IUGR( INTRA UTERINE GROWTH

RESTRICTION )

Prof. DrMuthulakshmi SRM MCH & RC

Definition:Failure of the fetus to reach its

genetic growth potential.wt below 10th percentile for its gestational agewt below 2500 gms.

Syn: Dysmature baby, chronic placental insufficiency, small for dates

Incidence: Developed countries 2-5% Term babies 5%Post term babies 15%

Types: Symmetrical IUGR- Type I – 20%

Asymmetrical IUGR – Type II – 80%

NORMAL GOWTH PRATTERN

UP TO 16 WEEKS – PHASE OF HYPER PLASIA – HEAD CIRCUMFERENCE WILL BE MORE THAN THEABD.CICUMFERENCE

AFTER 32 WEEKS PHASE OF HYPERTROPHY -ABD.CIRCUMFERENCE WILL BE MORE THAN THE HEAD CIRCUMFERENCE

AFTER 32 WEEKS PHASE OF HYPERTROPHY -ABD.CIRCUMFERENCE WILL BE MORE THAN THE HEAD CIRCUMFERENCE

Symmetric IUGR: Insult is very early during cellular hyperplasiaTotal cell number is less

Cause – structural or chromosomal abnormalities or congenital infection( TORCH)

Involves all the organs including headHead and abdominal circumferences - small

A symmetrical IUGR: The insult is during the phase of cellular hypertrophyTotal cell numbers remain same but cell size is smaller than normal

Cause: extrinsic in origin – maternal disease – PIHHead size is normal - abdominal circumference is

reduced –brain sparing effectLiver size and placental size - reduced

Etiology: Unknown – 20- 30%Maternal Placental Fetal

Maternal Causes:1.Constitutional 2. High altitude 3. Poor Nutrition 4. Poor socio economic status5. Poor weight gain6. Maternal habits – smoking, alcohol,

drug intake7. Maternal diseases – Anemia, hypertensive

disorders, chronic renal disease, DM with vascular disease, cardiac disease III & IV, connective tissue disorders, APL, Extra uterine pregnancy

Fetal Causes:Congenital malformation – 20 -25% cardio vascular and renal Chromosomal abnormalities. Trisomy 21, Trisomy18, Trisomy 16, Trisomy 13, Turner’s syndrome.Fetal infections, TORCH – CMV & RubellaParvo virus B 19, Protozoan- Toxoplasmosis, Malaria, hepatitis A&B, TB, Syphilis, listeriosisMultiple PregnancyDisorders of cartilage and bone – osteogenesis imperfecta and chondrodystrophies

Placental Causes: Placenta previaCircumvallate placentaPlacental infarctsPlacental HaemangiomasChronic placental abruptionSmall placentaCord abnormalities Velamentous and Marginal insertion of the cord

PathoPhysiology

Availability of nutrients in the mother Transfer by the placenta to the fetusUtilisation by the fetus Cell size ( asymmetrical IUGR)Cell number( symmetrical IUGR)Liver glycogen

Antepartum complications:Oligohydramnios Fetus – IU hypoxia, acidosis, IUD

Neonatal Complicatons:Perinatal asphyxia & acidosis Persistent fetal circulation, MAS, HIE.

Metabolic alterations: Hypoglycemia, hypocalcemia, hypothermia, hyperviscosity syndrome, abnormal neurological development

Related to specific Cause of IUGR:Infections, congenital malformations, chromosomal abnormalities.

Identification of IUGRBaby: -

Old man lookSoft tissue wasting, skin loose

and thinAbdomen scaphoid,

ribs protuberantMuscle mass arms, buttocks and thighs Umbilical cord – thin, meconium stained Head circumference larger than abdominal circumference in majority of cases.

Diagnosis

1. Past H/O IUGR fetus2. Look for maternal

disease 3. Obstetric Palpation.

Fundal Ht 4 wks less4. Gravidogram – 18 –

30 wks< 2-3 cm –inappropriate fetal growth

5. Poor weight gain

Investigations

Ultrasound measurement Fetal Biometry – BPD, HC, FL, ACAC corresponds with fetal weight.AFI – Normal 5-20 < 5 Oligohydraminos Exclude fetal structural anomalies Doppler velocimetryAbsent or reverse end diastolic flow, Diastolic notch esp Uterine arteries - IUGR

ManagementNo proven therapy for reverting the growthNear term – prompt delivery Before 37 wks - management problematicAdequate rest in LLPCorrect malnutrition – 300 cal extra / dayAstymin drip, hydration therapy.Treat maternal diseases Avoid smoking and alcoholLow dose aspirin Assessment of fetal growth every 10-14 days, both clinical & ultrasound

Assessment of fetal well being

DFMC - > 10 movements in 3 hrsNST – NR – further evaluation needed BPP – 8-10 is normal Modified BPP - AFI is very important

Management ( Continued)If IUGR is severe -Prematurity and dysmaturity- Dual problem Well equipped centre – assess lung maturity Not mature - Betamethasone - termination Mature - TerminationCentre with limited facilities – in utero transfer to a referral centre.Pregnancy continued to 34 wks if possible and then termination.

Methods of terminationCx favorable – ARM and Oxytocin dripIf cervix unfavorable – PG E2 gel.Liquor – Meconium stained – LSCS During Vaginal delivery – continuous intra partum monitoring (both clinical & electronic) During labour patient in LLP Slight evidence of hypoxia ( Meconium or abnormal CTG)1st stage LSCS2nd stage forceps delivery

Care of BabyPaediatrician available during deliveryEarly cord clamping Baby placed in NICUPrevent hypoglycemia If blood sugar < 30mg – IV 10%glucose 80 –100ml/ kg/ day Feeding – early feeding within 1 -2 hrs with 5 -10ml of 10% glucose, repeated every 2 hrs EBM or humanised milk 2 hourly for 48 hrs

Prognosis

Sym IUGR – grow slowly after birthAsym IUGR – grow faster after birthIUGR before III trimester – retarded neurological and intellectual development in infancy.Worst prognosis – congenital infection, congenital anomalies and chromosomal defects.Risk for morbidity & NND before 3rd trimester