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Intra Uterine Growth Retardation

Intra Uterine Growth Retardation. Dr.B Khani MD. Case 1. 27 Y G2 L1 36 w CC: VB & LP PMH: Iron deficiency anemia (no treatment) Spotting in 24 w pregnancy PH: The patient was pale FH: 32 cm V /E: 4cm The newborn birthed after 3 h

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Intra Uterine Growth Retardation

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  1. Intra Uterine Growth Retardation Dr.BKhani MD

  2. Case 1 • 27 Y G2 L1 36 w CC: VB & LP PMH: Iron deficiency anemia (no treatment) Spotting in 24 w pregnancy • PH: The patient was pale FH: 32 cm V /E: 4cm The newborn birthed after 3 h • N: female APGAR: 7/10 & 8/10 (1′ & 5′) • BW: 1590 g HC: 29.5 cm Height: 45 cm • DX: IUGR The newborn was Hospitalized and managed • BS was normal HB: 23.9 After 2 days bilirubin was 16 and phototherapy was started CXR: normal blood culture: WNL • After one Week the infant was discharged IUGR - Prof.S.N.Panda

  3. Intra Uterine Growth 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 IUGR - Prof.S.N.Panda

  4. 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. • Low birth weight (LBW) means a baby with a birth weight of less than 2500Gms, which could be due to IUGR or Prematurity Please also see notes pages for more details in most of the slides IUGR - Prof.S.N.Panda

  5. Classification Symmetricl Asymmetrical the baby's head and body are proportionately small. may occur when the foetus experiences a problem during early development. baby's brain is abnormally large when compared to the liver. may occur when the foetus experiences a problem during later development In a normal infant, the brain weighs about three times more than the liver. In asymmetrical IUGR, the brain can weigh five or six times more than the liver. IUGR - Prof.S.N.Panda

  6. Classification Newer Classification: - • 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. • Abnormal small fetuses- have chromosomal anomalies or structural malformations. They are lost cases and deserve termination as nothing can be done. • Growth restricted fetuses- are due to impaired placental function.Appropriate & timely treatment or termination can improve prospects. IUGR - Prof.S.N.Panda

  7. Aetiology • The foetal growth is dependent on multiple factors. • IUGR resulting in SGA babies can result from many factors known and unknown either acting alone or in conjunction or in association . • The aetiologic determinants of IUGR have two measures of effect: relative risk and etiologic fraction. • Most of the evidence on aetiologic determinants is based on observational studies and systematic overviews or meta-analyses of such studies. • In a majority of cases (40%) the cause is unknown– probably due to placental insufficiency (idiopathic). IUGR - Prof.S.N.Panda

  8. Aetiology • General- Racial / Ethnic origin, Small maternal / paternal height / weight, Foetal sex. • Maternal causes. • Foetal causes. • Placental causes. • Idiopathic- In a majority of cases (40%) the cause is unknown– probably due to placental insufficiency. IUGR - Prof.S.N.Panda

  9. Maternal Risk Factors • Has had a previous baby who suffered from IUGR. • Extremes of age. • Is small in size (Ht & Wt). • Has poor weight gain and malnutrition during pregnancy. • Is socially deprived. • Uses substances (like tobacco, narcotics, alcohol) that can cause abnormal development or birth defects. • Has a low total blood volume during early pregnancy. IUGR - Prof.S.N.Panda

  10. Maternal Risk Factors • Is pregnant with more than one baby. • High altitude. • Drugs like anticoagulants, anticonvulsants. • Has a cardio-vascular disease-preeclampsia, hypertension, cyanotic heart disease, cardiac disease Gr III & IV, diabetic vascular lesions. • Chronic kidney disease • Chronic infection- UTI, Malaria, TB, genital infections • Has an antibody problem that can make successful pregnancy difficult (antiphospholipid antibody syndrome, SLE). IUGR - Prof.S.N.Panda

  11. Fetal Risk Factors • Exposure to an infection-German measles (rubella), cytomegalovirus, herpes simplex, tuberculosis, syphilis, or toxoplasmosis, TB, Malaria, Parvo virus B19. • A birth defect (cardiovascular, renal, anencephally, limb defect, etc). • A chromosome defect-trisomy-18 (Edwards’ syndrome),21(Down’s syndrome), 16, 13, xo (turner’s syndrome. • A primary disorder of bone or cartilage. • A chronic lack of oxygen during development (hypoxia). • Developed outside of the uterus. • Placenta or umbilical cord defects. IUGR - Prof.S.N.Panda

  12. Placental Factors • Uteroplacental insufficiency resulting from -. • Improper / inadequate trophoblastic invasion and placentation in the first trimester. • 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 term pregnancy. IUGR - Prof.S.N.Panda

  13. Diagnosis Intrauterine - • IUGR can be difficult to diagnose. • Presence of risk factors. • Inadequate growth detected by serial measurement of Wt., abdominal girth and fundal Ht. • Ultrasound to evaluate the foetal growth. • Inadequate foetal growth. • Reduced AFI. • Placental calcification. IUGR - Prof.S.N.Panda

  14. Diagnosis Neonatal - • Low ponderal index (Wt./Fl). • Decreased subcutaneous fat. • Presence / appearance of – • Hypoglycemia, • Hyperbilirubinemia, • Narcotizing enterocolitis, • Hyper viscosity syndrome IUGR - Prof.S.N.Panda

  15. Neonate and Placenta in IUGR • Normal & IUGR Newborn babies • Normal & IUGR Placentas IUGR - Prof.S.N.Panda

  16. Prevention • Strategies include • prenatal care modalities, • protein/energy supplementation, • treatment of anaemia, • vitamin/mineral supplementation, • fish oil supplementation • prevention and treatment of • hypertensive disorders, • foetal compromise • infection. IUGR - Prof.S.N.Panda

  17. Prevention • Strong evidence of benefit only for the following interventions: • balanced protein/energy supplementation, • strategies to reduce maternal smoking, • antibiotic administration to prevent urinary tract infectionsand • antimalarial prophylaxis. • Few statistically significant reductions in the risk of IUGR have been demonstrated with other interventions. IUGR - Prof.S.N.Panda

  18. Surveillance • Unless delivery occurs, once treatment begins the 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 -Non-Stress Test, Amniotic Fluid Index, Doppler of the Umbilical Artery & Biophysical Profile, each of which addresses different aspects of surveillance. • Combination of tests are better than an isolated test. IUGR - Prof.S.N.Panda

  19. 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. IUGR - Prof.S.N.Panda

  20. 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. IUGR - Prof.S.N.Panda

  21. Surveillance • Amniotic Fluid Index (AFI) The current recommendations are that if the AFI decreases below 8 after 35 weeks, then delivery should occur. IUGR - Prof.S.N.Panda

  22. 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. IUGR - Prof.S.N.Panda

  23. 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 IUGR - Prof.S.N.Panda

  24. Treatment • IUGR has many causes, therefore, there is not one treatment that always works. IUGR - Prof.S.N.Panda

  25. 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. IUGR - Prof.S.N.Panda

  26. 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. IUGR - Prof.S.N.Panda

  27. Treatment • Maternal bed rest IUGR - Prof.S.N.Panda

  28. Treatment • Aspirin Therapy • The use of aspirin to treat foetuses with IUGR is still controversial. • If aspirin is used, it may be advantageous if 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 form of prevention for low risk patients. IUGR - Prof.S.N.Panda

  29. Treatment • Other Forms of Treatment • Otherforms of treatmentthat 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. IUGR - Prof.S.N.Panda

  30. RISK OF PREMATURITY DIFFICULT EXTRA UTERINE EXISTENCE RISK OF IUD HOSTILE INTRA UTERINE ENVIRONMENT Treatment Judge Optimum Time Of Delivery IUGR - Prof.S.N.Panda

  31. Short Term Risks of IUGR • 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 40 % of IUGR, leading to a high incidence of LSCS. • IUGR infants are at greater risk of dying because of neonatal complications- asphyxia, acidosis, meconium aspiration syndrome, infection, hypoglycemia, hypothermia, sudden infant death syndrome. • IUGR infants are likely to be susceptible to infections because of impaired immunity IUGR - Prof.S.N.Panda

  32. Long term Prognosis • Babies who suffer from IUGR are at an increased risk for death, low blood sugar, low body temperature, and abnormal development of the nervous system. These risks increase with the severity of the growth restriction. • The growth that occurs after birth cannot be predicted with certainty based on the size of the baby when it is born. • Infants with asymmetrical IUGR are more likely to catch up in growth after birth than are infants who suffer from prolonged symmetrical IUGR. • If IUGR is related to a disease or a genetic defect, the future of the infant is related to the severity and the nature of that disorder. IUGR - Prof.S.N.Panda

  33. Long term Prognosis • IUGR infants are more likely to remain small than those of normal birth weight. They will need the special attention of primary health, nutrition and social services during infancy and early childhood. • Implication of IUGR can be life long affecting: • Body size growth, composition and physical performance. • Immunocompetence. • It appears to predispose to adult adult-onset, degenerative diseases like maturity onset diabetes and cardiovascular diseases. • Each case is unique. Cannot reliably predict an infant's future progress. IUGR - Prof.S.N.Panda

  34. syndrome

  35. “mekonionarion” – “opium like” (Aristotle) • Meconium stained amniotic fluid – 8-15 % of all deliveries. • 5% of them – meconium aspiration syndrome • 5% mortality IUGR - Prof.S.N.Panda

  36. Origin and composition • Meconium is recognized – 70-85 d of gestation • Composition: • Water, Mucopolysaccharides, Cholesterol and sterol precursos, Protein, Lipid, Bile acids and salts, Enzymes, Blood group substances, Squamous cell, Vernix caseosa • No bacteria! IUGR - Prof.S.N.Panda

  37. In utero passage • Risk factors associated with in utero passage of meconium: • Postterm pregnancy • Little/no amniotic fluid at amniotomy • Oligohydramnion by US • IUGR/ placental insufficiency • Maternal HTN • Preeclampsia • Maternal drug abuse (tobacco, cocaine). • Gestational age > 34w – increasingly present with advancing gestational age. IUGR - Prof.S.N.Panda

  38. Pathophysiology • As the GI tract matures: vagal stimulation peristalsis+ rectal sphincter relaxation  meconium • Etiology not well understood: • Fetal response to intra-uterine stress: hypoxia  increased vagal tone • Transient compression of umbilical cord/head  increased vagal tone • Maturation of of fetal intestinal function IUGR - Prof.S.N.Panda

  39. Timing of the initial insult: • Traditional belief: immediately after birth • Several investigations: Most cases occur in utero when fetal gasping is initiated before delivery. IUGR - Prof.S.N.Panda

  40. Effects of meconium: • Reduce antibacterial activity (perinatal bacterial infection) • Irritating to fetal skin ( erythema toxicum) • The most severe complication of meconium passage in utrro is aspiration of stained amniotic fluid before, during, and after birth IUGR - Prof.S.N.Panda

  41. Meconium aspiration syndrome - pathophysiology • Airway obstruction: • Chemical pneumonitis: • Surfactant dysfunction: • Umbilical vessel damage • Persistent pulmonary hypertension of the newborn IUGR - Prof.S.N.Panda

  42. Airway obstruction: • Immediate : obstruction of large airways: (volume dependent ): hypoventilation => hypoxemia, hypercapnea, acidosis • Central clearing – obstruction of small airways: • Complete athelectasis • Partial  air trapping (ball valve phenomenon)  hyperdistention of alveoli  increaesed lung resistance during exhalation • pneumothorax, pneumomediastinum , pneumopericardium. IUGR - Prof.S.N.Panda

  43. IUGR - Prof.S.N.Panda

  44. IUGR - Prof.S.N.Panda

  45. IUGR - Prof.S.N.Panda

  46. Chemical pneummonitis: • 50% of cases • Enzemes, bile salts, fats – irritants PMN, MQ, inflammatory mediators. • Chemical pneumonitis, edema (6h)  inflamation (24h) • Hyalin membranes, hemorrhage, vascular necrosis can occur. • Bacterial superinfection. • Activated Vasoactive mediators play a role in the develipment of PPHN. IUGR - Prof.S.N.Panda

  47. Chemical pneummonitis: • 50% of cases • Enzemes, bile salts, fats – irritants PMN, MQ, inflammatory mediators. • Chemical pneumonitis, edema (6h)  inflamation (24h) • Hyalin membranes, hemorrhage, vascular necrosis can occur. • Bacterial superinfection. • Activated Vasoactive mediators play a role in the develipment of PPHN. IUGR - Prof.S.N.Panda

  48. IUGR - Prof.S.N.Panda

  49. Surfactant dysfunction • Free fatty acids (paimitic, stearic, oleic) – higher minimal surface tention than surfactant (striping effect) • decreased lung compliance • concentration dependent IUGR - Prof.S.N.Panda

  50. Umbilical vessel damage • Umbilical vessels exposed to meconium  may cause severe focal inflammation injury. • Spasm and necrosis  fetal hypoperfusion • 1% meconium induced umbilical vascular necrosis among meconium stained placentas. IUGR - Prof.S.N.Panda

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