IUGR & IUFD

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
 What is the deference between IUGR & SGA?

SGA < 10th centile for the population, 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 are the causes of IUGR?

Maternal medical conditions 1ry placental disease

Chromosomal anomalies & Extremes of maternal age

aneuploidy
Low socioeconomic
Genetic & Structural anomalies status

Exposure to drugs & toxins 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, PET, DM, HPT
Chronic partial abruption
Placental infarcts
Placenta previa
Chorioangioma
Circumvallate placenta
Placental mosaicism
Twin to twin transfusion Syndrome
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 /-blockers
Cyclosporin
What are the genetic disorders that can result in IUGR?

15% of IUGR Features suspicious of trisomy

Downs syndrome T21 Symmetric IUGR

Trisomy 13,18 AFV/ Doppler N
Turner syndrome Structural abnormalities
Neural tube defects Maternal age
Achondroplasia Nuchal translucency
Osteogenisis imperfecta Biochemical screening results
Abdominal wall defects
Duodenal atresia
Renal agenesis/ Poters S
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
 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

 Types of IUGR
2-Asymmetric IUGR80%

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, Fl N, AC

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

 How to evaluate a case of IUGR?
1-History:
Current preg
LMP, preg test, quickening
APH, abruptio placentae, & fetal movements
Previous obstetric Hx particularly looking for IUGR,& adverse
outcome
Medical Hx: connective tissue diseases, thrombotic events &
endocrine disorders
Hx of recent viral illness
Drug Hx
Family Hx of congenital abnormalities & thrombophilias
 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
 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, PROM, Preterm labor

Retrospective tests

Maternal blood tests for CMV, Rubella, Toxo

Metabolic disorders
thrombophilia
Placenta should be sent for HP
Postmortem examination
 The constitutionally small fetus

A fetus growing parallel to the lower centiles through out preg

Anatomically N
AFV N
Doppler N
Slim petite women
 Complications of IUGR

Maternal complications due to underlying disease

risk of CS
Fetal complications Stillbirth, hypoxia/acidosis,
malformations
Neonatal complications Hypoglycemia, hypocalcemia,
Hypoxia & acidosis, hypothermia, meconium aspiration ,
Polycythemia, hyperbilirubinemia, sepsis, low APGAR score
congenital malformations, apneic spells, intubation
sudden infant death syndrome
Long term complications Lower IQ, learning & behavior
Problems, major neurological handicap seizures, cerebral
Palsy, mental retardation, HPT
Perinatal mortalility 1.5-2X
 Treatment

Stop smoking / alcohol

Bed rest uterine blood flow for pt with asymmetric IUGR
Low dose aspirin
Weekly visits attention to : FM, SFH, maternal wt, BP, CTG,
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 -hcg
Loss of fetal movement
Absence of fetal heart
Disappearance of the signs & symptoms of pregnancy
X-ray Spalding sign
Roberts sign
U/S 100% accurate Dx
 Causes OF IUFD Maternal 5-10%
Antiphospholipid antibody
DM
Fetal causes 25-40%
HPT
Chromosomal anomalies
Trauma
Birth defects
Abnormal labor
Non immune hydrops
Sepsis
Infections
Acidosis/ Hypoxia
Placental 25-35%
Uterine rupture
Abruption
Postterm pregnancy
Cord accidents
Drugs
Placental insufficiency
Thrombophilia
Intrapartum asphyxia
Cyanotic heart disease
P Previa
Epilepsy
Twin to twin transfusion S
Severe anemia
Chrioamnionitis
Unexplained 25-35%
 A systematic approach to fetal death is valuable in
determining the etiology
B-Maternal History
1-History I-Maternal medical conditions
VTE/ PE
A-Family history DM
Recurrent abortions HPT
VTE/ PE Thrombophilia
Congenital anomalies SLE
Abnormal karyptype Autoimmune disease
Hereditary conditions Severe Anemia
Developmental delay 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
 1-History
Specific fetal conditions
Nonimmune hydrops
Current Pregnancy Hx IUGR
Maternal age Infections
Gestational age at fetal death Congenital anomalies
HPT Chromosomal abnormalities
DM/ Gestational D Complications of multiple gestation
Smooking , alcohol, or drug abuse
Abdominal trauma
Cholestasis
Placental or cord complications
Placental abruption Large or small placenta
PROM or prelabor SROM Hematoma
Edema
Large infarcts
Abnormalities in structure , length or
insertion of the umbilical cord
Cord prolapse
Cord knots
Placental tumors
 2-Evaluation of still born infants
Infant desciption Placenta
Malformation Weight
Skin staining Staining
Degree of maceration Adherent clots
Color-pale ,plethoric Structural abnormality
Umbilical cord Velamentous insertion
Prolapse Edema/ hydropic changes
Entanglement-neck, arms, ,legs Membranes
Hematoma or stricture Stained
Number of vessels Thickening
Length
Amniotic fluid
Color-meconium, blood
Volume
 3-Investigations
Maternal investigations
CBC
Bl Gp & antibody screen
HB A1 C
Kleihauer Batke test
Serological screening for Rubella
CMV, Toxo, Sphylis, Herpes &
Parovirus
Karyotyping of both parents (RFL,
Baby with malformation
Hb electrophorersis
Antiplatelet anbin tibodies
Throbophilia screening (antithrombin
Protein C & S , factor IV leiden,
Factor II mutation, , lupus
anticoagulant,
anticardolipin antibodies)
DIC
Fetal inveswtigations
Fetal autopsy
Karyotype
(spcimen taken from cord
blood, intracardiac blood,
body fluid, skin, spleen,
Placental wedge, or amniotic
Fluid)
Fetography
Radiography
Placental investigations
Chorionocity of placenta in
twins
Cord thrombosis or knots
Infarcts, thrombosis,abruption,
Vascular malformations
Signs of infection
Bacterial culture for Ecoli,
Listeria, gp B strpt.
 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