Refrat IUGR

L/O/G/O
DEFINISI
IUGR terjadi apabila janin yang belum lahir memiliki berat pada atau dibawah 10 persentil di usia kehamilan saat itu (dalam minggu). Janin tersebut dipengaruhi oleh keadaan patologi sehingga untuk kemampuan berkembang terhambat
Berat badan lahir rendah (BBLR): bayi dengan berat lahir kurang dari 2500 gram yang dapat berarti mengalami IUGR atau prematuritas
Pendahuluan
Disturbance of normal fetal growth Abnormal
Weight Body mass
body proportion at birth
Fetal Growth Disorder

Intrauterine Growth Restriction (IUGR) Macrosomia
Perinatal mortalitas and short- and long-term

Morbiditas
www.themegallery.com
Pendahuluan
Sebelum ada ANTENATAL ULTRASOUND Pertumbuhan Janin Diklasifikasikan dengan BERAT BADAN BAYI
Macrosomia (>4000 g), BBLR <2500 g BBLSR <1500 g BBLASR <1000 g
Lubchenco and colleagues

Sangat Kecil Masa Kehamilan (SKMK), very small for gestational age (VSGA) : < 3 persentil Kecil Masa kehamilan (KMK), Small for gestaational age (SGA) : < 10 persentil Sesuai Masa Kehamilan (SMK), Appropiate for gestaational age (AGA) : 10 90 persentil Besar Masa kehamilan (BMK), Large for gestaational age (LGA) : > 90 persentil
REGULASI Pertumbuhan Janin

Pertumbuhan Janin Maternal Placental Fetal compartments
Successful Placentation
development of maternal and fetal vascular supply synthetic activity of the placenta establishment of transplacental carrier proteins for substrates
Trimester 1 blastocyst adherence and implantation placental vascular development

Transport Nutrients and Oxygen growing trophoblast differentiation of placenta transport mechanisms
activation of paracrine and endocrine signaling pathways between the mother, the placenta, and the fetus
Coordinate Placental and Fetal Growth

Nutrients
Umbilical vein
Ductus venosus
70% to 80% of the umbilical venous nutrients
liver
Glycogen storage
liver
release of insulin-like growth factors I and II
Glucose and amino acids
Heart
hepatic veins
Stimulate Insulin release from the fetal pancreas.
Stimulus for fetal growth and differentiation.
Leptin
Fetal pancreatic growth
modulator of fetal body fat content and body proportions
affects fatty acid transport.
transplacental amino acid transport
Pola Pertumbuhan
Trimester hyperplasia 1 Trimester Hyperplasia hypertrophy 2 Trimester hypertrophy 3

KECEPATAN PERTUMBUHAN BERAT BADAN

1. 0-15 minggu : 10 gr/minggu 2. 16-27 minggu : 85 gr/minggu 3. 28-37 minggu : 200 gr/minggu 4. 38-42 minggu : 70 gr/minggu 20 minggu berat 10% 28 minggu kecepatan tumbuh maksimal, berat badan 1.000 gr Mempertahankan partus prematurus meskipun hanya beberapa minggu penting!!
Etiologi
Patofisiologi
Mechanisms of Placental Dysfunction
expression of vasoactive substances increases vascular reactivity hypoxia-stimulated angiogenesis is inadequate placental autoregulation becomes deficient Maternal placental floor infarcts and fetal villous obliteration and fibrosis increase placental blood flow resistance producing a maternal-fetal placental perfusion mismatch effective exchange area With progressive vascular occlusion fetoplacental flow resistance is increased throughout the vascular bed,
Which is the metabolically active placental mass

and nutrient exchange decreases
Metabolic and Cellular Effects of Placental Dysfunction

Oxygen delivery + Substrate Delivery (0.6 mmol/min/kg fetal body weight) fetal oxygen uptake is reduced Fetal hypoglycemia Nutrient supply worsens Proteins are catabolized to gluconeogenic amino acids Inability to establish essential adipose stores Fetal hypoxemia and protein energy malnutrition Placenta and fetus do not reach their size potential limits fetal growth and affects cellular and functional differentiation in many target organs.
Fetal Response in Major Organ Systems

Cardiovascular and central nervous system functions
placental resistance fetal oxygenation organ autoregulation Vascular reactivity
Mild placental dysfunction Progressive degrees of placental vascular damage

Delayed maturation of several fetal behaviors
appearance of movement, to coupling and cyclicity of behavior integration of movement patterns into stable behavioral states autonomic reflexes superimposed on intrinsic cardiac activity fetal heart rate
Fetal Decompensation
Placental dysfunction progressive and sustained Exhausted Decompensation
LOSS OF CARDIOVASCULAR HOMEOSTASIS Multiple-organ failure

Metabolic abnormalities
acidemia worsens
risks of intrauterine damage
perinatal death increase

Screening
Klinis
Pengukuran TFU
estriol human placental lactogen (hPL) human chorionic gonadotropin (hCG) -fetoprotein (AFP)
Biokimia Uterine Artery Doppler Pengukuran
Placental and Fetal Doppler Studies Pada usia kehamilan 22 dan 23 minggu
BIPARIETAL DIAMETER Lingkar Kepala Lingkar Abdominal Sonographic Estimate of Fetal Weight
Klasifikasi
< 20 minggu
Symmetric
Hyperplasia
IUGR
asymmetric
>20 minggu
Hypertrophy decreased nutrition and oxygen

Diagnosis Dan Evaluasi

Maternal History and Examination
Maternal medical Medication Obstetric histories
Two-Dimensional Ultrasound
Assessment of Fetal Size
Doppler Velocimetry of Arterial and Venous Circulation Computerized Cardiotocography and Biophysical Profile Score
Diagnosis dan Evaluasi
Terapi
potential external contributors
stress Smoking
maternal rest
Lateral position
Fetal oxygen and substrate delivery

Maternal hyperoxygenation Intravascular volume expansion
Pharmacology
low-dose aspirin therapy (81 mg/day) Mild IUGR Antenatal corticosteroids any fetus with IUGR when delivery is anticipated before 34 weeks www.themegallery.com
Timing and Mode of Delivery
High RISK
fetal acidemia
Low RISK
fetal testing less serious conditions Gestational age is more advanced
spontaneous late decelerations

late decelerations with minimal uterine activity
Per Vaginam
SC

Refrat IUGR

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Refrat IUGR

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L/O/G/O

body proportion at birth

Fetal Growth Disorder

Perinatal mortalitas and short- and long-term

Lubchenco and colleagues

REGULASI Pertumbuhan Janin

Trimester 1 blastocyst adherence and implantation placental vascular development

Coordinate Placental and Fetal Growth

70% to 80% of the umbilical venous nutrients

Glucose and amino acids

Stimulate Insulin release from the fetal pancreas.

Stimulus for fetal growth and differentiation.

Fetal pancreatic growth

modulator of fetal body fat content and body proportions

affects fatty acid transport.

transplacental amino acid transport

Trimester hyperplasia 1 Trimester Hyperplasia hypertrophy 2 Trimester hypertrophy 3

KECEPATAN PERTUMBUHAN BERAT BADAN

Which is the metabolically active placental mass

Metabolic and Cellular Effects of Placental Dysfunction

Fetal Response in Major Organ Systems

Mild placental dysfunction Progressive degrees of placental vascular damage

LOSS OF CARDIOVASCULAR HOMEOSTASIS Multiple-organ failure

risks of intrauterine damage

perinatal death increase

Biokimia Uterine Artery Doppler Pengukuran

Hypertrophy decreased nutrition and oxygen

Diagnosis Dan Evaluasi

Diagnosis dan Evaluasi

Fetal oxygen and substrate delivery

Timing and Mode of Delivery

spontaneous late decelerations

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