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Intrauterine Growth

Restriction
(IUGR)
OTHER NAMES
DYSMATURITY.
SMALL FOR DATE.
CHRONIC PLACENTAL INSUFFICIENCY.
Normal Fetal Growth
• Normal fetal growth is characterized by
cellular hyperplasia followed by
hyperplasia and hypertrophy and lastly by
hypertrophy alone.
Definition
• Intrauterine growth restriction is defined as
babies whose birth weight is below 10th
percentile of the average for the gestational
age.
• Growth restriction can occur in preterm, term
or post term babies.
Incidence
• About 2-8%.
• Among term babies (5%).
• Post term babies (15%).
Types of IUGR

SYMMETRICAL ASYMMETRICAL INTERMEDIATE


IUGR IUGR IUGR
Cont.,.,
Symmetrical IUGR:
 Fetus is affected from the noxious effect very early
in the phase of cellular hyperplasia.
 Caused by:
 Structural or chromosomal abnormalities.
 Congenital infection (TORCH).
 The pathological process is intrinsic to the fetus &
involves all the organs including the head.
Cont.,.,
Asymmetrical IUGR:
 The fetus is affected in later months during the
phase of cellular hypertrophy.
 Total cell number remains the same but SIZE is
smaller than normal.
 Alters the fetal size by reducing utero placental
blood flow or by restricting the O2 & nutrient
transfer or by reducing the placental size.
Cont.,.,
Intermediate IUGR:
• It is a combination of type 1 and type 2.
• Fetal growth restriction occurs during intermediate phase of
growth affecting both hyperplasia and hypertrophy, resulting
in decrease in cell no, as well as size.
• Causes include
 Chronic HT.
 Lupus nephritis.
 Maternal vascular diseases that are severe and have onset
in early 2nd trimester.
Cont.,.,.,
Features of IUGR Fetuses
Symmetrical Asymmetrical
• Uniformly small. • Head- larger than abdomen.
• Ponderal index(between • Low.
wt/crown to heel)-Normal.
• Head circumference: • Elevated.
Abdominal circumference.
Femur length: AC –Normal.
• Etiology: • Chronic placental
Genetic disease or insufficiency (Extrinsic to
infection (Intrinsic to fetus). fetus).
Cont.,..
Symmetrical Asymmetrical
• Total cell no: less . • Total cell no: Normal.
Cell size: Normal. Cell size: Smaller.
• Neonatal Course: • Neonatal Course:
Complicated with poor Usually uncomplicated
prognosis. having good prognosis.
A comparison between normal and
IUGR babies.
Normal and IUGR placenta
Etiology
• IUGR is a manifestation of maternal, fetal and
placental disorders that affect fetal growth.
• Maternal Causes:
1. Maternal Characteristics:
Those contributing to IUGR are-
 Extremes of maternal age.
 Grandmultiparity.
 History of IUGR in previous pregnancy.
 Low maternal weight gain in pregnancy.
Cont.,.,
2. Maternal diseases:
Uteroplacental insufficiency resulting from medical
complications like:
 Hypertension.
 Renal disease.
 Autoimmune disease.
 Hyperthyroidism.
 Long term insulin dependent diabetes.
 Smoking.
 Alcohol & drugs.
Cont.,.,
• Fetal Causes:
1. Chromosomal Disorders:
Usually result in early onset IUGR.
 Trisomies 13, 18, 21 contribute to 5% of IUGR
cases.
 Aneuploidy.
 Triploidy.
 Turner’s syndrome.
Cont.,.,
2. Congenital Infections:
• The growth potential of fetus may be severely
impaired by intrauterine infections.
• Viruses- rubella, CMV, varicella and HIV
 rubella is the most embryotoxic virus, it cause
capillary endothelial damage during
organogenesis and impairs fetal growth.
 CMV causes cytolysis and localized necrosis in
fetus.
• Protozoa- like malaria, toxoplasma, have also been
associated with growth restriction.
Cont.,.,
3. Structural Anomalies:
• All major structural defects involving
CNS,CVS,GIT, Genitourinary and
musculoskeletal system are associated with
increased risk of fetal growth restriction.
• If growth restriction is associated with
polyhydramnios, the incidence of structural
anomaly is substantially increased.
Cont.,.,
4. Genetic Causes:
• Maternal genes have greater influence on
fetal growth.
• Inborn errors of metabolism like agenesis of
pancreas, congenital lipodystrophy,
galactosemia, phenylketonuria also result in
growth restriction of fetus.
Cont.,.,
• Placental Causes:
Placenta is the sole channel for nutrition
and oxygen supply to the fetus.
Single umbilical artery.
Abnormal placental implantation.
Velamentous umbilical cord insertion.
placental haemangiomas have all been associated
with fetal growth restriction.
Cont.,.,
• Unknown Causes:
About 40% of the causes remains
unknown.
Pathophysiology
Signs & Symptoms
• PHYSICAL FEATURES AT BIRTH:
 Weight deficit at birth is about 600 g below
the minimum in percentile standard.
 Length is unaffected.
 H.C is larger than body.
 Physical features: Dry & wrinkled skin
because of less subcutaneous fat.
Scaphoid abdomen.
Cont.,.,
Thin meconium stained vernix caseosa.
Thin umbilical cord.
Pinna of ear: cartilaginous ridges.
Plantar creases: well defined.
Baby looks like: “OLD MAN”.
Baby is alert, active & having a normal
cry.
Reflexes are normal.
Diagnosis
Identifying mothers at risk:
Poor maternal nutrition.
Poor BMI at conception.
Pre-eclampsia.
Renal disorders.
Diseases causes vascular insufficiency.
Infections (TORCH).
Poor maternal wt. gain during pregnancy.
Cont.,..,
• Determination of gestational age is of utmost
importance:
– Can be calculated from the date of LMP- not
reliable
– Ultrasound dating before 21 wks of pregnancy
provides more accurate estimation.
Cont.,.,
1. Clinically- Serial measurement of fundal
height and abdominal girth.
 NORMAL: Symphysio-fundal height normally
increases by 1cm per wk b/w 14 and 32 wks.
 MODERATE: A lag in fundal ht. of 4 wks.
 SEVERE: A lag in fundal ht. of >6 wks.
Cont.,.,
2. Sonographic evaluation:
 Most useful tool for diagnosis of IUGR.
 To differentiate between symmetrical and
asymmetrical IUGR.
 To monitor the fetal condition.
Cont.,.,
3. Biophysical:
 H.C & A.C ratios:
 Asymmetrical IUGR: H.C/A.C is elevated.
 Symmetrical IUGR: Both H.C & A.C is reduced.
 FEMUR LENGTH (FL):
 If FL/AC ratio greater than 23.5 suggests IUGR.
 AMNIOTIC FLUID VOLUME:
 AFI: 5-25 cm (Normal).
 AFI: <5 ( Oligohydramnios).
Complications of IUGR
IMMEDIATE LATE
• Asphyxia, Broncho- • Retarded neurological &
pulmonary dysplasia & RDS. intellectual development in
• Hypoglycemia. infancy.
• MAS, DIC. • In adult life: Obesity,
• Hypothermia. HT,DM,CHD.
• Polycythemia. • Reduced no of nephrons
causes Renal vascular HT.
• Pulmonary hemorrhage.
• Thrombocytopenia, NEC.
• Hypokalemia.
• Hyperphosphatemia.
Management
If pregnancy < 37 weeks.

Severe IUGR Mild IUGR


Equipped center sed rest
Fetal surveillance Folic acid.
Non assuring fetal status sed fluid intake.
Assess lung maturity Fetal monitoring close
upon 37wks.
Cont.,.,

Delivery.
Not mature Mature
Betamethasone therapy
(Corticosteroids) Delivery.

Delivery.
Cont.,.,
If pregnancy > 37 weeks.

Delivery.