IUGR & IUFD

1. IUGR & IUFD DR. SALWA NEYAZI CONSULTANT OBSTETRICIAN GYNECOLOGIST PEDIATRIC & ADOLESCENT GYNECOLOGIST

2. 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

3. 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

4. What are the causes of IUGR? • Maternal medical conditions • Chromosomal anomalies & aneuploidy • Genetic & Structural anomalies • Exposure to drugs & toxins • 1ry placental disease • Extremes of maternal age • Low socioeconomic status • Infections • Multiple gestation

5. 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

6. 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

7. What infections result in IUGR? 5-10% of IUGR • Congenital infections: • CMV • Rubella • Herpes • Vericella zoster • Toxoplasmosis • Malaria • Listeriosis

8. Which drugs can result in IUGR? • Alcohol • Cigarette smoking 3-4X • Heroin & coccaine • Methotrexate • Anticonvulsants • Warfarin • Antihypertensives /ß-blockers • Cyclosporin

9. What are the genetic disorders that can result in IUGR? Features suspicious of trisomy 15% of IUGR • Down’s syndrome T21 • Trisomy 13,18 • Turner syndrome • Neural tube defects • Achondroplasia • Osteogenisis imperfecta • Abdominal wall defects • Duodenal atresia • Renal agenesis/ Poter’s S • Symmetric IUGR • AFV/ Doppler N • Structural abnormalities • Maternal age • Nuchal translucency • Biochemical screening results

10. 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

11. 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  

12. Types of IUGR 2-Asymmetric IUGR—80% • 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  

13. 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

14. 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

15. 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

16. 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

17. The constitutionally small fetus • A fetus growing parallel to the lower centiles through out preg • Anatomically N • AFV N • Doppler N • Slim petite women

18. 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

19. 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

20. IUFD Definition: dead fetuses or newborns weighing > 500gm Or > 20 wks gestation 4.5/ 1000 total births • Diagnosis • Absence of uterine growth • Serial ß-hcg Loss of fetal movement Absence of fetal heart Disappearance of the signs & symptoms of pregnancy X-ray Spalding sign Robert’s sign U/S 100% accurate Dx

21. Maternal 5-10% • Antiphospholipid antibody • DM • HPT • Trauma • Abnormal labor • Sepsis • Acidosis/ Hypoxia • Uterine rupture • Postterm pregnancy • Drugs • Thrombophilia • Cyanotic heart disease • Epilepsy • Severe anemia • Unexplained 25-35% Causes OF IUFD • Fetal causes 25-40% • Chromosomal anomalies • Birth defects • Non immune hydrops • Infections • Placental 25-35% • Abruption • Cord accidents • Placental insufficiency • Intrapartum asphyxia • P Previa • Twin to twin transfusion S • Chrioamnionitis

22. A systematic approach to fetal death is valuable in determining the etiology • B-Maternal History • I-Maternal medical conditions • VTE/ PE • DM • HPT • Thrombophilia • SLE • Autoimmune disease • Severe Anemia • 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 • A-Family history • Recurrent abortions • VTE/ PE • Congenital anomalies • Abnormal karyptype • Hereditary conditions • Developmental delay

23. 1-History • Specific fetal conditions • Nonimmune hydrops • IUGR • Infections • Congenital anomalies • Chromosomal abnormalities • Complications of multiple gestation • Current Pregnancy Hx • Maternal age • Gestational age at fetal death • HPT • DM/ Gestational D • Smooking , alcohol, or drug abuse • Abdominal trauma • Cholestasis • Placental abruption • PROM or prelabor SROM • Placental or cord complications • Large or small placenta • Hematoma • Edema • Large infarcts • Abnormalities in structure , length or • insertion of the umbilical cord • Cord prolapse • Cord knots • Placental tumors

24. 2-Evaluation of still born infants • Infant desciption • Malformation • Skin staining • Degree of maceration • Color-pale ,plethoric • Umbilical cord • Prolapse • Entanglement-neck, arms, ,legs • Hematoma or stricture • Number of vessels • Length • Amniotic fluid • Color-meconium, blood • Volume • Placenta • Weight • Staining • Adherent clots • Structural abnormality • Velamentous insertion • Edema/ hydropic changes • Membranes • Stained • Thickening

25. Fetal inveswtigations • Fetal autopsy • Karyotype • (spcimen taken from cord • blood, intracardiac blood, • body fluid, skin, spleen, • Placental wedge, or amniotic • Fluid) • Fetography • Radiography 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 • 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.

26. 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

27. Psychological aspect & counseling • A traumetic event • Post-partum depression • Anxiety • Psychotherapy • Recurrence 0-8% depending on the cause of IUFD