INTRAUTERINE GROWTH RESTRICTION

DEFINITION Intra uterine growth restriction is said to be present in those babies whose birth weight is below the tenth percentile of the average for gestational age

INCIDENCE 2 -8%

TYPES SYMMETRICAL OR TYPE – I Affected from the very early phase of cellular hyperplasia Slow rate of growth A reduction in absolute size The pathological process is intrinsic to the fetus All the organs including the head is affected ASYMMETRICAL OR TYPE – II Affected in the later months Phase of cellular hypertrophy is affected Pathological process is extrinsic to the fetus Fetal size is reduced

ETIOLOGY MATERNAL FACTORS Constitutional – Small women, racial back ground and genetic Maternal nutrition before and during pregnancy Maternal diseases Decreased blood supply due to high altitude,hemoglobinopathies and cyanotic heart disease Smocking and tobaco chewing Ingestion of drugs like etanol,cocaine,hydantoin and coumarin

Contd… FETAL FACTORS Congenital infections Congenital malformation Chromosomal abnormalities Infections - TORCH Multiple pregnancy

Contd… PLACENTAL FACTORS Abruptio placenta Placental infarction Small placenta Post term pregnancy Placental insufficiency due to maternal vascular diseases Poor implantation of the placenta Circumvallate placenta

DIAGNOSIS HISTORY Previous medical or obstetric problems Prior delivery of an IUGR baby WEIGHT GAIN Not a reliable indicator Remains stationary or at times falling UTERINE FUNDAL HEIGHT Stationary or may fall FETAL KICK COUNT Dimnished fetal movement

MANAGEMENT GENERAL Adequate bed rest especially in the left lateral position Balanced diet +300 extra calorie to be taken Management of associated complicating factors that cause IUGR Avoidance of smocking and alcohol Maternal hyperoxygenation for short term prolongation of pregnancy Low dose aspirin (50mg daily)

Contd… ANTEPARTUM EVALUATION Clinical examination USG Fetal kick counts Doppler velocimetry NST Cord blood for blood gas analysis

Contd… TERMINATION OF PREGNANCY Beyond 37 weeks :Termination of pregnancy should be done Before 37 weeks : Uncomplicated mild IUGR Treatment to improve placental function Severe degree of IUGR Attained lung maturity – Terminate pregnancy Not attained lung maturity – Dexamethasone therapy

Methods of termination LRM followed by oxytocin

INTRAPARTUM MANAGEMENT INTRAPARTUM MONITORING Continuous electronic fetal heart monitoring and scalp blood sampling CARE DURING VAGINAL DELIVERY Delivery in equipped hospital Intensive intranatal monitoring Facility for intensive neonatal care In – Utero transfer of baby to equipped hospital Precautions as for pre term labour INDICATIONS FOR LSCS Fetal distress Malpresentation Very low fetal weight Failed induction Arrest of progress Previous cesarean section

PHYSICAL FEATURES AT BIRTH Weight 600 gm below the minimum in percentile standard Length is unaffected Head circumference is relatively larger in assymetric variety Wrinkled skin Scaphoid abdomen Thin meconium stained vernix caseosa Thin umbilical cord Plantar creases are well developed The baby is alert ,active with normal cry Reflexes are normal