INTRAUTERINE GROWTH RESTRICTION By DR NOSHABA RAFIQ M.B.B.S; M.C.P.S; F.C.P.S. DEFINITION OF IUGR Fetus whose estimated weight is: • less than 10th percentile for its gestational age. • Abdominal circumference is less than 2.5th percentile. Incidence: 10 percent of all pregnancies. Fetal weight percentiles throughout gestation Risk of IUGR Babies 1. Still birth: 15 fold increase risk 2. Intra-partum hypoxia 3. Neonatal risk • Sepsis • Hypoglycemia • RDS • Hypothermia • Meconium Aspiration • Haematological disorders • Seizers in first 24 hours • Malformations …contd 4. Impaired Neurodevelopment • Long term neuromotor dysfunction • Poor school performance • Deficits in academic achievements 5. Complications in Adult Life • Obesity • Diabetes Mellitis • Hypertension • Cardio-vascular disease Classification of IUGR • Symmetrical growth restriction: fetus whose entire body is proportionally small. Incidence : 20 % • Asymmetrical growth restriction: Decrease in subcutaneous fat and abdominal circumference with relative sparing of head circumference and femur length. Incidence : 80 % ETIOLOGY Maternal Causes of IUGR • Chronic Illnesses (e.g. cystic fibrosis, CHD, renal failure, haemoglobinopathies, APS) • Nutrition (e.g. anorexia nervosa and bulimia) • Smoking • Alcohol • Drug Abuse (e.g. Cocaine, amphetamines, betal chewing) …contd • Infections (e.g. vaginal bacteria, specially M. hominis, U. urealyticum, T. vaginalis and bacteroides group). • Endocrine disorders (e.g. diabetic nephropathy, hyperthyroidism, addison’s disease). Placental Causes of IUGR 1. Uteroplacental insufficiency • Unexplained • Preeclampsia • Elevated maternal AFP 2. Fetoplacental insufficiency • Single Umbilical Artery • Velamentous insertion of cord • Placental Haemangioma 3. Abnormal Placentation • Abruptioplacentae • Placenta Previa • Placenta Accretia Fetal Causes of IUGR 1. Normal Small Fetus (Constitutionally small fetus) 2. Infection • CMV • Toxoplasmosis • Rubella • Herpes • Malaria • Syphilis …contd 3. Fetal Abnormality • Chromosomal (Trisomy, 13,18 and 21, deletions or tripliody) • Structural (Gastroschisis, e.g. anencepholy) 4. Multiple Gestation DIAGNOSIS OF IUGR 1. History • Previous infant with growth restriction • Decreased fetal movements • Medical disorders • Drugs • Poor nutrition • Adverse factors, e.g. bleeding 2. Clinical Examination • Poor maternal weight gain • Fundal height lag • Reduced amount of liquour • Clinical assessment of small fetus …contd • HC/AC ratio or FL/AC ratio • Estimated Fetal weight 4. Growth Velocity • Serial measurements of AC or EFT 5. Invasive Investigation • Karyotyping • Screening for congenital infections Doppler Ultrasound Umblical Artery 1. S/D ratio 2. Resistance index 3. Pulsatility index Middle Cerebral Artery Venous Doppler Reversal of blood flow in IVC, DV and UV at the end of diastole MANAGEMENT 1. Accurate dating is mandatory 2. Symmetric or Asymmetric IUGR • Assymmetric: rule out chromosomal abnormalities and congenital infections. 3. General Management • Treat maternal disease • Stop substance abuse • Good nutrition • Bed Rest • Maternal hyperoxygenation ANTENATAL SERVEILLANCE • Growth scans every 3 weeks • Daily fetal movement profile • NST twice weekly • BPP weekly if NST is abnormal • Umblical artery Doppler study every 2 to 3 weeks. • Oxytocin challenge test if NST is abnormal or BPP is <8 DELIVERY CONSIDERATIONS • Antenatal steroids: To promote fetal lung maturity if gestational age less than 34 weeks. • Delivery >= 32 weeks: If antenatal test results are abnormal. • Antenatal test results reassuring: continue fetal surveillance and delivery at term, if fetal growth is noted. • If no fetal growth or severe oligohydramnios: assess fetal lung maturity. Deliver if lungs are mature; otherwise, reassess after 1 week. • Abnormal antenatal test results at less than 32 weeks of gestation, each case must be considered individually. LABOR AND DELIVERY • Continuous fetal monitoring during labor. • Delivery in hospital, capable of providing intensive neonatal care. • Amnioinfusion: non-reassuring fetal response, low amniotic fluid index and meconium stained liquor. • Caesarean Section: Detoriating fetal status.