IUGR & IUFD
DR. SALWA NEYAZI
CONSULTANT OBSTETRICIAN GYNECOLOGIST
PEDIATRIC & ADOLESCENT GYNECOLOGIST
IUGR
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
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
What are the causes of IUGR?
Maternal medical conditions 1ry placental disease
Chromosomal anomalies & Extremes of maternal age
aneuploidy
Low socioeconomic
Genetic & Structural anomalies status
Exposure to drugs & toxins Infections
Multiple gestation
Which maternal medical conditions result in IUGR?
HPT
PET
DM with vascular involvement
SLE
Anemia
Sickle cell disease
Antiphospholipid syndrome
Renal disease
Malnutrition
Inflammatory bowel disease
Intestinal parasites
Cyanotic pulmonary disease
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, PET, DM, HPT
Chronic partial abruption
Placental infarcts
Placenta previa
Chorioangioma
Circumvallate placenta
Placental mosaicism
Twin to twin transfusion Syndrome
What infections result in IUGR?
5-10% of IUGR
Congenital infections:
CMV
Rubella
Herpes
Vericella zoster
Toxoplasmosis
Malaria
Listeriosis
Which drugs can result in IUGR?
Alcohol
Cigarette smoking 3-4X
Heroin & coccaine
Methotrexate
Anticonvulsants
Warfarin
Antihypertensives /-blockers
Cyclosporin
What are the genetic disorders that can result in IUGR?
15% of IUGR Features suspicious of trisomy
Downs syndrome T21 Symmetric IUGR
Trisomy 13,18 AFV/ Doppler N
Turner syndrome Structural abnormalities
Neural tube defects Maternal age
Achondroplasia Nuchal translucency
Osteogenisis imperfecta Biochemical screening results
Abdominal wall defects
Duodenal atresia
Renal agenesis/ Poters S
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
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
Types of IUGR
2-Asymmetric IUGR80%
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
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
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
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
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
The constitutionally small fetus
A fetus growing parallel to the lower centiles through out preg
Anatomically N
AFV N
Doppler N
Slim petite women
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
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
IUFD
Definition: dead fetuses or newborns weighing > 500gm
Or > 20 wks gestation
4.5/ 1000 total births
Diagnosis
Absence of uterine growth
Serial -hcg
Loss of fetal movement
Absence of fetal heart
Disappearance of the signs & symptoms of pregnancy
X-ray Spalding sign
Roberts sign
U/S 100% accurate Dx
Causes OF IUFD Maternal 5-10%
Antiphospholipid antibody
DM
Fetal causes 25-40%
HPT
Chromosomal anomalies
Trauma
Birth defects
Abnormal labor
Non immune hydrops
Sepsis
Infections
Acidosis/ Hypoxia
Placental 25-35%
Uterine rupture
Abruption
Postterm pregnancy
Cord accidents
Drugs
Placental insufficiency
Thrombophilia
Intrapartum asphyxia
Cyanotic heart disease
P Previa
Epilepsy
Twin to twin transfusion S
Severe anemia
Chrioamnionitis
Unexplained 25-35%
A systematic approach to fetal death is valuable in
determining the etiology
B-Maternal History
1-History I-Maternal medical conditions
VTE/ PE
A-Family history DM
Recurrent abortions HPT
VTE/ PE Thrombophilia
Congenital anomalies SLE
Abnormal karyptype Autoimmune disease
Hereditary conditions Severe Anemia
Developmental delay 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
Specific fetal conditions
Nonimmune hydrops
Current Pregnancy Hx IUGR
Maternal age Infections
Gestational age at fetal death Congenital anomalies
HPT Chromosomal abnormalities
DM/ Gestational D Complications of multiple gestation
Smooking , alcohol, or drug abuse
Abdominal trauma
Cholestasis
Placental or cord complications
Placental abruption Large or small placenta
PROM or prelabor SROM Hematoma
Edema
Large infarcts
Abnormalities in structure , length or
insertion of the umbilical cord
Cord prolapse
Cord knots
Placental tumors
2-Evaluation of still born infants
Infant desciption Placenta
Malformation Weight
Skin staining Staining
Degree of maceration Adherent clots
Color-pale ,plethoric Structural abnormality
Umbilical cord Velamentous insertion
Prolapse Edema/ hydropic changes
Entanglement-neck, arms, ,legs Membranes
Hematoma or stricture Stained
Number of vessels Thickening
Length
Amniotic fluid
Color-meconium, blood
Volume
3-Investigations Fetal inveswtigations
Fetal autopsy
Maternal investigations Karyotype
CBC (spcimen taken from cord
Bl Gp & antibody screen blood, intracardiac blood,
HB A1 C body fluid, skin, spleen,
Kleihauer Batke test Placental wedge, or amniotic
Serological screening for Rubella Fluid)
Fetography
CMV, Toxo, Sphylis, Herpes &
Radiography
Parovirus
Karyotyping of both parents (RFL,
Placental investigations
Baby with malformation
Chorionocity of placenta in
Hb electrophorersis
twins
Antiplatelet anbin tibodies
Cord thrombosis or knots
Throbophilia screening (antithrombin
Infarcts, thrombosis,abruption,
Protein C & S , factor IV leiden,
Vascular malformations
Factor II mutation, , lupus
Signs of infection
anticoagulant,
Bacterial culture for Ecoli,
anticardolipin antibodies)
Listeria, gp B strpt.
DIC
IUFD complications
Hypofibrinogenemia 4-5 wks after IUFD
Coagulation studies must be started 2 wks after IUFD
Delivery by 4 wks or if fibrinogen < 200mg/ml
Psychological aspect & counseling
A traumetic event
Post-partum depression
Anxiety
Psychotherapy
Recurrence 0-8% depending on the cause of IUFD
