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DR. SALWA NEYAZI
CONSULTANT OBSTETRICIAN GYNECOLOGIST PEDIATRIC & 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
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 is the deference between IUGR & SGA? SGA < 10th centile for the population.
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? •HPT •PET •DM with vascular involvement •SLE •Anemia •Sickle cell disease •Antiphospholipid syndrome •Renal disease •Malnutrition •Inflammatory bowel disease •Intestinal parasites •Cyanotic 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. HPT •Chronic partial abruption •Placental infarcts •Placenta previa •Chorioangioma •Circumvallate placenta •Placental mosaicism •Twin to twin transfusion Syndrome . PET. DM.
What infections result in IUGR? 5-10% of IUGR Congenital infections: •CMV •Rubella •Herpes •Vericella zoster •Toxoplasmosis •Malaria •Listeriosis .
Which drugs can result in IUGR? •Alcohol •Cigarette smoking 3-4X •Heroin & coccaine •Methotrexate •Anticonvulsants •Warfarin •Antihypertensives /ß-blockers •Cyclosporin .
18 •Turner syndrome •Neural tube defects •Achondroplasia •Osteogenisis imperfecta •Abdominal wall defects •Duodenal atresia •Renal agenesis/ Poter’s S Features suspicious of trisomy •Symmetric IUGR •AFV/ Doppler N •Structural abnormalities •Maternal age •Nuchal translucency •Biochemical screening results .What are the genetic disorders that can result in IUGR? 15% of IUGR •Down’s syndrome T21 •Trisomy 13.
Why does multiple pregnancy result in IUGR? •Placental insufficiency /inadequate placental reserve to sustain N growth of > one fetus •Twin to twin transfusion syndrome •Anomalies • with higher order gestations • monozygotic twins .
AC .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 . Fl N.Types of IUGR 2-Asymmetric IUGR—80% •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.
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 .
abruptio placentae.& adverse outcome •Medical Hx: connective tissue diseases.How to evaluate a case of IUGR? 1-History: •Current preg LMP. & fetal movements •Previous obstetric Hx particularly looking for IUGR. preg test. thrombotic events & endocrine disorders •Hx of recent viral illness •Drug Hx •Family Hx of congenital abnormalities & thrombophilias . quickening APH.
EXAMINATION •Symphysis fundal height in cm = gest age in wks after 24 wk •Sensitivity 46-86% in detecting IUGR •A difference of more than 2cm requires fetal assessment •Oligohydramnious may be detected on palpation U/S •Fetal biometry for dating then serial measurements •Anomaly scan •AF index •Doppler umbilical artery resistance index. MCA •Repeat tests every1-2 wks .
Toxo Metabolic disorders thrombophilia •Placenta should be sent for HP •Postmortem examination . PROM. Preterm labor Retrospective tests •Maternal blood tests for CMV. Rubella.Invasive fetal testing •Amniocentesis or placental biopsy/ fetal blood sampling for karyotyping if aneuploidy is suspected for viral studies if infections suspected •Caries the risks of infection.
The constitutionally small fetus •A fetus growing parallel to the lower centiles through out preg •Anatomically N •AFV N •Doppler N •Slim petite women .
malformations •Neonatal complications Hypoglycemia. Hypoxia & acidosis. apneic spells. hyperbilirubinemia. meconium aspiration . hypoxia/acidosis. learning & behavior Problems. hypocalcemia. sepsis. intubation sudden infant death syndrome •Long term complications Lower IQ.5-2X . major neurological handicap seizures. HPT •Perinatal mortalility 1.Complications of IUGR •Maternal complications due to underlying disease risk of CS •Fetal complications Stillbirth. mental retardation. low APGAR score congenital malformations. cerebral Palsy. Polycythemia. hypothermia.
SFH. CTG. maternal wt. BP.Treatment •Stop smoking / alcohol •Bed rest uterine blood flow for pt with asymmetric IUGR •Low dose aspirin •Weekly visits attention to : FM. AFV •U/S every 2-4 wks •BPP •Contraction stress test •Delivery 38 wks or earlier if there is fetal compromise •Glucocorticoids if planing delivery before 34 wks •Close monitoring in labor/ continuous monitoring /scalp PH •CS may be necessary .
IUFD Definition: dead fetuses or newborns weighing > 500gm Or > 20 wks gestation 4.5/ 1000 total births Diagnosis Absence of uterine growth Serial ß-hcg Loss of fetal movement Absence of fetal heart Disappearance of the signs & symptoms of pregnancy X-ray Spalding sign Robert’s sign U/S 100% accurate Dx .
Causes OF IUFD Fetal causes 25-40% •Chromosomal anomalies •Birth defects •Non immune hydrops •Infections Placental 25-35% •Abruption •Cord accidents •Placental insufficiency •Intrapartum asphyxia •P Previa •Twin to twin transfusion S •Chrioamnionitis Maternal 5-10% •Antiphospholipid antibody •DM •HPT •Trauma •Abnormal labor •Sepsis •Acidosis/ Hypoxia •Uterine rupture •Postterm pregnancy •Drugs •Thrombophilia •Cyanotic heart disease •Epilepsy •Severe anemia Unexplained 25-35% .
A systematic approach to fetal death is valuable in determining the etiology 1-History A-Family history •Recurrent abortions •VTE/ PE •Congenital anomalies •Abnormal karyptype •Hereditary conditions •Developmental delay B-Maternal History I-Maternal medical conditions •VTE/ PE •DM •HPT •Thrombophilia •SLE •Autoimmune disease •Severe Anemia •Epilepsy •Consanguinity •Heart disease II-Past OB Hx •Baby with congenital anomaly / hereditary condition •IUGR •Gestational HPT with adverse sequele •Placental abruption •IUFD •Recurrent abortions .
alcohol. length or insertion of the umbilical cord •Cord prolapse •Cord knots •Placental tumors . or drug abuse •Abdominal trauma •Cholestasis •Placental abruption •PROM or prelabor SROM Specific fetal conditions •Nonimmune hydrops •IUGR •Infections •Congenital anomalies •Chromosomal abnormalities •Complications of multiple gestation Placental or cord complications •Large or small placenta •Hematoma •Edema •Large infarcts •Abnormalities in structure .1-History Current Pregnancy Hx •Maternal age •Gestational age at fetal death •HPT •DM/ Gestational D •Smooking .
plethoric Umbilical cord •Prolapse •Entanglement-neck.2-Evaluation of still born infants Infant desciption •Malformation •Skin staining •Degree of maceration •Color-pale . blood •Volume Placenta •Weight •Staining •Adherent clots •Structural abnormality •Velamentous insertion •Edema/ hydropic changes Membranes •Stained •Thickening . .legs •Hematoma or stricture •Number of vessels •Length Amniotic fluid •Color-meconium. arms.
Listeria. Toxo. factor IV leiden. Baby with malformation •Hb electrophorersis •Antiplatelet anbin tibodies •Throbophilia screening (antithrombin Protein C & S . thrombosis. spleen.3-Investigations Maternal investigations •CBC •Bl Gp & antibody screen •HB A1 C •Kleihauer Batke test •Serological screening for Rubella •CMV. . •Vascular malformations •Signs of infection •Bacterial culture for Ecoli. Placental wedge. Sphylis. skin. . Herpes & Parovirus •Karyotyping of both parents (RFL. gp B strpt. anticardolipin antibodies) •DIC Fetal inveswtigations •Fetal autopsy •Karyotype (spcimen taken from cord blood.abruption. lupus anticoagulant. Factor II mutation. intracardiac blood. body fluid. or amniotic Fluid) •Fetography •Radiography Placental investigations •Chorionocity of placenta in twins •Cord thrombosis or knots •Infarcts.
IUFD complications •Hypofibrinogenemia 4-5 wks after IUFD •Coagulation studies must be started 2 wks after IUFD •Delivery by 4 wks or if fibrinogen < 200mg/ml .
Psychological aspect & counseling •A traumetic event •Post-partum depression •Anxiety •Psychotherapy •Recurrence 0-8% depending on the cause of IUFD .
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