Intrauterine growth restriction: A new concept in antenatal management Dr. Mohammed Khairy Ali Lecturer of Obstetrics and Gynecology Woman’s Health Hospital-Assiut university

INTRODUCTION

Introduction IUGR refers to a fetus that has failed to get a specific measures threshold by a specific gestational age. Asymmetric type of IUGR is known by normal sized head and brain with smaller abdomen. IUGR is a common obstetric problem which affects approximately 10-15 % of pregnant women. It is very serious for obstetricians to recognize the growth restricted fetuses, because these fetuses are at greater risk of stillbirth, birth hypoxia and neonatal complications. ACOG 2013 RCOG 2014 Vayssière et al 2016

Supplementation of zinc and fish oil Introduction There are many lines of treatment have been emerged now for treatment of asymmetric type of IUGR like: Maternal rest and oxygenation Aspirin therapy Supplementation of zinc and fish oil However; all mentioned lines of treatment lacking evidence of effectiveness in literature. The role of low-dose aspirin therapy in management of IUGR is controversial. It has been used, in many studies, in prevention of IUGR especially in women at high risk of pre-eclampsia or obstetrical antiphospholipid syndrome. Odibo et al 2011 Gutaj et al 2016

Introduction Oxidative stress during pregnancy leads to free radicals release and subsequent disruption of the ability for the vasodilatation; thus, vasoconstriction may lead to decreased blood flow to the uterus and placenta resulting in IUGR. Omega-3 fatty acids are antioxidants and used to improve pregnancy outcomes, without any comprehensible recommendations. The omega-3 fatty acids have been studied also as preventive treatment for IUGR with relatively good results. Joshi et al 2008 Makrides et al 2010

Introduction Most of studies in literature have reported the preventive effect of aspirin and omega 3 on IUGR with little information about its treatment roles. To our knowledge, no randomized clinical trials have been conducted or registered, to compare the effect of aspirin and omega 3 on asymmetrically IUGR fetuses.

OBJECTIVE

in asymmetrical IUGR cases. Objective The aim of our study was to address the effect of aspirin and omega-3 on Fetal and birth weight Feto-maternal blood flow in asymmetrical IUGR cases.

MATERIAL AND METHODS

Study Setting: WHH, Assiut University, Egypt. Materials and Methods Type of the study: Registered open, parallel, randomized controlled trial (NCT02696577). Study Setting: WHH, Assiut University, Egypt. Study period: From March 2015 and March 2016.

Inclusion criteria Women aged 20-35 years. Materials and Methods Inclusion criteria Women aged 20-35 years. Pregnant women in singleton fetus (28-30 weeks). Asymmetrically IUGR (when the abdominal circumference reduced out of proportion to biparietal diameter and head circumference and is below the 10th percentile, so there was increased HC:AC ratio. Normal Doppler indices in uterine and umbilical arteries at time of recruitment.

Women with any medical disorders Smokers Multiple gestations Materials and Methods Exclusion criteria Women aged ≤20 and ≥ 35 years Women with any medical disorders Smokers Multiple gestations Low amniotic fluid volume PROM Antepartum hemorrhage CFMF Women had abnormal Doppler indices at the time of recruitment.

Further evaluation 2- Clinical examination: BMI and blood pressure. Materials and Methods Further evaluation 1- Full history taking: Age, parity and gestational age. All risks factors for IUGR were revised with the recruited women. 2- Clinical examination: BMI and blood pressure. 3- Ultrasound evaluation

(Sonoline G60 S, Siemens, Germany) Materials and Methods 3- Ultrasound examination (Sonoline G60 S, Siemens, Germany) Gestational age Confirm IUGR Evaluate AFI Excluded CFMF The umbilical and uterine arteries Doppler indices (S/D, RI and PI) were measured.

Randomization Intervention Materials and Methods Randomization Randomization was done by computer-generated random table. Intervention The eligible women were allocated to either: Group I (aspirin group); received once daily for 6 weeks. Group II (low dose aspirin plus omega 3 group); received aspirin and omega 3 once daily for 6 weeks.

Materials and Methods Study outcomes Primary outcome was the changes in fetal weight after 6 weeks of treatment. Secondary outcomes Doppler blood flow changes in both uterine and umbilical arteries from before to 6 weeks after using aspirin and omega 3. Birth weight, time and method of delivery, Apgar score and admission to NICU were also reported.

RESULTS

Aspirin plus omega 3 (n= 34) Table (1): Baseline characteristics of the participants Group I Aspirin (n= 34) Group II Aspirin plus omega 3 (n= 34) P-value Mean ± SD Age (years) 27.50 ± 4.84 27.12 ± 4.33 0.721 Parity 2.97 ± 1.71 2.88 ± 1.61 0.745 Number of previous abortions 16 15 0.808 Number of previous C.S 17 Number of living children 2.79 ± 1.65 2.59 ± 1.42 0.482 Gestational age 30.24 ± 0.55 30.03 ± 0.39 0.069 BMI 21.53 ± 2.69 21.23 ± 1.49 0.985

Table (2): The main study outcomes (estimated fetal weight)

Table (3): Doppler blood flow changes in both uterine and umbilical arteries from before to 6 weeks after treatment

Table (4): Delivery and neonatal outcomes data

CONCLUIONS

Conclusions 1. Both aspirin and omega-3 fatty acids are effective in increasing fetal and birth in IUGR after 6 weeks of use with favorable neonatal outcome. 2. However, the combing between aspirin with omega-3 is superior to aspirin only for achieving this effect. 3. The increase in uterine and umbilical blood flow may be behind this treatment effect.

Thanks for your attention by MOHAMMED KHAIRY