IUGR Presentation in Obgy BY DR RAHUL.pptx

It is a topic of importance in obgy

1. UNDER THE GUIDANCE OF RESPECTED DR. VEENA MADAM RESPECTED DR. USHA MADAM PRESENTED BY DR. RAHOOL ATHAWALE CASE PRESENTATION ON INTRAUTERINE GROWTH RESTRICTION

2. Purna , 21 years old patient,G2P1L0, educated till 12 th standard and had an active married life of 2 years, residing at Rajputo ka Vas, Jalore , housewife by occupation, and belonging to Lower Middle Class according to Modified Kuppusswamy scale, comes with 36weeks of amenorrhoea for her regular antenatal checkup

3. Patient Purna came to ANC OPD on 25/4/23 at 36 weeks of gestation for her regular antenatal checkup . Patient also gives history of decreased appetite, generalised weakness and giddiness. She weighed 60kg during her last ANC checkup on 20 th February 2023 at 28 weeks of Gestation and her present weight is 50kg. Patient gives history of chronic low platelet counts during entire period of pregnancy and had been given 4 units of platelet transfusion due to severe thrombocytopenia Present History Of The Patient:

4. No History of abdominal pain, leaking per vagina and bleeding per vagina. No History of cough with or without sputum, haemoptysis, night sweats, evening rise of temperature or shortness of breath. No History of fever, loose motions, vomiting, black stools, or any other form of bleeding tendencies. No history of headache, nausea, vomiting, epigastric pain, blurring of vision, double vision(diplopia), loss of vision, diminished urinary output and swelling of hands face or ankles. No History of increased frequency of micturition, difficulty in micturition, burning micturition, loin pain, vaginal discharge. No History of alcohol consumption, smoking, tobacco, or any other recreational drugs like cocaine, charas , ganja , amphetamine, etc.

5. Three months after her active married life, patient conceived for the first time and carried the pregnancy up until 8 months without any antenatal checkup and had spontaneous preterm vaginal delivery of a Male child at home. Baby was having difficulty in breathing and died before reaching hospital. Baby weight was 1.5kg. Four months after her first pregnancy, Patient conceived for the second time had four antenatal check ups with h/o low platelet count during entire 36 weeks of her pregnancy. Patient gives no history of any kind of abortions in the past Therefore she is G2P1L0.

6. FIRST TRIMESTER HISTORY : Patient’s pre-pregnancy weight was 50kg and height 160 cms . Her BMI was 19.5. AFTER 2 months of amenorrhoea, patient did a UPT Test and it came out to be positive. On her first antenatal checkup visits.. She was advice following investigations to be done and their findings is as follows CBC: WBC-6.3 HAEMGLOBIN-9.8 PLATELET-96,ooo

7. FIRST TRIMESTER HISTORY (Cont’d) Thyroid PROFILE : T3 LEVEL – 1.0 ng/ml (normal level 0.6 – 1.81) T4 LEVEL – 6 micrograms/dl (normal level 5.5 – 11.0) TSH LEVEL – 3.7 mIU /ml (normal level 0.4 – 4.2) ABO & RH ANTIGEN: Patient’s Blood Group: A Negative Patients Husbands BG: B Positive VIRAL MARKERS : HIV – Non-Reactive HBsAg – Non-Reactive HCV – Non-Reactive VDRL – Non-Reactive blood sugar level (RBS ): FBS LEVEL: 96mg/dl PPBS LEVEL: 11Omg/dl

8. FIRST TRIMESTER HISTORY (Cont’d) Urine routine AND MICROSCOPY: URINE SUGAR - NIL URINE ALBUMIN- NIL RBC’S IN URINE- NIL USG Findings: (DONE ON 12/10/2022 ) Single Live Intrauterine Pregnancy Corresponding to 10 weeks 4days of maturity. EXPECTED DATE OF DELIVERY (EDD) – 06/05/2023 First Trimester Aneuploidy screening was not done by the patient. (PAPP--A < 0.4; normal range 0.6 to 3.3ng/dl) Negative history: No history of excessive vomiting by the patient. No history of fever with or without rashes or any ulcers or swellings. No history of Breast discomfort, swelling or discharge through breast. No history of cough with or without sputum, haemoptysis, shortness of breath, loose motions or loss of any sense of smell. No history of increased frequency of micturition, difficulty in micturition or burning micturition, loin pain. No history of any vaginal discharge or bleeding per vagina. No history of any drug intake or exposure to radiations. No history of smoking, tobacco chewing or alcohol intake. No history of any Medical or Surgical Intervention or any Trauma in the First trimester of her Pregnancy.

9. FIRST TRIMESTER HISTORY (CONT’D): Patients vitals were Within Normal Limit Patient had been started on Folic Acid tablets OD/DAY and is taking it on regular basis. Patient’s bowel bladder habits are normal. Patient is taking adequate 8 hours of sleep and notices an increase in her appetite.

10. 2. Second trimester history: Patient started on Tab IRON+FOLIC ACID x 1 tab + Tab Calcium+ Vit D3 x 1 tab daily on start of her Second Trimester. Patient has taken 1 st Dose of Td AT 16 TH Week of Her Pregnancy. Patient felt Quickening for the first time around 16-18 weeks of her pregnancy (exact date not known). She has been perceiving the same from that day till now. Two antenatal checkups were done in total during her 2 nd trimester of her pregnancy. Her weight at the end of 6 months was 60kg. Patient’s Bowel and Bladder habits were normal, Sleep adequate and appetite increased.

11. 2. Second trimester history: (CONT’D) Negative history: No history of fever with or without any rashes, ulcers or any swellings or any itching over body. No history of headache, nausea, vomiting, epigastric pain, blurring of vision, double vision(diplopia), loss of vision, diminished urinary output and swelling of hands face or ankles. No history of Breast discomfort, swelling or discharge through breast. No history of cough with or without sputum, haemoptysis, shortness of breath, loose motions or loss of any sense of smell or any form of bleeding tendencies. No history of increased frequency of micturition, difficulty in micturition or burning micturition, loin pain. No history of any vaginal discharge or bleeding per vagina. No history of any drug intake or exposure to radiations. No history of smoking, tobacco chewing or alcohol intake. No history of any Medical or Surgical Intervention or any Trauma in the SECOND TRIMESTER of her Pregnancy.

12. Second trimester history: ( Cont’D ) Investigations done in second trimester of purna’s pregnancy: CBC: WBC-------> 8.9 HB ----------> 9.0 PLATLETS- 60,000 Blood sugar level: FASTING BLOOD SUGAR LEVEL(FBS): 80mg/dl POST-PRANDIAL BLOOD SUGAR LEVEL:106mg/dl

13. 2. Second trimester history: ( Cont’D ) Investigations done in second trimester of purna’s pregnancy: Viral markers: HIV/HBsAg/HCV/VDRL: NON-REACTIVE Indirect coomb’s test: DONE AT 12 WEEKS, 20 WEEKS: Negative Urine routine and microscopy: URINE SUGAR - NIL URINE ALBUMIN- NIL RBC’S IN URINE- NIL Ultrasonography: USG s/o SINGLE LIVE INTRAUTRINE PREGNANCY WITH LONGITUDINAL LIE AND CHANGING PRESENTATION OF 24 WEEKS and 6days. Despite of repeated advice, Fetal Anomaly Scan not done by patient.

14. 2. Second trimester history: ( Cont’D ) Patient on repeated weekly CBC test was found to have Chronic TCP with platelet count falling to 28000/ mcL . Patient was given 4 units of Platelet Transfusion and was than advised for PBF Screening and Haematologist Reference, both of which were not done by the patient. 3. Third trimester history: Patient also gives history of decreased appetite, generalised weakness and giddiness. She weighed 60kg during her last ANC checkup 28 th week of gestation on 20 th February 2023 and her present weight is 50kg at 36 week of gestation Fetal movement can be felt at regularly at 10 to 12 kicks/12hrs period. Two Antenatal checkup done by patient at 28 weeks and now at 36 weeks by the patient in third trimester of pregnancy. INJECTION ANTI-D 300mcg i.m. given to the patient at 28 weeks of her pregnancy.

15. 3. Third trimester history: Negative history: No History of abdominal pain, leaking per vagina and bleeding per vagina. No History of cough with or without sputum, haemoptysis, night sweats, evening rise of temperature or shortness of breath. No History of fever, loose motions, vomiting, black stools, or any other form of bleeding tendencies. No history of headache, nausea, vomiting, epigastric pain, blurring of vision, double vision(diplopia), loss of vision, diminished urinary output and swelling of hands face or ankles. No History of increased frequency of micturition, difficulty in micturition, burning micturition, loin pain, vaginal discharge. No History of alcohol consumption, smoking, tobacco, or any other recreational drugs Patients vitals were Within Normal Limit: Pulse: 96/min BP: 130/80mmHg Sp02: 99% on Room AIR. Pallor: Present Icterus: Absent Pedal Oedema: Absent

16. 3. Third trimester history: Investigations done in third trimester of purna’s pregnancy: CBC: WBC------->: 11.0 HB ---------->: 7.8 PLATLETS- 74,000 Blood sugar level: FASTING BLOOD SUGAR LEVEL(FBS): 80 mg/dl POST-PRANDIAL BLOOD SUGAR LEVEL:100 mg/dl Lft : TOTAL BILIRUBIN: 1.0 DIRECT BILIRUBIN: 0.3 SGOT-------------------->: 42 SGPT-------------------->: 37

17. 3. third trimester history: ( Cont’D ) Investigations done in third trimester of purna’s pregnancy: Renal function test( rft ) Serum Urea: 24 Serum Creatinine: 1 .0 Viral markers: HIV/HBsAg/HCV/VDRL: NON-REACTIVE Urine routine and microscopy: Urine sugar - nil Urine albumin- nil RBC’s in Urine- nil

18. 3. third trimester history: ( Cont’D ) Ultrasonography: USG s/o Single Live Intrauterine Pregnancy With Longitudinal Lie And Cephalic Presentation and of 36 weeks and 1 day maturity. Intrauterine Fetal Growth Restriction (AC LAG: 3 to 4 weeks) Moderate Oligohydramnios (AFI – 3.58cm) Placenta:Fundo-Body Posterior; grade 2 EFW: 1924grams FHS: 142 bpm Color Doppler shows Mild UteroPlacental Insufficiency : UMBLICAL ARTERY PI: 1.31 MCA PI: 0.91(low) CEREBROPLACENTAL RATIO: 0.69(low)

19. Pt attained menarche at 14yrs of age PAST MENSTRUAL CYCLES: Patient’s past menstrual cycles were regular, coming every 28 days, every month. Bleeding was normal, lasting for 4 days with pain sometimes. Last normal menstrual period( lmp ): 29/07/2022 EXPECTED DATE OF DELIVERY ( edd ): 06/05/2023

20. Patient had used Condoms as a barrier method, but with irregular use and conceived in her first pregnancy. After her first pregnancy culminating into DEATH of her newborn , she did not use any other form of contraceptives intentionally and conceived immediately after 4 months of her first pregnancy .

21. PAST MEDICAL HISTORY: No history of TB, DM, Hypertension, Bronchial Asthma, any Heart Diseases or any history of any long term medications. Past surgical history: No history of any major or minor gynaecological or other operations/procedures in past. FAMILY HISTORY: No history of Hypertension, Diabetes Mellitus, Tuberculosis, Heart Diseases in patients close family relatives. PERSONAL HISTORY: Patient has had normal bowel movements during her entire course of pregnancy. No h/o tobacco, smoking, alcohol or any form of recreational drugs such Coccaine , Charas , Ganja , etc. DIETARY HISTORY: Patient comes from the family of people having both vegetarian and non-vegetarian meal, but Patient follows a strict vegetarian diet.

22. TIME MEAL TYPE MEAL CONTENT PROTEIN (GRAMS) FAT (GRAMS) CARBOHYDRATES(GRAMS) CALORIES (KCAL) TOTAL PER MEAL CALORIE INTAKE 8:00 AM BEFORE BREAKFAST TEA (1 CUP) 200 ML ---- ---- ---- 70 KCAL 70 KCAL 9:30 AM BREAKFAST MILK ( 1 GLASS/300ML) 1 X CHAPATI 8 gm 3 gm 8 Gm 0.5 gm 11 gm 11 gm 60 KCAL 150 KCAL 210 KCAL

23. 01:00 PM LUNCH 2 X CHAPATI 2. VEG SABJI (200 GRAMS) 6 gm 6 – 8 gm 1 gm 10 – 20 gm 22 GRAMS 30 – 60 GRAMS 300 KCAL 200 – 300 KCAL 500 – 600 KCAL TIME MEAL TYPE MEAL CONTENT PROTEIN (GRAMS) FAT (GRAMS) CARBOHYDRATES(GRAMS) CALORIES (KCAL) TOTAL PER MEAL CALORIE INTAKE

24. 5:pm evening snack tea ( 1 cup/200ml) 70 kcal 8 pm dinner 2 x chapati veg sabji (200 grams) 6 gm 6 – 8 gm 1 gm 10 – 20 gm 22 gm 30 – 60 gm 300 kcal 200 – 300 kcal 5 00 – 600 kcal 10pm pre bed time snack curd (100 grams) 11 gm 4.3 gm 3.4 grams 108 kcal 108 kcal TIME MEAL TYPE MEAL CONTENT PROTEIN (GRAMS) FAT (GRAMS) CARBOHYDRATES(GRAMS) CALORIES (KCAL) TOTAL/ MEAL CALORIE INTAKE

25. TOTAL 6 MEALS 5 ITEMS IN TOTAL MEAL 46 – 50 gmOF PROTEINS/ DAY 34.3 – 54.3 gm OF FATS/DAY 123.4 – 183.4 GRAMS OF CARBOHYDRATE/ DAY 1458 – 1658 KCAL/ DAY. T0TAL MEAL TYPE MEAL CONTENT PROTEIN (GRAMS) FAT (GRAMS) CARBOHYDRATES(GRAMS) CALORIES (KCAL) TOTAL PER MEAL CALORIE INTAKE

26. DIETARY HISTORY (CONT’D) The average calorie intake by Patient is 1458 to 1658 kcal/day. The average protein intake by patient is 46 to 50 grams of protein/day. Patient had almost same diet during her entire 36 weeks duration of pregnancy. The average daily caloric requirement in pregnancy is 2300--2500 kcal/day. The average protein requirement is 1.5 g/kg/day. The average protein requirement of patient Purna whose pre- pregnancy weight was 50 kg is 75 grams/day. Thus patient Purna diet has a calorie deficit of 600 to 800 kcal and protein deficit of 25 grams/day. SOCIO-ECONOMIC HISTORY: Patient lives in a 2BHK house with her husband and Inlaws , 4 member in total. Education: HSC; Score:5 Occupation: Skilled Worker; Score:4 Per Capita Income: 8200; Score: 6 Total Score: 15; Therefore Patient belongs to lower middle class according to Modified Kuppuswamy Scale.

27. GENERAL CONDITION : Fair, pt concious , average built and co-operative. Pulse: 96/minute Blood pressure: 130/80 mmHg Spo2 99% on Room Air Pallor: Present Icterus: absent Cyanosis: absent Pedal oedema: absent

28. Bmi : HEIGHT:160cm WEIGHT: 50kgs CURRENT BMI: 19.5 Tongue: T here is no Glossitis, Chelitis , Angular Stomatitis. Neck: There is no significant thyroid swelling, JVP is normal. There is no significant Lymphadenopathy. Nails: Nails do not show pallor, cyanosis,clubbing , platynychia , koilonychyia .

29. Breast examination: Breast development is normal Nipple and Areola: normal. Nipple has no cracks, fissures or retracted or any abnormal Nipple Discharge. No abnormal lump palpable in breast. RESPIRATORY SYSTEM EXAMINATION: Normal Vesicular Breath Sounds heard over all LUNG FIELDS No Abnormal Breath Sounds such as wheeze, Rhonchi or crepts heard . CARDIOVASCULAR SYSTEM EXAMINATION: Normal Heart Sounds Heard: S1S2 Present, Normal. No Abnormal Heart sound Heard: No Murmur Heard CENTRAL NERVOUS SYSTEM EXAMINATION: Pt is concious , oriented to time, place and person.

30. OBSTRETICS EXAMINATION: INSPECTION: Uterus appears as globular swelling arising from the Pelvis and midline in position. Umblicus is vertically stretched. Linea Nigra and Stria Gravidarum present. Flanks are not full. Skin condition is healthy. No scars over abdomen. No visible pulsation or venous prominence. Hernial Orifices were normal. Palpation: Patient examined in supine position with legs being semiflexed . Uterus is 36 weeks in size, soft relaxed and non tender.

31. Palpation: Symphysio -Fundal Height: 32cms Abdominal circumference(girth): 70cms Gestational Age according to McDonalds rule: 32x8/7= 36 weeks Fetal movements: Felt Fundal Height: corresponds to 32 weeks. OBSTRETICS GRIPS : Palpation is done with the Palmar Surface of the hand & not only with the fingertips. FIRST LEOPALD/ Fundal grip: Soft, Broad, Irregular and Non-Ballotable mass felt which corresponds to fetal buttock.

32. OBSTRETICS GRIPS : Second leopald / Lateral grip: Right Lateral Grip: Smooth, Curved, Firm , and resistant surface felt on the right side s/o Back of the Fetus Left Lateral Grip: Irregular Knob like structures felt which slip under fingers on deep palpation& correspond to Fetal limbs. Third leopald / pawlik’s grip/ first pelvic grip: A hard, Globular, smooth ballotable mass felt: corresponding to Fetal Head and is floating. Fourth leopald / DEEP PELVIC GRIP/ SECOND PELVIC GRIP: Findings of the Pawlik’s Grip are confirmed. Hands tend to converge below the presenting part indicating that the head is floating.

33. OBSTRETICS GRIPS : Fourth leopald / DEEP PELVIC GRIP/ SECOND PELVIC GRIP: CRICHTON’S RULE OF FIFTHS OR NOTELVITCH RULE: 4/5 th finger breaths of head is palpable above the pubic symphysis per abdominally suggestive of head being not engaged. The Cephalic prominence is on opposite side of the back indicating head is well flexed and the presenting part is vertex Uterus is full of fetus which is s/o Oligohydramnios.

34. AUSCULTATION OF THE ABDOMEN: FHS auscultated via stethoscope in the right spinoumblical line’s midpoint. Rate:142bpm Rhythm: Regular. Per vaginal examination: OS Opened; 1 cm dilated Cervix Not Taken Up. Pelvis seems Adequate DIFFERENTIAL DIAGNOSIS: Wrong Calculation of LMP Small for Gestational Age Intra Uterine Growth Restriction DIAGNOSIS: My Diagnosis is Patient Purna , 21 years old G2P1L0 comes with 36 weeks size uterus, with Single Live Intrauterine Fetus in Cephalic Presentation, with INTRAUTERINE GROWTH RESTRICTION AND OLIGOHYDRAMNIOS.

35. goal: HEALTHY MOTHER and HEALTHY BABY. PROBABLE CAUSE OF IUGR : Inadequate diet with calorie intake way below Normal Daily Calorie Requirement. It can also stem out from Low Socio-Economy status. As patient belongs to lower middle class. Moderate Oligohydramnios. ?Chronic Thrombocytopenia. Patient needs further evaluation i /v/o ?ITP or other Chronic TCP causing Disorder. Anaemia. TREATMENT OF CAUSE OF IUGR: DIET: To improve and recalculate meal plan of the patient and monitor diet intake.

36. TREATMENT OF CAUSE OF IUGR: b) Oligohydramnios: Injection Aminoacid 200ml iv x 3 doses given on alternate days. IVF RINGER LACTATE 1000ml iv 12hourly x 6 days given to the patient. c) ANAEMIA & TCP: FRESH BLOOD TRANSFUSION given to the patient due to lack of availability of Platelets at the hospital and patients refusal to go to higher center for further Management. Patients Platelet count increased to 87000 and HB to 9.6. GENERAL MANAGEMENT: Adequate Bed Rest in Left Lateral Position. Maternal Hyperoxygenation @ 2.5 litre/min. Daily fetal movement monitoring was done: >=12 every 12 hours.

37. DELIVERY OF THE BABY: Decision of Early Delivery has to be balanced with the risk of neonatal death. Delay in delivery increases the risk of IUFD. On day 2 nd of admission, patients NST WAS NON- REACTIVE and decision for Emergency LSCS with patient and her relatives consent was taken. Therefore after all investigations were within Normal Limit, Patient went under Emergency LSCS and a 2.1kg Male child delivered at 27/4/23 at 9:10am. Baby cried immediately after birth; Apgar score of 9/10 and Baby was initially sent to SNCU for observation but than shifted back to mother. Babies Blood sent for ABO &Rh Ag testing and was found to be B Positive Mother given Inj. Anti D 300 mcg im stat 2 hours after delivery . POST DELIVERY TREATMENT: W/F BPV and TPR and BP Monitoring NBM till bowel sounds are heard S/R Catheter x 2days I/O Charting

38. INJ. CEFTRIAXONE 1g iv BD X 7days INJ. AMIKACIN 500 iv BD x 7 days INJ. METRO 100 iv BD x 2 days INJ. Rantac 1 amp iv TDS X 2 days INJ. MCP 1 amp iv TDS X 2 days INJ. Diclofenac 1 amp im SOS Pain. Tab Paracetamol 500 TDS X 5 days 3 rd day onwards Tab B Complex BD X 5 days Tab Vit C TDS X 5 days IVF 1000ML RL + 1500ML GDW given over 24 hours x 2 days. Patients plain dressing done on Day 3.Stitch removal done on Day 6(ASR) and Day 7(CSR) post LSCS.

39. DISCHARGE SUMMARY: Patien t discharged after completing 7 day stay post LSCS delivery. Mother and Baby Healthy.

40. DEFINITION: Fetal growth restriction (a/k/a IUGR) is said to be present in those babies whose birth weight is below 10 th percentiles of the average for the gestational age. FGR can occur in preterm, term or post term babies Disparity of >=2 weeks: Mild IUGR Disparity of >=4 weeks: Severe IUGR INCIDENCE: IUGR comprises of about 1/3 rd of LBW babies. Overall incidence in developed countries: 2– 8% Term Babies: 5% Post Term Babies: 15% Fgr vs sga : FGR needs to be differentiated from SGA as SGA fetuses constitute 70% babies with birth weight <10 th percentile. SGA fetuses fulfil growth potential and are not growth restricted.

41. nomenclature FGR VS SGA: SGA fetuses are constitutionally small but anatomically normal. They have Normal Ponderal Index and Normal Subcutaneous Fat no increased obstetrics or neonatal risk and their growth is parallel to the lower centiles throughout the pregnancy. These babies are small and healthy and small due to constitutional reasons such as small Mother and Small Babies The relationship between birth weight and perinatal mortality and morbidity in SGA FETUSES. A progressive increase in both mortality and morbidity is observed as birth weight percentile falls.

42. FGR VS SGA IUGR : Early onset of pathological cessation of growth may produce a baby with typical feature of IUGR. Weight of the fetus is less than 10 th percentile of weight appropriate for that gestational age & < 10 th percentile. They have an increased risk of perinatal mortality & morbidity. First change seen in IUGR babies: Decrease in abdominal circumference of the fetus . Manifestation of IUGR is due the problems in maternal, fetal or placental component.

43. NORMAL FETAL GROWTH: Upto 1 st 16 weeks: Cellular hyperplasia 16 weeks to 32weeks: Hyperplasia + Hypertrophy More than 32 weeks: Hypertrophy ALSO, UPTO 14 – 15 Weeks: 5g/day UPTO 20 Weeks: 10g/day 32-34 weeks: 30—35g/day most of the fetal weight gain (2/3 rd ) occurs beyond 24 th week of pregnancy. FACTORS INFLUENCING FETAL GROWTH: Growth of the Parents. Hormone responsible for growth of fetus in intrauterine life : Insulin Like Growth Factor (IGF) Availability of the substrate: (Glucose, etc) MATERNAL PIH: Pressure(P): Increases. P is indirectly proportional to Volume(V) Volume of substrate delivered to the fetus decreases leading to IUGR. Smoking: Does not affect Maternal weight gain. BUT, Smoking leads to Vasoconstriction > Decrease volume > Decrease Substrate > IUGR.

44. Iugr : classification: Classified into two groups EARLY ONSET (SYMMETRICAL) (20%) LATE ONSET (ASYMMETRICAL) Abd(80%) UNIFORMLY SMALL Head larger than Abdomen P onderal Index: Estimated Fetal Weight (Crown heel length)3 Ponderal index: Normal Ponderal Index: Low HC/AC ratio: Normal FL/AC ratio: Normal HC/AC ratio: Normal FL/AC ratio: Normal Etiology : Genetic disease or infection (Intrinsic to fetus ) Early onset of severe hypertension Chronic Placental Insufficiency PIH Chronic Renal Disese

45. Iugr : classification Classified into two groups EARLY ONSET (SYMMETRICAL) (20%) LATE ONSET (ASYMMETRICAL) Abd(80%) All USG Parameters are affected. Abdominal Circumference: decreased Head Circumference: decreased Biparietal Diameter: decreased Femur Length: decreased Weight: decreased USG Parameters are affected in later Pregnancy: Blood from peripheral organs sent to brain in later stage of pregnancy k/a Brain Sparing Effect. First Organ Affected: Abdomen. Abdominal Circumference: Decreased. Weight: Decreased Head Circumference: Normal Biparietal Diameter: Normal Femur Length: Normal Crown Rump Length: normal Total Cell No- Less Cell Size------- Normal Total Cell No: Normal Cell Size------ Smaller Neonatal Course: Complicated with Poor Prognosis. Neonatal Course: Usually uncomplicated & having Good Prognosis.

46. CAUSES OF IUGR : MATERNAL CAUSES FETAL CAUSES PLACENTAL CAUSES UNKNOWN MATERNAL CAUSES: Constitutional Causes Maternal Nutrition Maternal Diseases Toxins: Constitutional Causes: These causes are usually associated with small babies. These babies are not at an increased risk of FGR. Small women Slim, Low BMI Maternal Genetic and Racial Background

47. CAUSES OF IUGR: MATERNAL CAUSES: Maternal Nutrition: Two important factors determining fetal birth weight: Pre pregnancy maternal weight Weight gain during Pregnancy Depends upon availability of critical nutrients such as Glucose, Amino acids, fat to mother and thus to fetus . Non- availability hinders fetal development leading to FGR. Maternal DISEASES: Anaemia Hypertension: PIH Thrombotic diseases Heart diseases (NYHA CLASS 3 & 4) Chronic Renal Diseases Collagen Vascular Diseases Diabetes with Vasculopathy Diabetes with PIH

48. MATERNAL CAUSES: Maternal Exposure to TOXINS: Alcohol Smoking Tobacco Cocaine Heroin Drugs FETAL CAUSES: Substrate in Maternal Blood > Cross the Placenta> Utilized by fetus for growth. Failure of Non-Utilization of substrate by fetus may be due to following causes: Structural Anomaly Chromosomal Abnormality Infections Multiple Pregnancies Chronic Hypoxia

49. FETAL CAUSES OF IUGR : Structural Anomaly : CVS RENAL Chromosomal Abnormality : seen in 8-12% of Growth retarded fetuses . Aneuploidy Triploidy Trisomies (13, 18, 21) Turners Syndrome Infections TORCH Agents: Toxoplasmosis, Rubella, Cytomegalo Virus, Herpes Simplex Virus Malaria Multiple Pregnancies: There is mechanical hindrance to growth and excessive fetal demand.

50. placenTAL CAUSES OF IUGR: Placental Insufficiency : Due to poor Uterine blood flow to the placental site for a long time Abnormal Placentation: Placenta Previa Placental Abruption Circumvallate Placenta 3) Placental Calcification Pathophysiology of IUGR: Reduced availability of nutrients in mothers Reduced Transfer by Placenta to fetus . Reduced Utilisation by fetus . Brain cell size as well as cell numbers are reduced. Liver Glycogen content is also reduced. Since Blood flow to renal and pulmonary organs is reduced, their contribution to Amniotic Fluid decreases leading to OLIGOHYDRAMNIOS. THUS, due to above causes SGA fetus is at the risk of Intrauterine hypoxia and Acidosis which if severe can lead to IUFD .

51. DIAGNOSIS OF IUGR: Done on basis of Clinical Assessments and Biophysical Methods. Clinical Assessment: To Identify mother at risk: PIH Chronic renal disease Infections Palpation of the Uterus: Can be used for screening but less sensitive. Done for Fundal Height Liquor Volume Fetal Mass Symphysis fundal height(SFH): (measured in cms ) It closely correlates with GA after 24 weeks Lag of 3cm or more s/o Growth Restriction Fairly Sensitive Parameter (30 to 80%) but Serial Measurement is important Maternal Weight Gain: Stationary weight of the patient or at times falling during 2 nd half`of pregnancy can be s/o IUGR Measurement of Abdominal Girth: Stationary or falling values s/o IUGR

52. Biophysical Profile: USG helps to identify FGR and weather it is Symmetrical IUGR or Asymmetrical IUGR. Determine the Gestational age of the Fetus : Overall the best time to measure Gestational Age via USG is FIRST TRIMESTER . Best Parameterto do so: CROWN RUMP LENGTH Other USG Parameters to Assess Fetal Growth : Head Circumference Ratio Abdominal Circumference Femur Length Amniotic Fluid Index Anatomical Survey TRIMESTER USG PARAMETER First Trimester ( Upto 14 weeks) Crown Rump Length b) Second Trimester Biparietal Diameter c) Third Trimester Femur Length

53. USG Parameters to Assess Fetal Growth : (Cont’d) [Head Circumference ] Ratio : [ Abdominal Circumference] 85% of IUGR fetuses are detected by using HC/AC Ratio AC is the single most sensitive parameter. To detect FGR. However Serial measurements of AC and Estimation of Fetal Weight is more diagnostic of IUGR. Femur Length : Femur length/ Abdominal Circumference Ratio: 22 (when measured from 21 weeks to term) FL/AC > 23.5; s/o IUGR FEMUR LENGTH is not affected in ASYMMETRIC IUGR. IN NORMAL FETUS IN ASYMMETRIC IUGR IN SYMMETRIC IUGR As Pregnancy advances; AC: INCREASES. THUS HC/ACDECREASES. Before 32 Weeks : > 1.0 32 – 34 Weeks : Approx 1.0 More than 34 Weeks : < 1.0 HC is Larger . Thus, HC/AC : Elevated HC/AC : Normal

54. USG Parameters to Assess Fetal Growth : (Cont’d) c) AMNIOTIC FLUID INDEX: Single Deepest Vertical Pocket of Amniotic Fluid < 1cm s/o IUGR IN 96% of fetuses . Four Quadrant Technique : Measuring of vertical diameter of the largest pocket of fluid in each of the four quadrant of the uterus f/b Sum of the result gives the AFI of the patient. d) Anatomical Survey: Done to exclude any Fetal Anomalies. ULTRASOUND DOPPLER PARAMETERS: ELevated Systolic/diastolic ratio : UTERINE ARTERY: UMBLICAL ARTERY: UMBLICAL ARTERY DOPPLER STUDY: UMBLICAL VENOUS PULSATION: MIDDLE CEREBRAL ARTERY: DOPPLER Cerebro PLACENTAL RATIO: DUCTUS VENOSUS DOPPLER STUDY:

55. DOPPLER PARAMETERS: (Cont’d) Doppler velocimetry: Elevated Systolic/Diastolic Ratio(S/D), Pulsatility Index(PI) and Resistance Index(RI) s/o increased blood flow resistance and decrease in END Diastolic Velocity They are associated with FGR and Intra-uterine Fetal Hypoxia B) UTERINE ARTERY: Normally; Diastolic flow increases as the pregnancy progresses. The Presence of Diastolic Notch is s/o incomplete invasion of the Placental trophoblast into spiral arteries. This Also Predicts Possible Development Of Pre Eclampsia. c) Umblical artery: Decreased End Diastolic velocity of Umblical artery is s/o Increased placental vascular resistance. There is progressive decrease in the Umblical artery end diastolic velocity s/o REDUCED fetomaternal Oxygen and nutrient exchange.

56. DOPPLER PARAMETERS: (Cont’d) D ) UMBLICAL ARTERY DOPPLER STUDY: It should be the primary Survelliance tool in THE FGR FETUS(RCOG) UA Doppler study can predict Moderate Acidosis and recommends delivery when there is presence of AREDV. (Absent or Reversed End-Diastolic Velocity) Reduced or Absent or Reversed End Diastolic Velocity (AREDV) presence indicates fetal jeopardy and poor perinatal outcome .

57. DOPPLER PARAMETERS: (Cont’d) E) Umblical venous pulsation: It is s/o inefficient Cardiac Output with rise in Central Venous Pressure and hence indicating Impending Cardiac Failure. F) MIDDLE CEREBRAL ARTERY: Increased Diastolic Velocity (BRAIN SPARING EFFECT) is observed in FGR. This is due to Cerebral Vasodilation in response to Hypoxaemia. Abnormal MCA PI, suggest Fetal compromise

58. DOPPLER PARAMETERS: (Cont’d) G) DOPPLER Cerebro PLACENTAL RATIO: ( cpr ) It is calculated as MCA PI . UA PI In IUGR: Fetal Brain Vascular Resistance (MCA PI) Decreases. = Decreased CPR Index Placental Resistance (UA PI) Increases CPR is more sensitive compared to UA Doppler or MCA Doppler alone. H) DUCTUS VENOSUS DOPPLER STUDY: It is used when Umblical Artery Doppler Study is Abnormal and also to decide time of delivery. It can predict Fetal Acidemia (since Oxygenated Blood flow to Doppler Vein decreased l/t Decreased Blood in IVC + ACCUMULATION OF FETAL METABOLITE l/t to Fetal Acidosis.)

59. DOPPLER PARAMETERS: (Cont’d) H) DUCTUS VENOSUS DOPPLER STUDY: AA

60. DOPPLER PARAMETERS: (Cont’d) H) DUCTUS VENOSUS DOPPLER STUDY A

61. DOPPLER PARAMETERS: (Cont’d) PONDERAL INDEX: (PI) The degree of Fetal wasting is judged by fetal PI. P onderal Index: Estimated Fetal Weight (grams) x 100 (Crown heel length)3 (cm3) PI below 10 th percentile is taken as IUGR. It is highly accurate. Estimation of PI by fetal sonography has been made. Reduction in Fetal Facial Fat stores has been associated with FGR. BIOCHEMICAL MARKERS: A low level of PAPP-A in maternal serum in the first Trimester is major risk factor for IUGR.

62. PREDICTIVE FACTORS FOR IUGR: Presence of High Risk Medical or Obstretics Factors. A low level of 1 st Trimester PAPP-1 value. Abnormal Uterine artery Doppler value (notching) at 20-24 weeks of Pregnancy. Fetal Echogenic Bowel on USG.

63. PHYSICAL FEATURES OF AN INFANT WITH IUGR: Weight deficit at birth is about 600 grams below the minimum in centile standard. Every hospital should have its own birth weight-gestational age chart. Length is unaffected. HC is relatively more than body in asymmetric IUGR. PHYSICAL FEATURES: Skin: dry and wrinkled. (d/t less subcutaneous fat) Scaphoid Abdomen. Thin Meconium stained vernix Caseosa and thin umblical cord. This gives the baby an Old man look. Pinna of the ear has cartilaginous ridges Plantar creases are well defined. The baby is alert, active and has normal cry. Eyes are open. Reflexes are normal, including Moro-Reflex.

64. COMPLICATIONS OF IUGR: FETAL COMPLICATIONS: Antenatal complications Intranatal complications Complications after Birth . IMMEDIATE FETAL COMPLICATIONS LATE FETAL COMPLICATIONS LONG TERM COMPLICATIONS MATERNAL COMPLICATIONS: FETAL COMPLICATIONS: Antenatal complications: Chronic Fetal Distress. Fetal Death.

65. COMPLICATIONS OF IUGR: FETAL COMPLICATIONS: Intranatal complications: Hypoxia Fetal acidosis COMPLICATIONS AFTER BIRTH: They are due to underlying diseases like Pre- Eclampsa , Heart Disease, Malnutrition. IMMEDIATE COMPLICATIONS AFTER BIRTH BRAIN RESPIRATORY SYSTEM LIVER INTESTINE KIDNEY BLOOD TEMPERATURE

66. COMPLICATIONS OF IUGR: FETAL COMPLICATIONS IMMEDIATE COMPLICATIONS AFTER BIRTH BRAIN : Intraventricular Haemorrhage. RESPIRATORY SYSTEM : Asphyxia Broncho Pulmonary Dysplasia Respiratory Distress Syndrome Pulmonary Haemorrhage Meconium Aspiration Syndrome LIVER: Hypoglycaemia due to shortage of Glycogen reserve in the liver Intestine: Necrotizing Enterocolitis (d/t decreased Intestinal Blood flow)

67. COMPLICATIONS OF IUGR: FETAL COMPLICATIONS IMMEDIATE COMPLICATIONS AFTER BIRTH: Kidney: Urinary excretion of Na, K, Ca due to impaired renal function. Haematological Problems : Micro-coagulation disorder l/t DIC Polycythaemia Anaemia Thrombocytopenia Hyper viscosity Thrombosis. Temperature: Hypothermia Multiorgan Failure: l/t to increased perinatal Mortality and Morbidity.

68. COMPLICATIONS OF IUGR: FETAL COMPLICATIONS LATE FETAL COMPLICATIONS AFTER BIRTH: Asymmetric IUGR Babies tend to catch up growth in early infancy. The probability of retarded neurological ad cognitive function is high. Complications are worse in babies with IUGR d/t Infections, Congenital Anomalies and Chromosomal Defects. LONG TERM FETAL COMPLICATIONS: Increased risk of Metabolic Syndrome: Obesity, Hypertension, DM, Coronary Diseases LBW infants have altered orexigenic mechanism l/t Increased appetite and decreased satiety. Decreased Nephron Number leading to Renal Vascular Resistance.

69. Mortality: The immediate Neonatal Mortality is 6 times more than Normal Newborn ; but less than premature Appropriate for Gestational age infants of the same birth weight. Most Babies die within 24hrs. The Morbidity rate is 50% They are at higher risk of poor postnatal growth and adverse cognitive outcome. MANAGEMENT: Constitutionally Small Fetus (70%): Require No Intervention. SYMMETRICALLY GROWTH RESTRICTED FETUS: Investigated to rule out fetal anomalies, infection or genetic syndrome. There is no effective treatment for this group. IUGR fetuses due to reduced Placental blood flow (Chronic placental insufficiency) or placental disease can be given some treatment Assessment of Fetal well being is more critical in the management as in majority there is no definitive treatment Perinatal Outcome is poor for women with early onset of FGR (<34 weeks) as compared to women with late onset of FGR.

70. MANAGEMENT: GENERAL MANAGEMENT: At present, there is no treatment that can reverse IUGR once it has set in. Following treatment can be tried though with some success. Adequate bed rest in Left Latersl position To correct Malnutrition bt Balanced diet: 300 exra calories can be taken. To institute appropriate therapy for the associated complicating factors likely to produce IUGR. Avoidance of smoking, Tobacco and Alcohol. Maternal Hyperoxygenation at the rate of 2.5 litre/min, for short term prolongation of pregnancy. Maternal Hyperailmentation by Amino acid can improve fetal growth if it was due to malnutrition. Maternal Circulatory Volume Expansion maybe helpful in improving Placental perfusion,

71. MANAGEMENT: ANTEPARTUM EVALUATION : Serial evaluation of fetal growth and assessment of fetal well being has to be done once diagnosis of IUGR has been done. ULTRASOUND EXAMINATION: It is done at an interval of of 3 – 4 weeks for the assessment of BPD, HC/AC, fetal weight and AFI. FETAL WELL BEING ASSESED BY : Kick Count, NST, BIOPHYSICAL PROFILE, Amniotic Fluid volume and cordocentesis for blood gases. Doppler ultrasound parameters are needed to be studied. Only effective intervention to improve FGR is delivery of the patient. Timing the delivery is of critical importance as one has to balance the risk of prematurity against the risk of continued pregnancy l/t IUFD. Optimum Time For Delivery Of IUGR Fetus : It is between 34 weeks to 37 weeks depending upon any of the additional risk factors such as Oligohydramnios, Pre eclampsia, abnormal Doppler study. PREGNANCY >=to 37 weeks: Delivery should be done

72. MANAGEMENT: TIMING OF DELIVERY : PREGNANCY < 37weeks: IN UNCOMPLICATED MILD FGR: Most cases of IUGR fall into this group. Usual treatment employed is to improve placental function. Pregnancy continued till 37 weeks and than delivery is done. IN Severe degree of FGR : Delivery planned on the basis of Fetal Surveillance report Lung maturity achieved: presence of Phosphatidyl choline+ L/S Ratio >= to 2 from amniotic fluid study; DELIVERY IS DONE. Lung maturity NOT achieved: Betamethasone Therapy if < 34 weeks. This reduces risk of neonatal HMD and Intraventricular Haemorrhage. Delivery to be done at 34 0/7 weeks of gestation in case of FGR WITH RISK FACTORS FOR ADVERSE PERINATAL OUTCOME. (Pre eclampsia, Oligohydramnios, AREDV) Delivery before 32 weeks: MGSO4 to be given to mother and fetus for Neuroprotection.

73. MANAGEMENT: METHODS OF DELIVERY : Low rupture of membranes followed by Oxytocin: Done in cases of pregnancy beyond 34 weeks with favourable Cervix and Head deep in pelvis. Prostaglandins (PGE2) gel to be used when cervix is unfourable . INTRAPARTUM MONITORING: By Clinical, continuous electronic and scalp Blood sampling is needed to be done as the risk of Intrapartum ASPHYXIA is high. CAESAREAN DELIVERY WITHOUT A TRIAL OF LABOR: Done when more risks are associated with fetus for Vaginal delivery are more( Presence of fetal Acidemia , Absent or Reversed End Diastolic in umblical artery or unfavourable cervix. CARE DURING VAGINAL DELIVERY: INTENSIVE Intra partum fetal Monitoring must be done along with facility for Neonatal Intensive Care Unit.