Intrauterine Growth Retardation Restriction

1
Intrauterine Growth Retardation (Restriction)

• Jignesh Patel, MD
• Texas Tech University HSC
• Department of Pediatrics

2
Definitions

• IUGR Failure of normal fetal growth caused by
  multiple adverse effects on the fetus.
• SGA Infant with wt lt 10 ile for GA, or gt 2
  SDs below mean for GA.

3
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.

4
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 lt 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.

5
Types of IUGR

• Symmetric IUGR weight,length and head
  circumference are all below the 10 th percentile.
  (33 of IUGR Infants)
• Asymmetric IUGR weight is below the 10 th
  percentile and head circumference and length are
  preserved. (55 of IUGR)
• Combined type IUGR Infant may have skeletal
  shortening, some reduction of soft tissue mass.
  (12 of IUGR)

6
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.

3
Mass (kgs) Height (cms)
7
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.

8
Normal Intrauterine Growth pattern

• Stage III ( Hypertrophy)
• - 28 to 40 weeks
• - Rapid increase in cell size.
• - Rapid accumulation of fat, muscle and
  connective tissue.
• 95 of fetal weight gain occurs during last 20
  weeks of gestations.

9
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
  
  

10
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.

11
Pathophysiology

• 1) Fetal factors
• Genetic Factors
• - Race, ethnicity, nationality
• - sex ( male weigh 150 -200 gm more than
  female )
• - parity ( primiparous, weigh less than
  subsequent siblings)
• -genetic disorders ( Achondroplasia, Russell -
  silver syn.)
• Chromosomal anomalies
• - Chromosomal deletions
• - trisomies 13,18 21

12
Pathophysiology

• Congenital malformations
• examplesAnencephaly, GI atresia, potters
  syndrome, and pancreatic agenesis.
• Fetal Cardiovascular anomalies
• Congenital Infections
• mainly TORCH infections.
• Inborn error of metabolism
• - Transient neonatal diabetes
• - Galactosemia
• - PKU

13
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 therapeutic
  agents such as trimethadione, warfarin, phenytoin

14
Pathophysiology

• Maternal hypoxemia
• - Hemoglobinopathies
• - High altitudes
• Others
• - Short stature
• - Younger or older age (lt15 and gt45)
• - Low socioeconomic class
• - Primiparity
• - Grand multiparity
• - Low pregnancy weight
• - Previous h/o preterm IUGR baby
• - Chronic illness ( DM, renal failure,
  cyanotic heart
  disease etc.)

15
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

16
Postnatal Assessment

• Growth parameters weight, height, HC
• Assess GA with Ballard score.
• Plotted growth parameters in growth chart

17
(No Transcript)
18
(No Transcript)
19
Physical Appearance
20
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

21

• 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 crown heel length
• - delayed development of epiphyses
• Comparison to premature infants,IUGR has brain
  and heart larger in proportion to the body
  weight, in contrast the liver, spleen, adrenals
  and thymus are smaller.

22
Complication

• Hypoxia
• - Perinatal asphyxia
• - Persistent pulmonary hypertension
• - meconium aspiration
• Thermoregulation
• - Hypothermia due to diminished subcutaneous fat
  and elevated surface/volume ratio

23
Complications

• Metabolic
• - Hypoglycemia
• - result from inadequate glycogen stores.
• - diminished gluconeogenesis.
• - increased BMR
• - Hypocalcemia
• - due to high serum glucagon level, which
  stimulate calcitonin excretion

24
Complications

• Hematologic
• - hyperviscosity and polycythemia due to
  increase erythropoietin level sec. to hypoxia
• Immunologic
• - IUGR have increased protein catabolism and
  decreased in protein, prealbumin and
  immunoglobulins, which decreased humoral and
  cellular immunity.

25
Management

• Antenatal diagnosis and management is the key 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 )

26
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

27
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

28
Management

• Early feeding and caloric intake should be
  100-120 kcal/kg/d
• Developmental and growth f/u in all IUGR infants

29
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 - handicap
  rate gt 50
• IUGR has higher rate of learning disability.

30
Thank You