 min observation. • NST still holds its importance in fetal monitoring because of its ease of performance and cost effectiveness.
  12. 12. Role of Amino Acids in IUGR Protein usually deficient in vegetarian,fastfood junky and milk and milk product avoiders Maternal proteins actively transported thru placenta to fetus Parenteral AA-highest bioavailability1st class proteins Parenteral AA improves amniotic fluid index and improve perinatal morbidity and mortality in IUGR fetus
  13. 13. BPP: NST, fetal breathing movement,fetal muscle tone,gross body movement,AF • Interpretation: 8-10 no hypoxia,<8 fetal hypoxia Modified BPP : Along with AFI
  14. 14. Fetal hypoxia Brain Sparing Reflex Increased blood flow to brain,heart and adrenals Increased end diastolic Velocity in MCA Decreased S/D ratio, PI and RI Decreased blood flow to Peripheral & placental circulation Decreased end diastolic Velocity in umbilical Vessels Increased S/D ratio, PI and RI
  15. 15. DOPPLER VELOCIMETRY • Doppler identifies fetal compromise earlier than NST. The lead time helps to plan delivery in preterm compromised pregnancies, resulting in better perinatal survival
  16. 16. Abnormal Doppler values • Pulsatility index (PI) of umbilical artery (UA) > 2 SD for the gestational age • Absence or reversal of end diastolic flow in UA. • PI of MCA < 5th percentile for the gestational age • Abnormal cerebroplacental ratios – PI MCA/UA<1.08
  17. 17. Fetal surveillance of IUGR fetus DFMC daily NST biweekly MBPP weekly DOPPLER every 2 weeks
  18. 18. DFMC/NST Normal Abnormal Continue Fetal surveillance till maturity DOPPLER STUDY Termination of pregnancy Normal Fetal survey and termination Abnormal
  19. 19. Abnormal doppler study Less than 34 weeks More than 34 weeks Steroid followed by termination AFI Less than 5 Caesarian delivery More than 5 Vaginal delivery attempted with Induction of labour Failed induction