Intra Uterine Growth Retardation

Prof.Surendra Nath Panda, M.S. Dept.of Obstetrics & Gynecology M.K.C.G.Medical College Berhampur, Orissa, INDIA

Intra Uterine Growth Retardation

Intra Uterine Growth Restriction
Small for gestational age (SGA)

Foetal growth restriction 'wasted' and 'stunted'

Please also see notes pages for more details in most of the slides
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Definition
Intrauterine growth retardation (IUGR)
occurs when the unborn baby is at or below the 10th weight percentile for his or her age (in weeks). The foetus is affected by a pathologic restriction in its ability to grow.

Low birth weight (LBW) means a baby

with a birth weight of less than 2500Gms, which could be due to IUGR or Prematurity

Please also see notes pages for more details in most of the slides
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Classification

Symmetricl
the baby's head and body are proportionately small. may occur when the foetus experiences a problem during early development.

Asymmetrical
baby's brain is abnormally large when compared to the liver. may occur when the foetus experiences a problem during later development

In a normal infant, the brain weighs about three times more than the liver. In asymmetrical IUGR, the brain can weigh five or six times more than the liver.
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Classification
Newer 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.
2. Abnormal small fetuses- have chromosomal anomalies or structural malformations. They are lost cases and deserve termination as nothing can be done. 3. Growth restricted fetuses- are due to impaired placental function.Appropriate & timely treatment or termination can improve prospects.
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Aetiology
The foetal growth is dependent on multiple factors. IUGR resulting in SGA babies can result from many factors known and unknown either acting alone or in conjunction or in association . The aetiologic determinants of IUGR have two measures of effect: relative risk and etiologic fraction. Most of the evidence on aetiologic determinants is based on observational studies and systematic overviews or meta-analyses of such studies. In a majority of cases (40%) the cause is unknown probably due to placental insufficiency (idiopathic).
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Aetiology
1. General- Racial / Ethnic origin, Small maternal /
paternal height / weight, Foetal sex.

2. 3. 4. 5.

Maternal causes. Foetal causes. Placental causes. Idiopathic- In a majority of cases (40%) the cause is unknown probably due to placental insufficiency.

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Maternal Risk Factors

Has had a previous baby who suffered from IUGR. Extremes of age. Is small in size (Ht & Wt). Has poor weight gain and malnutrition during pregnancy. Is socially deprived. Uses substances (like tobacco, narcotics, alcohol) that can cause abnormal development or birth defects. Has a low total blood volume during early pregnancy.
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Maternal Risk Factors

Is pregnant with more than one baby. High altitude. Drugs like anticoagulants, anticonvulsants. Has a cardio-vascular disease-preeclampsia, hypertension, cyanotic heart disease, cardiac disease Gr III & IV, diabetic vascular lesions. Chronic kidney disease Chronic infection- UTI, Malaria, TB, genital infections Has an antibody problem that can make successful pregnancy difficult (antiphospholipid antibody syndrome, SLE).
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Fetal Risk Factors

Exposure to an infection-German measles (rubella),
cytomegalovirus, herpes simplex, tuberculosis, syphilis, or toxoplasmosis, TB, Malaria, Parvo virus B19.

A birth defect (cardiovascular, renal, anencephally, limb defect, etc). A chromosome defect- trisomy-18 (Edwards
syndrome),21(Downs syndrome), 16, 13, xo (turners syndrome.

A primary disorder of bone or cartilage. A chronic lack of oxygen during development (hypoxia). Developed outside of the uterus. Placenta or umbilical cord defects.
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Placental Factors
Uteroplacental insufficiency resulting from -.
Improper / inadequate trophoblastic invasion and placentation in the first trimester. Lateral insertion of placenta. Reduced maternal blood flow to the placental bed.

Foetoplacetal insufficiency due to-.

Vascular anomalies of placenta and cord. Decreased placental functioning mass-.
Small placenta, abruptio placenta, placenta previa, post term pregnancy.

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Diagnosis
Intrauterine IUGR can be difficult to diagnose. Presence of risk factors. Inadequate growth detected by serial measurement of Wt., abdominal girth and fundal Ht. Ultrasound to evaluate the foetal growth.
Inadequate foetal growth. Reduced AFI. Placental calcification.
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Diagnosis
Neonatal Low ponderal index (Wt./Fl). Decreased subcutaneous fat. Presence / appearance of
Hypoglycemia, Hyperbilirubinemia, Narcotizing enterocolitis, Hyper viscosity syndrome

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Neonate and Placenta in IUGR

Normal & IUGR Newborn babies

Normal & IUGR Placentas

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Prevention
Strategies include
prenatal care modalities, protein/energy supplementation, treatment of anaemia, vitamin/mineral supplementation, fish oil supplementation prevention and treatment of
hypertensive disorders, foetal compromise infection.
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Prevention
Strong evidence of benefit only for the following interventions:
balanced protein/energy supplementation, strategies to reduce maternal smoking, antibiotic administration to prevent urinary tract infections and antimalarial prophylaxis.

Few statistically significant reductions in the risk of IUGR have been demonstrated with other interventions.
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Surveillance
Unless delivery occurs, once treatment begins the foetus must undergo surveillance. The purpose - to identify further progression of the disease process that would jeopardize the foetus to a point that it would be better to be delivered than to remain in utero. There are four testing modalities which are helpful -Non-Stress Test, Amniotic Fluid Index, Doppler of the Umbilical Artery & Biophysical Profile, each of which addresses different aspects of surveillance. Combination of tests are better than an isolated test.
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Surveillance

Non- Stress Test (NST)

This simplest to perform test should b used first in the surveillance of IUGR foetuses. With the help of a heart rate monitor, the changes in the foetal heart rate with foetal movement are to be determined. If the heart rate increases more than 15 beats for more than 15 seconds, this is considered to be a reactive test. If the heart rate does not accelerate, remains flat, or decreases, then this is an abnormal test. The problem with this test is that it changes late in the course of the disease and is not an early predictor of adverse outcome.
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Surveillance

Amniotic Fluid Index (AFI)

The vertical depth of four pockets of amniotic fluid are measured by USG, to obtain a total AFI. This method allows for comparison of changes in amniotic fluid with time. In the normal foetus the AFI remains relatively constant. In the foetus with IUGR, it may decrease slowly, or decrease abruptly with time. A decrease in AFI may occur before there are changes in the non-stress test.
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Surveillance

Amniotic Fluid Index (AFI)

The current recommendations are that if the AFI decreases below 8 after 35 weeks, then delivery should occur.
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Surveillance

Doppler of the Umbilical Artery

When IUGR is diagnosed, the value of sequential studies of the umbilical artery Doppler waveform is to determine if the Resistance Index is increasing or decreasing. If it is increasing, then this signifies a deteriorating condition.
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Surveillance

Biophysical Profile
If each of the tests are normal they are given a score of 2. If abnormal, a score of 0. A score of 6 or less suggests the foetus is at risk for adverse outcome.

This test combines the NST and the AFI with foetal movement, breathing, and muscle tone.

While the biophysical profile is an useful test, when it becomes abnormal the foetus may have already suffered some damage
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Treatment

IUGR has many causes, therefore, there is not one treatment that always works.

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Treatment
Although there are many causes of IUGR, the treatment consists of either delivery or remaining in utero and improving blood flow to the uterus. When blood flow is improved, the delivery of oxygen and other nutrients to the foetus occurs. If the foetus is lacking in these substances, their increased availability may result in improved growth and development. If IUGR is caused by a problem with the placenta and the baby is otherwise healthy, early diagnosis and treatment of the problem may reduce the chance of a serious outcome. There is no treatment that improves foetal growth, but IUGR babies who are at or near term have the best outcome if delivered promptly.
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Treatment
Maternal bed rest
This is the initial approach for the treatment of IUGR. The benefit of bed rest is that it results in increased blood flow to the uterus. Studies have shown, however, that in most cases bed rest at home is just as effective as bed rest in the hospital environment.

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Treatment
Maternal bed rest

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Treatment
Aspirin Therapy
The use of aspirin to treat foetuses with IUGR is still controversial. If aspirin is used, it may be advantageous if given to patients before 20 weeks of gestation. It is minimal to limited benefit if given at the time of diagnosis (third trimester). At the present time it is not recommended as a form of prevention for low risk patients.
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Treatment
Other Forms of Treatment
Other forms of treatment that have been studied are nutritional supplementation, zinc supplementation, fish oil, hormones and oxygen therapy.
Limited studies are available regarding the use of these modalities in the treatment of IUGR.

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Treatment
Judge Optimum Time Of Delivery
RISK OF PREMATURITY DIFFICULT EXTRA UTERINE EXISTENCE RISK OF IUD HOSTILE INTRA UTERINE ENVIRONMENT

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Short Term Risks of IUGR

Increased perinatal morbidity and mortality.
Intra uterine / Intrapartum death. Intrapartuum foetal acidosis characterized by-.
Late deceleration. Severe variable deceleration. Beat to beat variability. Episodes of bradicardia.

Intrapartum foetal acidosis may occur in as many as 40 % of IUGR, leading to a high incidence of LSCS. IUGR infants are at greater risk of dying because of neonatal complications- asphyxia, acidosis, meconium aspiration syndrome, infection, hypoglycemia, hypothermia,
sudden infant death syndrome.

IUGR infants are likely to be susceptible to infections because of impaired immunity

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Long term Prognosis

Babies who suffer from IUGR are at an increased risk for death, low blood sugar, low body temperature, and abnormal development of the nervous system. These risks increase with the severity of the growth restriction. The growth that occurs after birth cannot be predicted with certainty based on the size of the baby when it is born. Infants with asymmetrical IUGR are more likely to catch up in growth after birth than are infants who suffer from prolonged symmetrical IUGR. If IUGR is related to a disease or a genetic defect, the future of the infant is related to the severity and the nature of that disorder.

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Long term Prognosis

IUGR infants are more likely to remain small than those of normal birth weight. They will need the special attention of primary health, nutrition and social services during infancy and early childhood. Implication of IUGR can be life long affecting: Body size growth, composition and physical performance. Immunocompetence. It appears to predispose to adult adult-onset, degenerative diseases like maturity onset diabetes and cardiovascular diseases. Each case is unique. Can not reliably predict an infant's future progress.
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