IUGR

6,279 views

Published on

IUGR, JNMCH, AMU, ALIGARH

Published in: Education
1 Comment
15 Likes
Statistics
Notes
No Downloads
Views
Total views
6,279
On SlideShare
0
From Embeds
0
Number of Embeds
7
Actions
Shares
0
Downloads
548
Comments
1
Likes
15
Embeds 0
No embeds

No notes for slide

IUGR

  1. 1. PRESENTED BY : DR.NEHA JAIN Jnmch, amu aligarh
  2. 2. Mrs.X, Wife of Mr. Y, Age 23yrs Resident of N district. Unbooked case Presented with complaint of : Cessation of menses- 81/2 mths Ghabrahat- 3 days
  3. 3. History of present illness: Patient was apparently all right 81/2 mths back when she developed cessation of menses. 1st TRIMESTER: No H/O excessive nausea & vomitting bleeding p/v fever with or without rashes drug intake radiation exposure
  4. 4. 2nd TRIMESTER: H/O poor weight gain No H/O headache epigastric pain blurring of vision bleeding or leaking p/v Pain abdomen Quickening @ around 5th mth 3rd trimester: H/O Ghabrahat on & off No H/O headache epigastric pain blurring of vision bleeding or leaking p/v
  5. 5. Menstrual History: LMP-01/12/2013 By Dates-36 wks 3 days(dates sure) By 30 wks scan-32 wks 4 days No H/O prolonged menstrual cycles/ normal flow Obstetric history: G2P1+0L0  0 / IUD delivery @ 8mths GA / Govt.hospital / 1yr. back / cause N/K
  6. 6. Past history: No H/O Hypertension Renal disease Diabetes mellitus Heart disease Asthma Thrombophilias Personal history: Sleep-N,Bladder/Bowel-N No H/O smoking alcoholism drug abuse
  7. 7. Dietary history: 2-3 chapatis/day 1 small bowl of dal 1 small bowl of vegetables Rice occasionally 1 spoon ghee, 2 spoons oil Calorie intake-1200kcal./day(Requirement-1900kcal.) Iron tablets not regular No calcium tablets
  8. 8. Socio economic status: Poor Kuppuswamy class-Upper lower(IV) Family history: No H/O HTN/DM/Asthma/TB No H/O genetic disorder in family
  9. 9. General examination: Thin built Poor nutritional status Height -152cm. Weight - 55kg. BMI- 22.9 Kg/m2 Pallor + (clinically 8g%) Cyanosis & Icterus -nt Cervical lymphadenopathy-nt Pedal edema +nt
  10. 10. Vitals: Pulse - 94/min, regular, good volume, no radiofemoral delay Bld. Pressure- 110/70mmHg. Resp.rate- 20/min Temp.- Afebrile Systemic examination: CNS CVS RESP. WNL
  11. 11. Abdominal examination: Distended Skin loose Uterus 30-32wks SFH-30cms cephalic Liquor clinically normal FHS+nt, 132/min. regular Uterus relaxed X 10 min.
  12. 12. Hb% - 8.5 Bld grp.- A+ve TLC - 7800/cu mm. DLC - P70L28M02 Platelets- 1.8 lacs/cu mm. Bld Sugar ®- 124 mg/dl. S.Urea - 30mg% S.Creatinine- 0.42 mg% HIV, HBsAg, VDRL- NR
  13. 13. • • • • • Wrong Dates Small for Gestation Age(SGA) fetus Pathological Fetal Growth Restriction(PFGR) Intra Uterine Fetal demise Oligohydraminos
  14. 14. next investigation to confirm…???
  15. 15. Doppler effect: • Change in the apparent frequency due to relative motion between the source & the observer. (Doppler probe & RBCs) • When the sound wave strikes a moving target, the frequency of sound waves reflected back is proportionate to the velocity & direction of moving object. • Used to determine the volume & rate of blood flow through maternal vessels
  16. 16. Types: 1) CONTINUOUS WAVE DOPPLER: Two crystals are used, one transmits & other receives wave Used in M-mode echocardiography 1) PULSE WAVE DOPPLER: Only one crystal that Transmits-wait-Receives-wait-Transmits Allows precise targeting & visualization of the vessel of interest Have software that displays blood flowTowards transducer as RED Away from transducer as BLUE
  17. 17. • Angle of Insonation: Between doppler beam & direction of flow • Higher the angle lesser the frequency & more the error.
  18. 18. Frequency change relative to angle of insonation
  19. 19. • To minimize error we use RATIOS, to cancel off the cosϴ Arterial Doppler indices  S/D Ratio: Peak systolic flow(S) End diastolic flow(D)
  20. 20.  PULSATILITY INDEX : S-D Mean  RESISTANCE INDEX : S-D S Venous Doppler indices:
  21. 21.  PRELOAD INDEX : Peak velocity during atrial contraction Peak systolic velocity  PEAK VELOCITY INDEX : Peak Systolic – Peak velocity atrial contraction Peak Diastolic velocity  PERCENTAGE REVERSE FLOW : Systolic time averaged velocity X 100 Diastolic time averaged velocity  PULSATILITY INDEX :
  22. 22. MATERNAL COMPARTMENT FETAL COMPARTMENT •Uterine Artery •Umblical Artery •Middle Cerebral Artery •Venous Doppler
  23. 23. Uterine artery Doppler: • High diastolic flow velocities
  24. 24. • Its main use is in screening. • Early diastolic notch in the uterine artery @ 12-14 wks. suggest delayed trophoblastic invasion (JAMES) • Persistence of notch beyond 24 wks confirms & indicates an increase risk of Pre-eclampsia, Placental abruption & Early onset IUGR. (JAMES) • Increase impedence of flow in Uterine artery @ 16-20 wks was predictive of superimposed pre-eclampsia developing inwomen with chronic hypertension. (WILLIAMS)
  25. 25. Umbilical ARTERY DOPPLER • The amount of flow during diastole increases as gestation advances • Thus the S/D ratio dec. from 4 @ 20 wks to 2 @ 40 wks. (WILLIAMS) • Umbilical A. S/D ratio is generally < 3 after 30 wks. (WILLIAMS)
  26. 26. • Umbilical A. Doppler indices should be measured only after 23 wks (STUDD) • It is useful adjunct in the management of pregnancies complicated by fetal-growth restriction. (ACOG-2008) • It is not recommended for screening of low-risk pregnancies or for complications other than growth restriction. (WILLIAMS) • Umbilical artery Doppler becomes abnormal when at least 30% of the fetal villous structure is abnormal. (JAMES)
  27. 27. •In extreme cases of growth restriction, end-diastolic flow may become absent or even reversed (AREDF). •AREDF occurs when 60-70% of the fetal villous structure is abnormal. •About ½ of the cases of AREDF are associated with aneuploidy or a major anomaly (WILLIAMS) •Fetuses of preeclamptic women who had AREDF were more likely to have hypoglycemia & polycythemia. (WILLIAMS)
  28. 28. ABNORMAL Umbilical ARTERY WAVEFORM Resistance index & S/D ratio is increasing
  29. 29. ABNORMAL Umbilical ARTERY WAVEFORM Perinatal mortality rate in AEDF- 9-41% (IAN DONALD’S)
  30. 30. ABNORMAL Umbilical ARTERY WAVEFORM Reversal of the End Diastolic Flow Perinatal mortality rate of REDF- 33-73% (IAN DONALD’S)
  31. 31. • Abnormal Umbilical artery flow pattern indicate an increased risk of hypoxemia & acidemia proportionate to severity of Doppler abnormality. (JAMES) • Umbilical artery Doppler can also be used to distinguish b/w the high risk small fetus that is truly growth restricted that needs inc. monitoring & the low risk small fetus. (IAN DONALD’S) • When Umbilical artery Doppler are incorporated into management algorithm of growth restricted fetus, perinatal death is reduced as much as 29%. (STUDD) • In summary UA Doppler in suspected IUGR pregnancies improves perinatal outcome & should be used to monitor these fetuses
  32. 32. Ductus arteriosus doppler • Primarily used to monitor fetuses exposed to indomethacin and other NSAIDs. • Indomethacin was used for tocolysis • They causes Premature closure of Ductus Arteriosus  Increased pulmonary flow  Reactive hypertrophy of pulmonary arterioles  Pulmonary Hypertension. WILLIAMS 23rd EDITION
  33. 33. MIDDLE CEREBRAL ARTERY(MCA) DOPPLER • It was used for assessment ofFetal Anemia Growth restriction  FETAL ANEMIA: (In Rh isoimmunisation) With increasing anemia  cardiac output increases & blood viscosity decreases  increase flow to brain  Elevated peak systolic velocity WILLIAMS 23rd EDITION
  34. 34. Normal MCA WAVEFORM
  35. 35. MCA DOPPLER IN FETAL ANEMIA INCREASED PEAK SYSTOLIC VELOCITY
  36. 36. Why only Middle Cerebral Artery is used in assessing fetal anemia…??? • Other vessels have high insonating angles • MCA is an exception because anatomically, the path of this artery is such that flow velocity approaches the transducer "head-on," and the fontanel allows easy insonation (WILLIAMS 23RD EDITION)
  37. 37.  GROWTH RESTRICTION: It is involved in severely growth restricted fetus after involvement of Umbilical artery. It is the progression of the Doppler finding & is due to the adaptive compensatory mechanism in the fetus against increasing hypoxia (Brain sparing effect)
  38. 38. Umbilical artery involved Increasing hypoxia Inc. blood flow to Vital Organs(Brain, Heart& Adrenals) BRAIN SPARING EFFECT Or CEPHALISATION Dec. blood flow to Abdominal Organs(Liver & Kidneys) MCA DOPPLER- Inc. Diastolic Flow OLIGOHYDRAMINOS Dec. RI/PI/SD ratio & abn MCAPSV
  39. 39. MCA WAVEFORM IN IUGR INCREASED FLOW DURING DIASTOLE
  40. 40. CEREBRO-PLACENTAL RATIO(CPR): MCA Pulsatility Index Umbilical A. Pulsatility Index It is more sensitive index for detecting poor perinatal outcome than UA or MCA Doppler alone, but due to non standardized technique of calculating CPR limit its clinical utility. (STUDD)
  41. 41. • Abnormal MCA reflects inc risk of adverse perinatal outcome(PTL, Intrapartum acidemia & inc NICU admission) • Not superior to Umbilical artery Doppler • High negative predictive value for adverse outcome • Normal UA & MCA Doppler indices & normal AFI in growth restricted fetus <32 wks have negative predictive value of 97% for adverse outcome
  42. 42. Umbilical artery involved Increasing MCA-PSV IS THE BETTER TOOL TO hypoxia FOLLOW THE PROGRESSION OF THE DISEASE Dec. blood flow to (STUDD) Abdominal Organs(Liver & Kidneys) Inc. blood flow to Vital Organs(Brain, Heart& Adrenals) BRAIN SPARING EFFECT Or INCREASING HYPOXIA CEPHALISATION DECOMPENSATION MCA DOPPLER- Inc. OLIGOHYDRAMINOS Diastolic Flow NORMALSATION OF MCA DOPPLER INDICES EXCEPT Dec. RI/PI/SD ratio & FOR Abn MCA-PSV MCA-PSV
  43. 43. SUMMARY OF MCA: Despite the association of abn. MCA & adverse perinatal outcome, there are no specific interventions to improve outcome based on abn. findings. However abn. values should prompt more frequent fetal survillence
  44. 44. Venous Doppler studies • Reflects fetal cardiac function • Most commonly used Venous Doppler indices: Ductus Venosus Inferior vena cava Hepatic vein Umbilical vein(Intra abdominal portion)
  45. 45. VENOUS DOPPLER All venous Doppler have this type of waveform except for Umbilical vein waveform
  46. 46. Ductus venosus doppler PERINATAL MORTALITY IN ABSENT OR REVERSE FLOW OF DV IS 63-100% (IAN DONALD’S)
  47. 47. HYPOXIA INC BLOOD SHUNTING THROUGH DV B/W UMBILICAL VEIN & IVC PSV-ATRIAL CONTRACTION VELOCITY Avg. Vel. Drng cardiac cycle INC. PULSATILITY INDEX FOR VEINS (PIV) REVERSED a WAVE IN DV PULSATION PULSATIONS IN THE UMBILICAL VEIN REVERSAL OF FLOW IN IVC DURING ATRIAL CONTRACTION
  48. 48. ABNORMAL WAVEFORM IN UMBILICAL VEIN
  49. 49. Important points on venous Doppler • Especially useful in early onset IUGR Reason: In Term /near term fetuses there is shorter interval & delivery is often indicated With advancing GA cardiac activity becomes more efficient  slow Steady decline in Doppler indices • When DV & Umbilical vein Doppler- Sensitivity inc to 70-80%.
  50. 50. Current areas in research & investigation • POST TERM PREGNANCY: Pregnancy >41 wks Abn. CPR & MCA indicate adverse outcome • DETERMINATION OF PLACENTATION: To identify Placenta Accreta, Increta,Percreta Specific sonographic findings: Absence of hypo echoic zone retro placental zone Presence of numerous placental lakes interruption of bladder-myometrium interface Sensitivity is low Negative predictive value-95% 3D power Doppler: Sensitivity-97%; Specificity-92% • PREDICTION OF INTRAPARTUM ACIDEMIA: • OXYGEN THERAPY FOR IUGR FETUSES: Continuous oxygen therapy for AEDF fetuses 30% reduction in perinatal mortality
  51. 51. PERINATAL MORTALITY RATES DOPPLER PARAMETER PERINATAL MORTALITY INC. UMBLICAL A. RESISTANCE 5-6% ABSENT UMBLICAL A. EDF 11-13% REVERSED UMBLICAL A. EDF 20-24% DECREASED MCA 21% ABN. DV a WAVE 30-38% INTRA ABD. UMBLICAL VEIN PULSATIONS 35%
  52. 52. What is your diagnosis ???... G2P1+0L0 with 36wks 3 days pregnancy with moderate anemia with IUGR
  53. 53. hyperplasia • First 16 wks • Rapid mitosis • Inc. in DNA content Hyperplasia & hypertrophy • 17-32 wks • Dec. mitosis • Inc. in cell size hypertrophy • After 32 wks • Inc. in cell size, fat deposition, muscle mass & connective tissue 15 wks - 5g/day 24 wks - 1020g/day 34 wks - 3035g/day WILLIAMS OBSTETRICS -23rd EDITION
  54. 54. GENETIC POTENTIAL • Derived from both parents • Mediated through factors like insulin like growth factor  SUBSTRATE SUPPLY • Derived from placenta • Depend upon Uterine & Placental vascularity
  55. 55. glucose Fetal growth oxygen Amino acids
  56. 56. BIRTH WEIGHT thPERCENTILE OF THAT <10 GESTATION (OR) WEIGHT <2SD of THE MEAN
  57. 57. FETAL GROWTH RESTRICTION (Or) SMALL FOR GESTATION AGE(SGA)(3-10%) CONSTITUTIONAL PATHOLOGICAL (IUGR)
  58. 58. • TYPE 1/ SYMMETRICAL /INTRINSIC: (20-30%): • Growth inhibition early in the pregnancy (4-20 wks) • • • • • Affects Hyperplastic stage Causes are: Intrauterine infections (TORCH) Congenital malformations HC, AC, FL & Weight below 10th percentile for GA Hence Ponderal Index Wt.(gm)is normal FL(cm)3 • Causative factor is usually uncorrectable.
  59. 59. TYPE 2/ aSYMMETRICAL /exTRINSIC:(70-80%): • Occurs later, usually after 28 wks of GA • Affects hypertrophic stage • Due to restriction of nutrient supply in utero • Associated with maternal d/s.- Chronic Htn., Renal d/s., Vasculopathy etc. • Brain Sparing Effect • HC & FL- normal, AC- decreased • Ponderal index- low
  60. 60. TYPE 3/ intermediate iugr(5-10%) • Combination of Type-1 & type-2 • Affects both Hyperplasia & Hypertrophy • Associated with Chronic Htn., Lupus nephritis, vascular d/s. in early 2nd trimester
  61. 61. PLACENTAL CAUSES • • • • • • • Placenta Previa Abruptio Placentae Placental thrombosis or infarction Deciduitis, Placentitis, Vasculitis, Edema Chorioamnionitis Placental Cyst Chorioangioma
  62. 62. FETAL CAUSES • • • • • Infections Malformations Heart Disease Chromosomal abnormalities Osteogenesis Imperfecta
  63. 63. Maternal causes • • • • • • • • Race, Weight, Height Cardiovascular disease Renal disease, Acidosis Anemia Fever Drug intake(DES, Anticancer, Narcotics) Smoking Alcohol
  64. 64. Uterine Causes • Decreased uteroplacental blood flow • Atheromatosis or Arteriosclerosis of the decidual spiral arteries • Chronic Hypertension • Preeclamsia • Diabetes Mellitus • Connective tissue disorders • Fibromyomas • Morphologic abnormalities
  65. 65. • Perinatal morbidity & mortality of IUGR infants is 3-20 times greater than normal infants(IanDonalds) • Risk is increased 3times at 26 weeks compared with only a 1.13-fold increased risk at 40 weeks.(Williams 23rd edition)
  66. 66. Antenatal Period: • Oligohydraminos • Fetal Distress • IUD During labour: • • • • Still birth Meconium aspiration Fetal distress Acidosis
  67. 67. neonatal period: • Hypoxic Ischemic Encephalopathy • • • • • Persistent Fetal circulation Difficulty in temperature regulation Hypoglycemia Polycythemia Necrotising Enterocolitis
  68. 68. Childhood: • Infectious Diseases • • • • Congenital Anomalies Cerebral Palsy(4-6 times higher)[Ian Donalds] Subtle impairment in cognitive improvement Educational underachievement
  69. 69. Long term: Inc. risk of  • • • • • Coronary Heart Disease Hypertension Type II Diabetes Mellitus Dyslipidaemia Stroke
  70. 70. History: • Correct gestational age • • • • • • • History of Previous IUGR baby History of disorders affecting placental function Obstetric history Dietary history Drug / Radiation exposure / Addiction Family history Socioeconomic status
  71. 71. Examination:  General examination  Systemic examination  Obstetrical examination-SFH /AG • After 20 wks SFH corresponds to the no. of wks. of gestation. (JAMES) • Between 18-30wks. SFH coincides within 2wks of GA & a lag of 2-3cms. Denotes growth restriction (WILLIAMS) • SFH increases by 1cm/wk b/w 14-32wks. A lag of > 4 wks denotes moderate IUGR & > 6wks denotes severe IUGR. (IAN DONALD’S) • AG increases by 1 inch/wk. after 30 wks. It is 30inch @ 30 wks
  72. 72. Investigations:  Routine ANC investigations  ULTRASOUND: Most useful inv. • Gestation age determination- prior to 24 wks, but most accurate @10-12 wks CRL is the most accurate parameter(WILLIAMS) There is an error of around: 7days in 1sttrimester 10-11 days in 2ndtrimester 21 days in 3rdtrimester (JAMES) • Determination of EFW: AC & EFW inc the sensitivity • Determination of multiple gestation • Determination of Fetal wellbeing
  73. 73. • Determination of Congenital anomalies: @ 16-20 wks of gestation (WILLIAMS) • Determination of placenta: • Assessment of fetal growth: Repeat @ 32-34 wks BPD(Bi Parietal Diameter)- Most accurate for dating in 2ndtrimester (14-26wks) [WILLIAMS]
  74. 74. Proximally-outer table, Distally-inner table MEASURED@ THE LEVEL OF THALAMUS & CAVUM SEPTUM PELLUCIDUM WILLIAMS 23rd EDITION
  75. 75. HC(Head Circumference): More accurate than BPD in Dolicocephalic or Brachycephalic head CEPHALIC INDEX: Ratio of BPD to Occipitofrontal diameter.
  76. 76. FL(Femur Length): Measured @ the level perpendicular to shaft excluding the epiphysis Correlates well with the BPD & Gestational age AC(Abdominal Circumference): Single best parameter for detection of IUGR because it is related to the liver size which reflects fetal glycogen storage (JAMES) Its sensitivity is further inc. by serial measurements atleast 14 days apart (JAMES) We should not not label as growth restricted fetus unless AC is far below normal or unless other parameters correlate. (JAMES)
  77. 77. ABDOMINAL CIRCUMFERENCE DONALD SCHOOL OF ULTRASOUND
  78. 78. TCD(Trans Cerebellar Diameter): Correlates well with the gestation age Relatively spared in mild to moderate Uteroplacental dysfunction. Upto 25 wks TCD in cms. = GA (IAN DONALD’S)
  79. 79. Age independent ratios HC/AC: Decreases linearly from 16-40wks. normally. Ratio>2SD is suggestive of IUGR (IAN DONALD’S) FL/AC: Normal value = 22 + 2% in second half of preg. Ratio above23.5% is abnormal (IAN DONALD’S)
  80. 80. • Determination of Amniotic Fluid Volume: Type II IUGR causes Oligohydraminos Amniotic Fluid Index(AFI) = 5-18 cms. Maximum Liquor Pocket = 2-8 cms.
  81. 81. Other investigations  Amniocentesis  Karyotyping  Colour doppler  TORCH test  Antiphospholipid antibody  Thrombophillia screen  Thyroid function test  Detailed level II ultrasound  Biophysical Profile(BPP)  Cardiotocography
  82. 82. Presumptive diagnosis of iugr • SFH not increasing at a normal rate • Fetuses with small AC • Flattening of growth curve on two consecutive occasion 14 days apart • Beyond 24 wks., an elevated umbilical artery Doppler index • After 34 wks umbilical artery Doppler index may be normal & a dec. CPR or MCA Doppler index may be the only supporting evidence of placental-based IUGR
  83. 83. Based on the above findings, the fetus may have one of the four diagnosis: • • • • Aneuploidy Viral infection Placental dysfunction (Most Common) Non Aneuploidy fetal Syndrome
  84. 84. Diagnostic work-up • It is imp. to decide the cause of IUGR before delivering the fetus
  85. 85. Clinical suspicion of IUGR AC/EFW<10 th PERCENTILE Anatomical survey & AFI Normal / oligohydraminos Umbilical Artery Doppler / MCA Doppler Norma l Anomaly/ polyhydrami nos Dec./AREDF/ brain sparing effect •Aneuploidy •Syndromes •Viral infections Placental insufficiency Abnorm al Cerebro-Placental ratio Norma l Repeat USG after 14 days constitutional
  86. 86. Maternal & fetal therapy • Reduce/ Eliminate the potential external contributors(Stress/ smoking) • Encourage maternal rest daily in LLL • Low dose aspirin-75mg/day Used for mild placental dysfunction Found useful when started in 1st trimester • Fetal therapy: Maternal Hyper oxygenation Intra vascular volume expansion JAMES 4 edition Hyperailmentation th
  87. 87. • Antenatal administration of corticosteroids in < 34wk to hasten fetal lung maturity. • Delivery of the fetus in an institution having Neonatal care unit that can carry complex management of the neonate with IUGR JAMES 4th edition
  88. 88. Timing & mode of delivery • Frequent surveillance of growth-restricted fetuses is essential to optimize timing of delivery & maximizing GA while minimizing the risk of neonatal morbidity & mortality • More than 60% of the fetus with abnormal heart rate are already hypoxemic or acidemic. (STUDD) • Doppler findings precede Biophysical profile & Non Stress Test by several wks. (STUDD) • Umbilical A.  MCA  venous Doppler  BPP  CTG • Integrated fetal testing is used to monitor timing.
  89. 89. • Management algorithm depends heavily on  Gestation age(upto 29 wks)  Umbilical A. Doppler Difficult extrauterine environment Hostile intrauterine environment
  90. 90. IUGR> 24 WKS Normal / mildly elevated UMBILICAL A. DOPPLER •NST twice weekly •BPP weekly •AFI Weekly •Umbilical A. Doppler wkly •Fetal growth 3 wkly NOR MAL Deliver @ 37-39wks ABNOR MAL AREDF •Hospitalise the pt. •Continuous /frequent fetal monitoring •Corticosteroids •MCA Doppler wkly •DV Doppler every 3-4days •BPP daily •Fetal growth every 3 wks NOR MAL Deliver @34-36 wks RCOG 2013- 37wks RCOG 2013- 32wks STUDD
  91. 91. MODE OF DELIVERY UMBILICAL A. DOPPLER RAISED AREDF CAESAREAN VAGINAL CAESAREAN
  92. 92. THANK YOU

×