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INTRAUTERINE GROWTH RESTRICTION

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INTRAUTERINE GROWTH RESTRICTION

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    1. INTRAUTERINE GROWTH RESTRICTION By DR NOSHABA RAFIQ M.B.B.S; M.C.P.S; F.C.P.S.

    2. DEFINITION OF IUGR Fetus whose estimated weight is: less than 10th percentile for its gestational age. Abdominal circumference is less than 2.5th percentile. Incidence: 10 percent of all pregnancies.

    3. Fetal weight percentiles throughout gestation

    4. Risk of IUGR Babies Still birth: 15 fold increase risk Intra-partum hypoxia Neonatal risk Sepsis Hypoglycemia RDS Hypothermia Meconium Aspiration Haematological disorders Seizers in first 24 hours Malformations

    5. …contd 4. Impaired Neurodevelopment Long term neuromotor dysfunction Poor school performance Deficits in academic achievements 5. Complications in Adult Life Obesity Diabetes Mellitis Hypertension Cardio-vascular disease

    6. Classification of IUGR Symmetrical growth restriction: fetus whose entire body is proportionally small. Incidence : 20 % Asymmetrical growth restriction: Decrease in subcutaneous fat and abdominal circumference with relative sparing of head circumference and femur length. Incidence : 80 %

    7. ETIOLOGY Maternal Causes of IUGR Chronic Illnesses (e.g. cystic fibrosis, CHD, renal failure, haemoglobinopathies, APS) Nutrition (e.g. anorexia nervosa and bulimia) Smoking Alcohol Drug Abuse (e.g. Cocaine, amphetamines, betal chewing)

    8. …contd Infections (e.g. vaginal bacteria, specially M. hominis, U. urealyticum, T. vaginalis and bacteroides group). Endocrine disorders (e.g. diabetic nephropathy, hyperthyroidism, addison’s disease).

    9. Placental Causes of IUGR Uteroplacental insufficiency Unexplained Preeclampsia Elevated maternal AFP 2. Fetoplacental insufficiency Single Umbilical Artery Velamentous insertion of cord Placental Haemangioma 3. Abnormal Placentation Abruptioplacentae Placenta Previa Placenta Accretia

    10. Fetal Causes of IUGR Normal Small Fetus (Constitutionally small fetus) 2. Infection CMV Toxoplasmosis Rubella Herpes Malaria Syphilis

    11. …contd 3. Fetal Abnormality Chromosomal (Trisomy, 13,18 and 21, deletions or tripliody) Structural (Gastroschisis, e.g. anencepholy) 4. Multiple Gestation

    12. DIAGNOSIS OF IUGR 1. History Previous infant with growth restriction Decreased fetal movements Medical disorders Drugs Poor nutrition Adverse factors, e.g. bleeding 2. Clinical Examination Poor maternal weight gain Fundal height lag Reduced amount of liquour Clinical assessment of small fetus

    13. …contd HC/AC ratio or FL/AC ratio Estimated Fetal weight 4. Growth Velocity Serial measurements of AC or EFT 5. Invasive Investigation Karyotyping Screening for congenital infections

    14. Doppler Ultrasound Umblical Artery S/D ratio Resistance index Pulsatility index Middle Cerebral Artery Venous Doppler Reversal of blood flow in IVC, DV and UV at the end of diastole

    15. MANAGEMENT Accurate dating is mandatory Symmetric or Asymmetric IUGR Assymmetric: rule out chromosomal abnormalities and congenital infections. 3. General Management Treat maternal disease Stop substance abuse Good nutrition Bed Rest Maternal hyperoxygenation

    16. ANTENATAL SERVEILLANCE Growth scans every 3 weeks Daily fetal movement profile NST twice weekly BPP weekly if NST is abnormal Umblical artery Doppler study every 2 to 3 weeks. Oxytocin challenge test if NST is abnormal or BPP is <8

    17. DELIVERY CONSIDERATIONS Antenatal steroids: To promote fetal lung maturity if gestational age less than 34 weeks. Delivery >= 32 weeks: If antenatal test results are abnormal. Antenatal test results reassuring: continue fetal surveillance and delivery at term, if fetal growth is noted. If no fetal growth or severe oligohydramnios: assess fetal lung maturity. Deliver if lungs are mature; otherwise, reassess after 1 week. Abnormal antenatal test results at less than 32 weeks of gestation, each case must be considered individually.

    18. LABOR AND DELIVERY Continuous fetal monitoring during labor. Delivery in hospital, capable of providing intensive neonatal care. Amnioinfusion: non-reassuring fetal response, low amniotic fluid index and meconium stained liquor. Caesarean Section: Detoriating fetal status.

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