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Intrauterine Growth Restriction (IUGR) / Small For gestational Age

This document discusses fetal growth restriction (FGR), also known as intrauterine growth restriction (IUGR). It defines FGR as fetal weight below the 10th percentile for gestational age, indicating failure to reach genetic growth potential and increased risks. It describes the normal phases of fetal growth and classifications of IUGR. It outlines risk factors, potential complications, diagnostic methods including ultrasound assessments, and management approaches including monitoring, medical interventions and timing of delivery.

Health & Medicine◦
FETAL GROWTH RESTRICTION POOJA SANALKUMAR
INTRODUCTION  A condition where fetal weight is below 10th percentile or 2SD for the gestational age.  Fetus fails to reach its genetic growth potential  fetus is SMALL for GESTATIONAL AGE (SGA)  increased risk of perinatal morbidity and mortality.  Incidence: 3-10% of infants.
NORMAL GROWTH In 3 phases 1. Cellular hyperplasia phase:  increase in cell number.  lasts for first 16 weeks of gestation. 2. Phase of concomitant hyperplasia & hypertrophy:  increase in cell size and number.  Between 16 to 32 weeks. 3. Cellular hypertrophy phase:  Increase in size- fetal glycogen & fat deposition takes place.  Between 32 weeks to term.
Contin. Growth rates during 3 phases:  15 weeks- 5g/day  24 weeks-15-20g/day  34 weeks-30-35g/day
CLASSIFICATION Depending upon onset(32 weeks of gestation)  Early onset  Late onset Depending on pathologic process and time of onset.  Type I or symmetrical or intrinsic IUGR  Type II or asymmetrical or extrinsic IUGR  Intermediate IUGR
CHARACTER SYMMETRICAL IUGR ASYMMETRICAL IUGR Incidence 20-30% 70-80% Growth inhibition Hyperplastic stage - early pregnancy Hypertrophic stage - late pregnancy No. of cells reduced Normal but reduced in size Growth parameters HC/AC & Wt./Lt ratio <10 percentile HC/AC ratio altered- Head sparing effect Ponderal index normal Low Associated with Uterine infections-CMV, rubella, anemia, chromosomal abnormalities, maternal abuse c/c hypertensive disorder, severe malnutrition, genetic mutations Baby size Uniformly small Head – normal, rest of body- thin & small
TYPE I or SYMMETRICAL or INTRINSIC IUGR  Anthropometric measurements below 10 percentile for gestational age.  Causes: TORCH infections, chromosomal disorders & congenital malformations.  25% severe early IUGR have aneuploidy.
TYPE II or ASYMETRICAL or EXTRINSIC IUGR  Characterized by relatively greater decrease in abdominal size than head circumference.  D/t uteroplacental insufficiency- redistribution of blood flow to vital organs(brain sparing effect), head growth remains normal while abdominal girth slows down.  Leads to chronic hypoxia and fetal death.
INTERMEDIATE IUGR  Combination of type I & type II  5-10% of IUGR.
ETIOLOGY 1. MATERNAL FACTORS 2. FETAL FACTORS 3. PREGNANCY COMPLICATIONS
1.MATERNAL FACTORS  Extremes of maternal age.  Hypertension and vascular disease  Constitutionally small mothers  Chronic maternal hypoxia: d/t pulmonary disease, cyanotic heart disease & severe anemia  Prothrombotic disorder: antiphospholipid syndrome  Maternal malnutrition
MATERNAL FACTORS  Infection: CMV, Toxoplasmosis, Varicella-Zoster, Malaria  Substance abuse & cigarette smoking  Teratogens: Folate antagonists, antineoplastic agents, anticonvulsants.  History of IUGR in previous pregnancies.  Assisted reproductive technologies
2. FETAL FACTORS  Congenital malformations  Fetal infections: CMV, HIV, toxoplasma, etc.  Chromosomal abnormalities: trisomy 21 & trisomy 18  Genetic: agenesis of pancreas, galactosemia, phenylketonuria.
3. PREGNANCY COMPLICATIONS  Multiple pregnancies  Placental and cord abnormalities: Circumvallate placenta, chronic placental abruption, placenta previa, chorioangioma.
RISK FACTORS
MAJOR RISK FACTORS  Maternal age >40 years  Smoker > 11 cigarettes per day  Cocaine  Daily vigorous exercise  Previous SGA baby  Previous stillbirth  Maternal SGA  C/c HTN  Diabetes & vascular diseases  Renal impairment  Antiphospholipid syndrome  Echogenic bowel  preeclampsia  Severe pregnancy induced HTN  Low maternal weight  PAPP-A <0.4 MoM
MINOR RISK FACTORS  Maternal age > 35 years  Nulliparity  BMI <20  BMI 25-29.9  Smoker 1-10 per day  Low fruit intake per day  Preeclampsia  Pregnancy interval < 6 months  Paternal SGA
COMPLICATIONS
FETAL COMPLICATIONS  Antenatal: c/c fetal distress, hypoxia & acidosis, fetal death  After birth:  Asphyxia and RDS  Hypoglycemia  Meconium aspiration syndrome  Hypothermia  Pulmonary h’age  Polycythemia  Hyperviscosity syndrome  Necrotizing enterocolitis  Intraventricular h’age
DIAGNOSIS OF IUGR
DIAGNOSIS OF IUGR 1. SCREENING:  Accurate knowledge of gestational age  Past history of IUGR & any maternal complication  On obstetric palpation, height of uterus <4 weeks or more for the gestational age.  Uterine fundal height: serial fundal height measurements throughout pregnancy.
2. DIAGNOSIS: Ultrasound measurements:  Fetal biometry: fetal parietal diameter(BPD), femur length (FL) & abdominal circumference(AC) are measured.  AC diameter is considered to be correlated with fetal weight.  Increase in AC of <10mm over a 2 week period is suggestive of IUGR.  Body proportions: HC/AC ratio, FL/AC ratio & ponderal index for asymmetric IUGR.  HC/AC ratio: size of liver is disproportionately smaller than head circumference or length of femur
 Amniotic fluid volume: Oligohydramnios d/t ↓ fetal urine production.  Doppler velocimetry: abnormal umbilical artery Doppler velocimetry- increased systolic-diastolic ratio, absent or reverse end-diastolic flow.  In Hypoxic fetus, ratio of MCA S/D value to umbilical a. S/D value reflects fetal compromise.
MANAGEMENT
1. BEFORE 37 WEEKS OF GESTATION  Exclude any fetal malformations  Monitor fetal growth & well-being
MEDICAL INTERVENTION  Adequate BED REST in left lateral position- increase uteroplacental flow.  Maternal OXYGEN THERAPY  Pharmacotherapy: low dose aspirin, beta mimetics, heparin, calcium channel blockers  Treating associated MATERNAL CONDITIONS: anemia, hypertension  High protein diet
ASSESSMENT OF FETAL GROWTH  CLINICAL ASSESSMENT – maternal wt. and uterine growth charts (weekly)  ULTRASOUND ASSESSMENT: fetal parameters(BPD, HC, FL, AC) are measured every 10 -14 days
ASSESSMENT OF FETAL WELL-BEING  NON-STRESS TEST: based on the principle that fetal heart rate accelerates temporarily in response to fetal movements.  DAILY FETAL MOVEMENT COUNT: regular & frequent fetal movements.  BIOPHYSICAL PROFILE (MANNING’S)
OBSTETRIC INTERVENTION  Indications of delivery of IUGR:  Arrest of growth over 2-4 week interval.  Low BPP score  Oligohydramnios at >34 weeks determined by tests of fetal well being  REDF  Indications of delivery at 37 weeks in IUGR:  Mild or uncomplicated IUGR  End diastolic flow is present  Reassuring antepartum fetal testing
AT 37 WEEKS OR MORE  Mild IUGR & fetus is not under stress, labour can be induced and vaginal delivery can be attempted.  Severe IUGR: cesarean section
INDICATIONS FOR CESAREAN SECTION  Severe preeclampsia  Malpresentations  Fetal compromise  ARED flow
Ht. of uterus < 4 weeks than estimated gestation Consider IUGR after recalculating gestation & Confirm diagnosis by USG and Doppler velocimetry Gestation > 37 weeks Deliver the patient Gestation <37 weeks Monitor fetal growth and fetal well being Fetal movement count, NST twice weekly or on alternative days in severe IUGR If abnormal, modified biophysical profile, Doppler velocimetry to determine degree of asphyxia If fetus grow & is well, deliver at 37 weeks. If shows signs of asphyxia deliver with proper neonatal setup. Fetal growth: serial uterine ht. and maternal wt. ,USG every 10-14 days
THANK YOU
Daily fetal movements count Methods:  Mother records the time taken each day to feel 10 movements.  Normally, its perceived in 2-3 hours.  Failure to perceive 10 movements in 12hrs. Time needs assessment by biophysical methods.  Monitoring number of movements made by the fetus in one hour.  Done on full stomach & preferably at the same period of time everyday.
Non-stress test  Normal/Reactive non stress test- 2 or more acceleration pf heart rate (15beats or more) each lasting for >15 secs. with fetal movements within 20 mins. of testing.  To account for fetal sleep cycles, recording may be done for 40 mins. Before concluding insufficient fetal reactivity.  Non-reactive: if there is no fetal movements or fetal accelerations for a period of 40 mins.
BIOPHYSICAL PROFILE VARIABLE SCORE 2 SCORE 0 Non-stress test Reactive Non-reactive Fetal breathing >1 episodes of rhythmic breathing lasting for 30 secs or more within 30mins. <30 secs. Breathing in 30 mins Fetal movements >3 body or limb movements in 30 mins. <2 movements in 30secs. Fetal tone Extension of fetal extremity with return to flexion, or closing or opening hand No extension/flexion. Amniotic fluid volume Single vertical pocket >2cm Largest single vertical pocket <2cm A biophysical score of 0 – significant academia While 8-10 is associated with normal pH.