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S U P E RV I S E D B Y D R . E L I A S E L - S U N A A PRESENTED BY : OSAMA ALHUMISI OMAR ABU KAUSH M O H A M M E D TA H A ABDULRAHMAN OMAR HASAN KULMIAH
mortality.
Ethinc group Geographical area (altitude ) . Socioeconomic status , ( nutrition and smoking)
Physical examination
Investigations
of bleeding. Regularity of the last 3 cycles. Lactation in the last 3 months. Combined oral contraceptive pills use. Date of quickening: - primi-gravida feels it btw 18-20 weeks - multi-gravida feels it btw 16-18 weeks
Physical examination
General examination
Obstetric examination
Fundal height
Pelvic exam
Physical examination
Obtaining serial uterine
fundal height measurements. The Mcdonalds rule in pregnancy is a rough determination of fetal age in weeks compared to uterine/fundal size Less valid during the 3rd trimester
Physical examination
2. Evaluating the size of the uterus by pelvic examination in the first trimester and subsequent antenatal visits
Ultrasound
Diagnosis and confirmation of viability in early pregnancy Determintion of gestational age and asessment of fetal size Intrauterine or Extrauterine (Ectopic) pregnancy. Multiple pregnancy Diagnosis of fetal abnormalities Placental localization Assessment of fetal well-being Measurment of cervical length
IUGR : 1. Biparietal diameter 2. Head circumference 3. Abdominal circumference 4. Head to abdominal circumference ratio 5. Femoral length 6. Femoral length to abdominal circumference ratio 7. aminiotic fluid volum 8. Calculated fetal weight
3. Multiple pregnancy
birth weight below the 10th centile for the stated gestational age. The incidence of SGA fetuses is 5-10%.
Not always pathological
below the 10th percentile for gestational age are small simply due to constitutional factors
Significance
Major cause of neonatal morbidity and mortality.
problems such as meconium aspiration ,asphyxia ,polycythemia ,hypoglycemia and mental retardation . Significant cost in terms of facilities required to look after these infants . They are at grater risk for developing adult onset conditions such as hypertension ,diabetes and atherosclerosis .
CAUSES
Reduced fetal growth potential fetal
Fetal factors
Chromosome defects ; trisomy 18 , triplooidy . Single gene defect ; seckles syndrome . Structural abnormalities ; renal agenesis
Maternal factors
Under-nutrition , e.g. poverty, eating disorder. Maternal hypoxia, e.g. altitude , CHD. Drugs , e.g. smoking , alcohol , cocaine .
PLACENTAL FACTORS
Reduced uteroplacental perfusion e.g. inadequate trophoblast inavsion , antiphospholipid syndrome , DM, sickle-cell disease , multiple gestation
Reduced feto-placental perfusion e.g. single umbilical artery , twin-twin transfusion syndrome.
Classification of IUGR
Symmetrical (20-30%)
This is characterized by inadequate growth of the
head, body and extremities and occurs in 2030% of IUGR fetuses . Etiology is decreased growth potential :e.g aneuploidy ,early IU ,infection ,gross anatomical anomaly . Antepartum test usually normal .
Asymmetrical 70-80%
Asymmetric FGR is characterized by a relatively
greater decrease in abdominal size (eg, liver volume and subcutaneous fat tissue) than head circumference and is found in the remaining 70 to 80 percent of the FGR population. Asymmetric fetal growth is thought to result from the capacity of the fetus to adapt to a hostile environment by redistributing blood flow in favor of vital organs (eg, brain, heart, placenta) at the expense of non vital fetal organs (eg, abdominal viscera, lungs, skin, kidneys .
Asymmetrical IUGR
This illustrates asymmetrical IUGR in which the head and femur are growing normally but the abdomen is not growing properly. This results in an elevated head/abdomen ratio and an estimated fetal weight just above the 10th percentile
Diagnosis of IUGR
History Physical examination
Investigations
Growth restriction may go undiagnosed unless the obstetrician establishes the correct gestational age of the fetus , identifies high risk factors from obstetric database & serially assesses fetal growth by fundal height or US
History
Assure accurate dating. Current pregnancy history. Past obstetric history. Past medical history. Drug history. Family history. Socioeconomic history.
nutritional supply.
- Antenatal care and visits. - Supplements.
Drug history:
Immunosuppressive, anti convulsant agents , SLE drugs and drug abuse can lead to fetal growth retardation.
Family history:
- Inherited diseases, any congenital deformities.
Socioeconomic history :
- Malnutrition, smoking, alcohol drinking.
Chronic diseases:
- (DM, HTN, chronic RF)
Physical Examination
fundal height measurements :primary screening tool for
IUGR. If: - 3 cm variation ? Or, - the mother has a high risk condition a more thorough U/S assessment should be undertaken.
New promising charts
~Customized growth curves for ethnicity, parental size, and gender are in development so as to improve sensitivity and specificity of diagnosing IUGR. ~Study : using fundal height curves that customized for maternal weight, height, and ethnicity was able to increase the detection rate .
Ultrasound
Abdominal circumference is the single most effective
parameter for predicting fetal weight because its reduced in both symmetrical & Asymmetrical IUGR .
abdominal circumference (AC) measurements of less than 2 standard deviations below the mean appear to be a reasonable cutoff to consider a fetus asymmetric.
Complications of IUGR
Antenatal
Intrapartum
Neonatal
Antenatal Complications
Metabolic changes in fetus (acidosis, hypoxia). Oligohydramnios (80%) Abnormal fetal heart patterns. Abnormal Doppler studies. Intra-uterine fetal death.
Intrapartum complications
Abnormal CTG. Meconium-stained liquor. Increased incidence of instrumental and caesarean
Neonatal complications Related to hypoxia and acidosis: Metabolic: Related to the etiology:
1. Meconium aspiration. 2. Persistent fetal circulation. 3. Hypoxic ischemic encephalopathy (HIE).
Management principles
Pre-pregnancy. Antepartum (during
pregnancy).
Labor & delivery.
Pre-pregnancy
Modify lifestyle habits. Balanced nutrition. Magnesium & Folate
supplements decrease rate of SGA. Quit smoking, alcohol, & drug abuse. Detect and treat medical disorders. Correction of anemia. Control any chronic illnesses (anti-phospholipids syndrome , sickle cell
Antepartum
Regular antenatal care: assess Fetal heart beat and
fetal movement Serial fetal growth assessment. Fetal surveillance & serial US measurements at three weekly intervals are indicated Fetal weight every 2 weeks Serial fetal wellbeing assessment. 1-Biophysical profile 2-Computerized CTG 3-Umblical artery Doppler Bed rest to maximize uterine blood flow Betamethasone administration between GA 3035weeks.
without the fetus suffering any neurological abnormality, and increasing maturity as possible before delivery.
Mode of delivery.
1. in the presence of evidence of fetal distress 2. for traditional obstetrical indications for cesarean delivery
Induction of labor
continuous heart rate monitoring and scalp pH monitoring optimize success of vaginal delivery
Postpartum
The infant should be carefully
examined for any congenital anomalies and infections. Monitor blood glucose, hypoglycemia is a common finding. Hypothermia is not uncommon. optimized nutrition may help the baby to catch up height and weight
Prognosis
Main danger is neurological injury Some will suffer morbidity or die as a result
of prematurity.
insufficiency show catch up growth after delivery when feeding is optimized While IUGR related to chromosomal abnormality or congenital infection the development depend on abnormality present.
a link between birth weight and increased incidence of HTN and diabetes in adults