IUGR - Intra Uterine Growth Intra Retardation Retardation...

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Unformatted text preview: Intra Uterine Growth Intra Retardation Retardation Prof.Surendra Nath Panda, M.S. Dept.of Obstetrics & Gynecology M.K.C.G.Medical College Berhampur, Orissa, INDIA Intra Uterine Growth Retardation Intra Retardation Intra Uterine Growth Restriction Small for gestational age (SGA) Foetal growth restriction 'wasted' and 'stunted' Please also see notes pages for more details in most of the slides Definition Definition Intrauterine growth retardation (IUGR) occurs when the unborn baby is at or below the 10th weight percentile for his or her age (in weeks). The foetus is affected by a pathologic restriction in its ability to grow. restriction Low birth weight (LBW) means a baby with a birth weight of less than 2500Gms, which could be due to IUGR or Prematurity which Please also see notes pages for more details in most of the slides Classification Classification Symmetricl Symmetric the baby's head and body are proportionately small. are may occur when the foetus experiences a problem during early development. development. Asymmetrical baby's brain is abnormally baby's large when compared to the liver. liver may occur when the foetus may foetus experiences a problem during later development during In a normal infant, the brain weighs about three times more than the liver. In In asymmetrical IUGR, the brain can weigh five or six times more than the liver. asymmetrical Classification Newer Classification: 1. Normal small fetuses- have no structural abnormality, normal umbilical artery & liquor but wt., is less.They are not at risk and do not need any special care. 2. Abnormal small fetuses- have chromosomal anomalies or structural malformations. They are lost cases and deserve termination as nothing can be done. 3. Growth restricted fetuses- are due to impaired placental function.Appropriate & timely treatment or termination can improve prospects. Aetiology Aetiology The foetal growth is dependent on multiple factors. The IUGR resulting in SGA babies can result from many IUGR factors known and unknown either acting alone or in conjunction or in association . conjunction The aetiologic determinants of IUGR have two The etiologic measures of effect: relative risk and etiologic fraction. etiologic Most of the evidence on aetiologic determinants is Most etiologic based on observational studies and systematic overviews or meta-analyses of such studies. overviews In a majority of cases (40%) the cause is unknown– In probably due to placental insufficiency (idiopathic). probably Aetiology Aetiology 1. General- Racial / Ethnic origin, Small maternal / Generalpaternal height / weight, Foetal sex. paternal 2. 3. 4. 5. Maternal causes. Foetal causes. Placental causes. Idiopathic- In a majority of cases (40%) the Idiopathiccause is unknown– probably due to placental insufficiency. insufficiency. Maternal Risk Factors Maternal Has had a previous baby who suffered from Has IUGR. IUGR. Extremes of age. Extremes Is small in size (Ht & Wt). Has poor weight gain and malnutrition during Has malnutrition pregnancy. pregnancy Is socially deprived. Uses substances (like tobacco, narcotics, alcohol) Uses that can cause abnormal development or birth defects. defects Has a low total blood volume during early Has pregnancy. pregnancy. Maternal Risk Factors Maternal Is pregnant with more than one baby. High altitude. Drugs like anticoagulants, anticonvulsants. Has a cardio-vascular disease-preeclampsia, Has cardiohypertension, cyanotic heart disease, cardiac disease Gr III & IV, diabetic vascular lesions. disease Chronic kidney disease Chronic kidney Chronic infection- UTI, Malaria, TB, genital Chronic infections infections Has an antibody problem that can make Has successful pregnancy difficult (antiphospholipid antibody syndrome, SLE). antibody Fetal Risk Factors Fetal Exposure to an infection-German measles (rubella), German ), cytomegalovirus, herpes simplex, tuberculosis, syphilis, or herpes syphilis, toxoplasmosis, TB, Malaria, Parvo virus B19. toxoplasmosis, A birth defect (cardiovascular, renal, anencephally, renal, limb defect, etc). limb A chromosome defect- trisomy-18 (Edwards’ trisomy Edwards’ syndrome),21(Down’s syndrome), 16, 13, xo (turner’s syndrome ,21(Down’s syndrome. syndrome. A primary disorder of bone or cartilage. A chronic lack of oxygen during development chronic (hypoxia). (hypoxia). Developed outside of the uterus. Placenta or umbilical cord defects. Placental Factors Placental Uteroplacental insufficiency resulting from -. Improper / inadequate trophoblastic invasion and Improper placentation in the first trimester. placentation Lateral insertion of placenta. Reduced maternal blood flow to the placental bed. Foetoplacetal insufficiency due to-. Vascular anomalies of placenta and cord. Decreased placental functioning mass-. » Small placenta, abruptio placenta, placenta previa, post Small term pregnancy. term Diagnosis Diagnosis Intrauterine IUGR can be difficult to diagnose. Presence of risk factors. Inadequate growth detected by serial Inadequate measurement of Wt., abdominal girth and fundal Ht. fundal Ultrasound to evaluate the foetal growth. Ultrasound growth. Inadequate foetal growth. Reduced AFI. Placental calcification. Diagnosis Diagnosis Neonatal Low ponderal index (Wt./Fl). Decreased subcutaneous fat. Presence / appearance of – Presence Hypoglycemia, Hypoglycemia, Hyperbilirubinemia, Hyperbilirubinemia, Narcotizing enterocolitis, Narcotizing Hyper viscosity syndrome Hyper Neonate and Placenta in IUGR Neonate Normal & IUGR Newborn Normal babies babies Normal & IUGR Placentas Prevention Strategies include Strategies prenatal care modalities, prenatal protein/energy supplementation, protein/energy treatment of anaemia, treatment vitamin/mineral supplementation, vitamin/mineral fish oil supplementation prevention and treatment of prevention » hypertensive disorders, hypertensive » foetal compromise foetal » infection. Prevention Strong evidence of benefit only for the Strong following interventions: balanced protein/energy supplementation, strategies to reduce maternal smoking, strategies antibiotic administration to prevent urinary tract antibiotic infections and infections antimalarial prophylaxis. Few statistically significant reductions in the Few risk of IUGR have been demonstrated with other interventions. Surveillance Unless delivery occurs, once treatment begins the Unless foetus must undergo surveillance. The purpose - to identify further progression of the disease process that would jeopardize the foetus to a point that it would be better to be delivered than to remain in utero. There are four testing modalities which are helpful There -Non-Stress Test, Amniotic Fluid Index, Doppler of the Umbilical Artery & Biophysical Profile, each of which addresses different aspects of surveillance. aspects Combination of tests are better than an isolated ombination test. test. Surveillance Non- Stress Test (NST) This simplest to perform test should b used first in the surveillance of IUGR foetuses. With the help of a heart rate monitor, the changes in the foetal heart rate with foetal movement are to be determined. If the heart rate increases more than 15 beats for more than 15 seconds, this is considered to be a reactive test. If the heart rate does not accelerate, remains flat, or decreases, then this is an abnormal test. The problem with this test is that it changes late in the course of the disease and is not an early predictor of adverse outcome. predictor Surveillance Amniotic Fluid Index (AFI) The vertical depth of four pockets of amniotic fluid are measured by USG, to obtain a total AFI. This method allows for comparison of changes in amniotic fluid with time. In the normal foetus the AFI remains relatively constant. In the foetus with IUGR, it may decrease slowly, or decrease abruptly with time. A decrease in AFI may occur before there are changes in the non-stress test. Surveillance Amniotic Fluid Index (AFI) The current recommendations are that if the AFI decreases below 8 after 35 weeks, then delivery should occur. Surveillance Doppler of the Umbilical Artery When IUGR is diagnosed, the value of sequential studies of the umbilical artery Doppler waveform is to determine if the Resistance Index is increasing or decreasing. If it is increasing, then this signifies a deteriorating condition. Surveillance Biophysical Profile This test combines the NST and the AFI with foetal movement, breathing, and muscle tone. If each of the tests are normal they are given a score of 2. If abnormal, a score of 0. A score of 6 or less suggests the foetus is at risk for adverse outcome. While the biophysical profile is an useful test, when it becomes abnormal the foetus may have already suffered some damage Treatment Treatment IUGR has many causes, therefore, there is IUGR not one treatment that always works. Treatment Treatment Although there are many causes of IUGR, the treatment consists of either delivery or remaining in utero and improving blood flow to the uterus. When blood flow is improved, the delivery of oxygen and other nutrients to the foetus occurs. If the foetus is lacking in these substances, their increased availability may result in improved growth and development. If IUGR is caused by a problem with the placenta and the baby is otherwise healthy, early diagnosis and treatment of the problem may reduce the chance of a serious outcome. There is no treatment that improves foetal growth, but IUGR babies who are at or near term have the best outcome if delivered promptly. Treatment Treatment Maternal bed rest This is the initial approach for the treatment of IUGR. The benefit of bed rest is that it results in increased blood flow to the uterus. Studies have shown, however, that in most cases bed rest at home is just as effective as bed rest in the hospital environment. Treatment Treatment Maternal bed rest Treatment Treatment Aspirin Therapy The use of aspirin to treat foetuses with IUGR is The still controversial. If aspirin is used, iit may be advantageous if t If aspirin given to patients before 20 weeks of gestation. It is minimal to limited benefit if given at the time of diagnosis (third trimester). At the present time it is not recommended as a At form of prevention for low risk patients. Treatment Treatment Other Forms of Treatment Other forms of treatment that have been studied are nutritional supplementation, zinc supplementation, fish oil, hormones and oxygen therapy. Limited studies are available regarding the use of these modalities in the treatment of IUGR. Treatment Treatment Judge Optimum Time Of Delivery RISK OF PREMATURITY DIFFICULT EXTRA DIFFICULT UTERINE UTERINE EXISTENCE EXISTENCE RISK OF IUD RISK HOSTILE INTRA HOSTILE UTERINE UTERINE ENVIRONMENT ENVIRONMENT Short Term Risks of IUGR Short Increased perinatal morbidity and mortality. Intra uterine / Intrapartum death. Intrapartuum foetal acidosis characterized by-. » » » » Late deceleration. Severe variable deceleration. Beat to beat variability. Episodes of bradicardia. Intrapartum foetal acidosis may occur in as many as Intrapartum 40 % of IUGR, leading to a high incidence of LSCS. 40 IUGR infants are at greater risk of dying because of neonatal complications- asphyxia, acidosis, meconium aspiration syndrome, infection, hypoglycemia, hypothermia, hypoglycemia sudden infant death syndrome. IUGR infants are likely to be susceptible to infections IUGR because of impaired immunity because Long term Prognosis Prognosis Babies who suffer from IUGR are at an increased risk for Babies death, low blood sugar, low body temperature, and death low abnormal development of the nervous system. These risks increase with the severity of the growth restriction. increase The growth that occurs after birth cannot be predicted with The certainty based on the size of the baby when it is born. certainty Infants with asymmetrical IUGR are more likely to catch Infants up in growth after birth than are infants who suffer from prolonged symmetrical IUGR. prolonged If IUGR is related to a disease or a genetic defect, the If future of the infant is related to the severity and the nature of that disorder. of Long term Prognosis Prognosis IUGR infants are more likely to remain small than those of IUGR normal birth weight. They will need the special attention of primary health, nutrition and social services during infancy and early childhood. and Implication of IUGR can be life long affecting: Body size growth, composition and physical composition performance. performance Immunocompetence. It appears to predispose to adult adult-onset, degenerative It diseases like maturity onset diabetes and cardiovascular disease diseases. diseases. Each case is unique. Can not reliably predict an infant's Each future progress. future ...
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