intrauterine growth restriction

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Diagnosis and Management of Intrauterine Growth Restriction

Dr Okechukwu UgwuLagos University Teaching Hospital.

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OUTLINEINTRODUCTIONDEFINITIONSPATHOPHYSIOLOGYCLASSIFICATION OF IUGRRISK FACTORSDIAGNOSISMANAGEMENTCOMPLICATIONSPREVENTIONCONCLUSION

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INTRODUCTIONIUGR is a common and complex obstetric problem3 - 10% of all pregnancies50 % of preterm stillbirths/ 25% of term stillbirths.Perinatal mortality is 8 - 10 times higher for these fetuses: 6- 30% in developing

countries

IUGR is the second leading cause of perinatal mortality

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DEFINITIONSIUGR is failure of a foetus to reach its full growth potential.

EFW ≤ 10th percentile for GA- (ACOG and RCOG)

EFW < 2 SDs below mean weight for GA

AC < 10% for GA

EFW ≤ 5th percentile for GA

Ponderal Index < 10th percentile

Normal & IUGR Newborn babies

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PATHOPHYSIO -1 (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

Stage III ( Hypertrophy) - 28 to 40 weeks - Rapid increase in cell size. - Rapid accumulation of fat, muscle

and connective tissue.80% of fetal weight gain occurs during

last 20 weeks of gestations.

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PATHOPHYSIO-2 DETERMINANTS OF FETAL GROWTH

Maternal nutrition and health status- weight and height

Uteroplacental blood flow

Uteroplacental substrate uptake

Placental transfer function

Umbilical blood flow

Fetal endocrine status

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PATHOPHYSIO-3 Physiology of Growth Factors

Glucose

IGF-1

IGF-2

Thyroxine- cerebral and skeletal

Leptin

Angiogenic factors

Cortisol

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CLASSIFICATIONBased on onset in pregnancy, cause and prognosis

Symmetric: early onset, proportionate decrease in all organs, ≈ 20%

Assymetric : late onset ,disproportionate decrease in all organs- AC affected > HC- 80%

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Classification• Based on USS examination small fetuses are

divided into two categories

Healthy SGA or True IUGR orConstitutionally small Pathologically growth restricted

Type –I Type –IISymmetrical IUGR Asymmetrical IUGRIntrinsic IUGR Extrinsic IUGR

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Symmetrical IUGR(20%)Growth inhibition in stage I (hyperplastic

stage): - Reduced number of cells in fetus. - Normal cell size.Features-

Uniformly smallPonderal Index(Birth wt /Normal

HC/AC-NormalFL/AC-Normal

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Asymmetrical IUGR(80%)Pathophysiology Growth Inhibition in Stage II/III

(Hyperplasia & Hypertrophy) -Decrease in cell size and fetal weight-Less effect on total cell numeric, fetal length, head circumference.

FeaturesHead > Abdomen(Due to brain sparing effect)Ponderal Index(Birth wt /-LowHC/AC- IncreasedFL/AC- Increased

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RISKMaternal

Placental

Foetal

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RISK FACTORS- MATERNALMaternal malnutritionlow socioeconomic statusSubstance abuse/AlcoholMaternal BMIPrevious hx of IUGR babySmokingDrugs- warfarin, anticonvulsants, antineoplastic agents, and folic acid antagonists Maternal Chronic anaemiaCaffeine

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RISK FACTORS-2 MATERNALHemoglobinopathies

High altitudes

short inter pregnancy interval

ART

maternal disease conditions- HTN, DM, Renal dx, PE.

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RISK FACTORS-3 PLACENTAPlacental abruption, Placental infarction Foetal villous obliterationDiffuse chronic villitis Placental haemangiomaSingle umbilical arteryVelamentous cord insertion Placenta praeviaChorioangioma

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RISK FACTORS-4 FoetalCongenital malformationsInborn errors of metabolismCongenital InfectionsChromosomal anomaliesMultiple pregnanciessex ( male 150 -200g >female )Single gene disorders such as Cornelia de Lange syndrome, Russell

Silver syndrome, Fanconi’s anemia, Bloom syndrome

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Diagnosis- 1 Establish accurate dating

Identification of risk factors by obtaining medical history

BP, Urinalysis

SFH/ Abdominal girth

Infectious workup/MP/FBC

Ultrasound- Biometry HC/AC ratio, FL/AC ratio, BPD

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Diagnosis-2

Ponderal index (PI),

Amniocentesis

serum analytes screening

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MANAGEMENT-1Gestational age at diagnosis, confirmed aetiology, Risk of IUD versus

preterm delivery, level of expertise- Paradox

Parental counselling extremely important

Each case must be individualized

Investigating for underlying causes and instituting appropriate

treatment

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MANAGEMENT -2Fetal movement count (FMC)

Biophysical profile (BPP)/modified BPP

Serial USS for growth

Doppler studies

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Doppler StudiesRecent advances in foetal surveillance technique

Umbilical artery

MCA

Ductus Venosus

Descending aorta

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Timing of Delivery At present there is no effective intervention to alter the course of FGR except delivery-GRIT

Risk of fetal hypoxaemia and acidaemia versus complications of prematurity must be weighed

Evidence of fetal Lung maturity

Delivery should be considered at or near term

Must be in a center with facilities for CS and Neonatal care

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GROWTH RESTRICTION NEAR TERMPrompt delivery is likely best for the foetus

Most obstetricians recommend delivery from 34 weeks and beyond

With reassuring foetal surveillance, Vaginal delivery may be attempted

Expectant management can be guided using Antepartum foetal surveillance

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GROWTH RESTRICTION REMOTE FROM TERMObservation is recommended while doing foetal surveillanceScreen for likely aetiology

Managements decision depends on relative risk of foetal death versus preterm delivery

No specific treatment measure ameliorates the condition.

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TREATMENT MEASURESAdmission, Bed rest- Left lateral positionImproving dietCessation of alcohol, smoking, illicit drugsCorticosteroidsFrequent antenatal visits3-4 Weekly USS for EFWAspirin, nitric oxide donorsMgSO4Phosphodiesterase inhibitors Sildenafil

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Mode of DeliveryEvery case must be individualizedDeterminants: underlying aetiology, GA, severity of IUGR, fetal surveillance

Parameters, Facilities availableObstetric factors e.g. malpresentationVaginal delivery Low threshold for CSCS better with severe growth restriction

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Mode of Delivery• Fetuses with significant IUGR should be preferably delivered in well equiped

centres which can provide intrapartum continuous fetal heart monitoring , fetal blood sampling and expert neonatal care.

• Vaginal delivery: can be allowed as long as there is no obstetric indication for caesarian section and fetal heart rate is normal.

• Fetuses with major anomaly incompatible with life should also be delivered vaginally.

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Labour and DeliveryIntense surveillance in labourHigh risk of fetal distress, cord compressionUse of PantographContinuous electronic fetal monitoringLeft lateral positionO2 administration (if indicated)Low threshold for CSNeonatologist or personnel skilled in NN resuscitation present

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Caesarian sectionThese include: Repetitive late decelerations

poor biophysical profilereversal of end diastolic flow in umbilical arteryabnormal venous dopplerblood gas analysis showing acidic pH on cordocentesis.

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COMPLICATIONS- NeonatePrematurityPerinatal asphyxiaMeconium aspirationSepsisNECStillbirthSIDSIncreased PN morbidity and mortality

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COMPLICATIONS- Long term

Risk of IHD, stroke ,HTN, DM , Metabolic syndrome

Low IQ

Short stature in adult life

Poor neurologic and cognitive function

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Prevention• Improvement in nutritional status• Preconception counseling and care• Malarial antiprophylaxis• Cessation of smoking, alcohol and illicit drug use• Low dose aspirin• Correction of anaemia, iron supplememtation• Care with use of medications• Immunization with rubella vaccine in susceptible females• protein/energy supplementation• vitamin/mineral supplementation

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ConclusionIUGR is associated with high perinatal morbidity and mortality. It is important for obstetricians to recognize the foetus(es) at risk of IUGR. The foremost priority is to establish the dating criteria and further identify the modifiable risk factors and optimize the maternal systemic disease.

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