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I.U.G.R. Intrauterine Growth Retardation (Restriction). Presented by:. DR. NABEEL S. BONDAGJI. DEFINITIONS:. Low birth weight (LBW) Very low birth weight (VLBW) Extremely low birth weight (ELBW) Premature Small for Gestational Age (SGA) Large for Gestational Age (AGA)
Intrauterine Growth Retardation (Restriction)
DR. NABEEL S. BONDAGJI
By definition, babies with BW < 10th centile on growth curves are SGA.
Therefore, 10% of babies are SGA.
However, not as simple as this.
4. Altitude:In USA for example, growth curves based on the Denver population located approximately 5000 feet above sea level tend to underestimate infants' weights after 32 weeks' gestation.
5. Maternal size:direct association between maternal height and weight and the size of the fetus is well established. Birth weight variation of 750 g between infants born to mothers of 170 cm in height and 75 kg weight when compared with infants born to mothers 150 cm tall and weighing 40 kg has been described.
weight decreases with the number of
? Need for different growth curves to
take the above into account.
Symmetric IUGR babies are more likely to have an underlying “cause”.
9-27% of IUGR infants have anatomic and or genetic abnormalities.
The overall perinatal mortality in IUGR infants is increased eight- to ten-fold that of AGA infants.
Higher risk of developmental problems in SGA infants.
28-40 weeks – cells rapidly increasing in size, with peak at 33 weeks. In addition, rapid accumulation of fat, muscle and connective tissue occurs.
Ninety five percent of fetal weight gain occurs during the last 20 weeks of gestation.
Growth inhibition during stage II and III will cause a decrease of cell size and fetal weight with less effect on total cell number and fetal length and head circumference, causing asymmetric IUGR.
- chronic hypertension,
- placental infarcts
- abruptio placenta
- velamentous insertion of the
umbilical cord and circumvallate
- chronic renal disease,
- cyanotic heart disease,
- substance abuse and cigarette
- multiple gestation
- BPD (biparietal diam) 43-100% accurate
but inaccuracy due to head-sparing in
- AC (Abdominal circumference better
sensitivity than that of cephalometry for
- HC/AC (Head circumference/abdominal
circumference ratio) is an important
measurement for detection of asymmetric
Ratio of femoral length to abdominal circumference (FL/AC) provides also an accurate prediction of IUGR.
due to decreased renal blood flow and
5. Blood flow measurements: by Doppler
flow studies, fetal and uterine blood flow
can be measured and therefore
uteroplacental circulation dysfunctions
can be assessed.
- Symmetric IUGR – need to consider amniocentesis and TORCH analysis, along with Maternal TORCH antibody titres.
- Also need to look at Maternal Health – e.g. illness such as chronic renal disease need to be considered. This includes discouraging tobacco use, and substance abuse as well as regular checks through pregnancy
- Ongoing close observations, with U/S (including doppler flows) and CTG’s.
- Early delivery has to be considered based upon the relative chance of fetal morbidity and mortality in-utero to the chance of morbidity and mortality of prematurity. Can often be a difficult choice.
- IUGR infants are more prone to hypoxemia during labor and delivery because of uteroplacental insufficiency, and more prone to cord compression due to lack of amniotic fluid and a thin cord.
- A neonatal team capable of managing asphyxia and meconium aspiration syndrome should be available at the time of delivery.
- Special attention should be addressed to prevention of hypothermia and hypoglycemia.
- lack of subcutaneous fat
- skin is dry cracked and peeling
(especially palms & soles)
- often thin cord due to lack of Wharton’s
- may be meconium stained
- ruddy appearance due to polycythaemia
- may be jittery due to low sugar or calcium - may also be irritable and show signs of
asphyxia, including fitting.
a. Vascular diseases of the mother
(hypertension, renal disease, diabetes, etc.) - 35%.
b. Chromosomal and other congenital
anomalies of the infant - 10%.
c. Normal variations (low maternal
weight/height, high altitude, multiple
gestation) - 10%.
e. Alcohol, smoking, substance abuse, and
medications (antimetabolites for cancer
therapy, hydantoin and trimethadion for
anticonvulsant therapy) - 5%.
f. Placenta and cord defects - 2%.
g. Uterine abnormalities - 1%.
h. Other: Therapeutic radiation, low
socioeconomic level and unknown
causes - 32%.
* Careful history and examination can identify
SGA babies are at risk as noted. Therefore attention to WARM, PINK, SWEET & INFECTION needed.
Need to attend to basics of care – in particular:
1. Respiratory care – esp. with meconium
2. Hypoglycaemiadue to low sugar reserves and higher energy consumption – esp. with cold stress.
fat and relatively high S.A to body weight
4. Beware infection – at risk as immune
system of babies is immature – being
SGA worsens this.
Can cause venous thrombo-emboli and
can also worsen cerebral ischaemia and
6.Haemorrhage – can develop due to lack of
liver coag factor production, and also may
have low platelets if TORCH
7. Management of asphyxia
Initially, babies need to be examined in a warm environment.
True blood glucoseshould be assessed at ½ to 1 hour of age, and pre-feeds for at least the next 2 feeds. Feeds should be frequent (2-3 hourly initially).
and magnesium must be checked.
Full blood count - 3 reasons
- platelet count
- white cells
- TORCH screen
- CXR if respiratory distress
- Sepsis workup if possibility of infection - - Urine drug screen, etc., if suspect
maternal substance abuse
- Cranial US – esp. if concerned about
risk for physical and developmental
sequelae, and risk of IUGR in a
subsequent pregnancy, should be
Increased mortality and morbidity as noted.
Long term outlook:
- IUGR infants have an increased risk of
long-term neurologic and behavioral
handicaps. Infants with ultrasonographic
evidence of delayed head growth before the
third trimester also have delayed neurologic
and intellectual development.
detected prenatal infections are excluded,
studies show normal IQ/DQ in most SGA
- Preterm IUGR infants have similar outcomes at
18-24 months of age, compared to AGA preterm
- Severe malnutrition in utero can decrease the
number of brain cells. Normally in the first 2
years of life there occurs a "spurt in brain
growth" during which the predominant change is
increase in myelinization.
incidence of lower intelligence, learning
and behavioral disorders and neurologic
- The long-term neurologic outcome in SGA
infants is related to the type of SGA,
severity and concomitant asphyxial insult.
- Future handicap is dependent also on the
existence of perinatal complications such as
asphyxia, meconium aspiration syndrome,
hypothermia, hypoglycemia and
- Asymmetric IUGR infants have better growth
potential than symmetric IUGR infants who
typically have suffered a genetic, infectious
or teratogenic insult early in life.
- Asymmetric SGA infants capable of
achieving normal weight and proportions
within 6-12 months of birth.
- Symmetric SGA infants born often remain
shorter, lighter and have a smaller head
circumference throughout life.
-Delayed eruption of teeth and enamel
- Increased incidence of postnatal infections
possibly due to delayed humoral and
cellular immunity found .
- Risk of SIDS considerably greater (30% of
SIDS cases occur in SGA infants) – reasons
behind SGA may account for this however.