iugr and iufd

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IUGR & IUFD DR. SALWA NEYAZI CONSULTANT OBSTETRICIAN GYNECOLOGIST PEDIATRIC & ADOLESCENT GYNECOLOGIST

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intra uterine growth retardation

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  • IUGR & IUFDDR. SALWA NEYAZICONSULTANT OBSTETRICIAN GYNECOLOGISTPEDIATRIC & ADOLESCENT GYNECOLOGIST

  • IUGR What is the definition of IUGR?< 10th centile for age include normal fetuses at the lower ends of the growth curve + fetuses with IUGR This definition is not helpful clinically

    < 5th centile for age

    < 3rd centile for age the most appropriate definition but associated with adverse perinatal outcome

  • What is the deference between IUGR & SGA?SGA < 10th centile for the population, which means it is at the lower end of the normal distribution ie. Constitutionally small but have reached their full growth potential

    IUGR Failure of the fetus to chieve the expected weight for a given gestation

  • What are the causes of IUGR?Maternal medical conditions

    Chromosomal anomalies & aneuploidy

    Genetic & Structural anomalies

    Exposure to drugs & toxins

    1ry placental disease

    Extremes of maternal age

    Low socioeconomic status

    Infections

    Multiple gestation

  • Which maternal medical conditions result in IUGR?HPTPETDM with vascular involvementSLEAnemiaSickle cell diseaseAntiphospholipid syndromeRenal diseaseMalnutritionInflammatory bowel diseaseIntestinal parasitesCyanotic pulmonary disease

  • How does the placenta play a role in the development of IUGR?Abnormalities in placental development & trophoblast invasion Idiopathic or due to maternal disease eg SLE, PET, DM, HPTChronic partial abruptionPlacental infarctsPlacenta previaChorioangiomaCircumvallate placentaPlacental mosaicismTwin to twin transfusion Syndrome

  • What infections result in IUGR?Congenital infections:CMVRubellaHerpesVericella zosterToxoplasmosisMalariaListeriosis

    5-10% of IUGR

  • Which drugs can result in IUGR?AlcoholCigarette smoking 3-4XHeroin & coccaineMethotrexateAnticonvulsantsWarfarinAntihypertensives /-blockersCyclosporin

  • What are the genetic disorders that can result in IUGR?Downs syndrome T21Trisomy 13,18Turner syndromeNeural tube defectsAchondroplasiaOsteogenisis imperfectaAbdominal wall defectsDuodenal atresiaRenal agenesis/ Poters S15% of IUGRSymmetric IUGRAFV/ Doppler NStructural abnormalitiesMaternal ageNuchal translucency Biochemical screening resultsFeatures suspicious of trisomy

  • Why does multiple pregnancy result in IUGR?Placental insufficiency /inadequate placental reserve to sustain N growth of > one fetusTwin to twin transfusion syndromeAnomalies with higher order gestations monozygotic twins

  • What are the types of IUGR?1-Symmetric 20%Proportionate decrease in many organ weights including the brain

    Deprivation occurs early

    The fetus is more likely to have an endogenous defect that preclude N development U/S biometry All measurements BPD, FL, AC

  • Types of IUGR2-Asymmetric IUGR80%Relative sparing of the brain

    Deprivation occurres in the later half of pregnancy

    The infant is more likely to be N but small in size due to intrauterine deprivation

    U/S biometry BPD, Fl N, AC

  • Why IUGR often associated with olighydramnios? blood flow to the lungs pulmonary contribution to amniotic fluid volume

    blood flow to the kidneys GFR urine output

    It is present in 80-90% of IUGR fetuses

  • How to evaluate a case of IUGR?1-History:Current preg LMP, preg test, quickening APH, abruptio placentae, & fetal movementsPrevious obstetric Hx particularly looking for IUGR,& adverse outcomeMedical Hx: connective tissue diseases, thrombotic events & endocrine disordersHx of recent viral illnessDrug HxFamily Hx of congenital abnormalities & thrombophilias

  • EXAMINATIONSymphysis fundal height in cm = gest age in wks after 24 wkSensitivity 46-86% in detecting IUGRA difference of more than 2cm requires fetal assessmentOligohydramnious may be detected on palpationU/SFetal biometry for dating then serial measurementsAnomaly scanAF indexDoppler umbilical artery resistance index, MCARepeat tests every1-2 wks

  • Invasive fetal testingAmniocentesis or placental biopsy/ fetal blood sampling for karyotyping if aneuploidy is suspectedfor viral studies if infections suspectedCaries the risks of infection, PROM, Preterm labor Retrospective testsMaternal blood tests for CMV, Rubella, Toxo Metabolic disorders thrombophiliaPlacenta should be sent for HPPostmortem examination

  • The constitutionally small fetusA fetus growing parallel to the lower centiles through out pregAnatomically N AFV N Doppler NSlim petite women

  • Complications of IUGRMaternal complications due to underlying disease risk of CSFetal complications Stillbirth, hypoxia/acidosis, malformations Neonatal complications Hypoglycemia, hypocalcemia, Hypoxia & acidosis, hypothermia, meconium aspiration ,Polycythemia, hyperbilirubinemia, sepsis, low APGAR scorecongenital malformations, apneic spells, intubation sudden infant death syndromeLong term complications Lower IQ, learning & behaviorProblems, major neurological handicap seizures, cerebral Palsy, mental retardation, HPT Perinatal mortalility 1.5-2X

  • TreatmentStop smoking / alcoholBed rest uterine blood flow for pt with asymmetric IUGRLow dose aspirin Weekly visits attention to : FM, SFH, maternal wt, BP, CTG, AFVU/S every 2-4 wksBPPContraction stress testDelivery 38 wks or earlier if there is fetal compromiseGlucocorticoids if planing delivery before 34 wksClose monitoring in labor/ continuous monitoring /scalp PHCS may be necessary

  • IUFDDiagnosisAbsence of uterine growthSerial -hcgLoss of fetal movementAbsence of fetal heartDisappearance of the signs & symptoms of pregnancyX-ray Spalding sign Roberts signU/S 100% accurate DxDefinition: dead fetuses or newborns weighing > 500gmOr > 20 wks gestation4.5/ 1000 total births

  • Fetal causes 25-40%Chromosomal anomaliesBirth defectsNon immune hydropsInfectionsPlacental 25-35%AbruptionCord accidentsPlacental insufficiencyIntrapartum asphyxiaP PreviaTwin to twin transfusion SChrioamnionitisMaternal 5-10%Antiphospholipid antibodyDMHPTTraumaAbnormal laborSepsisAcidosis/ HypoxiaUterine rupturePostterm pregnancyDrugsThrombophiliaCyanotic heart diseaseEpilepsySevere anemiaUnexplained 25-35%Causes OF IUFD

  • A systematic approach to fetal death is valuable in determining the etiology 1-HistoryA-Family historyRecurrent abortionsVTE/ PECongenital anomaliesAbnormal karyptypeHereditary conditionsDevelopmental delay

    B-Maternal HistoryI-Maternal medical conditionsVTE/ PEDMHPTThrombophiliaSLEAutoimmune diseaseSevere AnemiaEpilepsyConsanguinityHeart diseaseII-Past OB HxBaby with congenital anomaly / hereditary conditionIUGRGestational HPT with adverse sequelePlacental abruptionIUFDRecurrent abortions

  • Current Pregnancy HxMaternal age Gestational age at fetal deathHPTDM/ Gestational DSmooking , alcohol, or drug abuseAbdominal traumaCholestasisPlacental abruptionPROM or prelabor SROMSpecific fetal conditionsNonimmune hydropsIUGRInfectionsCongenital anomaliesChromosomal abnormalitiesComplications of multiple gestation

    Placental or cord complicationsLarge or small placentaHematomaEdemaLarge infarctsAbnormalities in structure , length or insertion of the umbilical cordCord prolapseCord knotsPlacental tumors1-History

  • 2-Evaluation of still born infantsInfant desciptionMalformationSkin stainingDegree of macerationColor-pale ,plethoricUmbilical cordProlapseEntanglement-neck, arms, ,legsHematoma or strictureNumber of vesselsLengthAmniotic fluidColor-meconium, bloodVolumePlacentaWeightStainingAdherent clotsStructural abnormalityVelamentous insertionEdema/ hydropic changesMembranesStained Thickening

  • 3-InvestigationsMaternal investigationsCBCBl Gp & antibody screenHB A1 CKleihauer Batke testSerological screening for RubellaCMV, Toxo, Sphylis, Herpes & ParovirusKaryotyping of both parents (RFL,Baby with malformationHb electrophorersisAntiplatelet anbin tibodiesThrobophilia screening (antithrombinProtein C & S , factor IV leiden, Factor II mutation, , lupus anticoagulant, anticardolipin antibodies)DICFetal inveswtigationsFetal autopsyKaryotype (spcimen taken from cord blood, intracardiac blood,body fluid, skin, spleen,Placental wedge, or amniotic Fluid)FetographyRadiographyPlacental investigationsChorionocity of placenta in twins Cord thrombosis or knots Infarcts, thrombosis,abruption,Vascular malformationsSigns of infectionBacterial culture for Ecoli, Listeria, gp B strpt.

  • IUFD complicationsHypofibrinogenemia 4-5 wks after IUFDCoagulation studies must be started 2 wks after IUFDDelivery by 4 wks or if fibrinogen < 200mg/ml

  • Psychological aspect & counselingA traumetic eventPost-partum depressionAnxietyPsychotherapyRecurrence 0-8% depending on the cause of IUFD