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Intrauterine GrowthRetardation (Restriction)
Jignesh Patel, MD
Texas Tech University HSC
Department of Pediatrics
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Definitions
IUGR: Failure of normal fetal growth
caused by multiple adverse effects on the
fetus.
SGA: Infant with wt < 10% ile for GA, or
> 2 SDs below mean for GA.
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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.
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Incidence
3 - 10 % 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.
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Types of IUGR
Symmetric IUGR: weight,length and headcircumference are all below the 10 thpercentile. (33 % of IUGR Infants)
Asymmetric IUGR: weight is below the10 th percentile and head circumference andlength are preserved. (55 % of IUGR)
Combined type IUGR: Infant may haveskeletal shortening, some reduction of softtissue mass. (12 % of IUGR)
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Ponderal Index
Way of characterizing the relationship of height to
mass for an individual.
PI = 1000 x
Typical values are 20 to 25. PI is normal in symmetric IUGR.
PI is low in asymmetric IUGR.
Mass (kgs)
Height (cms)
3
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Normal Intrauterine Growth pattern
Stage I (Hyperplasia)
- 4 to 20 weeks
- Rapid mitosis
- Increase of DNA content
Stage II (Hyperplasia & Hypertrophy)
- 20 to 28 weeks- Declining mitosis.
- Increase in cell size.
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Normal Intrauterine Growth pattern
Stage III ( Hypertrophy)
- 28 to 40 weeks
- Rapid increase in cell size.
- Rapid accumulation of fat, muscle andconnective tissue.
95% of fetal weight gain occurs during last20 weeks of gestations.
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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
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Etiology
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.
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Pathophysiology
1) Fetal factors: Genetic Factors:
- Race, ethnicity, nationality
- sex ( male weigh 150 -200 gm more thanfemale )
- parity ( primiparous, weigh less thansubsequent siblings)
-genetic disorders ( Achondroplasia, Russell -silver syn.)
Chromosomal anomalies:
- Chromosomal deletions
- trisomies 13,18 & 21
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Pathophysiology
Congenital malformations:
examples:Anencephaly, GI atresia, potterssyndrome, and pancreatic agenesis.
Fetal Cardiovascular anomalies Congenital Infections:
mainly TORCH infections.
Inborn error of metabolism:
- Transient neonatal diabetes
- Galactosemia
- PKU
P th h i l
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Pathophysiology
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 therapeuticagents such as trimethadione, warfarin, phenytoin
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Pathophysiology
Maternal hypoxemia- Hemoglobinopathies
- High altitudes
Others
- Short stature- Younger or older age (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.)
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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
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Postnatal Assessment
Growth parameters: weight, height, HC
Assess GA with Ballard score.
Plotted growth parameters in growth chart
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Physical Appearance
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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
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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 crownheel length
- delayed development of epiphyses
Comparison to premature infants,IUGR has brainand heart larger in proportion to the body weight,in contrast the liver, spleen, adrenals and thymusare smaller.
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Complication
Hypoxia
- Perinatal asphyxia
- Persistent pulmonary hypertension- meconium aspiration
Thermoregulation
- Hypothermia due to diminishedsubcutaneous fat and elevatedsurface/volume ratio
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Complications
Metabolic
- Hypoglycemia
- result from inadequate glycogen stores.
- diminished gluconeogenesis.
- increased BMR
- Hypocalcemia
- due to high serum glucagon level, whichstimulate calcitonin excretion
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Complications
Hematologic
- hyperviscosity and polycythemia due to
increase erythropoietin level sec. to hypoxia Immunologic
- IUGR have increased protein catabolism
and decreased in protein, prealbumin andimmunoglobulins, which decreased humoraland cellular immunity.
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Management
Antenatal diagnosis and management is thekey 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 )
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Management
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
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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
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Management
Early feeding and caloric intake should be
100-120 kcal/kg/d
Developmental and growth f/u in all IUGRinfants
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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 - handicaprate > 50%
IUGR has higher rate of learning disability.
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Thank You