IUGR

Intra UterineIntra Uterine Growth Growth RetardationRetardation

Prof.Surendra Nath Panda, M.S.Prof.Surendra Nath Panda, M.S.

Dept.of Obstetrics & GynecologyDept.of Obstetrics & Gynecology

M.K.C.G.Medical CollegeM.K.C.G.Medical College

Berhampur, Orissa, INDIABerhampur, Orissa, INDIA

12 October 2002 IUGR - Prof.S.N.Panda 2

Foetal growth restriction

Small for gestational age (SGA)

'wasted' and 'stunted'

Intra UterineIntra Uterine Growth Growth RetardationRetardation

Please also see notes pages for more details in most of the slides

Intra Uterine Growth Restriction


DefinitionDefinition

Intrauterine growth retardation (IUGR)Intrauterine growth retardation (IUGR) occurs when the unborn baby is at or below the occurs when the unborn baby is at or below the 10th weight percentile for his or her age (in 10th weight percentile for his or her age (in weeks). weeks). The foetus is affected by a pathologic The foetus is affected by a pathologic restriction in its ability to grow.restriction in its ability to grow.

LowLow birth weight (LBW) birth weight (LBW) means a baby means a baby with a birth weight of less than 2500Gms, with a birth weight of less than 2500Gms, which could be due to IUGR or Prematuritywhich could be due to IUGR or Prematurity

Please also see notes pages for more details in most of the slides


ClassificationClassification

SymmetricSymmetricll AAsymmetricalsymmetrical

baby's brain is abnormally baby's brain is abnormally large when compared to the large when compared to the liverliver..may occur when the may occur when the foetusfoetus experiences a problem experiences a problem during later developmentduring later development

the baby's head and body the baby's head and body are proportionately smallare proportionately small. . may occur when the may occur when the foetus foetus experiences a experiences a problem during early problem during early development.development.

In a normal infant, the brain weighs about three times more than the liver. In 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.asymmetrical IUGR, the brain can weigh five or six times more than the liver.


Newer Classification: -

1. 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.

2. Abnormal small fetuses- have chromosomal anomalies or structural malformations. They are lost cases and deserve termination as nothing can be done.

3. Growth restricted fetuses- are due to impaired placental function.Appropriate & timely treatment or termination can improve prospects.

ClassificationClassification


AetiologyAetiology The foetal growth is dependent on multiple factors. The foetal growth is dependent on multiple factors. IUGR resulting in SGA babies can result from many IUGR resulting in SGA babies can result from many

factors known and unknown either acting alone or in factors known and unknown either acting alone or in conjunction or in association .conjunction or in association .

The The aaetiologic determinants of IUGR etiologic determinants of IUGR have have two two measures of effect: relative risk measures of effect: relative risk and and etiologic fraction.etiologic fraction.

Most of the evidence on Most of the evidence on aaetiologic determinants is etiologic determinants is based on observational studies and systematic based on observational studies and systematic overviews or meta-analyses of such studies.overviews or meta-analyses of such studies.

In a majority of cases (40%) the cause is unknown– In a majority of cases (40%) the cause is unknown– probably due to placental insufficiency (idiopathic).probably due to placental insufficiency (idiopathic).


AetiologyAetiology

1.1. General- General- Racial / Ethnic origin, Small maternal / Racial / Ethnic origin, Small maternal / paternal height / weight, Foetal sex.paternal height / weight, Foetal sex.

2.2. Maternal causesMaternal causes..

3.3. Foetal causes.Foetal causes.

4.4. Placental causes.Placental causes.

5.5. Idiopathic- In a majority of cases (40%) the Idiopathic- In a majority of cases (40%) the cause is unknown– probably due to placental cause is unknown– probably due to placental insufficiency.insufficiency.


Maternal Risk FactorsMaternal Risk Factors Has had a previous baby who suffered from Has had a previous baby who suffered from

IUGR.IUGR. Extremes of age. Extremes of age. Is small in sizeIs small in size (Ht & Wt) (Ht & Wt).. Has poor weight gain and Has poor weight gain and malmalnutrition during nutrition during

pregnancypregnancy.. Is socially deprived.Is socially deprived. Uses substances (like tobacco, narcotics, alcohol) Uses substances (like tobacco, narcotics, alcohol)

that can cause abnormal development or that can cause abnormal development or birth birth defectsdefects..

Has a low total blood volume during early Has a low total blood volume during early pregnancy.pregnancy.


Maternal Risk FactorsMaternal Risk Factors Is pregnant with more than one baby.Is pregnant with more than one baby. High altitude.High altitude. Drugs like anticoagulants, anticonvulsants.Drugs like anticoagulants, anticonvulsants. Has a Has a cardio-cardio-vascular diseasevascular disease--preeclampsiapreeclampsia, ,

hypertension, cyanotic heart disease, cardiac hypertension, cyanotic heart disease, cardiac disease Gr III & IV, diabetic vascular lesions.disease Gr III & IV, diabetic vascular lesions.

Chronic Chronic kidney diseasekidney disease Chronic infection- UTI, Malaria, TB, genital Chronic infection- UTI, Malaria, TB, genital

infectionsinfections Has an antibody problem that can make Has an antibody problem that can make

successful pregnancy difficult (antiphospholipid successful pregnancy difficult (antiphospholipid antibody syndromeantibody syndrome, SLE, SLE).).


Fetal Risk FactorsFetal Risk Factors

Exposure to an infectionExposure to an infection--German German measles measles ((rubellarubella), ), cytomegalovirus, cytomegalovirus, herpes simplex, tuberculosisherpes simplex, tuberculosis, , syphilis,syphilis, or or toxoplasmosis, TB, Malaria, Parvo virus B19.toxoplasmosis, TB, Malaria, Parvo virus B19.

A birth defect (cardiovascularA birth defect (cardiovascular, renal, anencephally, , renal, anencephally, limb defect, etclimb defect, etc).).

A chromosome defectA chromosome defect-- trisomytrisomy--18 (18 (Edwards’ Edwards’ syndromesyndrome)),21(Down’s syndrome), 16, 13, xo (turner’s ,21(Down’s syndrome), 16, 13, xo (turner’s syndrome.syndrome.

A primary disorder of bone or cartilage.A primary disorder of bone or cartilage. A chronic lack of oxygen during development A chronic lack of oxygen during development

(hypoxia).(hypoxia). Developed outside of the uterus.Developed outside of the uterus. Placenta or umbilical cord defects.Placenta or umbilical cord defects.


Placental FactorsPlacental Factors

Uteroplacental insufficiency resulting from -.Uteroplacental insufficiency resulting from -. Improper / inadequate trophoblastic invasion and Improper / inadequate trophoblastic invasion and

placentation in the first trimester.placentation in the first trimester.

Lateral insertion of placenta.Lateral insertion of placenta.

Reduced maternal blood flow to the placental bed.Reduced maternal blood flow to the placental bed.

Foetoplacetal insufficiency due to-.Foetoplacetal insufficiency due to-. Vascular anomalies of placenta and cord.Vascular anomalies of placenta and cord.

Decreased placental functioning mass-.Decreased placental functioning mass-.» Small placenta, abruptio placenta, placenta previa, post Small placenta, abruptio placenta, placenta previa, post

term pregnancy.term pregnancy.


DiagnosisDiagnosis

IUGR can be difficult to diagnoseIUGR can be difficult to diagnose.. Presence of risk factors.Presence of risk factors. Inadequate growth detected by serial Inadequate growth detected by serial

measurement of Wt., abdominal girth and measurement of Wt., abdominal girth and fundal Ht.fundal Ht.

Ultrasound to evaluate the Ultrasound to evaluate the foetal foetal growth.growth. Inadequate foetal growth.Inadequate foetal growth. Reduced AFI.Reduced AFI. Placental calcification.Placental calcification.

Intrauterine -


DiagnosisDiagnosis

Low ponderal index (Wt./Fl).Low ponderal index (Wt./Fl). Decreased subcutaneous fat.Decreased subcutaneous fat. Presence / appearance of – Presence / appearance of –

Hypoglycemia, Hypoglycemia, Hyperbilirubinemia, Hyperbilirubinemia, Narcotizing enterocolitis, Narcotizing enterocolitis, Hyper viscosity syndrome Hyper viscosity syndrome

Neonatal -


Neonate and Placenta in IUGRNeonate and Placenta in IUGR

Normal & IUGR Newborn Normal & IUGR Newborn babiesbabies

Normal & IUGR PlacentasNormal & IUGR Placentas


Prevention Prevention

Strategies include Strategies include prenatal care modalities, prenatal care modalities, protein/energy supplementation, protein/energy supplementation, treatment of anaemia, treatment of anaemia, vitamin/mineral supplementation, vitamin/mineral supplementation, fish oil supplementationfish oil supplementation prevention and treatment of prevention and treatment of

» hypertensive disorders, hypertensive disorders,

» foetal compromise foetal compromise

» infection.infection.


Prevention Prevention

Strong Strong evidence of benefit only for the evidence of benefit only for the following interventions: following interventions: balanced protein/energy supplementation,balanced protein/energy supplementation, strategies to reduce maternal smoking, strategies to reduce maternal smoking, antibiotic administration to prevent urinary tract antibiotic administration to prevent urinary tract

infectionsinfections and and antimalarial prophylaxis.antimalarial prophylaxis.

Few statistically significant reductions in the Few statistically significant reductions in the risk of IUGR have been demonstrated with risk of IUGR have been demonstrated with other other interventions. interventions.


SSurveillanceurveillance Unless delivery occurs, once treatment begins the Unless delivery occurs, once treatment begins the

foetus must undergo surveillance. foetus must undergo surveillance. The purposeThe purpose - - to identify further progression of to identify further progression of

the disease process that would jeopardize the the disease process that would jeopardize the foetus to a point that it would be better to be foetus to a point that it would be better to be delivered than to remain in utero. delivered than to remain in utero.

There are four testing modalities which are helpful 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 each of which addresses different aspects of surveillanceaspects of surveillance..

CCombination of tests are better than an isolated ombination of tests are better than an isolated test.test.


SSurveillanceurveillance

This simplest to perform test should b used first in This simplest to perform test should b used first in the surveillance of IUGR foetuses. With the help of the surveillance of IUGR foetuses. With the help of a heart rate monitor, the changes in the foetal heart a heart rate monitor, the changes in the foetal heart rate with foetal movement are to be determined. If rate with foetal movement are to be determined. If the heart rate increases more than 15 beats for the heart rate increases more than 15 beats for more than 15 seconds, this is considered to be a more than 15 seconds, this is considered to be a reactive test. If the heart rate does not accelerate, reactive test. If the heart rate does not accelerate, remains flat, or decreases, then this is an abnormal remains flat, or decreases, then this is an abnormal test. The problem with this test is that it changes test. The problem with this test is that it changes late in the course of the disease and is not an early late in the course of the disease and is not an early predictor of adverse outcome.predictor of adverse outcome.

Non- Stress Test (NST)Non- Stress Test (NST)



The vertical depth of four pockets of amniotic The vertical depth of four pockets of amniotic fluid are measured by USG, to obtain a total fluid are measured by USG, to obtain a total AFI. This method allows for comparison of AFI. This method allows for comparison of changes in amniotic fluid with time. In the changes in amniotic fluid with time. In the normal foetus the AFI remains relatively normal foetus the AFI remains relatively constant. In the foetus with IUGR, it may constant. In the foetus with IUGR, it may decrease slowly, or decrease abruptly with decrease slowly, or decrease abruptly with time. A decrease in AFI may occur before time. A decrease in AFI may occur before there are changes in the non-stress test. there are changes in the non-stress test.

Amniotic Fluid Index (AFI)Amniotic Fluid Index (AFI)



The current The current recommendations recommendations are that if the AFI are that if the AFI decreases below 8 decreases below 8 after 35 weeks, after 35 weeks, then delivery then delivery should occur. should occur.

Amniotic Fluid Index (AFI)Amniotic Fluid Index (AFI)



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.



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

Biophysical Profile


TreatmentTreatment

IUGR has IUGR has many causes, therefore, there is causes, therefore, there is not one treatment that always works. not one treatment that always works.


TreatmentTreatment 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.


TreatmentTreatment

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.

Maternal bed rest


TreatmentTreatment Maternal bed rest


TreatmentTreatment

The use of aspirin to treat foetuses with IUGR is The use of aspirin to treat foetuses with IUGR is

still controversial. still controversial. If If aspirin is usedaspirin is used, it may be advantageous if , it may be advantageous if

given to patients before 20 weeks of gestation. given to patients before 20 weeks of gestation.

It is minimal to limited benefit if given at the time It is minimal to limited benefit if given at the time

of diagnosis (third trimester). of diagnosis (third trimester). At the present time it is not recommended as a At the present time it is not recommended as a

form of prevention for low risk patients. form of prevention for low risk patients.

Aspirin TherapyAspirin Therapy


TreatmentTreatment

Other forms of treatment that 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.

Other Forms of TreatmentOther Forms of Treatment


TreatmentTreatment

RISK OF PREMATURITYRISK OF PREMATURITY DIFFICULT DIFFICULT EXTRA EXTRA

UTERINEUTERINE EXISTENCEEXISTENCE

RISK OF IUD RISK OF IUD HOSTILE HOSTILE INTRA INTRA

UTERINEUTERINE ENVIRONMENTENVIRONMENT

Judge Optimum Time Of DeliveryJudge Optimum Time Of Delivery


Short Term Risks of IUGRShort Term Risks of IUGR Increased perinatal morbidity and mortality.Increased perinatal morbidity and mortality.

Intra uterine / Intrapartum death.Intra uterine / Intrapartum death. Intrapartuum foetal acidosis characterized by-.Intrapartuum foetal acidosis characterized by-.

» Late deceleration.Late deceleration.» Severe variable deceleration.Severe variable deceleration.» Beat to beat variability.Beat to beat variability.» Episodes of bradicardia.Episodes of bradicardia.

Intrapartum foetal acidosis may occur in as many as Intrapartum foetal acidosis may occur in as many as 40 % of IUGR, leading to a high incidence of LSCS.40 % of IUGR, leading to a high incidence of LSCS.

IUGR infants are at greater risk of dyingIUGR infants are at greater risk of dying because of because of neonatal complications- neonatal complications- asphyxia, acidosis, meconium asphyxia, acidosis, meconium aspiration syndrome, infection, aspiration syndrome, infection, hypoglycemiahypoglycemia,, hypothermia hypothermia, , sudden infant death syndrome. sudden infant death syndrome.

IUGR infants are likely to be susceptible to infections IUGR infants are likely to be susceptible to infections because of impaired immunitybecause of impaired immunity


Long term Long term PrognosisPrognosis Babies who suffer from IUGR are at an increased risk for Babies who suffer from IUGR are at an increased risk for

deathdeath, low blood sugar, low blood sugar, , low body temperaturelow body temperature, , and and abnormal development of the nervous system. These risks abnormal development of the nervous system. These risks increase with the severity of the growth restriction.increase with the severity of the growth restriction.

The growth that occurs after birth cannot be predicted with The growth that occurs after birth cannot be predicted with certainty based on the size of the baby when it is born.certainty based on the size of the baby when it is born.

Infants with asymmetrical IUGR are more likely to catch Infants with asymmetrical IUGR are more likely to catch up in growth after birth than are infants who suffer from up in growth after birth than are infants who suffer from prolonged symmetrical IUGR.prolonged symmetrical IUGR.

If IUGR is related to a disease or a genetic defect, the If IUGR is related to a disease or a genetic defect, the future of the infant is related to the severity and the nature future of the infant is related to the severity and the nature of that disorder.of that disorder.


Long term Long term PrognosisPrognosis IUGR infants are more likely to remain small than those of IUGR infants are more likely to remain small than those of

normal birth weight. They will need the special attention of normal birth weight. They will need the special attention of primary health, nutrition and social services during infancy primary health, nutrition and social services during infancy and early childhood.and early childhood.

Implication of IUGR can be life long affecting:Implication of IUGR can be life long affecting: Body sizeBody size growth growth, composition and physical , composition and physical

performanceperformance.. Immunocompetence.Immunocompetence.

It appears to predispose to adult It appears to predispose to adult adult-onset, degenerative adult-onset, degenerative diseasediseases s like maturity onset diabetes and cardiovascular like maturity onset diabetes and cardiovascular diseases.diseases.

Each case is unique. Each case is unique. CCanan not reliably predict an infant's not reliably predict an infant's future progress.future progress.

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