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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

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