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IUGR boom&fnd latest

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IUGR boom&fnd latest

  1. 1. IUGR<br />(Intrauterine Growth Restriction)<br />4th Year Medical Student PCM 34<br />Present 17th October ,2011 <br />
  2. 2. 1<br />2<br />3<br />4<br />5<br />6<br />7<br />Definition<br />Classification<br />Cause<br />Diagnosis<br />Prevention<br />Management<br />Long term sequelae<br />Contents<br />
  3. 3. Definition<br /><ul><li>Failure of normal fetal growth
  4. 4. Most common definition </li></ul>“ fetus weighing below 10th percentile for GA”<br />(SGA)<br /><ul><li>Other definition
  5. 5. BW < -2SD for GA
  6. 6. BW < 3rd percentile for GA </li></li></ul><li>10th Percentile<br />
  7. 7.
  8. 8. Classification<br />Campbell and Thoms (1977) described the use of the sonographically determined head-to-abdomen circumference ratio (HC/AC) to differentiate growth-restricted fetuses.<br />Symmetrical IUGR (type I)<br />Asymetrical IUGR (type II)<br />Combined type<br />
  9. 9. Classification<br />1.Symmetrical growth restriction<br />20 % of IUGR Infants <br />proportional decrease in all organs<br />HC/AC ratio is normal<br />Occurs inearly pregnancy : cellular hyperplasia<br />Increase risk for long term neurodevelopmental dysfunction<br />
  10. 10. Classification<br />1.Symmetrical growth restriction<br />Intrinsic factor<br />Chromosomal abnormalities<br />Congenital anomalies<br />Intrauterine infection<br />LOGO<br />
  11. 11. Classification<br />1. Symmetrical growth restriction<br /><ul><li>An early insult could result in a relative decrease in cell number and size.
  12. 12. chemical exposure
  13. 13. viral infection
  14. 14. cellular maldevelopment with aneuploidy
  15. 15. It may cause a proportionate reduction of both head and body size.</li></ul>LOGO<br />
  16. 16. LOGO<br />
  17. 17. Classification<br />2.Asymmetrical growth restriction<br />75 % of IUGR Infants <br /> Increase HC/AC ratio : decrease in abdominal size<br /> Brain sparing effects<br /> Occurs in late pregnancy : cellular hypertrophy<br /> Risk for perinatal hypoxia, neonatal hypoglycemia<br /> Good prognosis <br />LOGO<br />
  18. 18. Classification<br />2.Asymmetrical growth restriction<br />Extrinsic factors : uteroplacental insufficiency<br />Maternal vascular disease: hypertension<br />Multiple gestations<br />Placental disease<br />Abruption, infarcts<br />Abnormal cord insertion, hemangioma<br />LOGO<br />
  19. 19. Classification<br />2.Asymmetrical growth restriction<br /><ul><li>It might follow a late pregnancy insult such as
  20. 20. placental insufficiency from hypertension
  21. 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.</li></ul>LOGO<br />
  22. 22. Classification<br /><ul><li>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. 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.</li></ul>LOGO<br />
  24. 24. LOGO<br />
  25. 25. Classification<br />3. Combine type<br /><ul><li>Asymmetricalsymmetrical
  26. 26. Symmetricalasymmetrical </li></ul> More morbidities and mortalities <br /> More long term effects<br />LOGO<br />
  27. 27. Classification<br />3. Combine type<br /><ul><li>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. 28. A fetus with symmetrical IUGR how have complication with circulation in late gestational aged, may cause reduction of abdominal circumference.</li></ul>LOGO<br />
  29. 29. Cause<br />Fetal causes<br />Maternal causes<br />Placental causes<br />LOGO<br />
  30. 30. Cause<br />Fetal causes<br /><ul><li>Infection
  31. 31. CMV, Rubella, Toxoplasmagondii – severe IUGR
  32. 32. Syphilis, Tuberculosis, Malaria, listeriosis
  33. 33. Herpes simplex, chicken pox
  34. 34. Chromosomal abnormality
  35. 35. Trisomy 18,13 –severe IUGR
  36. 36. Trisomy 21
  37. 37. Turner syndrome (45,XO), Klinefelter syndrome (47,XXY)</li></ul>LOGO<br />
  38. 38. Cause<br />Fetal causes<br /><ul><li>Congenital anomalies
  39. 39. Congenital Heart diseases
  40. 40. Anencephaly
  41. 41. Renal agenesis, osteogenesisimperfecta</li></ul>LOGO<br />
  42. 42. Cause<br />Maternal causes<br /><ul><li>Maternal malnutrition
  43. 43. Poor maternal weight gain
  44. 44. Severe anemia
  45. 45. Chronic hypoxemia
  46. 46. Cardiovascular disease
  47. 47. Drugs and teratogens
  48. 48. Multiple pregnancy
  49. 49. Antiphospholipid antibodies syndrome</li></li></ul><li>Cause<br />Placental causes<br /><ul><li>Placental infarction
  50. 50. Placental abruption
  51. 51. Chorioangioma
  52. 52. Placenta previa , circumvallate placenta
  53. 53. Marginal or velamentous insertion of umbilical cord</li></li></ul><li>Cause<br /> Fetal causes (intrinsic factors)<br /> Symmetrical IUGR<br />Maternal causes Plcental causes <br />(extrinsic factors)<br /> Asymmetrical IUGR<br />
  54. 54. Diagnosis<br /><ul><li>Clinical assessment
  55. 55. Ultrasonic measurement
  56. 56. Doppler velocity</li></li></ul><li>Diagnosis<br />I. Clinical assessment<br /><ul><li>History for risk factor
  57. 57. Socioeconomic factor
  58. 58. Smoking , Alcohol , Drugs
  59. 59. Previous IUGR pregnancy history
  60. 60. Family history : previous IUGR in family</li></li></ul><li>Diagnosis<br /><ul><li>Physical examination
  61. 61. Uterine fundal height
  62. 62. Uterine fundus Pubic symphysis
  63. 63. Simple, Safe, Inexpensive for screening
  64. 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</li></li></ul><li>Diagnosis<br />I. Clinical assessment<br /><ul><li>Physical examination
  65. 65. Uterine fundal height
  66. 66. Maternal body weight </li></ul> : BW<45 kg or<br /> : BW increased < 6.5 kg all over pregnancy<br />
  67. 67. Diagnosis<br />Maternal underlying disease<br />Medical condition <br />ภาวะขาดสารอาหาร <br />โลหิตจางอย่างรุนแรง <br />ภาวะขาดออกซิเจนอย่างเรื้อรัง <br />โรคไตบางชนิด <br />โรคหลอดเลือดในมารดา<br />Antiphospholipid antibody syndrome<br />Obstetric condition<br />ครรภ์แฝด<br />
  68. 68. Diagnosis<br />II. Ultrasonic measurement<br /><ul><li>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</li></li></ul><li>Diagnosis<br />II. Ultrasonic measurement<br /><ul><li>Abdominal circumference (AC) ***
  69. 69. Sensitivity 90-100% , Specificity 95% (ดีที่สุด)
  70. 70. < 5 thpercentile
  71. 71. Biparietal diameter (BPD)
  72. 72. Growth curve < 10 th percentile
  73. 73. Sensitivity to Symmetrical > Asymmetrical
  74. 74. Head-Abdominal circumference ratio (HC/AC ratio)
  75. 75. Diagnosis for asymmetrical IUGR
  76. 76. HC/AC ratio > 2 SD</li></li></ul><li>Diagnosis<br />II. Ultrasonic measurement<br /><ul><li>Femur length– abdominal circumference ratio (FL/AC ratio)
  77. 77. เป็น age independent index ในทารกที่ GA>20 wks
  78. 78. จะมีค่าคงที่เท่าๆกันทุกอายุครรภ์คือ 20-24%
  79. 79. ในรายที่ >24% ให้สงสัย IUGR
  80. 80. Estimate fetal weight
  81. 81. < 10 thpercentile</li></li></ul><li>Diagnosis<br />II. Ultrasonic measurement<br /><ul><li>Amniotic fluid volume
  82. 82. ในภาวะ IUGR จะลดลงเป็นอย่างแรก
  83. 83. เกิดจาก renal perfusion ลดลง
  84. 84. Vertical pocket ที่ใหญ่ที่สุด ได้ < 1 cm. ถือว่าผิดปกติ
  85. 85. การตรวจพบน้ำคร่ำน้อยอย่างเดียว ไม่สามารถวินิจฉัยภาวะ IUGR ได้ต้องร่วมกับการตรวจอื่นๆด้วย</li></li></ul><li>
  86. 86. < 5th Percentile<br />
  87. 87. < 10th Percentile<br />
  88. 88. Diagnosis<br />III. Doppler velocimetry<br /><ul><li>Abnormal umbilical artery Doppler velocimetry
  89. 89. characterized by absent or reversed end-diastolic flow
  90. 90. associated with fetal growth restriction</li></ul>Normal velocimetry pattern with an S/D ratio of <30.<br /> The diastolic velocity approaching zero reflects increased placental vascular resistance. <br />During diastole, arterial flow is reversed (negative S/D ratio), which is an ominous sign that may precede fetal demise<br />
  91. 91. Prevention<br /><ul><li>Stop and avoid all of the risk factors
  92. 92. Control maternal U/D
  93. 93. Antimalarial prophylaxis
  94. 94. Correction of nutritional deficiencies
  95. 95. Low-dose aspirin prophylaxis
  96. 96. Hypertension
  97. 97. Prior IUGR history </li></li></ul><li>Management<br /><ul><li>Growth restriction near term
  98. 98. Prompt delivery
  99. 99. Recommend delivery at 34 weeks or beyond if there is clinically significant oligohydramnios</li></li></ul><li>Management<br /><ul><li>Growth restriction remote from term
  100. 100. No specific treatment
  101. 101. If diagnosed in prior to 34 weeks, and amnionic fluid volume and fetal surveillance are normal</li></ul> “Observation is recommended± screening for toxoplasmosis,herpes,rubella,CMV and others”<br /> Specific treatment(causes of IUGR) and supportive care<br /><ul><li>If severe IUGR or bad obstetric conditions </li></ul>  Terminate pregnancy should be considered<br />
  102. 102. Long-term sequelae<br /><ul><li>Type 2 DM
  103. 103. Atherosclerosis
  104. 104. Hypertension
  105. 105. Heart diseases
  106. 106. Cerebral palsy
  107. 107. Learning deficits</li></li></ul><li>Thank You !<br />

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