Intrauterine Growth Restriction
Intrauterine Growth Restriction
Growth & Development Perinatology Division, Child Health Department, Medical Faculty of Hasanuddin University
Definitions
IUGR: Failure of a pregnancy to reach
expected fetal growth and manifest as a deviation of fetal growth from normal pattern. SGA: birth weight < 10th percentile for GA, or > 2 SDs below mean for GA.
Low birth weight (LBW) birth weight < 2500 g, which could be due to IUGR or Prematurity
IUGR vs SGA
IUGR suggests diminished intrauterine growth
velocity IUGR indicates the presence of a pathologic process in-utero that inhibits fetal growth SGA and IUGR are not synonymous SGA refers to the size of the infant at birth and not fetal growth
IUGR vs SGA
A child who is born SGA is not always IUGR
Infants born after a short period of IUGR are
Symmetric IUGR Associated conditions: - Genetic - Congenital anomalies - Intrauterine infections - Substance abuse - Cigarette smoking - Therapeutic irradiation
- Rapid accumulation of fat, muscle and connective tissue. 95% of fetal weight gain occurs during last 20 weeks of gestations.
Patophysiology, cont
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.
Types of IUGR
Symmetric IUGR (33 % of IUGR Infants) :
weight,length and head circumference are all below the 10th percentile. Asymmetric IUGR (55 % of IUGR) : weight is below the 10th percentile and head circumference and length are preserved Combined type IUGR (12 % of IUGR) : Infant may have skeletal shortening, some reduction o soft tissue mass.
Types of IUGR
Symmetrical
Baby's head and body are proportionately small May occur when the fetus experiences a problem during early development
Asymmetrical
Baby's head and length are preserved Occur when the fetus experiences a problem later in pregnancy
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.
13
Types of IUGR
Symmetric IUGR Type I Asymmetric IUGR Type II
restriction Uniform growth restriction Long-term growth failure Associated with decreased cell number Associated with less catch-up growth in the first year of life
restriction Head Sparing Potentially reversible Associated with decreased cell size Infants demonstrate more catch-up growth than symmetric IUGR in first year of life
14
Etiology
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
Etiology, cont
Congenital malformations:
examples:Anencephaly, GI atresia, potters syndrome, and pancreatic agenesis. Fetal Cardiovascular anomalies Congenital Infections: mainly TORCH infections. Inborn error of metabolism: - Transient neonatal diabetes - Galactosemia - PKU
Maternal malnutrition Multiple pregnancy Drugs - Cigarettes, alcohol, heroin, cocaine - Teratogens, antimetabolites and therapeutic agents such as trimethadione, warfarin, phenytoin
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.)
3) Placental Factors:
Diagnosis
Intrauterine IUGR can be difficult to diagnose. Presence of risk factors. Inadequate growth detected by serial measurement of Wt., abdominal girth and fundal Ultrasound to evaluate the foetal growth. Inadequate fetal growth. Placental calcification.
20
Diagnosis, cont...
Neonatal Postnatal assessment
Growth parameters: weight, height, HC Assess GA with Ballard score. Plotted growth parameters in growth chart
Ponderal index
21
Ponderal Index
Way of characterizing the relationship of height to mass for an individual.
3
PI = 1000 x
IUGR - Prof.S.N.Panda
12 October 2002
25
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
Physical Appearance
and heart larger in proportion to the body weight, in contrast the liver, spleen, adrenals and thymus are smaller.
Complications
Metabolic
- Hypoglycemia - result from inadequate glycogen stores.
- diminished gluconeogenesis. - increased BMR
Complication
Hypoxia
- Perinatal asphyxia - Persistent pulmonary hypertension - meconium aspiration Thermoregulation - Hypothermia due to diminished subcutaneous fat and elevated surface/volume ratio
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
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 )
Management
Hypothermia : Incubator, Kangaroo Mother Care Hematological Disorder - central Hct to detect polycythemia
- CBC with diff to r/o leukopenia or thrombocytopenia
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
Management
Early feeding and caloric intake should be 100-120 kcal/kg/d
Developmental and growth follow up in all
IUGR infants
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.
by-. Late deceleration. Severe variable deceleration. Beat to beat variability. Episodes of bradicardia.
37
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
38
39
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.
40
degenerative diseases like maturity onset diabetes , obesity, and cardiovascular diseases. Impaired Neurodevelopment Long term neuromotor dysfunction Poor school performance Deficits in academic achievements
Each case is unique. Can not reliably predict an