FETAL GROWTH

DISORDERS
 :Symmetrical IUGR
 Exclusion of important fetal congenital and
or chromosomal anomalies.
 Screening for Toxoplasmosis, Rubella,
CMV, Herpes viruses.
 Evaluation of fetal well being (in normal
fetus)
 N.B.: Once the fetus starts being
compromised, termination of pregnancy is
advised.
 DEFINITIONS
 Low birth weight (LBW) infants: Infants with
birth weight <2500 gm regardless of their
gestational age.

 Small for gestational age (SGA) fetuses are

<10th percentile weight for gestational age.

 Large for gestational age (LGA) fetuses are

>90th percentile weight for gestational age.

 Appropriate for gestational age (AGA)

fetuses are between 10th & 90th percentile
weight for gestational age.
Birth weight is a function of both gestational age and rate of fetal
growth.

Therefore the correct assignment of fetal weight (FW) depends on :

Accurate dating of pregnancy.

During the intrauterine period of life

:abnormal fetal growth patterns may be either

• Restricted fetal growth ( IUGR - SGA)

• Accelerated fetal growth (Fetal macrosomia - LGA)
I -)INTRAUTERINE GROWTH RESTRICTION )IUGR

It refers to any fetus that fails to reach its full growth potential
.(10th percentile weight according to fetal growth curves<)
 AETIOLOGY

 I. Constitutionally Small:
Small women typically have smaller babies.

 II. Growth Restriction (retardation):

It is divided into two major clinical types; Symmetrical and
Asymmetrical.

These two types are likely to be the consequence of different causes,

time
of onset and duration of events.

 Symmetrical IUGR (Type I):

Symmetric IUGR usually results from fetal injury very early in
development.
It is thus intrinsic to the fetus and constitutes about 20% of IUGR
cases.

 Asymmetrical IUGR (Type II):

 Aetiology of symmetrical IUGR:

 Poor maternal weight gain.

 Fetal infections:

Viral: Rubella, Cytomegalovirus, Hepatitis.

Bacterial: Listeriosis, tuberculosis, syphilis.

 Congenital malformation: cardiovascular malformation

or renal hypoplasia.

 Chromosomal abnormalities: Trisomies.

 Skeletal anomalies: Osteogenesis imperfecta .

Aetiology Of Asymmetric IUGR

 Vascular disease:Chronic hypertension,

Preeclampsia, and Diabetic vasculopathy.

 Chronic Renal disease: Renal insufficiency

 Chronic Hypoxia:Fetuses of mothers with

cyanotic heart disease.

 Placental and cord abnormalities:

Chronic focal placental abruption, extensive
infarction.
Marginal and velamentous insertions of the cord.
 In Asymmetrical IUGR

The fetal size is affected via:

•Reducing uteroplacental blood flow: as with hypertensive

disorders.

•Restricting oxygen and nutrient transfer: as with sickle cell

disease.

•Reducing placental size with infarctsand vasculopathy: as with

PIH and diabetes
The fetus reacts to such chronic placental insufficiency by

redirecting its blood flow to be maintained to the brain and

decreased to most visceral organs, a condition known as

“
Brain sparing” phenomenon
.
This will result in:

• Abnormal head to abdominal circumference ratio

• Reduced renal perfusion and decresaed urine output,
leading to oligohydramnios.
DIAGNOSIS of IUGR

• Proper pregnancy dating.

• Symphyseal to fundal height
ratio.
• Ultrasonic Assessment :
Decreased BPD and AC measurements.
Estimated fetal weight.
Oligohydramnios associated with IUGR.
Accelerated placental aging.
Abnormal umblical and cerebral aretry
 COMPLICATIONS OF IUGR

 Fetal: FHR abnormalities during

labour, asphyxia and IUFD.
 Neonatal:
 Immediate (50%): meconium
aspiration, hypoglycemia,
polycythaemia and pulmonary
hemorrhage.
 Late (2%): Cerebral dysfunction (mild
to cerebral palsy).
 MANAGEMENT of IUGR
 Near Term IUGR:
Prompt delivery is likely to afford the best
outcome whether symmetrical or
asymmetrical type
 IUGR Remote From Term:
Symmetrical IUGR:
Asymmetrical growth
retardation:
 :Symmetrical IUGR
Exclusion of important fetal congenital and or
.chromosomal anomalies

,Screening for Toxoplasmosis, Rubella, CMV

.Herpes viruses

(Evaluation of fetal well being (in normal fetus

,N.B.: Once the fetus starts being compromised

.termination of pregnancy is advised
 Asymmetrical growth
:retardation
After diagnosis, fetal surveillance is
started.
In such cases, the fetus is usually severely
ill and often acidotic
 Once antepartum fetal surveillance
program shows abnormal results,
termination of pregnancy is advisable.

 Suctioning pharynx as soon as the fetal

head is identified,the trachea should be
aspirated as soon as possible after
delivery.
 FETAL MACROSOMIA

 DEFINITION: fetus with absolute

birth weight of either >4000g or
>4500g.

 INCIDENCE: 5% of neonates are>

4000g and 0.5% are>4500g at birth.
 RISK FACTORS
 Maternal diabetes (the most
common risk factor).
 Post-term pregnancy.
 Maternal obesity (a prepregnancy
weight of >90kg),
 Increased maternal height.
 Multiparity and prior macrosomic
infant.
 DIAGNOSIS
 Clinical estimates of fetal size are often
unreliable and are markedly affected by
clinical experience and maternal obesity.
 Ultrasound estimates of fetal weight are
reasonably accurate with only 15-20%
error range, in correlation to actual fetal
weight after delivery.
( However US estimates of fetal weight
are more difficult in obese women.)
 PREVENTION
 Meticulous control of maternal
diabetes.

 Obese women should loose

weight before conception, and
once pregnant should gain less
weight than the average
patient.
 MANAGEMENT
 During pregnancy: Serial US to chart
fetal growth, and exclude anomalies.
 Induction of labor >37 weeks: to
minimize the need for a CS delivery.
( Controversial).
 Elective cesarean section (C.S): If US
EFW ≥4250 especially in diabetic
pregnancies.
 Vaginal delivery: If attempted,
anesthesia staff and neonatal
resuscitation team must be available.
Assisted instrumental vaginal delivery
MUST BE AVOIDED.
 COMPLICATIONS
Fetal Complications:
 IUFD (in diabetic macrosomia or serious
congenital malformations)
 Birth trauma (shoulder dystocia and brachial
plexus palsy)
 Hypoglycemia, polycythaemia, hypocalcaemia
and jaundice.
Maternal:
 Higher incidence of C.S. deliveries.
 Traumatic injuries of birth canal, postpartum
hemorrhage (PPH)and puerperal infection.