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Amrutha Ramakrishnan Nair, profile picture
Uploaded byAmrutha Ramakrishnan Nair
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INTRA UTERINE GROWTH RETARDATION

This document summarizes information about intrauterine growth restriction (IUGR). It discusses normal fetal growth occurring in three stages: hyperplasia, hyperplasia and hypertrophy, and hypertrophy. Causes of IUGR include maternal, fetal, placental, and environmental factors. Maternal causes include medical conditions, malnutrition, smoking, and infections. Fetal causes include genetic abnormalities and infections. Placental causes include improper placentation and reduced blood flow. Clinical features of IUGR infants include a large head, thin skin, and scaphoid abdomen. Risk prediction methods include ultrasound and Doppler. Problems for IUGR infants include hypoxia, hypoglycemia, and immunological and metabolic issues. Management

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IUGR PRESENTED BY AMRUTHA R 1st yr MSc nsg 18-03-2013 CHILD HEALTH NURSING
SGA IUGR
NORMAL FOETAL GROWTH • Cellular hyperplasia • Hyperplasia and hypertrophy • hypertrophy
Stages • Stage I (Hyperplasia) - 4 to 20 weeks - Rapid mitosis - Increase of DNA content
Stages • Stage II (Hyperplasia & Hypertrophy) - 20 to 28 weeks - Declining mitosis. - Increase in cell size.
Stages • Stage III ( Hypertrophy) - 28 to 40 weeks - Rapid increase in cell size. - Rapid accumulation of fat, muscle and connective tissue. • 95% of fetal weight gain occurs during last 20 weeks of gestations.
CAUSES OF IUGR • • • • Maternal factors Fetal factors Placental factors Environmental factors
MATERNAL FACTORS • Medical disease • Malnutrition  BMI < 19 twice the risk of IUGR • Multiple pregnancy • Smoking (460 gm < then none smoker)
MATERNAL FACTORS • Alcohol  12-fold increase risk of IUGR • Drugs  Beta- Blockers(Atenolol in second trimster, Anticoagulants, Anticonvulsants( phenytoin) • Hypoxemia • Infections  UTI, Malaria, TB, Genital Infections
MATERNAL FACTORS • • • • Small stature/ low pre-pregnancy weight Teen pregnancy Primi gravida Grand multiparity
FETAL FACTORS • A Chromosome Defect In second trimester 20% SGA fetuses have chromosomal abnormality  Triploid is most common under 26 wks.  Trisomy-18 is common after 26 wks .  Other are 21(Down’s syndrome), 16, 13, xo (turner’s syndrome).
FETAL FACTORS • Exposure to an infection• German measles (rubella), cytomegalovirus, herpes simplex, tuberculosis, syphilis, or toxoplasmosis, TB, Malaria, Parvo virus
FETAL FACTORS • birth defects • (cardiovascular, renal, anencephally, limb defect, etc). • A primary disorder of bone or cartilage. • A chronic lack of oxygen during development (hypoxia • Placenta or umbilical cord defects.
PLACENTAL FACTORS • Uteroplacental Insufficiency Resulting From -. – Improper / inadequate trophoblastic invasion and placentation in the first trimester. – Lateral insertion of placenta. – Reduced maternal blood flow to the placental bed.
PLACENTAL FACTORS • Fetoplacetal Insufficiency Due To-. – Vascular anomalies of placenta and cord. – Decreased placental functioning mass-. • Small placenta, abruptio placenta, placenta previa, post term pregnancy
Normal & IUGR Newborn babies
Normal & IUGR Placentas
Environmental Causes of IUGR • High altitude - lower environmental oxygen saturation • Toxins
Types of IUGR • Symmetric IUGR: (33 % of IUGR Infants) • Asymmetric IUGR (55 % of IUGR) • Combined type IUGR: (12 % of IUGR)
SYMMETRICAL • height, weight, head circ proportional • early pregnancy insult: • commonly due to congenital infection, genetic disorder, or intrinsic factors • Reduced no of cells in fetus • normal ponderal index • low risk of perinatal asphyxia • low risk of hypoglycemia
PONDERAL INDEX • The ponderal index is used determine those infants whose soft tissue mass is below normal for their stage of skeletal development. Ponderal Index = birth weight x 100 crown-heel length
PONDERAL INDEX • Typical values are 20 to 25. • Those who have a ponderal index below the 10th % can be classified as SGA • PI is normal in symmetric IUGR. • PI is low in asymmetric IUGR
ASSYMETRICAL • later in pregnancy: • commonly due to utero placental insufficiency, maternal malnutrition, hypoxia, or extrinsic factors • low ponderal index • Cell number remains same but size is small • increased risk of asphyxia • increased risk of hypoglycemia
• Growth restriction in the stage of hypertrophy • Brain sparing effect • Head growth remains normal but abdominal girth slows down
Newer Classification: 1. Normal Small Fetuses- Have no structural abnormality, normal umbilical artery & liquor but wt., is less. They are not at risk and do not need any special care.
Abnormal Small Fetuses- have chromosomal anomalies or structural malformations. They are lost cases and deserve termination as nothing can be done. Growth Restricted Fetuses- are due to impaired placental function. Appropriate & timely treatment or termination can improve prospects.
CLINICAL FEATURES
Weight deficit Large head circumference Old man look Cartilaginous ridges on pinna Dry wrinkled skin
Length remain unaffected Open eyes Well defined creases Alert and active Normal reflexes Normal cry Thin umbilical
• Scaphoid abdomen
• Signs of recent wasting - soft tissue wasting - diminished skin fold thickness - decrease breast tissue - reduced thigh circumference • Signs of long term growth failure - Widened skull sutures, large fontanelles - shortened crown – heel length - delayed development of epiphyses
PREDICTION OF IUGR • History risk factors last menstrual period - most precise size of uterus time of quickening (detection of fetal movements) • Examination /
MATERNAL SERUM SCREENING • AFP • more for gestation in the absence of fetal anomaly, there is a 5-10 fold increase in the risk of FGR
• Uterine Artery Doppler Velocimetry - Notching of the waveform /reduce EDF associated 3-fold increase in risk of FGR. • Bright or echogenic fetal bowel in the second trimester is associated with increase risk of FGR.
• Combination of un-explain elevated maternal AFP is powerful predictor of adverse perinatal outcome (FGR) • Increase AFP combine with echogenic bowel is strong predictor of FGR
• DOPPLER OF THE UMBILICAL ARTERY • Reduced end diastolic flow. • Absent end diastolic flow • Reversed end diastolic flow( severe cases)
Problems • Hypoxia - Perinatal asphyxia - Persistent pulmonary hypertension - meconium aspiration • Thermoregulation - Hypothermia due to diminished subcutaneous fat and elevated surface/volume ratio
Metabolic - Hypoglycemia - result from inadequate glycogen stores. - diminished gluconeogenesis. - increased BMR - Hypocalcemia - due to high serum glucagon level, which stimulate calcitonin excretion
• Hematologic - hyperviscosity and polycythemia due to increase erythropoietin level sec. to hypoxia • Immunologic - IUGR have increased protein catabolism and decreased in protein, prealbumin and immunoglobulins, which decreased humoral and cellular immunity.
• Fetal distress, • Hypoxia, Acidosis and Low Apgar Score at birth. Increased perinatal morbidity and mortality • Grade 3-4 intraventricular haemorrhage • Necrotizing enterocolitis
• • • • • • BIOPHYSICAL HC:AC Brfore 32 wks more than 1 32—34 wks app 1 FEMUR LENGTH FL:AC IS 22at all gest wks from 21 wks to term • More than 23.5 indicate IUGR
• AFI • <2 Suggest IUGR • PI
PREVENTION OF HYPOTHERMIA • MUMMIFICATION • KMC • NESTING • DELAY BATH • WARMER
MAINTAINING BREATHING • VENTILATOR • C PAP • 02 SUPPLEMENTATION
NUTRITION FLUID AND FEEDING • <30– IV FLUIDS, NG ,KATORI, BREAST FEEDS • 30—34 NG ,KATORI, BREAST FEEDS • >34 KATORI, BREAST FEEDS
Monitoring • Vital signs • Activity and behaviour. • Color; Pink, pale, grey, blue, yellow. • Tissue perfusion • Fluids, electrolytes and ABG's.
• Bronchopulmonary dysplasia Metabolic disturbances and hypoglycemia Polycytemia Hypothermia Impaired cognitive function and cerebral paresis
MEDICAL • ASPIRIN THERAPY • Other forms of treatment that have been studied are • nutritional supplementation, • zinc supplementation, • fish oil, • hormones and • oxygen therapy
MANAGEMENT • • • • • 3—10 Percentile Skin to skin care Breast feeding Glucose level monitoring Polycythemia
<3 percentile • Thermal protection • feeding
THANK YOU