Intrauterine growth restriction 2007 DURAND HOSPITAL JJC Synonymy Intrauterine growth retardation riction CIR JJC Definition

"It is the arrest of growth and development that causes hypoplasia or hypotrophy embryo, as early or late, caused by intrinsic or extrinsic factors generating c hanges in newborns with weight, height and head circumference, which can lead to prenatal hypoxic conditions or neonatal, postnatal and other signs such as hypo glycemia, polycythemia, etc., or being able to present long-term deficits in int ellectual and learning. " JJC Definition The intrauterine growth restriction (IUGR) occurs when a fetus has an approximat e weight below the 10th percentile for gestational age. The same has been affect ed by a pathological restriction on their growth. Low birth weight (LBW) means a child with a birth weight less than 2500 gr. This may be due to IUGR or prematu rity. JJC Intrauterine growth restriction The most accepted one considers the 10th percentile curve of birth weight, gesta tional age. The ponderal index less than 2 DS. Other countries use the percentil e 25-5. WHO recommendation is that the calibration curve each perinatal center u se is recent and representative of its own population. JJC Incidence of IUGR Between 1 to 20% depending on the definition adopted. 50% are diagnosed after bi rth. 50% of fetuses with suspected IUGR are born with normal weights. Presents 1 0% of perinatal mortality. 50 -80% of the low weights are not NURC. JJC Physiology of Fetal Growth Placental Factors Factors Factors Maternal Fetal JJC Intrauterine growth restriction MATERNAL FACTORS Nutrition: a determinant of fetal growth. No nutrition: growth hormone and insul in-feeding (indirect action on maternal blood glucose and other nutrients) JJC Intrauterine growth restriction MATERNAL FACTORS Mother less than 50 kg. , 1.50 m, 18. Socio-economic status. Low gestational wei ght gain and / or after maternal undernutrition. Maternal vascular disease: hype rtension, diabetes, autoimmune diseases. Chronic kidney disease. Chronic Hypoxia : respiratory failure, cyanotic heart disease. Smoking, drugs, alcohol, cocaine. Infection, TORCH, HIV + Small for gestational age, fetal growth rest

JJC Intrauterine growth restriction FETAL FACTORS Genetic mechanisms: acting on the formation of the placental vesse ls. Insulin responsible for fetal growth from the 26th week of gestation. Somato medins (Insulin Factor) IGF1IGF2. Growth hormone: from the 6th month. Other horm ones: Thyroid - Cortisol. JJC Intrauterine growth restriction FETAL FACTORS previous growth retardation: 25% recurrence when there is no causa l etiology. Twinning: 25-30% Malformations: Potter, agenesis of the pancreas, du odenal atresia, gastroschisis. Previous stillbirth. Prolonged pregnancy recurren t abortion chromosomal abnormalities: trisomy 13, 18 y21. JJC Intrauterine growth restriction Uteroplacental FACTORS Placenta previa Placenta abruptio normoincerta not complete or partial. Placenta l thrombosis. Abnormal uterine vascular abnormalities, fibroids, septum or bicor nuate JJC Placental Factors Uteroplacental insufficiency resulting from: - Trophoblastic invasion and inadequate placentation. - Abnormal placental inser tion. - Reduced blood flow in the placental bed. Fetoplacental insufficiency due to: - Vascular abnormalities in the placenta and / or cord. - Mass disminuída.Placen ta small placental functioning, prolonged pregnancy, abruptio placenta, placenta previa. JJC Classification IUGR IUGR IUGR I II III JJC Intrauterine growth restriction CLASSIFICATION: TYPE 1 Frequency 20% Causes: intrinsic (genetic) or extrinsic (i ntrauterine infection, drugs, teratogens). Two subtypes: constitutional and nonconst. Early onset; cel.de No less than normal size. Normal placenta. Ultrasound . Biometrics harmonic diminished. Doppler: Umbilical and ACM S / D increased. Po stnatal Growth: Poor JJC IUGR curve I JJC - IUGR I Intrinsic - Harmonic - Symmetric - eutrophic - Hypoplastic - Early - Al teration Weight, height, head circumference Frequency: 15% to 20% JJC

Etiopathogenesis: IUGR I Chromosomal: TR18-21-TurnerMosaicismos Genetic Disorders - malformations. Terato gens - drugs - tobacco - alcohol. Infections: rubella-cytomegalovirus-herpes-tox oetc. Dystopia twinning or placental hypoplasia. JJC Intrauterine growth restriction CLASSIFICATION: TYPE 2 Causes: insufficient extrinsic placenta.€Frequency: 80% T op. Third quarter cel Features: No normal size smaller. Organs: Brain / Liver R <3 / 1 Placenta: diminished. Ultrasound: ALT Morphometric proportions. Doppler: Umbilical ACM increases decreases. Postnatal growth good. JJC Curve II IUGR Weeks of pregnancy JJC CIR II Etiopathogenesis Maternal conditions Toxemia endocrine hypertension Kidney S. Antiphospholipid Placental disorders - vasculitis Placental placental hypoplasia Corioangiosis Dystopia JJC - IUGR II Outward - disharmonious - Asymmetric - Dystrophic - hypotrophic - Late - Altered Frequency Weight: 75% to 85% JJC Classification Symmetrical The fetal head and body are proportionately small. It can occur when the fetus e arly. a problem during development Asymmetric The fetal brain is abnormally large compared to the liver can occur when the fet us has a problem late in the course JJC - Outward or mixed IUGR III deficiency - Semiarmónica - hypotrophic malnourished - Semiprecoz - Alteration Weight and Size Frequency: 5%? JJC Etiopathogenesis CIR III -? Cultural Factors Malnutrition smoking - drugs - alco hol JJC Pathophysiological mechanisms IUGR Determinants of fetal growth and development Genetic * Gender * ethnicity * gestational age Nutrition * Oxygen * * drug substrates

Metabolic * Enzymes * receivers * hormones * infection JJC Risk factors for IUGR Demographics • Maternal age <= 16 or> = 35 years • Black • Low socioeconomic status • No part ner • Low level of education JJC Risk factors for IUGR • Parity 0 or> = 5 • Low weight for height • malformations (GU) or chronic hypertension • Diabetes JJC Risk factors for IUGR previous obstetric history: Preterm newborns with previous IUGR Spontaneous Abortions previous maternal ge netic factors as the very low birth weight JJC Risk factors for IUGR Smoking Alcohol Addiction Malnutrition High Altitude Exposure to Env ironmental Toxins JJC Risk factors for IUGR During the current pregnancy • Multiple pregnancy • Poor weight gain • Short birth intervals • Hypotension • Hypertension / preecl ampsia JJC Risk factors for IUGR During the current pregnancy • Infections: bacteriuria, rubella, cytomegalovirus. • Metrorrhagia 1st or 2nd quarter • Placenta previa or abrupt, chorioamnionitis JJC Risk factors for IUGR during the current pregnancy • • • • • • Anemia, abnormal hemoglobin Isoimmunization fetal abnormalities of the cervix in competence Spontaneous rupture of the membranes Poor prenatal care JJC IUGR: DIAGNOSIS Clinical. Conventional ultrasound. Doppler ultrasound. JJC Diagnosis Suspicion (Clinical) of Presumption (ultrasound) of certainty (neonatologists) JJC Clinical

Clinical and obstetric history. SFH - Perimeter abdominal weight curve maternal nutritional status. JJC Value SFH JJC Diagnosis RISK FACTORS. Abdominal palpation (EIII). SFH (IBD). ECOBIOMETRIA AC (IBD) WEIGH T (IBD). Biophysical profile. (IBD) UTERINE DOPPLER (EI, II, III). UMBILICAL DOP PLER (IBD) JJC Ultrasound Growth Curve Measuring DBP AC Measurement Measurement Measurement HC L. L. Femur Measurement Fetal Weight Humerus ponderal index = weight (g) / height (cm) x 100 Ecobiometría JJC IUGR: DIAGNOSIS Ultrasound: • DBP has two patterns: • Profile of slow growth or low profile flattening • Lat e • Sensitivity 24-88% • Specificity 62-94% • Predictive value + 21-44% • Predic tive value - 92-98% 75 % 70% 25% 96% JJC Ecobiometría Ultrasound Growth Curve One must assess any decline in the growth curve, percentiles and serial. Local c harts should be used and updated. When using percentiles of weight for gestation al age in studies of risk factors for low birth weight, or in the evaluation of data for public health, should be used "standars", derived from a population of RN similar to the population being tested. JJC IUGR: Ultrasound diagnosis Ecobiométrico growth arrest in more than two weeks of amenorrhea (amenorrhea tru e) on ultrasound. Stop the ultrasound fetal growth curve over two weeks. JJC Fetal Weight Value / weeks of amenorrhea JJC Neonatal Diagnosis Low birthweight (wt. / Fl). Decreased subcutaneous cellular tissue. Presence / a ppearance - Hypoglycemia - Hyperbilirubinemia - necrotizing enterocolitis - hype rviscosity syndrome. JJC Surveillance Once the diagnosis and begin treatment,€the fetus should be monitored. There

are four useful forms of surveillance: "Non-Stress Test, biophysical profile, L A volume, and umbilical artery Doppler, each of which assesses various aspects o f fetal health. The combination of these is better than one alone. The objec tive is to identify a progression of the disease which would endanger the fetus, the point at which delivery is better, to stay in utero. JJC Decreased amniotic fluid VOLU ME TR IA PLACENTAL AGING SUBMIT VARIABLES LOSS OF GROWTH MEDIUM AND LONG PLA CE GRA S OJ S CD OBI NTA RIO RI A DO PPLER OMET JJC TERM FETAL HEART REDISTRIBUTION OF EXPENDITURE Surveillance Non-Stress Test (NST) This simple test should be used routinely in those fetuses with suspected IUGR. If the FHR does not accelerate, stable or decreasing is considered abnormal. The problem with this test is that it changes late in the course of the disease, an d is not an early predictor of adverse prognosis. JJC Surveillance Manning Test Tone limb movements fetal breathing movements amniotic fluid volume fetal heart rate JJC Surveillance Assessment of Amniotic Fluid The IUGR may be associated with oligohydramnios presumptive giving an idea of th e trade deficit in maternal and fetal vitality vulnerability of the fetus with I UGR in the LA may decrease slowly or abruptly. We can also see a decrease in thi s index before there are changes in the NST. JJC Surveillance Doppler Assessment Allows the evaluation of hemodynamic changes, fetoplacental and uteroplacental, differentiating hypoxic fetuses at high risk for fetal health, those who have on ly biometric changes. JJC Flow redistribution Vasoconstriction Vasodilation AREAS AREAS NOT ESSENTIAL ESSENTIAL Anterior Cerebral Artery middle and posterior Internal carotid artery ART. RENAL ARTERY descending thoracic aorta JJC

GIST STRA AS DOPPLER IN IUGR Normal Outpatient hospital Abnormal (admission) Other methods of normal evaluative / therapeutic Ominous signs Control 15/30 days Control 7 days Control 3 / 4 days Termination of pregnancy JJC Surveillance Placental echostructure Placental premature aging by deposits of fibrinoid substance in the spaces by al tering the exchange fetoplacental intervellositarios Grade 3 previous appearance at 34 wk. JJC Treatment: IUGR What treatment is appropriate? IUGR has various causes, so there is no single treatment that always works. JJC Deciding the optimal time for delivery Prematurity RISK EXISTENCE OF EXTRA HARD UTERINE INTRAUTERINE DEATH RISK OF INTR A UTERINE HOSTILE ENVIRONMENT Treatment JJC Treatment If the ultrasound controls showed no growth or negative (increases the offset) in two separate controls for a week: With Doppler normal => repeat in a week. JJC Treatment If no growth: > 34 weeks ........... induce labor <34 weeks ........... perfo rm amniocentesis: if lung maturity => inducing labor if no maturity => to co rticosteroids and induce within 48-72hs JJC Treatment With pathological Doppler => not wait to practice ultrasound. Induce labor, if necessary after maturation If there is one with little or no oligohydramnios fetal growth > 34 weeks ........... induce labor <34 weeks ....... .... perfo rm amniocentesis: if lung maturity => induce labor if no maturity => give ster oids and induce JJC

Conservative treatment Maternal bed rest This should be the initial approach in the treatment of IUGR. The benefit of bed rest is that there is an increase in blood flow to the uterus. Different studie s have shown however, that in most cases, bed rest at home is as effective as on e conducted in a hospital environment. JJC SCIENTIFIC EVIDENCE SUFFICIENT WITHOUT TREATMENT NUTRITIONAL THERAPY ASPIRIN Oxygen Hospitalization and REST betamimetics hormone plasma expansion Inhibitors RCOG GUIDELINE No 31 (2002) JJC Intrauterine growth retardation There is strong evidence in favor, only the following interventions: - Administr ation of steroids before the 36s (EIA) - Strategies to reduce cigarette consumpt ion - intrapartum fetal monitoring is recommended. - Neonatal Unit of acceptable complexity. It has been shown that other interventions have been statistically insignificant in reducing the risk of IUGR (ACOG-2000) (RCOG 2002) JJC Neonatal minimal assistance Thermoregulation 1.Cuidado 2.Reanimación prompt and adequate under the rules of CPR. 3.€Determination of pH and blood gases in umbilical cord. 4. Presence of a trained professional. JJC Neonatal Morbidity • perinatal asphyxia • Alterations of thermoregulation • Hypoglycemia • Polycyth emia and hyperviscosity JJC Neonatal Morbidity • • • • • • • hypoxic-ischemic encephalopathy meconium aspiration syndrome fetal circulation Persistence of necrotizing enterocolitis IRA Hypocalcemia Stigmata of chromosomal abnormalities JJC Short-term risk of IUGR Increased perinatal morbidity and mortality - stillbirths / Intrapartum - Intrap artum fetal acidosis intrapartum fetal acidosis can occur in about 40% of IUGR, leading to increased risk of PC. - The IUGR have an increased risk of death from neonatal complications: SALAM, infections, hypoglycemia, hypothermia, etc. .. The IUGR are more susceptible to infections due to impaired immunity. JJC Long-term prognosis Each case is unique. It is more likely to remain smaller children born with IUGR They will need special care from primary care, nutrition and social services du ring infancy and early childhood. In adulthood appears to predispose to degenera tive diseases such as diabetes, and cardiovascular disease. JJC Prevention Strategies - - - - - - Methods of prenatal supplements treatment of anemia protein / energy supplementation of vitamin / mineral supplement of fish oils Prevention and tre

atment of hypertensive disease Commitment fetal infections. JJC PREVENTION Criteria Intervention programs: medical, social and economic programs that reduce economic barriers to allow access of pregnant wo men to prenatal care. Programs that help improve the health system to provide adequate prenatal care or change the institutional practices of care providers t o make more acceptable. JJC IUGR PREVENTION Strict prenatal care for women with diseases associated with IUGR are known appr opriate treatment of specific complications Prolonged periods of rest and proper nutrition can help prevent, delay or reduce IUGR. Identification of small but o therwise normal fetuses. IUGR associated with severe fetal malformations in many cases of poor prognosis JJC IUGR: Childbirth Delivery is indicated when the intrauterine environment presents a greater risk than the rigors of life outside the womb. There are no strict rules to be implem ented. Cases are handled on an individual basis. If fetal growth ceases to be de monstrable and / or signs of fetal distress indicated delivery 30 to 35% of fetu ses with IUGR presented SFA in labor JJC IUGR Normal and IUGR RN Normal and IUGR Placenta JJC SUMMARY intrauterine growth retardation Obstetric history: prenatal care, 50% not diagnosed. 50% of the suspects are PAE G. Biochemical tests: no. Ultrasound: Routine and serial CA better predictor. FL / CA. Sensitivity 63%, specificity 90%. Oligohydramnios. Placental maturity. Po nderal index. Abdomen-femur ratio Doppler uterine, umbilical and cerebral JJC SUMMARY intrauterine growth retardation Strict prenatal care for women with diseases associated with IUGR are known appr opriate treatment of specific complications Prolonged periods of rest and proper nutrition could help prevent, delay or reduce IUGR. Identification of small but otherwise normal fetuses. IUGR associated with severe fetal malformations in ma ny cases of poor prognosis JJC SUMMARY intrauterine growth retardation Increased perinatal morbidity intra birth asphyxia, acidosis and meconium aspira tion. Increased frequency of genetic abnormalities. Risk of intellectual impairm ent and neurological Increased perinatal mortality: 10 fold higher at RN <2 SD a nd 30 times higher RN <3 DS Major neonatal morbidity hypoglycemia, hypocalcemia, hypothermia, and polycythemia. Increased risk of sudden infant death. JJC THANK YOU