PERTU MBUHAN JANIN TERHAMBAT (PJT)

A. Kurdi Syamsuri

IUGR - INTRAUTERINE GROWTH RETARDATION

defined as failure of normal fetal growth caused by multiple adverse effects on fetus due to process that inhibits normal growth potential of fetus

SGA - SMALL FOR GESTATIONAL AGE INFANTS

an infant whose weight is lower than the population norms defined as weight below 10th percentile for gestational age or greater than 2 standard deviations below the mean cause may be pathologic or nonpathologic

SO WHAT IS THE DIFFERENCE BETWEEN SGA AND IUGR?

These terms are related but non synonimuous. Not all IUGR infants are small enough to fit the qualifications for SGA. Not all SGA infants are small because of a growth-restrictive process, and therefore, do not meet criteria for IUGR.

INCIDENCE

3 - 10 % of all pregnancies 10 % of general obstetric population 4-7 % of all infants born in developed countries 6-30 % of all infants born in developing countries

IUGR : SO WHAT!

2nd leading contributor to perinatal mortality!!! 1/3 of infants with BW < 2800 gms are growth retarded and not premature. 9 - 27 % have anatomic and/or genetic abnormalities Perinatal mortality : x 6-10 Intrapartum asphyxia : up to 50% As many as 40% stillborn are IUGR A portion of perinatal complication is preventable (morbidity and mortality) Association with mutiple sequelae (short and longterm morbidity)

PATTERNS OF GROWTH

Three phases of fetal growth and development : 1. Occurring from 4 to 20 weeks gestation, is characterized by proportional increases in fetal weight, protein content, and DNA content (cellular hyperplasia). 2. From 20 to 28 weeks gestation, is characterized by increases in protein and weight and lesser increases in fetal DNA content (hyperplasia and concomitant hypertrophy). 3. From 28 weeks to term, is characterized by continued increases in fetal protein and weight but no increase in DNA content (hypertrophy).
Enid Gilbert-Barness, Diane Debich-Spicer, BS. Embryo and Fetal Pathology 2004 ; 310-20.

FETAL GROWTH CHARTS

Single Fetus

FETAL GROWTH CHARTS

Multiple Fetus

Extrinsic :
-Cigarette smoking - Alkohol / cocaine - viral infection

Maternal :

Placental factor : - placental mosaicsm

- Hypertension
- Preeclampsia - APS - Trombhophilia

FETAL GROWTH RESTRICTION

- abnormal placentation - uterine abnormality - chronic placental abruption

Fetal :
-Chromosomal (trisomy 18,13, 21) - Mendelian single gen disorder - Congenital structural abnormalities - Other syndromes
Baschat AA, Pathophysiology of Fetal Growth Restriction: Implications for Diagnosis and Surveillance; CME Review Article, Vol.59 No.8 2004, 617627

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.
Abnormal small fetuses- have chromosomal anomalies or structural malformations. Growth restricted fetuses- are due to impaired placental function.Appropriate & timely treatment or termination can improve prospects.

2. 3.

Symmetrical growth restriction :

comprises

20 to 30 percent, all fetal organs are decreased proportionally

due to impairment of early fetal cellular hyperplasia (early onset)

such as chromosomal abnormalities and congenital malformations, drugs or other chemical agents, or infection
Robert Resnik, MD Intrauterine Growth Restriction. AMJOG vol. 99; 3; march 2002 : 490-6

Asymmetrical growth restriction :

comprises

70 to 80 percent

extrinsic factors, limited fetal metabolic substrate availability (most commonly maternal vascular disease and decreased uteroplacental perfusion)
the skeletal dimensions and head circumference are spared and the abdominal circumference is decreased because of subnormal liver size and a paucity of subcutaneous fat late onset
Robert Resnik, MD Intrauterine Growth Restriction. AMJOG vol. 99; 3; March 2002 : 490-6

BARKER: BAYI YANG MENDERITA PJT LEBIH BANYAK YANG MENDERITA KELAINAN METABOLIK, HIPERTENSI DAN KELAINAN JANTUNG DI MASA DEWASA

ULTRASOUND DIAGNOSTIC

The most common determination of fetal growth restriction is based on the EFW, determined from a combination of BPD and AC (Campbell,1975) Fetal measurements using formulas of BPD, HC, AC and FL, have the highest accuracy for in utero weight estimation The best interval for serial scanning is every 2-3 weeks.

Dr. Helen Kay, Professor of OB-GYN , Director, Division of Maternal-Fetal Medicine , University of Wisconsin Meriter Hospital, Madison, Wisconsin http://www.iame.com/learning/IUGR/iugr_content.html (1 of 11)09/08/2006 1:36:48

DIAGNOSTIC
-

Last Menstrual Period (menstrual diary)

- Curvilinear fundal height measurements in centimeters from the symphysis pubis could be closely correlated with gestational age: a lag of 4 cm or more suggests growth restriction (Belizan et al)
-

A sensitivity of only 27 percent and a positive predictive value of 18 percent using carefully performed fundal height measurements to detect IUGR (Persson et al)

Additional studies have confirmed the lack of sensitivity of fundal height measurements for detecting fetal growth restriction.
Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed.

ULTRASOUND DIAGNOSTIC
Ratio of HC/AC, which normally exceeds 1.0 before 32

weeks, 1.0 at 32-34 weeks and falls below 1.0 after 34 weeks
In asymmetric IUGR, the HC remains larger compared to the AC because of the brain sparing growth phenomenon In symmetric IUGR, the HC and AC are both reduced and therefore, the HC/AC ratio is not helpful

Dr. Helen Kay, Professor of OB-GYN , Director, Division of Maternal-Fetal Medicine ,

University ofWisconsin Meriter Hospital, Madison, Wisconsin

http://www.iame.com/learning/IUGR/iugr_content.html (1 of 11)09/08/2006 1:36:48

ULTRASOUND DIAGNOSTIC
One other ratio that may be useful is the FL/AC ratio. In asymmetric IUGR, the FL is spared in comparison to the

AC measurements from 21 weeks on and therefore, a ratio

greater than 23.5 suggests the presence of IUGR.

Dr. Helen Kay, Professor of OB-GYN , Director, Division of Maternal-Fetal Medicine , University ofWisconsin Meriter Hospital, Madison, Wisconsin

http://www.iame.com/learning/IUGR/iugr_content.html (1 of 11)09/08/2006 1:36:48

ULTRASOUND DIAGNOSTIC
Fluid measurements Decreased amniotic fluid volume has been associated with IUGR

This is due to poor perfusion of the fetal kidneys and therefore decreased urine production. A 2-cm vertical pocket was considered normal, 1 to 2 cm marginal, and less than 1 cm decreased. Manning et al observed : 6 percent incidence of IUGR with a pocket 2 cm or larger, 20 percent with a pocket 1 to 2 cm, and 39 percent with a pocket less than 1 cm. One may also use the amniotic fluid index to quantitate amniotic fluid volume
Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed.

ULTRASOUND DIAGNOSTIC
Doppler Sonography
Systolic/diastolic flow velocity ratios correlate with placental resistance :

a. Decrease over the course of pregnancy b. Increased values for gestational age indicate increased placental

resistance
c. Absent or reversed end diastolic flow is often associated with imminent fetal compromise

Enid Gilbert-Barness, Diane Debich-Spicer, BS. Embryo and Fetal Pathology 2004 ; 310-20.

EARLY NEONATAL MORBIDITY

RDS Meconium aspiration Hypoglycemia Hypocalcemia Hypothermia Polycythemia, hyperbilirubinemia Thrombocytopenia Pulmonary hemorrhage Necrotizing enterocolitis Sepsis

LONG-TERM OUTCOME Depend on underlying cause Poor cognitive function Adverse neurological outcome in childhood Impaired gross motor development, hyperactivity, poor concentration, lower IQ, speech and reading disabilities (Gembruch & Gortner 1998) Cerebral palsy

LONG-TERM OUTCOME

David Barker, epidemiologist from England Fetal origin of adult diseases: The risk of coronary artery disease, stroke and hypertension Intrauterine conditions could program development of the cardiovascular system later in life Infants with birth weight less than 5.5 lb had a 3x increase in death due to coronary artery disease later in life. Other risks: Abdominal obesity, type 2 diabetes mellitus, hyperlipidemia

Reported associations between impaired fetal growth with various outcomes Increased cardiovascular disease (CVD) mortality and possible CVD risk factors: Raised blood pressure (Barker and Martyn, 1997)

Impaired glucose tolerance/type 2 diabetes/gestational diabetes (Barker, 1999a)

Dyslipidaemia: higher cholesterol, LDL-cholesterol and triglycerides levels (Barker, 1999b) Obesity (Fall et al., 1995) Higher plasma levels of fibrinogen, Factor VII and other blood-clothing factors (Martyn et al., 1995) Renal disease/increased mean albumin:creatinine ratio (Garrett et al., 1993) Reduced arterial compliance (Leeson et al., 1997) Higher plasma leptin concentrations (Lissner et al., 1999) Increased thryroid function (Phillips et al., 1993)

Higher sympathetic nervous system activity (Philips and Barker, 1997)

Higher plasma cortisol levels (Phillips et al., 2000)

Reported associations between impaired fetal growth with various outcomes Psychological disorders: Increased risk of schizophrenia (Hoek et al., 1996) Increased risk of depression (Thompson et al., 2001) Increased risk of suicide (Barker et al., 1995a) Respiratory disorders: Increased risk of asthma (Xu et al., 2002) Increased risk of chronic obstructive pulmonary disease (Barker et al., 1991) Early menarche (dos Santos Silva et al., 2002) Early menopause (Cresswell et al., 1999) Ovarian cancer (Barker et al., 1995b) Osteoporosis (Dennison et al., 2001) Lower IQ scores (Sorensen et al., 1997) Lower rates of marriage (Phillips et al., 2001)

MANAGEMENT

SKORE PROFIL BIOFISIK 5 variabel : skore 0 10

NST, FBM, FM, FT, AF

MANAJEMEN
Nilai BBP 8-10 observasi 7 hari Nilai BPP 6 observasi tiap 3-4 hari, bila usia > 34 minggu /paru matang - induksi, awasi persalinan, KTG berkala Nilai BPP <5 Seksio sesarea

MANAGEMENT
If delivery is not elected, or indication for delivery is not certain, the patient should undergo continuous monitoring of fetal condition Evidence of fetal lung maturity may provide sufficient reassurance to proceed with delivery in many instances

Robert Resnik, MD Intrauterine Growth Restriction. AMJOG vol. 99; 3; march 2002 : 490-6

MANAGEMENT
The term or near-term IUGR fetus should be delivered if there is evidence of : - maternal hypertension, or - failure of apparent growth over a 24 week period, or

- the BPP score is low (less than 6), and/or

- umbilical arterial Doppler velocimetry reveals absence or reversal of flow

Robert Resnik, MD Intrauterine Growth Restriction. AMJOG vol. 99; 3; march 2002 : 490-6

DELIVERY IS INDICATED IN FOLLOWING CONDITIONS

When end diastolic flow is present (PED), and other surveillance findings are normal, delay delivery to 37 weeks. When end diastolic flow is absent or reversed, deliver at 34w regardless of biophysical tests When end diastolic flow is absent or reversed and other surveillance results (biophysical profile, venous Doppler) are abnormal, delivery is indicated at any time
RCOG 2002, Evidence Level IIA

ANTEPARTUM FETAL MONITORING

Doppler velocimetry of the umbilical arteries

40% of combined ventricular output is directed to the placenta by umbilical arteries. Assessment of umbilical blood flow provides information on blood perfusion of the fetoplacental unit. Volume of flow increases and vascular impedance decreases with advancing gestational age. Low vascular impedance allows a continuous forward blood flow throughout the cardiac cycle.

Thank you very much