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Intrauterine Growth Restriction

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Intrauterine Growth Restriction Powered By Docstoc
					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.

				
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posted:4/15/2008
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