Fetal growth restriction

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 Outline objective
At the end of course student be able
to Define IUGR
Describe about cause of IUGR
Clinical feature of IUGR
Dx of IUGR
Mgt of IUGR
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defn
- is the term used to designate a fetus
that has not reached its growth
potential because of genetic or
environmental factors.
- FGR results in the birth of an infant who
is small for gestational age (SGA).
- Mortality and morbidity are increased
in SGA infants compared to those who
are appropriate for gestational age (AGA
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Cause and risk factor

It may be caused by fetal, placental,
or maternal factors, with significant
overlap among these entities. This
term should not be used to describe
a constitutionally small, but
otherwise healthy fetus. Determining
the underlying cause of poor fetal
growth is not always possible, but is
important for estimating the
potential risk of recurrence
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FETAL FACTORS
Genetic factorsPopulationbased intergenerational studies of
birth weight have found that genetic
factors contribute 30 to 50 % of the
variation in birth weight, with the
remainder due to environmental
factors.
Maternal genes influence birth
weight more than paternal genes,
but both have an effect.
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 Genetic abnormalities associated with

FGR include
Aneuploidy (eg, trisomy 18 or 13, Turner
45 X, triploidy)
Partial deletions, duplications,
mutations
Ring chromosomes
Uniparental disomy (eg, for
chromosomes 6, 7, 14, or 16)
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 Congenital anomaliesMajor or
multiple congenital anomalies are
associated with failure to maintain
normal fetal growth, but account for
only 1 to 2% of all FGR in fetuses
without identifiable genetic defects .
The combination of structural and
chromosomal abnormalities and FGR,
however, is common.
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Multiple gestation
FG in multiple gestations has a direct
relationship to the number of fetuses present;
the type of placentation also plays a role
(monochorionic versus dichorionic). Growth is
similar to that of singletons until the third
trimester and then slows. The lower weight of
fetuses from multiple gestations is thought to
be due to an inability of the environment to
meet the nutritional needs of multiple fetuses,
as well as pregnancy complications more
common in multiple gestation
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Infection
Infections that develop early in pregnancy have
the greatest effect on subsequent growth, but
account for less than 5 % of all cases of FGR.
Viruses and parasites (e.g., rubella, toxoplasmosis,
cytomegalovirus, varicella-zoster, malaria, syphilis,
herpes) may gain access to the fetus
transplacentally or across the intact fetal
membranes and impair fetal growth by a variety of
mechanisms (eg, cell death, vascular insufficiency).
Although uncommon, CMV is the most frequent
viral etiology of FGR in developed countries

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PLACENTAL FACTORS
Many cases of FGR, particularly
recurrent cases, are the result of
ischemic placental disease.
This term refers to a disease process
of the placenta that clinically
manifests as preeclampsia, FGR,
abruption, or a combination of these
disorders
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Gross and histological

lesions
Any mismatch between fetal
nutritional or respiratory demands
and placental supply can result in
impaired fetal growth. The fetus may
be more sensitive to a reduction in
placental mass. placental weight is
24 % smaller in growth restricted
fetuses than in normally grown
fetuses when adjustments are made
for gestational age.
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MATERNAL FACTORS

Disorders resulting in reduced uteroplacental blood flow

Uteroplacental blood flow may be diminished by

faulty development, acquired obstruction, or

disruption of the uteroplacental vasculature.
Maternal medical disorders (eg, hypertension,
renal insufficiency, diabetes, collagen vascular
disease, systemic lupus erythematosus,
antiphospholipid syndrome) and obstetrical
complications (eg, preeclampsia) associated with
vasculopathyand/or reduced maternal blood
volume or blood pressure diminish uteroplacental
perfusion and result in FGR
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 Low prepregnancy weight and

poor weight gainMaternal
weight at birth, prepregnancy weight,
and weight gain during pregnancy
are generally responsible for about
10 % of the variance in fetal weight .
However, severe maternal starvation
during pregnancy can have a major
impact on fetal growth.
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 HypoxemiaChronic maternal hypoxemia

due to pulmonary disease, cyanotic heart
disease, or severe anemia is associated with
diminished fetal growth. As an example, a
study of 96 pregnancies in women with
cyanotic congenital heart disease reported
that the mean birth weight of full term infants
was only 2575 grams, which is significantly
lower than the mean birth weight of 3500
grams in the general population
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CLINICAL FEATURES

(SGA) infants appear thin with loose,

peeling skin and decreased skeletal
muscle mass and subcutaneous fat tissue.
The face has a typical shrunken or
"wizened" appearance, and the umbilical
cord often is thin . Meconium staining may
be present . In newborns with asymmetric
fetal growth restriction (FGR), the head
appears relatively large compared to the
size of the trunk and extremities.
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Gestational age
assessment
The physical criteria used to assess
gestational age are altered in SGA infants .
as eg decreased vernix production
associated with reductions in either estriol
synthesis or skin perfusion leads to increased
exposure of the skin to amniotic fluid.
This exposure results in increased
desquamation and enhanced wrinkling (and
more mature appearance) of the soles of the
feet
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Cont
. Other findings are diminished
breast bud formation, less mature
appearance of the female genitalia,
and reduced ear cartilage.
The neurologic assessment is reliable
in SGA infants without disorders
affecting the nervous system

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DX
Diagnosis of FGR is based upon
sonographic estimation of fetal
weight, CLINICAL ASSESSMENT,
Accurate assessment of
gestational age ,Symphysisfundal height measurement
,Estimated fetal weight
(EFW),Abdominal circumference
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OBSTETRICAL MANAGEMENT
Antepartum fetal assessmentto
identify FGR during ANC and plan for
premature birthb/c
INTRAPARTUM MANAGEMENT, Growth
restricted fetuses may exist in a state of
mild-to-moderate chronic oxygen and
substrate deprivation. Potential
consequences include antepartum or
intrapartum fetal heart rate abnormalities,
passage of meconium with risk of
aspiration, and neonatal polycythemia,
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impaired thermoregulation, hypoglycemia,

 perform continuous intrapartum fetal

monitoring to detect nonreassuring
fetal heart rate patterns suggestive
of progressive hypoxia during labor,
and provide immediate skilled
neonatal care

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MANAGEMENT OF SUBSEQUENT
PREGNANCIES
In subsequent pregnancies, we
address any potentially treatable
causes of FGR (eg, cessation of
smoking and alcohol intake,
chemoprophylaxis and mosquito
avoidance in areas where malaria is
prevalent,
balancedenergy/proteinsupplement
ation in women with significant
nutritional deficiencies
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 Rx under lying cause

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 THANK 4 UR ATTENTIONAND
ANSWER UR FINAL EXAM
PROPERLY!!!

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