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Intrauterine Growth Restriction (IUGR) (:factory:Facts (Def (Def: :…
Intrauterine Growth Restriction (IUGR)
:factory:
Facts
Common complication of pregnancy
Complicates 5-10% of pregnancies
3rd leading cause of perinatal mortaility
after anomalies and prematurity
40% of all stillbirths are IUGR
Def
Def: : pathologic conditions where there's a
restriction of growth in utero
&
fetus doesn't attain its full growth potential
Most accepted def: fetus with IUGR that has
EFW < 10th percentile for GA
➭ for Early Dx
Perinatal mortality inversely proportional to percentile growth:
1.5% < 10%
, 2.5% < 5th%
we should confirm date by U/S,
F/U in 7 months ➭ see how it goes?
:beer_mugs:
Types
Symmetrical
Def: SGA all parts of body
Causes :carousel_horse: ➭ Chromosomal, structural, early infection
'Weight, Length, and Head circumference are
ALL below 10th percentile
'
Asymmetrical
Def: some parts are small, save brain** so normal brain size, usu. at ช่วงหลังๆ,
Causes :carousel_horse: ➭ Uteroplacental insufficiency (from bad blood flow ➭ Head sparing & :arrow_down: blood to abd.
'
Weight
is
below the 10th percentile
, Length and Head circumference are preserved --
Head sparing
& small abdomen
Constitutionally small
Normal Rate of Fetal Growth :grapes:
:umbrella_on_ground:
Staging
Stage I
(Hyperplasia)
:timer_clock:Timing: GA 4 - 20 wks
Rapid mitosis
:arrow_up: DNA content
Growth inhibition in this stage:
Undersized fetus with fewer cells
Normal cell size
:small_blue_diamond:Associated conditions
Genetic
Congenital anomalies
Intrauterine infections
(eg. Syphilis)
Substance abuse
Cigarette smoking
Therapeutic irradiation
:kiwifruit: resulting in
Symmetric
IUGR (1/3)
Stage II
(Hyperplasia & Hypertrophy)
:timer_clock:Timing: GA 20 - 28 wks
Declining mitosis
:arrow_up: in cell size
Growth inhibition in these stages (II & III):
#
#
:arrow_down: cell size & fetal wt
less effect on total cell numeric, fetal length, head circumference
:kiwifruit: resulting in
Asymmetric
IUGR (2/3)
:small_blue_diamond: Associated conditions
Uteroplacental insufficiency (
UPI
)
Stage III
(Hypertrophy)
:timer_clock:Timing: GA 28 - 40 wks
Rapid increase in cell size
Rapid accumulation of Fat, Muscle, and CNT
95% of
fetal wt gain
occurs during
last 20 wks of gestations
:star: ≥ 7 months:
Stage II + Stage III
≥ 7 mo can begins FMC cuz good accuracy
:cat:
Etiology
:mother_christmas::skin-tone-3:
Maternal
Chronic disorder associated with Vascular ds
Preg-related hypertensive ds
(eg. preeclampsia with or without chronic HT)
Impaired trophoblastic arteriolar invasion
Atherosis & necrosis
:arrow_down: utero-placental blood flow
Antiphospholipid syndrome
(Acquired immune-mediated thrombophilia)
not seen in hereditary thrombophilia
Pregestational DM
Renal insuff
Autoimmune ds (eg. SLE)
Cyanotic cardiac ds
Substance use and abuse (eg. Tobacco, alcohol, cocaine or narcotics)
Teratogen exposure (eg. Cyclophosphamide, valproic acid, or antithrombotic drugs)
Infectious ds (eg. Malaria, CMV, Rubella, Toxoplasmosis, or Syphilis)
:baby::skin-tone-3:
Fetus
Multiple gestation
Congenital heart ds
Gastroschisis
Genetic and structural disorder (like Trisomy 13, Trisomy 18)
:small_orange_diamond:
Placental
Small placenta
Fetal/Placental weight ratio > 10
Placental chronic abruption
Post-term
Cord anomalies
Velementous insertion of cord
Major umbilical vss
seperate
in the fetal membranes before reaching the placental disk
Battledore placenta
Cord is attached to the
margin
of the placenta
:earth_americas:
Epidemiology
IUGR are predispose to Development of cognitive delay in childhood & diseases in adulthood
:notebook_with_decorative_cover:
Barker hypothesis
:arrow_up: Risk of adult metabolic syndrome, obesity, Type 2 DM, Coronary artery disease, Stroke
:rice_ball:
Screening
Fundal height
(uses cm) during
between
GA 24 - 38 wks
to approximate GA
(up to 85% sensitivity 32-34 wks)
Ultrasound
for biometric measures (BPD, HC, :star:
AC
, FL) to yield EFW and % growth
for GA and EDC also
Doppler
(with
umbilical arteries blood flow
)
How it works?
Flow of blood thru arteries
depends
on Strength of fetal heart contraction & Health of placenta
Umbilical arteries: from fetus ➯ placenta
Umbilical veins: from placenta ➯ fetus
Within placenta contains 2 umbilical arteries & 1 umbilical vein
Doppler principle
based on
Changes in sound waves related to Flow of velocity of blood traveling thru these vss
:<3:
Umbilical arteries
Umbilical arterial waveform ➯ usu. Sawtooth type pattern with flow always in Forward direction
evaluated by Measuring Blood flow velocity at
Peak systole (Maximal contraction of heart)
Peak diastole (Maximal relaxation of heart)
values are in 'ratio'
Note that as GA advances ➯ :arrow_up: blood flow at
diastole
= placenta less resistant
Growth-retarded & developing intrauterine distress fetuses
➯ more placental resistance
➯ & umbilical artery blood velocity
waveform
usu changes in
progressive manner
:arrow_up:
resistance
index
(From :arrow_down: blood flow during diastole ➯ inc. RI values, PI values and S:D ratios)
Absent
end diastolic flow
Reverse
flow
Notching
in late in pregnancy = indicator of :arrow_up: uterine vascular resistance and Impaired uterine circulation
:leaves:
Management
Serial US q 2 - 4 wks as I/C
Antenatal surveillance with umbilical artery Doppler velocimetry and Antepartum testing (NST, BPP)
Delivery depends on U/D etiology & estimated GA
Term ➯ Delivery
Preterm + any Complication ➯ Corticosteroid then evaluation again
GA Delivery
before 34 wks
➯ Planned at a center with NICU & consult with a maternal-fetal specialist & Antenatal corticosteroids
before 32 wks
➯
MgSO4
should considered for Fetal and Neonatal neuroprotection
Neonatal complications
:grapes:
Calculatings
:grapes:
:deciduous_tree:
S&S
Heads - disproportionately large for their trunks & ext.
Facial appearance like Wizened old man
Long nails
Scaphoid abdomen
:clock11:
Long-term Sequale
up to 50% ➯ Cognitive disability
:arrow_up: risk of Cerebral palsy (preterm < 32 wks)
Chronic growth lag in < 50%