INTRAUTERINE GROWTH RESTRICTION

Growth & Development Perinatology Division, Child Health Department, Medical Faculty of Hasanuddin University

Definitions
IUGR: Failure of a pregnancy to reach

expected fetal growth and manifest as a deviation of fetal growth from normal pattern. SGA: birth weight < 10th percentile for GA, or > 2 SDs below mean for GA.

Low birth weight (LBW) birth weight < 2500 g, which could be due to IUGR or Prematurity

IUGR vs SGA
IUGR suggests diminished intrauterine growth

velocity IUGR indicates the presence of a pathologic process in-utero that inhibits fetal growth SGA and IUGR are not synonymous SGA refers to the size of the infant at birth and not fetal growth

IUGR vs SGA
A child who is born SGA is not always IUGR
Infants born after a short period of IUGR are

not always SGA SGA:

IUGR Constitutionally small infant

Intrauterine Growth pattern & Patophysiology of IUGR

Stage I (Hyperplasia)

- 4 to 20 weeks - Rapid mitosis - Increase of DNA content

Growth inhibition in stage I: - Undersized fetus with fewer cells.

- Normal cell size. Result in symmetric IUGR.

 Growth inhibition in stage I:

Symmetric IUGR Associated conditions: - Genetic - Congenital anomalies - Intrauterine infections - Substance abuse - Cigarette smoking - Therapeutic irradiation

Intrauterine Growth pattern & Patophysiology of IUGR

Stage I (Hyperplasia)

- 4 to 20 weeks - Rapid mitosis - Increase of DNA content

Growth inhibition in stage I: - Undersized fetus with fewer cells.

- Normal cell size. Result in symmetric IUGR.

Intrauterine Growth pattern & Patophysiology of IUGR

Stage II (Hyperplasia & Hypertrophy)

- 20 to 28 weeks - Declining mitosis. - Increase in cell size.

Intrauterine Growth pattern & Patophysiology of IUGR

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.

Patophysiology, cont
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.

Types of IUGR
Symmetric IUGR (33 % of IUGR Infants) :

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

Types of IUGR
Symmetrical
Baby's head and body are proportionately small May occur when the fetus experiences a problem during early development

Asymmetrical
Baby's head and length are preserved Occur when the fetus experiences a problem later in pregnancy

In a normal infant, the brain weighs about three times more than the liver. In asymmetrical IUGR, the brain can weigh five or six times more than the liver.
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Types of IUGR
Symmetric IUGR Type I Asymmetric IUGR Type II

Early onset growth

restriction Uniform growth restriction Long-term growth failure Associated with decreased cell number Associated with less catch-up growth in the first year of life

Late onset growth

restriction Head Sparing Potentially reversible Associated with decreased cell size Infants demonstrate more catch-up growth than symmetric IUGR in first year of life
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Etiology
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

Etiology, cont
Congenital malformations:

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

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

 Maternal hypoxemia

- Hemoglobinopathies
- High altitudes

Others

- Short stature
- Younger or older age (<15 and >45) - Low socioeconomic class - Primiparity - Grand multiparity - Low pregnancy weight - Previous h/o preterm IUGR baby - Chronic illness ( DM, renal failure, cyanotic heart disease etc.)

3) Placental Factors:

Utero-placental insufficiency resulting from:

Improper / inadequate trophoblastic invasion and

placentation in the first trimester

Aberrant placental insertion Reduced maternal blood flow to the placental bed

(thrombosis, infarcts, hemangioma)

Feto-placetal insufficiency due to:

Vascular anomalies of placenta and cord

Decreased placental functioning mass:

Small placenta, abruptio placenta, placenta previa, post term pregnancy.

Diagnosis
Intrauterine IUGR can be difficult to diagnose. Presence of risk factors. Inadequate growth detected by serial measurement of Wt., abdominal girth and fundal Ultrasound to evaluate the foetal growth. Inadequate fetal growth. Placental calcification.

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Diagnosis, cont...
Neonatal Postnatal assessment
Growth parameters: weight, height, HC Assess GA with Ballard score. Plotted growth parameters in growth chart

Ponderal index

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Ponderal Index
Way of characterizing the relationship of height to mass for an individual.
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PI = 1000 x

Mass (kgs) Height (cms)

Typical values are 20 to 25.

PI is normal in symmetric IUGR.

PI is low in asymmetric IUGR.

Neonate and Placenta in IUGR

Normal & IUGR Newborn babies

Normal & IUGR Placentas

IUGR - Prof.S.N.Panda

12 October 2002

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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

Physical Appearance

 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.

Complications
Metabolic
- Hypoglycemia - result from inadequate glycogen stores.
- diminished gluconeogenesis. - increased BMR

- Hypocalcemia - due to high serum glucagon level, which

stimulate calcitonin excretion

Complication
Hypoxia

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

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.

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 )

Management
Hypothermia : Incubator, Kangaroo Mother Care 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

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

Management
Early feeding and caloric intake should be 100-120 kcal/kg/d
Developmental and growth follow up in all

IUGR infants

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 > 50% IUGR has higher rate of learning disability.

Short Term Risks of IUGR

Increased perinatal morbidity and mortality.
Intra uterine / Intrapartum death. Intrapartuum foetal acidosis characterized

by-. Late deceleration. Severe variable deceleration. Beat to beat variability. Episodes of bradicardia.

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Short Term Risks of IUGR

Intrapartum foetal acidosis may occur in as

many as 40 % of IUGR, leading to a high incidence of LSCS. IUGR infants are at greater risk of dying because of neonatal complications- asphyxia, acidosis, meconium aspiration syndrome, infection, hypoglycemia, hypothermia, sudden infant death syndrome. IUGR infants are likely to be susceptible to infections because of impaired immunity
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Long term Prognosis

. Infants with asymmetrical IUGR are more likely to catch up in growth after birth than are infants who suffer from prolonged symmetrical IUGR. If IUGR is related to a disease or a genetic defect, the future of the infant is related to the severity and the nature of that disorder.

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Long term Prognosis

IUGR infants are more likely to remain small

than those of normal birth weight. They will need the special attention of primary health, nutrition and social services during infancy and early childhood. Implication of IUGR can be life long affecting: Body size growth, composition and physical performance. Immunocompetence.
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Long term Prognosis

It appears to predispose to adult-onset,

degenerative diseases like maturity onset diabetes , obesity, and cardiovascular diseases. Impaired Neurodevelopment Long term neuromotor dysfunction Poor school performance Deficits in academic achievements
Each case is unique. Can not reliably predict an

infant's future progress.

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