INTRAUTRINE GROWTH RESTRICTION

1. INTRAUTRINE GROWTH RESTRICTION Dr. Miroslawa Bednarek

2. Diagnosis of symptom • Fetal growth failing (arising from maternal, placental, or fetal origins) • Birth weight lower than expected in the suitable gestational week (may be the variable described as below the 3rd, 5th, or 10th percentile) • A perinatological definition of fetal IUGR

3. Dynamic phenomenon defined the best • A a delay of the growth of the fetus estimated as a decrease of 25 centiles in the measure of the abdominal circumference, according to the standard curve at the gestational age, and in subsequent echograhic evaluations performed at least every 2 weeks.

4. Classification • Asymmetrical (late onset – around 30 weeks of pregnancy) – affects abdominal growth more that the head circumference. • Symmetrical (early – from the beginning of the second trimester) – proportional lagging of the head circumference, abdominal circumference, and long bone growth.

5. Natural History • The first 16 weeks of pregnancy – cellular hyperplasia • From 16 to 32 weeks of pregnancy, both cellular hyperplasia and cellular hypertrophy occur. • The last weeks, cellular hypertrophy predominates

6. Risk factors – fetal : • Chromosomal abnormalities (triploidy, trisomy 13 and 18) • Structural malformations (especially cardiac malformations) • Fetal infections (TORCH, parvovirus B19, syphilis, listeriosis)

7. Risk factors – placental : • Abnormalities of the placentation (reduction of number of thin-walled, distended uteroplacental vessels) • Acute atherosis • Obliteration of small muscular arteries of the tertiary villi • Confined placental mosaicism • Chorioangioma

8. Risk factors – maternal : • Low socioeconomic status • Chronic maternal under nutrition • Malnutrition (anorexia nervosa, bulimia) • Cardiovascular diseases (cardiac failures, hypertension, pre-eclampsia) • Gastroenteric diseases (chronic enteritis, malabsorption diseases)

9. Risk factors – maternal : • Pulmonary diseases (CF, asthma, respiratory failure) • Renal diseases • Anemia • Alcohol and drug abuse, smoking • Uterine abnormalities (fibroids, uterine malformations)

10. Clinical features : • Clinical examination (symphyseal – fundal distance) • Diagnostic ultrasound (BPD, FL, AC, EFW) – serial measurements • AFI – amniotic fluid index • Maturity of the placenta – stages according to Grannum

11. Doppler examination • Uterine arteries – approximately 25% of women with unilateral persistant notch and 50% of those with bilateral notch at 24 weeks of pgregnancy will have an IUGR fetus, develop pre-eclampsia, or experience both (sensitivity 82% and specificity of 38%) • Umbilical arteries – affected fetuses show a reduced blood flow pattern during diastole

12. Fetal compromise • Gradually increasing resistance to blood flow in umbilical arteries • End diastolic component may disappear or may reverse • Redistribution of blood flow occurs • Brain, heart and adrenal glands are preferentially perfused • MCA blood flow increases

13. Brain Sparing Phenomenon • Cerebroplacental ratio is below 2 SD • Prior to abnormal CTG recordings about a couple days to 2 weeks • Associated with fetal hypoxia • When resistance in MCA begins to rise – cerebral edema occurs

14. Utero-placental insufficiency during pregnancy Diagnosis and management

15. During pregnancy, fetus depends on the placenta and umbilical vessels for transport of oxygen and nutrients from maternal blood, and for excretion of carbon dioxide and products of metabolism

16. During pregnancy and labor, fetus may be at risk of damage or death from acute or chronic utero-placental insufficiency.

17. Acute placental failure may result from placental separation by hemorrhage (abruptio placentae) or it may come at the end of a phase of gradually declining placental efficiency.

18. Chronic restriction of maternal blood flow through the placenta can have a serious effect upon fetal growth and development.

19. Medical History : • Pregnancy induced hypertension • Maternal diseases (DM; severe anemia; renal, intestinal, cardiac and lung failures; malnutrition) • Infections in pregnancy • Multiple pregnancies • Some drugs • Addictions (smoking, alcohol, drug abuse) • Placental pathology (placental infarction, fetal stem artery thrombosis, antepartum, hemorrhage)

20. Tests of placental function : • Maternal weight • Uterine growth – fundal height • Fetal body movements • Fetal growth – obtained by ultrasound • Fetal activity – biophysical profile, non-stress test (CTG) • Color doppler studies • Placental biochemical tests

21. Maternal weight • Should normally increase by about 0.5 kg weekly after the first trimester (provided that the patient is not dieting or vomiting and has no other disorder causing malnutrition) • Components of this weight gain include: the fetus, plcenta, liquid, uterus, breasts and fat store. Additionally there is the increase in blood volume and ECF. • These changes depend directly on placental function, or indirectly by the hormone production

22. Uterine growth • Simple measurements of the height of the fundus of uterus in relation to the symphysis pubis and umbilicus (eg. in 16th week of gestation – midpoint between pubic symphysis and the umbilicus; at 24th week – umbilical level) • Fundal height should increase by about 1 cm weekly from the 16th week of pregnancy, and with an average sized fetus, should equal the number of weeks of gestation plus or minus 2cm

23. Fetal body movements • The most important indication of placental function is the well being of the fetus • The oldest and simplest method of evaluation of the fetal well being is “kick count” • Mother is asked to note how frequently the fetus moves in a gives period of time, perhaps in 30 minutes • Alternatively, she can be asked to note how long it takes for the fetus to move 10 times

24. Fetal growth • Dating a pregnancy • Serial measurements obtained with ultrasound • BPD, AC, HC/AC, FL, EFW • Centers of ossification in long bones – to confirm fetal maturity • Detecting congenital abnormality

25. Fetal activity • Continuous record of FHR over a period of 30 minutes or more – so called NST (non stress test). It includes recording of changes in FHR variability (from beat to beat) in association with fetal movements and uterine contractions – cardiotocography (CTG) • Biophysical profile – a score based on real time ultrasound observation of fetal breathing, gross body movements, tone and amniotic fluid volume

26. Stress test • In a case of doubtful or suspicious results of non stress test • Contraction stress test – CST • Oxitocin challenge test – OCT • Fetal acoustic stimulation test – FAST

27. Color Doppler examination • Reflection of ultrasound waves from the wave produced by the pulse of blood moving along a blood vessel is detected and compared with the energy output of the source • This provides a measure of the speed of passage of the pulse wave and appears as a typical shape of blood waveform • Seems to be the most useful tool in prediction of chronic fetal hypoxia

28. Biochemical markers of placental function • Evaluation of functional activity of the placenta by measuring one or more of its hormone or enzymes products in maternal blood or urine • Excretion of estriol in the maternal urine during 24 hour period gives an indication of placental function, isolated observations are of little value, but related observations may show an obvious trend • Other tests: serum levels of placental lactogen and of heat stable alkaline phosphatase