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Iugr by dr derar ismerat

1. Intrauterine growth restriction (IUGR) is a complication of pregnancy where the fetus does not attain its full growth potential, affecting up to 10% of pregnancies. 2. Risk factors for IUGR include maternal conditions, fetal anomalies, infections, and placental insufficiency. Abnormal umbilical artery Doppler is associated with increased risk of adverse outcomes. 3. Serial ultrasounds and Doppler studies are used to monitor fetal growth and well-being. Timing of delivery depends on gestational age and severity of IUGR.

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INTRAUTERINE GROWTH RESTRICTION PRESENTED AND PREPARED BY DR . DERAR I . I . ISMERAT OBSTETRICS AND GYNECOLOGY RESIDENT DOCTOR AT AL-AHLI HOSPITAL
Intrauterine growth restriction (IUGR) is a poorly understood complication of pregnancy, affecting up to 10% of live-born infants. It is characterized as a rate of fetal growth less than normal for the gestational-age appropriate growth potential Quantitatively, this poor fetal growth has been defined by the American College of Obstetricians and Gynecologists as estimated fetal weight of <10th percentile for gestational age, often times with ultrasound evidence of growth deceleration late in gestation or abnormal Doppler indexes in the umbilical artery or middle cerebral artery.
Fetal growth restriction, (IUGR), is a common complication of pregnancy. • Pathologic condition where there is a restriction of growth in utero, and the fetus does not attain its full growth potential. • Complicates ≈5-10% of pregnancies • Third leading cause of perinatal mortality after anomalies and prematurity Perinatal mortality inversely proportional to percentile growth: 1.5% <10% 2.5% < 5th %
Correlation of birth weight percentile to perinatal morbdity and mortalility
IUGR (Intrauterine Growth Restriction) SGA (Small for Gestation Age) 30% babies with birthweight <10th percentile 70% babies with birthweight <10th percentile Growth restricted Not growth restricted Constitutionally and anatomically abnormal Constitutionally small but anatomically normal ↑ Obstetric/neonatal risk NO obstetric/neonatal risk {Variable} Normal subcutaneous fat
• Stage I (Hyperplasia) • - 4 to 20 weeks • - Rapid mitosis • - Increase of DNAcontent • Stage II (Hyperplasia & Hypertrophy) • - 20 to 28 weeks • - Declining mitosis. • - Increase in cell size. • 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.
• 15 weeks = 5 grams/day • 20 weeks = 10 grams/day • 30 weeks = 25 grams/day • 35 weeks = 35 grams/day • 40 weeks = 15 grams/day • May vary by race, gender, multiple gestation
Reduce fetal growth support.. EXTRINSIC CAUSES Reduce fetal growth potential.. INTRINSIC CAUSES PALCENTAL FACTORS MATERNAL FACTORS ANEUPLOIDY INTRA UTERINE INFECTION More morbidities and mortalities More long term effects
Infection  CMV, Rubella, Toxoplasma gondii – severe IUGR  Syphilis, Tuberculosis, Malaria, listeriosis  Herpes simplex, chicken pox Chromosomal abnormality  Trisomy 18,13 –severe IUGR  Trisomy 21  Turner syndrome (45,XO(  Klinefelter syndrome (47,XXY( Congenital anomalies  Congenital Heart diseases  Anencephaly
• Maternal malnutrition • Poor maternal weight gain • Severe anemia • Chronic hypoxemia • Cardiovascular disease • Drugs and teratogens • Multiple pregnancy • Antiphospholipid antibodies syndrome
• Placental infarction • Placental abruption • Twin-twin transfusion syndrome • Placenta previa , circumvallate placenta • Marginal or velamentous insertion of umbilical cord
: proposed in 1990 by the British epidemiologist David Barker (b. 1939) that intrauterine growth retardation will increase :. • Increased risk of adult metabolic syndrome • Obesity • Type 2 diabetes mellitus • Coronary artery disease • Stroke • Up to 50% cognitive disability • Increased risk of cerebral palsy • <10th percentile at 8 years • Early IUGR less likely to catch up
• Clinical assessment • Ultrasonic measurement • Doppler velocity
– Teen age – High altitude – Socioeconomic factor – Smoking , Alcohol , Drugs – Previous IUGR pregnancy history – previous IUGR in family
Seldom elicited before 28 weeks of gestation: . Failure of fetus and uterus to grow at the normal rate over a 4 week period; .Uterine fundal height should be at least 2cm less than expected for the length of gestation; .Poor maternal weight gain; . Diminished fetal movements.
Uterine fundal height  Uterine fundus  symphysis Pubic  Simple, Safe, Inexpensive for screening  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 suspected
 Inter-observer variations  Obese patients  Transverse lie  Multiple gestation  Polyhydramnios / Oligohydram  Uterine fibroids nios
Initial U/S at 16 to 20 weeks to establish gestational age and identify anomalies and repeated at 32 to 34 weeks to evaluate fetal growth
The measurements most commonly used to measure and follow fetal growth are: Biparietal Diameter HeadCircumference Femur Length Abdominal Circumference Used between 15-42 weeks. Normal ratio: <36 weeks = 1:1 >36 weeks - ratio decreases as the AC increases.
Mild IUGR – Normal amniotic fluid Severe IUGR – Oligohydramnios (AFI is ≤ 5) Incidence 40%
• Blood flowing through the umbilical arteries originates from the fetus and enters the placenta. • The flow of blood through the arteries is dependent upon the strength of the fetal heart contraction and the health of the placenta. • Blood returning from the placenta goes throughthe umbilical vein to the fetus.
• Doppler principle based on changes in sound waves related to the flow velocity of blood traveling through these vessels. • The umbilical artery was first used to study this flow velocity in in 1977. • The umbilical arterial waveform usually has a "saw tooth" type pattern with flow always in the forward direction •The umbilical artery is evaluated by measuring the blood flow velocity at peak systole (maximal contraction of the heart) and peak diastole (maximal relaxation of the heart). • These values are then computed to derive a ratio.
• As GA advances, increase blood flow at diastole means placenta less resistant.
• In growth-retarded fetuses and fetuses developing intra- uterine distress, there is more placental resistance and the umbilical artery blood velocity waveform usually changes in a progressive manner. • Increased resistance, absent end diastolic flow, reverse flow. • Increasing RI values and S:D ratios if blood flow during diastole is decreased.
• Absent End Diastolic flow
• reversal of end diastolic flow (REDF)
• notching in late in pregnancy is an indicator of increased uterine vascular resistance and impaired uterine circulation’
: – characterized by absent or reversed end-diastolic flow – associated with fetal growth restriction A. Normal velocimetry pattern with an S/D ratio of < 3.0 B. The diastolic velocity approaching zero reflects increased placental vascular resistance. C. During diastole, arterial flow is reversed (negative S/D ratio), which is an ominous sign precede fetal demise
Hypothermia? Hypoglycemia? Or Hypocalcemia? decreased subcutaneous fat, increased surface- volume ratio, decreased heat production decreased glycogen stores/ glycogenolysis/ gluconeogenesis increased metabolic rate deficient catecholamine release Associated with perinatal stress, asphyxia, prematurity
Prepregnancy: to prevent it by identifying risk factors and treat as necessary (e.g. improve nutrition intake, stop smoking or alcohol, ASA in APA syndrome, and Heparin in thrombophilias) Antepartum: identify risk factors that can be changed. Fetal surveillance by ultrasound (BPP) and fetal heart monitoring (Non-Stress Test). To decide on timing and mode of delivery.
Near term  Prompt delivery Recommend delivery at 34 weeks or beyond if there is clinically significant oligohydramnios • Growth Restriction Intervention Trial • Only published randomized trial to assess the timing of delivery of the early preterm (less than 34 weeks of gestation) growth-restricted fetus. • Randomized to either the early delivery group (delivery within 48 hours) or to the expectant management group (with antepartum surveillance until it was felt that delivery should not be delayed any longer) • Betamethasone administration were the same in both groups
• Prospective Observational Trial to Optimize Pediatric Health in Intrauterine Growth Restriction (IUGR) (PORTO STUDY) • National prospective observational multicenter study • Evaluate which sonographic findings were associated with perinatal morbidity and mortality in pregnancies affected by growth restriction (defined as estimated fetal weight (EFW) <10th centile) • Am J Obstet Gynecol. 2013Apr;208(4)
• STUDY DESIGN: • Over 1100 consecutive ultrasound-dated singleton pregnancies with EFW <10th centile were recruited from January 2010 through June 2012. • A range of IUGR definitions were used, including EFW orabdominal circumference <10th, <5th, or <3rd centiles • with or without oligohydramnios • with or without abnormal umbilical arterial Doppler • Adverse perinatal outcomes included intraventricular hemorrhage, periventricular leukomalacia, hypoxic ischemic encephalopathy, necrotizing enterocolitis, bronchopulmonary dysplasia, sepsis, and death • Am J Obstet Gynecol. 2013Apr;208(4)
• RESULTS: • N=1116 fetuses • 312 (28%) were admitted to neonatal intensive care unit • 58 (5.2%) were affected by adverse perinatal outcome including 8 mortalities (0.7%) • The presence of abnormal umbilical Doppler was significantly associated with adverse outcome, irrespective of EFW or abdominal circumference measurement. • The only sonographic weight-related definition consistently associated with adverse outcome was EFW <3rd centile (P = .0131), all mortalities had EFW <3rd centile. • Presence of oligohydramnios was clinically important when combined with EFW <3rd centile (P = .0066). • Am J Obstet Gynecol. 2013 Apr;208(4)
• CONCLUSION: • Abnormal umbilical artery Doppler and EFW <3rd centile were strongly and most consistently associated with adverse perinatal outcome. • Stricter IUGR cutoffs may be warranted and future studies should comparing various definitions of IUGR and management strategies
• Management • Serial US q 2-4 weeks is indicated • Antenatal surveillance with umbilical artery Doppler velocimetry and antepartum testing (NST,BPP) • Delivery depends on the underlying etiology and estimated gestational age • Eunice Kennedy Shriver National Institute of Child Health and Human Development/Society for Maternal-Fetal Medicine/American College of Obstetricians and Gynecologists Joint Conference • Dx fetal growth restriction: • Delivery at 38 0/7–39 6/7 weeks of gestation isolated fetal growth restriction • Delivery at 34 0/7–37 6/7 weeks of gestation in cases of fetal growth restriction with additional risk factors for adverse outcome (eg, oligohydramnios, abnormal umbilical artery Doppler velocimetry results, maternal risk factors, or co- morbidities)
• Delivery for fetal growth restriction before 34 weeks: • Planned at a center with a neonatal intensive care unit and consultation with a maternal–fetal specialist. • Antenatal corticosteroids should be administered • For cases in which delivery occurs before 32 weeks: • Magnesium sulfate should be considered for fetal and neonatal neuroprotection.
• Heads are disproportionately large for their trunks and extremities • Facial appearance has been likened to that of a “wizened old man”. • Long nails. • Scaphoid abdomen
• Way of characterizing the relationship of height to mass for an individual. • PI = 1000 x cubed root of Mass (kgs) Height (cms) • Typical values are 20 to 25. • PI is normal in symmetric IUGR. • PI is low in asymmetric IUGR
Iugr by dr derar ismerat