Download presentation
Presentation is loading. Please wait.
1
Fetal growth disturbances LGA, IUGR & IUFD
Barbora Kubesova Departement of Gynaecology and Obstetrics
2
Extremes of Newborn Growth
3
IUGR / Macrosomia SGA / LGA Early diagnosis Management, termination of pregnancy Decrease of perinatal morbidity and mortality
4
Macrosomia Antenatal Description
Fetus that is at greater than the 90th percentile for gestational age Ultrasound criteria is notoriously imprecise Post-Partum Description General: birth weight 2-SD above the mean (97%) ACOG – (2000): Birth weight of 4500gm or more When defining macrosomia there are two types of descriptors:
5
Macrosomia Risk Factors (40%)
Maternal DM: only a small proportion of macrosomic infants (considerable increased head and shoulder size) Previous history of macrosomia Excessive maternal weight gain (30% chance if mother > 300lbs) Multiparity Male fetus Gestational age > 40 wks Ethnicity (most common in mothers of African origin, partly due to the higher incidence of diabetes) Maternal age < 17 yrs Risk factors are only noted in 40% of mothers that deliver a macrosomic infant.
6
Diagnosis of Macrosomia
Ultrasound diagnosis inaccurate Maternal size often a factor Fetal size alone will often make dx imprecise Frequently a post-partum diagnosis Fundal height (+3cm as a screen)
7
Intrapartum Complications
Increased risk of: Arrest of dilation or descent – necessitating cesarean delivery Shoulder dystocia: More Common in mothers with GDM Maternal concern for PP Hemorrhage from Uterine Atony and Cervical Laceration Signs: Maternal Risk Factors // Prolonged second stage // Turtle Sign // Failure to restitute H= call for help E= evaluate for episotomy L= Legs into McRoberts Manuver P= Suprapubic (not fundal pressure) watch direction E= extend the posterior arm R= rotate baby – woods screw Z= zanvanelli manuver
8
Macrosomia Management
Prophylactic labor induction not recommended Inaccuracies of diagnosis No decrease in rates of Shoulder Dystocia or C/S Elective cesarean can be considered if: Estimated weight ≥ 4000 g in diabetic woman
9
What is the definition of IUGR?
< 10th centile for age include normal fetuses at the lower ends of the growth curve + fetuses with IUGR This definition is not helpful clinically < 5th centile for age < 3rd centile for age the most appropriate definition but associated with adverse perinatal outcome
10
What is the deference between IUGR & SGA?
SGA < 10th centile for the population, which means it is at the lower end of the normal distribution ie. Constitutionally small but have reached their full growth potential IUGR Failure of the fetus to chieve the expected weight for a given gestation
11
What are the causes of IUGR?
Maternal medical conditions Chromosomal anomalies & aneuploidy Genetic & Structural anomalies Exposure to drugs & toxins placental disease Extremes of maternal age Low socioeconomic status Infections Multiple gestation
12
Which maternal medical conditions result in IUGR?
HPT PEE DM with vascular involvement SLE Anemia Sickle cell disease Antiphospholipid syndrome Renal disease Malnutrition Inflammatory bowel disease Intestinal parasites Cyanotic pulmonary disease
13
How does the placenta play a role in the development of IUGR?
Abnormalities in placental development & trophoblast invasion Idiopathic or due to maternal disease eg SLE, DM, HPT,PEE Chronic partial abruption Placental infarcts Placenta previa Chorioangioma Circumvallate placenta Placental mosaicism Twin to twin transfusion Syndrome
14
What infections result in IUGR?
5-10% of IUGR Congenital infections: CMV Rubella Herpes Vericella zoster Toxoplasmosis Malaria Listeriosis
15
Which drugs can result in IUGR?
Alcohol Cigarette smoking 3-4X Heroin & coccaine Methotrexate Anticonvulsants Warfarin Antihypertensives /ß-blockers Cyclosporin
16
What are the genetic disorders that can result in IUGR?
Features suspicious of trisomy 15% of IUGR Down’s syndrome T21 Trisomy 13,18 Turner syndrome Neural tube defects Achondroplasia Osteogenisis imperfecta Abdominal wall defects Duodenal atresia Renal agenesis/ Poter’s S Symmetric IUGR AFV/ Doppler N Structural abnormalities Maternal age Nuchal translucency Biochemical screening results
17
Why does multiple pregnancy result in IUGR?
Placental insufficiency /inadequate placental reserve to sustain N growth of > one fetus Twin to twin transfusion syndrome Anomalies with higher order gestations monozygotic twins
18
What are the types of IUGR?
1-Symmetric –20% Proportionate decrease in many organ weights including the brain Deprivation occurs early The fetus is more likely to have an endogenous defect that preclude N development U/S biometry All measurements BPD, FL, AC
19
Types of IUGR 2-Asymmetric IUGR—80% Relative sparing of the brain
Deprivation occurres in the later half of pregnancy The infant is more likely to be N but small in size due to intrauterine deprivation U/S biometry BPD, Fl N, AC
20
Why IUGR often associated with olighydramnios?
blood flow to the lungs pulmonary contribution to amniotic fluid volume blood flow to the kidneys GFR urine output It is present in 80-90% of IUGR fetuses
21
How to evaluate a case of IUGR?
1-History: Current preg LMP, preg test, quickening APH, abruptio placentae, & fetal movements Previous obstetric Hx particularly looking for IUGR,& adverse outcome Medical Hx: connective tissue diseases, thrombotic events & endocrine disorders Hx of recent viral illness Drug Hx Family Hx of congenital abnormalities & thrombophilias
22
EXAMINATION Symphysis fundal height in cm = gest age in wks after 24 wk Sensitivity 46-86% in detecting IUGR A difference of more than 2cm requires fetal assessment Oligohydramnious may be detected on palpation U/S Fetal biometry for dating then serial measurements Anomaly scan AF index Doppler umbilical artery resistance index, MCA Repeat tests every1-2 wks
23
Invasive fetal testing
Amniocentesis or placental biopsy/ fetal blood sampling for karyotyping if aneuploidy is suspected for viral studies if infections suspected Caries the risks of infection, PROM, Preterm labor Retrospective tests Maternal blood tests for CMV, Rubella, Toxo Metabolic disorders thrombophilia Placenta should be sent for HP Postmortem examination
24
The constitutionally small fetus
A fetus growing parallel to the lower centiles through out preg Anatomically N AFV N Doppler N Slim petite women
25
Complications of IUGR Maternal complications due to underlying disease risk of CS Fetal complications Stillbirth, hypoxia/acidosis, malformations Neonatal complications Hypoglycemia, hypocalcemia, Hypoxia & acidosis, hypothermia, meconium aspiration , Polycythemia, hyperbilirubinemia, sepsis, low APGAR score congenital malformations, apneic spells, intubation sudden infant death syndrome Long term complications Lower IQ, learning & behavior Problems, major neurological handicap seizures, cerebral Palsy, mental retardation, HPT Perinatal mortalility 1.5-2X
26
Treatment Stop smoking / alcohol Bed rest uterine blood flow for pt with asymmetric IUGR Low dose aspirin Weekly visits attention to : FM, SFH, maternal wt, BP, CTG, AFV U/S every 2-4 wks BPP Contraction stress test Delivery 38 wks or earlier if there is fetal compromise Glucocorticoids if planing delivery before 34 wks Close monitoring in labor/ continuous monitoring /scalp PH CS may be necessary
27
IUFD Definition: dead fetuses or newborns weighing > 500gm
Or > 20 wks gestation 4.5/ 1000 total births Diagnosis Absence of uterine growth Serial ß-hcg Loss of fetal movement Absence of fetal heart Disappearance of the signs & symptoms of pregnancy X-ray Spalding sign Robert’s sign U/S 100% accurate Dx
28
Maternal 5-10% Antiphospholipid antibody DM HPT Trauma Abnormal labor Sepsis Acidosis/ Hypoxia Uterine rupture Postterm pregnancy Drugs Thrombophilia Cyanotic heart disease Epilepsy Severe anemia Unexplained 25-35% Causes OF IUFD Fetal causes 25-40% Chromosomal anomalies Birth defects Non immune hydrops Infections Placental 25-35% Abruption Cord accidents Placental insufficiency Intrapartum asphyxia P Previa Twin to twin transfusion S Chrioamnionitis
29
A systematic approach to fetal death is valuable in
determining the etiology B-Maternal History I-Maternal medical conditions VTE/ PE DM HPT Thrombophilia SLE Autoimmune disease Severe Anemia Epilepsy Consanguinity Heart disease II-Past OB Hx Baby with congenital anomaly / hereditary condition IUGR Gestational HPT with adverse sequele Placental abruption IUFD Recurrent abortions 1-History A-Family history Recurrent abortions VTE/ PE Congenital anomalies Abnormal karyptype Hereditary conditions Developmental delay
30
1-History Maternal age Gestational age at fetal death HPT
Specific fetal conditions Nonimmune hydrops IUGR Infections Congenital anomalies Chromosomal abnormalities Complications of multiple gestation Current Pregnancy Hx Maternal age Gestational age at fetal death HPT DM/ Gestational D Smooking , alcohol, or drug abuse Abdominal trauma Cholestasis Placental abruption PROM or prelabor SROM Placental or cord complications Large or small placenta Hematoma Edema Large infarcts Abnormalities in structure , length or insertion of the umbilical cord Cord prolapse Cord knots Placental tumors
31
2-Evaluation of still born infants
Infant desciption Malformation Skin staining Degree of maceration Color-pale ,plethoric Umbilical cord Prolapse Entanglement-neck, arms, ,legs Hematoma or stricture Number of vessels Length Amniotic fluid Color-meconium, blood Volume Placenta Weight Staining Adherent clots Structural abnormality Velamentous insertion Edema/ hydropic changes Membranes Stained Thickening
32
3-Investigations Fetal inveswtigations Fetal autopsy Karyotype
(spcimen taken from cord blood, intracardiac blood, body fluid, skin, spleen, Placental wedge, or amniotic Fluid) Fetography Radiography Maternal investigations CBC Bl Gp & antibody screen HB A1 C Kleihauer Batke test Serological screening for Rubella CMV, Toxo, Sphylis, Herpes & Parovirus Karyotyping of both parents (RFL, Baby with malformation Hb electrophorersis Antiplatelet anbin tibodies Throbophilia screening (antithrombin Protein C & S , factor IV leiden, Factor II mutation, , lupus anticoagulant, anticardolipin antibodies) DIC Placental investigations Chorionocity of placenta in twins Cord thrombosis or knots Infarcts, thrombosis,abruption, Vascular malformations Signs of infection Bacterial culture for Ecoli, Listeria, gp B strpt.
33
IUFD complications Hypofibrinogenemia 4-5 wks after IUFD DIC
34
Psychological aspect & counseling
A traumetic event Post-partum depression Anxiety Psychotherapy Recurrence 0-8% depending on the cause of IUFD
Similar presentations
