Rafat Mosalli MD Abnormal Gestation

Objectives What is Normal gestation? What is Normal gestation? Newborn classification according to age and Weight. Newborn classification according to age and Weight. How to assess for Gestational age? How to assess for Gestational age? Causes of abnormal gestation Causes of abnormal gestation Complications of abnormal Gestation. Complications of abnormal Gestation. - LGA & SGA - LGA & SGA -Premature & Post mature -Premature & Post mature

Definitions Full Term : W GA Full Term : W GA Prematurity : < 37 W GA Prematurity : < 37 W GA Post term : > 42W GA Post term : > 42W GA Large for gestational age (LGA): Large for gestational age (LGA): BWT >2 SD from the mean of GA(>90 percentile) BWT >2 SD from the mean of GA(>90 percentile) Small for gestational age( SGA): BWT<2SD from the mean of GA(<10 percentile) Small for gestational age( SGA): BWT<2SD from the mean of GA(<10 percentile)

Low birth weight (LBW): Low birth weight (LBW): Bwt <2500gm Bwt <2500gm Very low birth weight (VLBW): Very low birth weight (VLBW): Bwt<1500gm Bwt<1500gm Extremely-very-low-birth-weight (ELBW) : Extremely-very-low-birth-weight (ELBW) : Bwt < 1000 g Bwt < 1000 g

LBW could be both! - An infant of birth weight 1.8 kg born at 36 weeks is classified as preterm and LBW

Gestational age assessment LMP LMP Ultrasound Ultrasound Balllard score : Balllard score : -Physical and neuromuscular maturity -correlate the cumulative score with a gestational age (usually lies within 2weeks)

Large for gestational age (LGA) Bwt > 90% for their age Bwt > 90% for their age Causes: Causes:-Familial-IDDM-Others

LGA(IDM) :Complications -Prematurity - GIT -Birth injuries - Prenatal death -CNS - Congenital anomalies -Respiratory-CVS-Metabolic-Hematologic-Renal

Fetal growth has been divided into three phases. 1-cellular hyperplasia 2- hyperplasy & hypertrophy 3- hypertrophy  cell size.  fat deposition  fetal weight as much as 200 G.r. per week.

Normal Intrauterine Growth Pattern 95% of fetal weight gain occurs during the last 20 weeks of gestation 95% of fetal weight gain occurs during the last 20 weeks of gestation Late insult will affect weight the most Late insult will affect weight the most

Intrauterine Growth Retardation (IUGR) Is deviation from expected fetal growth pattern Is deviation from expected fetal growth pattern a fetus is unable to grow to its genetically determined potential size to a degree that may affect the health of the fetus.

A late pregnancy insult such as placental insufficiency would affect cell size. Asymmetrical

symmetrical An early insult due to : chemical viral aneuploidy  Cell size  Cell num. Proportionate reduction in head & body

Symmetric Vs Asymmetric IUGR Symmetric IUGR Symmetric IUGR Entire body is proportionally small. Asymmetric IUGR Asymmetric IUGR A fetus who is undernourished ( “Head sparing” effect)

IUGR vs SGA SGA : Bwt <2SD from the mean of GA (<10 %) A fetus that has failed to achieve a expected weight by a specific gestational age(Bwt <2SD from the mean of GA (<10 %)   IUGR: a fetus is unable to grow to its genetically determined potential size to a degree that may affect the health of the fetus.

IUGR vs SGA 50–70% of fetuses with a BWT <10% For GA are constitutionally small, and the lower the centile for defining SGA, the higher the likelihood of IUGR Not all fetuses who are SGA (<10th percentile) have IUGR, and not all fetuses who have IUGR are SGA.

Small for gestational age (SGA) Causes : Causes : Fetal Fetal Maternal Maternal Placental and Uterine Abnormalities Placental and Uterine Abnormalities impaired nutrient delivery impaired nutrient delivery

Fetal impaired fetal uptake impaired fetal uptake Genetics Genetics Congenital anomalies/ Infections Congenital anomalies/ Infections Multiple gestation Multiple gestation

Maternal Infection Infection Pre- eclampsia, Diabetes, Hypoxemia Pre- eclampsia, Diabetes, Hypoxemia Drug misuse / SMOKING Drug misuse / SMOKING Chronic medical illness Chronic medical illness impaired nutrient uptake impaired nutrient uptake

Uterine &Placental impaired nutrient delivery impaired nutrient delivery Short cervix,Incompetent cervix Short cervix,Incompetent cervix Placenta Previa,Abruptio Placentae Placenta Previa,Abruptio Placentae

Others Premature rupture of membrane Premature rupture of membrane Hydramnios Hydramnios Iatrogenic Iatrogenic Trauma/ Trauma/

Which is common? Vascular disease (HTN, DM, etc) 35% Vascular disease (HTN, DM, etc) 35% Chromosomal and congenital anomalies 10% Chromosomal and congenital anomalies 10% Normal variation 10% Normal variation 10% Congenital infections 5% Congenital infections 5% Drug misuse 5% Drug misuse 5% Placenta and cord defect 2% Placenta and cord defect 2% Uterine defects 1% Uterine defects 1% Others : Low socioeconomic status, unknown Others : Low socioeconomic status, unknown

Problems of SGA

SGA: associated problems Intrauterine death Intrauterine death Asphyxia Asphyxia Meconium aspiration Meconium aspiration Persistent pulmonary hypertension Persistent pulmonary hypertension Polycythemia/hypervi scosity Polycythemia/hypervi scosity Hypothermia Hypothermia Hypo-er glycemia Hypo-er glycemia Acute renal failure Acute renal failure Gastrointestinal perforation Gastrointestinal perforation Immunodeficiency Immunodeficiency Neonatal death(1%) Neonatal death(1%)

IUGR : long term problems! Depend on the causes &Type? Depend on the causes &Type? The asymmetrically GR is more likely to catch up after birth The asymmetrically GR is more likely to catch up after birth Impaired neurodevelopment, CP Impaired neurodevelopment, CP type 2 diabetes type 2 diabetes hypertension. hypertension.

Prematurity < 37W GA

Prematurity Incidence: 6-8 % all birth Incidence: 6-8 % all birth Causes: Causes: Idiopathic Idiopathic Maternal Maternal fetal fetal

Prematurity complications Affect every system ! Affect every system ! Short term Short term Long term Long term

Neurologic &Ophthalmologic Immature temperature regulation  hypothermia Immature temperature regulation  hypothermia Asphyxia Asphyxia IVH IVH PVL PVL CP and neurodevelopment delay CP and neurodevelopment delay ROP ROP

Respiratory and CVS RDS RDS Apnea of prematurity Apnea of prematurity BPD BPD pneumonia pneumonia Hypotension Hypotension PDA PDA

GIT and Nutrition Feeding difficulty Feeding difficulty NEC NEC

Renal and Metabolic Immature kidneys Immature kidneys Electrolyte dist. Electrolyte dist. Acidosis Acidosis Hypo-er glycemia Hypo-er glycemia Hypocalcemia Hypocalcemia Osteopenia of prematurity Osteopenia of prematurity

Hematologic &Immunology Anemia of prematurity Anemia of prematurity Jaundice Jaundice Infection Infection

Post maturity > 42 weeks GA > 42 weeks GA C/P C/P Complications: Complications: MAS and related complications MAS and related complications Hypoxic ischemic encephalopathy(HIE sequences) Hypoxic ischemic encephalopathy(HIE sequences) Metabolic Metabolic Polycythemia Polycythemia

We Talked about What is Normal gestation? What is Normal gestation? Newborn classification according to age and Weight. Newborn classification according to age and Weight. How to assess for Gestational age? How to assess for Gestational age? Causes of abnormal gestation Causes of abnormal gestation Complications of abnormal Gestation. Complications of abnormal Gestation. - LGA & SGA - LGA & SGA -Premature & Post mature -Premature & Post mature