1 / 30

Intrauterine Growth Retardation (Restriction)

Intrauterine Growth Retardation (Restriction). Jignesh Patel, MD Texas Tech University HSC Department of Pediatrics. Definitions. IUGR : Failure of normal fetal growth caused by multiple adverse effects on the fetus.

twila
Download Presentation

Intrauterine Growth Retardation (Restriction)

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Intrauterine Growth Retardation (Restriction) Jignesh Patel, MD Texas Tech University HSC Department of Pediatrics

  2. Definitions • IUGR: Failure of normal fetal growth caused by multiple adverse effects on the fetus. • SGA: Infant with wt < 10% ile for GA, or > 2 SDs below mean for GA.

  3. Easiest way to think about these terms are • IUGR: is a term used by OB to describe a pattern of growth over a period of time. • SGA: is a term used by Peds to describe a single point on a growth curve.

  4. Incidence • 3 - 10 % of all pregnancies. • 20 % of stillborns are growth retarded. • 30 % of infants with SIDS were IUGR. • 1/3 of infants with BW < 2800 gms are growth retarded and not premature. • 9 - 27 % have anatomic and/or genetic abnormalities. • Perinatal mortality is 8 - 10 times higher for these fetuses.

  5. Types of IUGR • Symmetric IUGR: weight,length and head circumference are all below the 10 th percentile. (33 % of IUGR Infants) • Asymmetric IUGR: weight is below the 10 th percentile and head circumference and length are preserved. (55 % of IUGR) • Combined type IUGR: Infant may have skeletal shortening, some reduction of soft tissue mass. (12 % of IUGR)

  6. Ponderal Index • Way of characterizing the relationship of height to mass for an individual. • PI = 1000 x • Typical values are 20 to 25. • PI is normal in symmetric IUGR. • PI is low in asymmetric IUGR. 3 Mass (kgs) Height (cms)

  7. Normal Intrauterine Growth pattern • Stage I (Hyperplasia) - 4 to 20 weeks - Rapid mitosis - Increase of DNA content • Stage II (Hyperplasia & Hypertrophy) - 20 to 28 weeks - Declining mitosis. - Increase in cell size.

  8. Normal Intrauterine Growth pattern • Stage III ( Hypertrophy) - 28 to 40 weeks - Rapid increase in cell size. - Rapid accumulation of fat, muscle and connective tissue. • 95% of fetal weight gain occurs during last 20 weeks of gestations.

  9. Etiology • Growth inhibition in stage I: - Undersized fetus with fewer cells. - Normal cell size. Result in symmetric IUGR. Associated conditions: - Genetic - Congenital anomalies - Intrauterine infections - Substance abuse - Cigarette smoking - Therapeutic irradiation

  10. Etiology • Growth Inhibition in Stage II/III -Decrease in cell size and fetal weight - Less effect on total cell numeric, fetal length, head circumferance. Result in asymmetric IUGR. Associated Conditions: - Uteroplacental insufficiency. • Combination above associated mixed type IUGR.

  11. Pathophysiology 1) Fetal factors: • Genetic Factors: - Race, ethnicity, nationality - sex ( male weigh 150 -200 gm more than female ) - parity ( primiparous, weigh less than subsequent siblings) -genetic disorders ( Achondroplasia, Russell - silver syn.) • Chromosomal anomalies: - Chromosomal deletions - trisomies 13,18 & 21

  12. Pathophysiology • Congenital malformations: examples:Anencephaly, GI atresia, potter’s syndrome, and pancreatic agenesis. • Fetal Cardiovascular anomalies • Congenital Infections: mainly TORCH infections. • Inborn error of metabolism: - Transient neonatal diabetes - Galactosemia - PKU

  13. Pathophysiology 2) Maternal Factors: • Decrease Uteroplacental blood flow: - Pre eclampsia / eclampsia - chronic renovascular disease - Chronic hypertension • Maternal malnutrition • Multiple pregnancy • Drugs - Cigarettes, alcohol, heroin, cocaine - Teratogens, antimetabolites and therapeutic agents such as trimethadione, warfarin, phenytoin

  14. Pathophysiology • Maternal hypoxemia - Hemoglobinopathies - High altitudes • Others - Short stature - Younger or older age (<15 and >45) - Low socioeconomic class - Primiparity - Grand multiparity - Low pregnancy weight - Previous h/o preterm IUGR baby - Chronic illness ( DM, renal failure, cyanotic heart disease etc.)

  15. Pathophysiology 3) Placental Factors: • Placental insufficiency ( most imp in 3rd trimester) • Anatomic problems: • Multiple infarcts • Aberrant cord insertions • Umbilical vascular thrombosis & hemangiomas • Premature placental separation • Small Placenta

  16. Postnatal Assessment • Growth parameters: weight, height, HC • Assess GA with Ballard score. • Plotted growth parameters in growth chart

  17. Physical Appearance

  18. Physical appearance: • Heads are disproportionately large for their trunks and extremities • Facial appearance has been likened to that of a “wizened old man”. • Long nails. • Scaphoid abdomen

  19. Signs of recent wasting - soft tissue wasting - diminished skin fold thickness - decrease breast tissue - reduced thigh circumference • Signs of long term growth failure - Widened skull sutures, large fontanelles - shortened crown – heel length - delayed development of epiphyses • Comparison to premature infants,IUGR has brain and heart larger in proportion to the body weight, in contrast the liver, spleen, adrenals and thymus are smaller.

  20. Complication • Hypoxia - Perinatal asphyxia - Persistent pulmonary hypertension - meconium aspiration • Thermoregulation - Hypothermia due to diminished subcutaneous fat and elevated surface/volume ratio

  21. Complications • Metabolic - Hypoglycemia - result from inadequate glycogen stores. - diminished gluconeogenesis. - increased BMR - Hypocalcemia - due to high serum glucagon level, which stimulate calcitonin excretion

  22. Complications • Hematologic - hyperviscosity and polycythemia due to increase erythropoietin level sec. to hypoxia • Immunologic - IUGR have increased protein catabolism and decreased in protein, prealbumin and immunoglobulins, which decreased humoral and cellular immunity.

  23. Management • Antenatal diagnosis and management is the key to proper management of IUGR • Delivery and Resuscitation - appropriate timing of delivery - skilled resuscitation should be available - prevention of heat loss • Hypoglycemia - close monitoring of blood glucose - early treatment ( IV dextrose, early feeding )

  24. Management • Hematological Disorder - central Hct to detect polycythemia - CBC with diff to r/o leukopenia or thrombocytopenia • Congenital infection - infant should be examined for signs of congenital infection (eg.rash, microcephaly hepatosplenomegaly, lymphadenopathy, cardiac anomalies etc….) - TORCH titer screening - Viral cx of urine, nasopharynx - Head CT to r/o calcification

  25. Management • Genetic anomalies - screening as indicated by physical exam - chromosomal analysis (infant with dysmorphic features) • Others - serum calcium to r/o hypocalcemia - fractionated bilirubin sec to polycythmia, congenital infection - urine, meconium tox for substance abuse

  26. Management • Early feeding and caloric intake should be 100-120 kcal/kg/d • Developmental and growth f/u in all IUGR infants

  27. Outcome • Symmetric vs. Asymmetric IUGR - symmetric has poor outcome compare to asymmetric • Preterm IUGR has high incidence of abnormalities • IUGR with chromosomal disease has 100% incidence of handicap • Congenital infection has poor outcome - handicap rate > 50% • IUGR has higher rate of learning disability.

  28. Thank You

More Related