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 34 Present 17th October ,2011

2. 1 2 3 4 5 6 7 Definition Classification Cause Diagnosis Prevention Management Long term sequelae Contents

5. BW < -2SD for GA

8. Classification Campbell 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. Classification 1.Symmetrical growth restriction 20 % of IUGR Infants proportional decrease in all organs HC/AC ratio is normal Occurs inearly pregnancy : cellular hyperplasia Increase risk for long term neurodevelopmental dysfunction

10. Classification 1.Symmetrical growth restriction Intrinsic factor Chromosomal abnormalities Congenital anomalies Intrauterine infection LOGO

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. Classification 2.Asymmetrical growth restriction 75 % 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. Classification 2.Asymmetrical growth restriction Extrinsic factors : uteroplacental insufficiency Maternal vascular disease: hypertension Multiple gestations Placental disease Abruption, infarcts Abnormal cord insertion, hemangioma LOGO

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

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

26. Symmetricalasymmetrical More morbidities and mortalities More long term effects LOGO

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

29. Cause Fetal causes Maternal causes Placental causes LOGO

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

39. Congenital Heart diseases

40. Anencephaly

41. Renal agenesis, osteogenesisimperfectaLOGO

43. Poor maternal weight gain

44. Severe anemia

45. Chronic hypoxemia

46. Cardiovascular disease

47. Drugs and teratogens

48. Multiple pregnancy

50. Placental abruption

51. Chorioangioma

52. Placenta previa , circumvallate placenta

55. Ultrasonic measurement

57. Socioeconomic factor

58. Smoking , Alcohol , Drugs

59. Previous IUGR pregnancy history

61. Uterine fundal height

62. Uterine fundus Pubic symphysis

63. Simple, Safe, Inexpensive for screening

65. Uterine fundal height

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

67. Diagnosis Maternal underlying disease Medical condition ภาวะขาดสารอาหาร โลหิตจางอย่างรุนแรง ภาวะขาดออกซิเจนอย่างเรื้อรัง โรคไตบางชนิด โรคหลอดเลือดในมารดา Antiphospholipid antibody syndrome Obstetric condition ครรภ์แฝด

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

77. เป็น age independent index ในทารกที่ GA>20 wks

78. จะมีค่าคงที่เท่าๆกันทุกอายุครรภ์คือ 20-24%

79. ในรายที่ >24% ให้สงสัย IUGR

80. Estimate fetal weight

82. ในภาวะ IUGR จะลดลงเป็นอย่างแรก

83. เกิดจาก renal perfusion ลดลง

84. Vertical pocket ที่ใหญ่ที่สุด ได้ < 1 cm. ถือว่าผิดปกติ

86. < 5th Percentile

87. < 10th Percentile

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

92. Control maternal U/D

93. Antimalarial prophylaxis

94. Correction of nutritional deficiencies

95. Low-dose aspirin prophylaxis

96. Hypertension

98. Prompt delivery

100. No specific treatment

103. Atherosclerosis

104. Hypertension

105. Heart diseases

106. Cerebral palsy