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IUGR _ IUFD

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					IUGR & IUFD

         DR. SALWA NEYAZI
CONSULTANT OBSTETRICIAN GYNECOLOGIST
 PEDIATRIC & ADOLESCENT GYNECOLOGIST
                       IUGR

What is the definition of IUGR?

•< 10th centile for age  include normal fetuses at the
lower ends of the growth curve + fetuses with IUGR
 This definition is not helpful clinically

•< 5th centile for age 

•< 3rd centile for age the most appropriate definition but
associated with adverse perinatal outcome
 What is the deference between IUGR & SGA?

SGA  < 10th centile for the population, which means it is
at the lower end of the normal distribution ie.
Constitutionally small but have reached their full growth
potential

IUGR Failure of the fetus to chieve the expected weight
for a given gestation
      What are the causes of IUGR?


•Maternal medical conditions      •1ry placental disease

•Chromosomal anomalies &          •Extremes of maternal age
aneuploidy
                                  •Low socioeconomic
•Genetic & Structural anomalies   status

•Exposure to drugs & toxins       •Infections

                                  •Multiple gestation
Which maternal medical conditions result in IUGR?

       •HPT
       •PET
       •DM with vascular involvement
       •SLE
       •Anemia
       •Sickle cell disease
       •Antiphospholipid syndrome
       •Renal disease
       •Malnutrition
       •Inflammatory bowel disease
       •Intestinal parasites
       •Cyanotic pulmonary disease
How does the placenta play a role in the development of IUGR?

 •Abnormalities in placental development & trophoblast
   invasion Idiopathic or due to maternal disease eg
   SLE, PET, DM, HPT
 •Chronic partial abruption
 •Placental infarcts
 •Placenta previa
 •Chorioangioma
 •Circumvallate placenta
 •Placental mosaicism
 •Twin to twin transfusion Syndrome
What infections result in IUGR?
           5-10% of IUGR

         Congenital infections:
         •CMV
         •Rubella
         •Herpes
         •Vericella zoster
         •Toxoplasmosis
         •Malaria
         •Listeriosis
Which drugs can result in IUGR?

•Alcohol
•Cigarette smoking 3-4X
•Heroin & coccaine
•Methotrexate
•Anticonvulsants
•Warfarin
•Antihypertensives /ß-blockers
•Cyclosporin
What are the genetic disorders that can result in IUGR?

       15% of IUGR             Features suspicious of trisomy

  •Down’s syndrome T21         •Symmetric IUGR
  •Trisomy 13,18               •AFV/ Doppler N
  •Turner syndrome             •Structural abnormalities
  •Neural tube defects         •Maternal age
  •Achondroplasia              •Nuchal translucency
  •Osteogenisis imperfecta     •Biochemical screening results
  •Abdominal wall defects
  •Duodenal atresia
  •Renal agenesis/ Poter’s S
Why does multiple pregnancy result in IUGR?

   •Placental insufficiency /inadequate placental
   reserve to sustain N growth of > one fetus
   •Twin to twin transfusion syndrome
   •Anomalies
   • with higher order gestations
   • monozygotic twins
         What are the types of IUGR?

                  1-Symmetric –20%

•Proportionate decrease in many organ weights including
the brain

•Deprivation occurs early

•The fetus is more likely to have an endogenous defect that
preclude N development

•U/S biometry  All measurements BPD, FL, AC  
                    Types of IUGR
              2-Asymmetric IUGR—80%


•Relative sparing of the brain

•Deprivation occurres in the later half of pregnancy

•The infant is more likely to be N but small in size due to
intrauterine deprivation

•U/S biometry BPD, Fl  N, AC  
Why IUGR often associated with olighydramnios?


     blood flow to the lungs  pulmonary
    contribution to amniotic fluid volume

    blood   flow to the kidneys GFR
           urine output

    It   is present in 80-90% of IUGR fetuses
      How to evaluate a case of IUGR?
1-History:
•Current preg
   LMP, preg test, quickening
   APH, abruptio placentae, & fetal movements
•Previous obstetric Hx particularly looking for IUGR,& adverse
 outcome
•Medical Hx: connective tissue diseases, thrombotic events &
 endocrine disorders
•Hx of recent viral illness
•Drug Hx
•Family Hx of congenital abnormalities & thrombophilias
                  EXAMINATION

•Symphysis fundal height in cm = gest age in wks after 24 wk
•Sensitivity 46-86% in detecting IUGR
•A difference of more than 2cm requires fetal assessment
•Oligohydramnious may be detected on palpation


                       U/S

    •Fetal biometry for dating then serial measurements
    •Anomaly scan
    •AF index
    •Doppler umbilical artery resistance index, MCA
    •Repeat tests every1-2 wks
                 Invasive fetal testing

•Amniocentesis or placental biopsy/ fetal blood sampling
for karyotyping if aneuploidy is suspected
for viral studies if infections suspected
•Caries the risks of  infection, PROM, Preterm labor


                  Retrospective tests

    •Maternal blood tests for  CMV, Rubella, Toxo
     Metabolic disorders
     thrombophilia
    •Placenta should be sent for HP
    •Postmortem examination
            The constitutionally small fetus

•A fetus growing parallel to the lower centiles through out preg
•Anatomically N
•AFV N
•Doppler N
•Slim petite women
             Complications of IUGR

•Maternal complications due to underlying disease
 risk of CS
•Fetal complications Stillbirth, hypoxia/acidosis,
                            malformations
•Neonatal complications Hypoglycemia, hypocalcemia,
Hypoxia & acidosis, hypothermia, meconium aspiration ,
Polycythemia, hyperbilirubinemia, sepsis, low APGAR score
congenital malformations, apneic spells, intubation
 sudden infant death syndrome
•Long term complications Lower IQ, learning & behavior
Problems, major neurological handicap seizures, cerebral
Palsy, mental retardation, HPT
•Perinatal mortalility 1.5-2X
                      Treatment

•Stop smoking / alcohol
•Bed rest  uterine blood flow for pt with asymmetric IUGR
•Low dose aspirin
•Weekly visits attention to : FM, SFH, maternal wt, BP, CTG,
 AFV
•U/S every 2-4 wks
•BPP
•Contraction stress test
•Delivery 38 wks or earlier if there is fetal compromise
•Glucocorticoids if planing delivery before 34 wks
•Close monitoring in labor/ continuous monitoring /scalp PH
•CS may be necessary
                          IUFD

Definition: dead fetuses or newborns weighing > 500gm
Or > 20 wks gestation
 4.5/ 1000 total births

Diagnosis
Absence of uterine growth
Serial ß-hcg
Loss of fetal movement
Absence of fetal heart
Disappearance of the signs & symptoms of pregnancy
X-ray Spalding sign
        Robert’s sign
U/S 100% accurate Dx
   Causes OF IUFD             Maternal 5-10%
                              •Antiphospholipid antibody
                              •DM
Fetal causes 25-40%
                              •HPT
•Chromosomal anomalies
                              •Trauma
•Birth defects
                              •Abnormal labor
•Non immune hydrops
                              •Sepsis
•Infections
                              •Acidosis/ Hypoxia
Placental 25-35%
                              •Uterine rupture
•Abruption
                              •Postterm pregnancy
•Cord accidents
                              •Drugs
•Placental insufficiency
                              •Thrombophilia
•Intrapartum asphyxia
                              •Cyanotic heart disease
•P Previa
                              •Epilepsy
•Twin to twin transfusion S
                              •Severe anemia
•Chrioamnionitis
                              Unexplained 25-35%
   A systematic approach to fetal death is valuable in
   determining the etiology
                         B-Maternal History
 1-History               I-Maternal medical conditions
                         •VTE/ PE
A-Family history         •DM
•Recurrent abortions     •HPT
•VTE/ PE                 •Thrombophilia
•Congenital anomalies    •SLE
•Abnormal karyptype      •Autoimmune disease
•Hereditary conditions   •Severe Anemia
•Developmental delay     •Epilepsy
                         •Consanguinity
                         •Heart disease
                         II-Past OB Hx
                         •Baby with congenital anomaly / hereditary condition
                         •IUGR
                         •Gestational HPT with adverse sequele
                         •Placental abruption
                         •IUFD
                         •Recurrent abortions
 1-History
                                      Specific fetal conditions
                                      •Nonimmune hydrops
Current Pregnancy Hx                  •IUGR
•Maternal age                         •Infections
•Gestational age at fetal death       •Congenital anomalies
•HPT                                  •Chromosomal abnormalities
•DM/ Gestational D                    •Complications of multiple gestation
•Smooking , alcohol, or drug abuse
•Abdominal trauma
•Cholestasis
                                     Placental or cord complications
•Placental abruption                 •Large or small placenta
•PROM or prelabor SROM               •Hematoma
                                     •Edema
                                     •Large infarcts
                                     •Abnormalities in structure , length or
                                      insertion of the umbilical cord
                                     •Cord prolapse
                                     •Cord knots
                                     •Placental tumors
              2-Evaluation of still born infants
Infant desciption                 Placenta
•Malformation                     •Weight
•Skin staining                    •Staining
•Degree of maceration             •Adherent clots
•Color-pale ,plethoric            •Structural abnormality
Umbilical cord                    •Velamentous insertion
•Prolapse                         •Edema/ hydropic changes
•Entanglement-neck, arms, ,legs   Membranes
•Hematoma or stricture            •Stained
•Number of vessels                •Thickening
•Length
Amniotic fluid
•Color-meconium, blood
•Volume
        3-Investigations                Fetal inveswtigations
                                        •Fetal autopsy
Maternal investigations                 •Karyotype
•CBC                                    (spcimen taken from cord
•Bl Gp & antibody screen                blood, intracardiac blood,
•HB A1 C                                body fluid, skin, spleen,
•Kleihauer Batke test                   Placental wedge, or amniotic
•Serological screening for Rubella      Fluid)
                                        •Fetography
•CMV, Toxo, Sphylis, Herpes &
                                        •Radiography
Parovirus
•Karyotyping of both parents (RFL,
                                        Placental investigations
Baby with malformation
                                        •Chorionocity of placenta in
•Hb electrophorersis
                                          twins
•Antiplatelet anbin tibodies
                                        •Cord thrombosis or knots
•Throbophilia screening (antithrombin
                                        •Infarcts, thrombosis,abruption,
Protein C & S , factor IV leiden,
                                        •Vascular malformations
 Factor II mutation, , lupus
                                        •Signs of infection
anticoagulant,
                                        •Bacterial culture for Ecoli,
 anticardolipin antibodies)
                                        Listeria, gp B strpt.
•DIC
               IUFD complications


•Hypofibrinogenemia  4-5 wks after IUFD
•Coagulation studies must be started 2 wks after IUFD
•Delivery by 4 wks or if fibrinogen < 200mg/ml
    Psychological aspect & counseling

•A traumetic event
•Post-partum depression
•Anxiety
•Psychotherapy
•Recurrence 0-8% depending on the cause of IUFD

				
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posted:10/8/2011
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