Growth & Development

Perinatology Division, Child Health Department,

Medical Faculty of Hasanuddin University

Intra Uterine Growth Restriction

Intra Uterine Growth Retardation
Small for gestational age (SGA)

Foetal growth restriction

'wasted' and 'stunted'

Definitions
IUGR: Failure of a pregnancy to

reach expected fetal growth and

manifest as a deviation of fetal
growth from normal pattern.
SGA: Infant with wt < 10 % for GA,
or > 2 SDs below mean for GA.

Low birth weight (LBW) means a baby

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

Easiest way to think about

these terms are
IUGR: is a term used by OB to

describe a pattern of growth over a

period of time.
SGA: is a term used by Peds to
describe a single point on a growth
curve.

Incidence
5 - 8 % of all pregnancies.
20 % of stillborns are growth retarded.
30 % of infants with SIDS were IUGR.
1/3 of infants with BW < 2800 gms are
growth retarded and not premature.
9 - 27 % have anatomic and/or genetic
abnormalities.
Perinatal mortality is 8 - 10 times
higher for these fetuses.

Types of IUGR
Symmetric IUGR: weight,length and

head circumference are all below the

10 th percentile. (33 % of IUGR Infants)
Asymmetric IUGR: weight is below the
10 th percentile and head
circumference and length are
preserved. (55 % of IUGR) Combined
type IUGR: Infant may have skeletal
shortening, some reduction o soft
tissue mass. (12 % of IUGR)

Symmetrical
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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Diagnosis
Intrauterine IUGR can be difficult to diagnose.
Presence of risk factors.
Inadequate growth detected by serial

measurement of Wt., abdominal girth and

fundal .
Ultrasound to evaluate the foetal growth.
Inadequate foetal growth.
Placental calcification.

Diagnosis,
cont...
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
IUGR - Prof.S.N.Panda

12 October 2002

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Ponderal Index
Way of characterizing the relationship

of height to mass for an individual.

3

PI = 1000 xMass (kgs)

Height (cms)

Typical values are 20 to 25.

PI is normal in symmetric IUGR.
PI is low in asymmetric IUGR.

Etiology
Growth inhibition in stage I:

- Undersized fetus with fewer cells.

- Normal cell size.
Result in symmetric IUGR.
Associated conditions:
- Genetic
- Congenital anomalies
- Intrauterine infections
- Substance abuse
- Cigarette smoking
- Therapeutic irradiation

Etiology, cont
Growth Inhibition in Stage II/III

-Decrease in cell size and fetal weight

- Less effect on total cell numeric, fetal
length,
head circumferance.
Result in asymmetric IUGR.
Associated Conditions:
- Uteroplacental insufficiency.
Combination above associated mixed type
IUGR.

Normal Intrauterine
Growth pattern
Stage III ( Hypertrophy)

- 28 to 40 weeks
- Rapid increase in cell size.
- Rapid accumulation of fat, muscle
and
connective tissue.
95% of fetal weight gain occurs
during last 20 weeks of gestations.

Pathophysiology
1) Fetal factors:
Genetic Factors:

- Race, ethnicity, nationality

- sex ( male weigh 150 -200 gm more than
female )
- parity ( primiparous, weigh less than
subsequent siblings)
-genetic disorders ( Achondroplasia,
Russell silver syn.)
Chromosomal anomalies:
- Chromosomal deletions
- trisomies 13,18 & 21

Pathophysiology
Congenital malformations:

examples:Anencephaly, GI atresia,
potters
syndrome, and
pancreatic agenesis.
Fetal Cardiovascular anomalies
Congenital Infections:
mainly TORCH infections.
Inborn error of metabolism:
- Transient neonatal diabetes
- Galactosemia
- PKU

2) Maternal Factors:
Decrease Uteroplacental blood flow:
- Pre eclampsia / eclampsia
- chronic renovascular disease
- Chronic hypertension

Maternal malnutrition
Multiple pregnancy
Drugs
- Cigarettes, alcohol, heroin, cocaine
- Teratogens, antimetabolites and
therapeutic agents such as
trimethadione, warfarin, phenytoin

Pathophysiology
Maternal hypoxemia

- Hemoglobinopathies
- High altitudes

Others

- Short stature
-

Younger or older age (<15 and >45)

Low socioeconomic class
Primiparity
Grand multiparity
Low pregnancy weight
Previous h/o preterm IUGR baby
- Chronic illness ( DM, renal failure, cyanotic
heart
disease etc.)

Pathophysiology
3) Placental Factors:
Placental insufficiency ( most imp in 3rd

trimester)
Anatomic problems:

Multiple infarcts
Aberrant cord insertions
Umbilical vascular thrombosis &

hemangiomas
Premature placental separation
Small Placenta

Postnatal Assessment
Growth parameters: weight, height,

HC
Assess GA with Ballard score.
Plotted growth parameters in growth
chart

Physical
Appearance

Physical appearance:
Heads are disproportionately large for their

trunks and extremities

Facial appearance has been likened to that
of a wizened old man.
Long nails.
Scaphoid abdomen

 Signs of recent wasting

- soft tissue wasting

- diminished skin fold thickness
- decrease breast tissue
- reduced thigh circumference
Signs of long term growth failure
- Widened skull sutures, large fontanelles
- shortened crown heel length
- delayed development of epiphyses

 Comparison to premature

infants,IUGR has brain and heart

larger in proportion to the body
weight, in contrast the liver,
spleen, adrenals and thymus are
smaller.

Complication
Hypoxia
- Perinatal asphyxia
- Persistent pulmonary hypertension
- meconium aspiration

Thermoregulation
- Hypothermia due to diminished
subcutaneous
fat and elevated surface/volume ratio

Complications
Metabolic
- Hypoglycemia
- result from inadequate glycogen stores.
- diminished gluconeogenesis.
- increased BMR

- Hypocalcemia
- due to high serum glucagon level, which
stimulate calcitonin excretion

Complications
Hematologic
- hyperviscosity and polycythemia due to
increase erythropoietin level sec. to
hypoxia

Immunologic
- IUGR have increased protein catabolism and
decreased in protein, prealbumin and
immunoglobulins, which decreased
humoral and cellular immunity.

Management
Antenatal diagnosis and management is

the key to proper management of IUGR

Delivery and Resuscitation
- appropriate timing of delivery
- skilled resuscitation should be available
- prevention of heat loss

Hypoglycemia
- close monitoring of blood glucose
- early treatment ( IV dextrose, early
feeding )

Management
Hypothermia : Incubator, Kangaroo Mother Care
Hematological Disorder

- central Hct to detect polycythemia

- CBC with diff to r/o leukopenia or thrombocytopenia

Congenital infection

- infant should be examined for signs of congenital

infection (eg.rash, microcephaly hepatosplenomegaly,

lymphadenopathy, cardiac anomalies etc.)
- TORCH titer screening
- Viral cx of urine, nasopharynx
- Head CT to r/o calcification

Management
Genetic anomalies

- screening as indicated by physical

exam
- chromosomal analysis (infant with
dysmorphic features)
Others
- serum calcium to r/o hypocalcemia
- fractionated bilirubin sec to
polycythmia,
congenital infection
- urine, meconium tox for substance
abuse

Management
Early feeding and caloric intake

should be 100-120 kcal/kg/d

Developmental and growth follow up
in all IUGR infants

Outcome
Symmetric vs. Asymmetric IUGR

- symmetric has poor outcome compare to

asymmetric

Preterm IUGR has high incidence of

abnormalities
IUGR with chromosomal disease has
100% incidence of handicap
Congenital infection has poor outcome handicap rate > 50%
IUGR has higher rate of learning disability.

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.
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Short Term Risks of IUGR

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 complicationsasphyxia, 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

.
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.
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Long term Prognosis

It appears to predispose to adult adult-

onset, degenerative diseases like maturity

onset diabetes , obesity, and
cardiovascular diseases.
Impaired Neurodevelopment
Long term neuromotor dysfunction
Poor school performance
Deficits in academic achievements
Each case is unique. Can not reliably

predict an infant's future progress.

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Asfiksia

Asfiksia :
Bayi tidak mampu bernapas secara

spontan, teratur dan adekuat segera

setelah lahir
- perinatal asfiksia
- Hipoxic ischemic encephalopaty
(HIE)

HIE :
Kumpulan gejala : kejang, gangguan

pada kesadaran, tonus otot, refleks

primitif, pernafasan dan intake
belajar (spesifik), masalah sekolah
Berat : kematian atau kecacatan
(mikrosefal, lumpuh) dll