Intrauterine growth restriction (IUGR) can be classified as symmetrical or asymmetrical based on ultrasound measurements of head and abdominal circumference. Symmetrical IUGR results in proportional growth restriction from early pregnancy insults while asymmetrical IUGR shows brain sparing and a decreased abdominal circumference from late pregnancy placental insufficiency. IUGR is diagnosed through clinical assessment, ultrasound measurements of fetal size below the 10th percentile, and abnormal Doppler velocimetry of the umbilical artery. Management depends on gestational age, with delivery near term for growth restriction and observation with fetal surveillance for earlier restriction unless severe complications arise. Long term risks for infants with IUGR include metabolic and neurological sequel

1. IUGR(Intrauterine Growth Restriction)4th Year Medical Student PCM 34Present 17th October ,2011

2. 1234567DefinitionClassificationCauseDiagnosisPreventionManagementLong term sequelaeContents

3. DefinitionFailure of normal fetal growth

4. Most common definition “ fetus weighing below 10th percentile for GA”(SGA)Other definition

5. BW < -2SD for GA

6. BW < 3rd percentile for GA 10th Percentile

8. ClassificationCampbell and Thoms (1977) described the use of the sonographically determined head-to-abdomen circumference ratio (HC/AC) to differentiate growth-restricted fetuses.Symmetrical IUGR (type I)Asymetrical IUGR (type II)Combined type

9. Classification1.Symmetrical growth restriction20 % of IUGR Infants proportional decrease in all organsHC/AC ratio is normalOccurs inearly pregnancy : cellular hyperplasiaIncrease risk for long term neurodevelopmental dysfunction

10. Classification1.Symmetrical growth restrictionIntrinsic factorChromosomal abnormalitiesCongenital anomaliesIntrauterine infectionLOGO

11. Classification1. Symmetrical growth restrictionAn early insult could result in a relative decrease in cell number and size.

12. chemical exposure

13. viral infection

14. cellular maldevelopment with aneuploidy

15. It may cause a proportionate reduction of both head and body size.LOGO

16. LOGO

17. Classification2.Asymmetrical growth restriction75 % of IUGR Infants Increase HC/AC ratio : decrease in abdominal size Brain sparing effects Occurs in late pregnancy : cellular hypertrophy Risk for perinatal hypoxia, neonatal hypoglycemia Good prognosis LOGO

18. Classification2.Asymmetrical growth restrictionExtrinsic factors : uteroplacental insufficiencyMaternal vascular disease: hypertensionMultiple gestationsPlacental diseaseAbruption, infarctsAbnormal cord insertion, hemangiomaLOGO

19. Classification2.Asymmetrical growth restrictionIt might follow a late pregnancy insult such as

20. placental insufficiency from hypertension

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.LOGO

22. ClassificationSuch 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. 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.LOGO

24. LOGO

25. Classification3. Combine typeAsymmetricalsymmetrical

26. Symmetricalasymmetrical More morbidities and mortalities More long term effectsLOGO

27. Classification3. Combine typeA 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. A fetus with symmetrical IUGR how have complication with circulation in late gestational aged, may cause reduction of abdominal circumference.LOGO

29. CauseFetal causesMaternal causesPlacental causesLOGO

30. CauseFetal causesInfection

31. CMV, Rubella, Toxoplasmagondii – severe IUGR

32. Syphilis, Tuberculosis, Malaria, listeriosis

33. Herpes simplex, chicken pox

34. Chromosomal abnormality

35. Trisomy 18,13 –severe IUGR

36. Trisomy 21

37. Turner syndrome (45,XO), Klinefelter syndrome (47,XXY)LOGO

38. CauseFetal causesCongenital anomalies

39. Congenital Heart diseases

40. Anencephaly

41. Renal agenesis, osteogenesisimperfectaLOGO

42. CauseMaternal causesMaternal malnutrition

43. Poor maternal weight gain

44. Severe anemia

45. Chronic hypoxemia

46. Cardiovascular disease

47. Drugs and teratogens

48. Multiple pregnancy

49. Antiphospholipid antibodies syndromeCausePlacental causesPlacental infarction

50. Placental abruption

51. Chorioangioma

52. Placenta previa , circumvallate placenta

53. Marginal or velamentous insertion of umbilical cordCause Fetal causes (intrinsic factors) Symmetrical IUGRMaternal causes Plcental causes (extrinsic factors) Asymmetrical IUGR

54. DiagnosisClinical assessment

55. Ultrasonic measurement

56. Doppler velocityDiagnosisI. Clinical assessmentHistory for risk factor

57. Socioeconomic factor

58. Smoking , Alcohol , Drugs

59. Previous IUGR pregnancy history

60. Family history : previous IUGR in familyDiagnosisPhysical examination

61. Uterine fundal height

62. Uterine fundus Pubic symphysis

63. Simple, Safe, Inexpensive for screening

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 suspectedDiagnosisI. Clinical assessmentPhysical examination

65. Uterine fundal height

66. Maternal body weight : BW<45 kg or : BW increased < 6.5 kg all over pregnancy

67. DiagnosisMaternal underlying diseaseMedical condition ภาวะขาดสารอาหาร โลหิตจางอย่างรุนแรง ภาวะขาดออกซิเจนอย่างเรื้อรัง โรคไตบางชนิด โรคหลอดเลือดในมารดาAntiphospholipid antibody syndromeObstetric conditionครรภ์แฝด

68. DiagnosisII. Ultrasonic measurementInitial U/S at 16 to 20 weeks to establish gestational age and identify anomalies and repeated at 32 to 34 weeks to evaluate fetal growthDiagnosisII. Ultrasonic measurementAbdominal circumference (AC) ***

69. Sensitivity 90-100% , Specificity 95% (ดีที่สุด)

70. < 5 thpercentile

71. Biparietal diameter (BPD)

72. Growth curve < 10 th percentile

73. Sensitivity to Symmetrical > Asymmetrical

74. Head-Abdominal circumference ratio (HC/AC ratio)

75. Diagnosis for asymmetrical IUGR

76. HC/AC ratio > 2 SDDiagnosisII. Ultrasonic measurementFemur length– abdominal circumference ratio (FL/AC ratio)

77. เป็น age independent index ในทารกที่ GA>20 wks

78. จะมีค่าคงที่เท่าๆกันทุกอายุครรภ์คือ 20-24%

79. ในรายที่ >24% ให้สงสัย IUGR

80. Estimate fetal weight

81. < 10 thpercentileDiagnosisII. Ultrasonic measurementAmniotic fluid volume

82. ในภาวะ IUGR จะลดลงเป็นอย่างแรก

83. เกิดจาก renal perfusion ลดลง

84. Vertical pocket ที่ใหญ่ที่สุด ได้ < 1 cm. ถือว่าผิดปกติ

85. การตรวจพบน้ำคร่ำน้อยอย่างเดียว ไม่สามารถวินิจฉัยภาวะ IUGR ได้ต้องร่วมกับการตรวจอื่นๆด้วย

86. < 5th Percentile

87. < 10th Percentile

88. DiagnosisIII. Doppler velocimetryAbnormal umbilical artery Doppler velocimetry

89. characterized by absent or reversed end-diastolic flow

90. associated with fetal growth restrictionNormal velocimetry pattern with an S/D ratio of <30. The diastolic velocity approaching zero reflects increased placental vascular resistance. During diastole, arterial flow is reversed (negative S/D ratio), which is an ominous sign that may precede fetal demise

91. PreventionStop and avoid all of the risk factors

92. Control maternal U/D

93. Antimalarial prophylaxis

94. Correction of nutritional deficiencies

95. Low-dose aspirin prophylaxis

96. Hypertension

97. Prior IUGR history ManagementGrowth restriction near term

98. Prompt delivery

99. Recommend delivery at 34 weeks or beyond if there is clinically significant oligohydramniosManagementGrowth restriction remote from term

100. No specific treatment

101. If diagnosed in prior to 34 weeks, and amnionic fluid volume and fetal surveillance are normal “Observation is recommended± screening for toxoplasmosis,herpes,rubella,CMV and others” Specific treatment(causes of IUGR) and supportive careIf severe IUGR or bad obstetric conditions  Terminate pregnancy should be considered

102. Long-term sequelaeType 2 DM

103. Atherosclerosis

104. Hypertension

105. Heart diseases

106. Cerebral palsy

107. Learning deficitsThank You !