Intrauterine Growth Restriction Obstetrics.pptx

IUGR OBG MBBS FINAL YEAR

1. INTRAUTERINE GROWTH RESTRICTION DIAGNOSIS AND MANAGEMENT 94

2. DIAGNOSIS CLINICAL : Clinical palpation of the uterus for fundal height liquor volume fetal mass Symphyseofundal height in cm closely relate with gestational age after 24 weeks. A lag of 3 cm or more suggest growth restriction. Maternal weight gain remains stationary or falls during second half of pregnancy Measurement of abdominal girth remains stationary or falls

3. BIOPHYSICAL – ULTRASOUND BIOMETRY Best method to diagnose growth restriction After the routine anomaly scan at 18-20 weeks,a follow up scan at 32-34weeks is suggested for growth restriction The important parameters BPD,HC,AC,FL,EFW Head circumference and abdominal circumference ratios : in asymmetric IUGR HC remains larger,HC /AC then elevated in symmetric IUGR,both AC andHC are reduced.HC/AC ratio remains normal

4. Femur length: not affected in asymmetric IUGR,FL/AC ratio greater than 23.5 suggests IUGR AMNIOTIC FLUID VOLUME: reduced volume is associated with asymmetric IUGR.AFI less than 5 or single deepest pocket<2cm indicates oligohydraminos.

5. ULTRASOUND DOPPLER PARAMETERS DOPPLER VELOCIMETRY :Elevated systolic/diastolic ratio, resistance index, pulsatility index indicates increased blood flow resistance and decrease in end diastolic velocity UMBILICAL ARTERY : used to detect growth restricted fetus at risk for hypoxia. In IUGR, there will be a reduced diastolic blood flow. there are three different patterns-reduced end diastolic flow,absent end diastolic flow ,reversal of flow UMBILICAL VENOUS PULSATIONS: Indicates inefficient cardiac output MIDDLE CEREBRAL ARTERY : Increased diastolic velocity is observed in compromised foetus due to cerebral vasodilation in response to hypoxemia DUCTUS VENOUS DOPPLER STUDY can predict fetal acidemia

6. GENERAL: Adequate bed rest; left lateral position correct malnutrition by balanced diet appropriate therapy for complicating factors that are likely to produce IUGR avoidance of smoking ,tobacco and alcohol maternal hyperoxygenation low dose aspirin in case with history of thrombotic disease, hypertension

7. Management Depends on the severity of Growth restriction and how early the problems begins in the pregnancy. Earlier the onset, more severe the IUGR and greater the risk to foetus.

8. ANTEPARTUM FETAL SURVEILLANCE Used when fetus is too immature to be delivered ultrasound examination should be done at interval of 3-4 weeks for assessment of BPD,HC/AC,AFI and fetal weight fetal well-being is assessed by kick count, non stress test, biophysical profile, amniotic fluid volume

9. TIMING OF DELIVERY A late delivery may lead to hypoxia and intrauterine death ,early intervention can cause prematurity at 36 weeks: delivery at 36 week is advocated Between 32 and 36 weeks : If there is reduced end diastolic flow,try to postpone delivery until 36 weeks ,provided other surveillance test are normal.surveillance test should done frequently.meanwhile steroid are given Before 32 weeks: only when good neonatal intensive care unit is available

10. CORTICOSTERIOD In all cases where gestation is less than 36 weeks,antenatal steroid are given as they significantly improve perinatal outcome

11. INTRAPARTUM MANAGEMENT Delivery should be in a unit with good neonatal care facility route of delivery will depend upon medical problem and state of cervix Caesarean section is indicated if there is absent or reverse flow in umbilical artery or an abnormal venous Doppler If the cervix is favourable ,artificial rupture of membranes and oxytocin is advisable If the cervix is unfavourable PGE2 gel can be used to ripen the cervix first Prolonged labour is best avoided

12. Neonatal care A person trained in neonatal resuscitation should be present Intensive care protocol : preterm babies are functionally immature and special care is needed Principles are taken in special care to maintain a relatively stable thermoneutral condition –keep delivery room warm, dry and then wrap the baby with warm towel,keep baby and mother skin to skin contact adequate humidification to counterbalance the waterloss oxygen therapy and adequate ventilation to prevent infection To maintain nutrition and adequate nursing care

13. THANK YOU