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Intrauterine growth restriction Intrauterine growth restriction

This document discusses intrauterine growth restriction (IUGR), including definitions, health burden, classification, etiology, pathophysiology, screening, prevention, diagnosis, interventions, management, and long-term outcomes. IUGR is defined as a fetus that does not achieve expected in utero growth potential due to genetic or environmental factors. It affects about 10% of live births and is a leading cause of perinatal morbidity and mortality. Causes include fetal, maternal, placental, and environmental factors. Screening involves ultrasound and Doppler assessments. Management involves timing of delivery based on gestational age and severity. IUGR is associated with short and long-term complications.

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Intrauterine Growth RestrictionPathogenesis & interventions to improve outcome DR. PRAMAN KUSHWAH Neonatology Resident NICE Hospital, Hyderabad
Objectives 1. Definition 2. Health Burden 3. Classification 4. Aetiology 5. Pathophysiology 6. Screening 7. Prevention 8. Diagnosis 9. Intervention & Management
Intoduction “Fetus who does not achieve the expected in utero growth potential due to genetic or environmental factors” Shrunken or "wizened" appearance of an infant with intrauterine growth restriction
Definitions IUGR / (Fetal growth Restriction) ◦ Fetus who does not achieve the expected in utero growth potential due to genetic or environmental factors (Brodsky and Christou, 2004) ◦ An estimated fetal weight <10th percentile ◦ Moderate FGR BW 3rd to 10th percentile ◦ Severe FGR BW < 3rd percentile
Small-for-gestational age (SGA) ◦ Majority are constitutionally small and healthy ◦ 10–15% of SGA infants are growth restricted, i.e., with slow growth velocity in utero (Alberry and Soothill, 2007)
Health Burden 10 % of live-born are IUGR 2nd leading cause - perinatal morbidity and mortality 1.5% risk of fetal death
Classification
The Ponderal index [birth weight in grams ×100]/[length in centimeters]3 the weight-to-length ratio may be Used to categorize growth-retarded infants. Those with asymmetric growth retardation have low Ponderal index. Ponderal index for symmetric IUGR may be normal
Etiology
Fetal Etiologies ◦ Chromosomal etiologies classically, trisomies more common (5 - 20 %) ◦ Congenital birth defects (e.g. gastroschisis)
Maternal Etiologies Factors affecting Health & reproductive potential ◦ maternal age, parity, or last pregnancy interval ◦ maternal health conditions prior to pregnancy ◦ hypertension and diabetes, either pre-existing or gestational, ◦ pulmonary and renal disease, ◦ autoimmune disease, thrombophilic disorders ◦ congenital heart disease. Mother’s own diet and access to nutrition image distortion disorders such as bulimia, anorexia or hyperemesis gravidarum.
Environmental Etiologies Infections in early pregnancy (5-10%) • Malaria, rubella, cytomegalovirus, Toxoplasma gondii, syphilis • (malaria represents the largest portion of global burden of IUGR secondary to infectious etiologies.) Substance Abuse • Alcohol, Cocaine, heroin, and narcotic use during pregnancy Teratogens, maternal medications, or maternal substance abuse • antiepileptic medications (valproic acid), • antithrombotic agents (e.g., warfarin) • chemotherapeutic/ antineoplastic agents (e.g., cyclophosphamide). Location • High altitude versus near sea level • developed versus developing nations.
Placental Etiologies (m/c) Placental disorders ◦ chronic placental abruption, infarction, circumvallate shape, chorioangioma Umbilical cord abnormalities ◦ velamentous or marginal cord Multiple gestation ◦ A/w both SGA and prematurity ◦ risk of SGA 25% in twin pregnancies, 60% for triplet and quadruplet ◦ monochorionicity at higher risk of SGA and IUGR (unequal placental sharing, twin-to-twin transfusion) Small size placentas and histopathologically hypovascular villi, fibrin deposition, and/ or trophoblast degeneration Poor nutrient and oxygen provision to the fetus on a physiologic level
Pathophysiology
Placental insufficiency ◦ Majority of IUGR neonates ( idiopathic IUGR). ◦ Disruption in normal early vascularization of the placenta ◦ Incomplete spiral artery remodelling  shallow placental vasculature ◦ Failure of these vessels to appropriately become low- resistance vessels ◦ Limiting blood flow to the fetus ◦ Limiting nutrient/oxygen provision to the fetus and placenta itself.
Cont. Hormones - Insulin, thyroid hormones, adrenal hormones, pituitary hormones Insulin ◦ control cell number via direct mitogenic effects on cellular development, ◦ regulate glucose uptake and consumption in somatic tissues ◦ regulate other metabolic pathways, such as protein breakdown. ◦ IGF-1, IGF-2, IGFBP-2 and -3 implicated in the pathophysiology of IUGR in experimental models Chromosomal abnormalities ◦ Decreased numbers of fetal cells and poor cellular growth  IUGR
Screening 1. Maternal and family history  identify presence of etiologic risk factors 2. Accurate gestational dating  True SGA from wrong dates 3. Recurrence risk ◦ risk of recurrent SGA 20% ◦ risk of recurrent IUGR is estimated at ~20%-50% 4. Detailed maternal physical exam including Fundal height measurement
Evaluation 1. Fetal ultrasound: ◦ Biometric parameters (1) biparietal diameter, (2) head circumference, (3) abdominal circumference, and (4) femur length ◦ To distinguish symmetric from asymmetric IUGR ◦ Abdominal circumference - best “stand-alone” with specificity and a negative predictive value of almost 90% for diagnosing IUGR
◦ If EFW < 10th percentile for gestational age ◦ detailed evaluation - Doppler & Amniotic fluid ◦ Evaluation of fetal anatomy ◦ structural and genetic abnormalities (a/w chromosomal disorders or infections) ◦ ACOG suggest every 3-4 weeks assessment to minimize false-positive rates
2. Doppler velocimetry, (esp. umbilical artery) ◦ Severity of fetal growth restriction ◦ Reflection of maternal circulation ◦ Placental insufficiency, resistance will increase, diastolic flow will decrease, absent or reversed end- diastolic flow in the umbilical artery ◦ absent or reversed end-diastolic flow  poor prognostic factor a/w increased perinatal Mortality
3. Timing of delivery • Based on • Underlying etiology • Estimated gestational age • Early delivery of an IUGR fetus • Aneuploidy or congenital infection no improved outcomes • Placental insufficiency - antenatal surveillance helpful
RECOMMENDATION (ACOG) In Isolated fetal growth restriction oDelivery at 38 0/7 to 39 6/7 weeks in cases of, and IUGR fetuses with additional risk factors for poor prognosis odelivery at 34 0/7 to 37 0/7 weeks oRisk Factors - oligohydramnios, abnormal umbilical artery Doppler velocimetry Delivery ideally should be performed at a center with both high-risk maternal fetal medicine teams and a neonatal intensive care unit.
Prevention Very few “preventative” strategies Altering modifiable risk factors can help. (e.g. Cigarette smoking, diet, malarial prophylaxis in high-risk areas) No role - Nutritional and dietary supplementation regimens Not recommended - Bed rest New Modality – Aspirin Efficient in mitigating severe IUGR with abnormal Dopplers Increased birth weight at delivery Prolonging gestation Decreased need for NICU admission very less existing studies  NOT ROUTINELY INDICATED
Postnatal Diagnosis of IUGR  Problematic (lack of clarity in definition) 1. History 1. Prenatal history 2. Prenatal pattern of growth 3. Prenatal condition - Placental and Fetal structural abnormalities, abnormal genetic testing, family and previous maternal pregnancy history, and pregnancy infections 2. Evaluation 1. Histopathologic evaluation of the placenta - structural abnormalities, and large infarctions.
3. Examination 1. Anthropometric measurements at birth 2. Examination of the infant ◦ Stigmata of “malnourishment” ◦ Features of aneuploidies - dysmorphic facies, congenital anomalies ◦ stigmata congenital infections - microcephaly, petechiae and “blueberry muffin” rashes ◦ Cardiac murmur – a/w CHD
Stigmata of “Malnourishment” Large and wide anterior fontanelle, Absent buccal fat Small and scaphoid abdomen Thin umbilical cord, Decreased skeletal muscle & subcutaneous fat, Disproportionately large hands and feet, Loose and dry skin (axilla &gluteal regions) Large head compared to the body (Asymmetric IUGR)
Stigmata of “congenital infections”
Interventions to improve OUTCOME High risk of stillbirth, neonatal death, and prematurity 5 to 30-fold increase in morbidity and mortality 2.5 times more likely to be born premature Chances of needing more perinatal intervention like caesarean delivery, exposure to antenatal steroids, and admission to NICU
POSTNATAL CONCERN OVERALL RISK & ETIOLOGY MANAGEMENT RECOMMENDATIONS Perinatal distress / asphyxia • IUGR infants, compared to AGA, have a 5-30x increase in morbidity and mortality, even when born at term • 2.5x more likely to be born premature. • Increased risk for stillbirth and prematurity makes the delivery of an IUGR neonate high risk. • Increased risk of perinatal distress given in the setting of chronic poor blood flow and hypoxia. Attendance at delivery by a skilled team that can resuscitate a low birth weight or premature infant, ideally at a center with a neonatal intensive care unit
POSTNATAL CONCERN OVERALL RISK & ETIOLOGY MANAGEMENT RECOMMENDATIONS Hypoglycemia <2.6 mmol/L OR < 46 mg/dL • 1/3 of infants with a birth weight <10% have severe, recurrent, and/or prolonged hypoglycemia. • Due to suboptimal glycogen stores, impaired gluconeogenesis. • Decreased fat, increased sensitivity to insulin. May be exacerbated by polycythemia or hypothermia. Serial monitoring for hypoglycemia soon after birth. If persistent, prolonged, or severe: Formula supplementation, gavage feeding, provision of dextrose- containing intravenous fluids.
POSTNATAL CONCERN OVERALL RISK & ETIOLOGY MANAGEMENT RECOMMENDATIONS Respiratory complications • Poor in utero growth and concomitant risk for prematurity put IUGR infants at risk for respiratory distress syndrome in the short term and chronic lung disease in the long term. • IUGR infants exhibit evidence of pulmonary vascular remodeling, which may result in increased risk of pulmonary hypertension. Supportive care and respiratory support, as necessary.
POSTNATAL CONCERN OVERALL RISK & ETIOLOGY MANAGEMENT RECOMMENDATIONS Hypothermia • Decreased brown fat deposition in utero. Temperature monitoring, initiated soon after birth. • Provision of an exogenous heat source or incubator may be required Necrotizing enterocolitis/ feeding intolerance • Severe cases of IUGR (UA Dopplers), with concomitant prematurity, may have increased susceptibility to NEC and/or feeding intolerance. • Breastmilk provision and avoidance of formula. • Early initiation of trophic or small volume feeding.
POSTNATAL CONCERN OVERALL RISK & ETIOLOGY MANAGEMENT RECOMMENDATIONS Intraventricular hemorrhage • Due to cerebral vascular remodeling, cerebral autoregulatory mechanisms, and overall hemodynamic instability in IUGR. • Surveillance with head ultrasound. • Avoiding fluctuations in cerebral oxygenation using continuous monitoring such as near infrared spectroscopy. Electrolyte abnormalities • Hyperglycemia and hypocalcemia • Monitor for and correct abnormalities Polycythemia/jaundice • May occur as a response to long-standing hypoxia in utero. • Check for underlying hematologic abnormalities, and treat when clinically indicated.
POSTNATAL CONCERN OVERALL RISK & ETIOLOGY MANAGEMENT RECOMMENDATIONS Abnormal innate and humoral immunity • Due to bone marrow suppression secondary to chronic hypoxia. • Check for underlying abnormalities with a complete blood count and differential. • Low threshold for infectious work-up and aggressive management of infection
Potential targets for therapy Malhotra A, Allison BJ, Castillo-Melendez M, Jenkin G, Polglase GR, Miller SL. Neonatal morbidities of fetal growth restriction: pathophysiology and impact. Frontiers in endocrinology. 2019 Feb 7;10:55.
Complications
Neonatal morbidities in IUGR
Long Term Outcomes 1. Neurodevelopmental consequences ◦ increased risk for cerebral palsy ◦ lower scores across multiple neurocognitive domains including cognition, attention, mood, and social skills ◦ decreased brain volume, gray matter, and hippocampal volumes ◦ asymmetric IUGR - brain-sparing appears to be regional, not global “Optimized postnatal growth seems to portend better neurocognitive outcomes”
2. Cardiometabolic consequences Phenomenon of – “Developmental programming” ◦ Based on epidemiologic studies showing that maternal gestation during periods of famine results in IUGR offspring that are at increased risk for cardio-metabolic disease during adulthood. ◦ Examples - obesity, cardiovascular disease, and diabetes
3. Other Long term Outcomes ◦ Propensity toward cancer, ◦ schizophrenia, ◦ Alzheimer’s disease, ◦ polycystic ovarian syndrome, ◦ shorter life span ◦ immune dysfunction
What's New 1. Behavioral interventions and SGA (December 2021) ◦ Participants were randomly assigned to a structured Mediterranean diet, mindfulness-based stress reduction, OR usual care from 20 weeks of gestation to delivery. The rate of SGA births was significantly lower for both structured diet (14 percent) and stress reduction (16 percent) compared with usual care (22 percent) 2. Timing of delivery in fetal growth restriction (August 2021) ◦ Infants who were severely small for gestational age (SGA, birth weight <3rd percentile) and delivered early for suspected FGR had poorer school outcomes in grades 3, 5, and 7 compared with infants with the same degree of SGA who were not suspected of having FGR (mean gestational age at birth: 37.9 versus 39.4 weeks)
Take Home Message IUGR is due to fetal growth less than its genetic potential. To diagnose, prevent, and develop therapies for intrauterine growth restriction – A challenge Broad Aetiologies are: Fetal, Maternal, Environmental and Placental Prenatal screening largely depends on serial USG & Doppler - still debate as to how these should be used to dictate prenatal care and delivery planning IUGR has significant short- and long-term consequences for the neonate
Thank You
Fanaroff and martin's neonatal-perinatal medicine www.UpToDate.com
Intrauterine growth restriction Intrauterine growth restriction