Macrosomia and iugr with case study for undergraduare
- 1. Macrosomia and Intrauterine Growth Restriction(IUGR) DR Manal Behery Zagazig University, 2013
- 2. Macrosomia
- 3. Definition: A fetal weight of more than 4.5 kg at term or fetal birth weight > 90 percentile for the gestational age..
- 4. Causes Genetic or constitutional: obese women tend to give birth to macrosomic babies. Diabetes and prediabetes. Post-date (postmaturity). Multiparity: The first baby is about 100 gm smaller than the next. Hydrops foetalis.
- 5. Macrosomia and diabetes ¼ th of insulin dependent mothers have Macrosomic infants Excess growth happens in 3rd trimester. GDM mothers have same incidence of Macrosomic infants as other diabetics
- 6. Risk factors Excessive maternal weight gain during pregnancy. Advanced maternal age. Male fetus than female. Previous macrosomic infant.
- 7. Diagnosis Clinical palpation: can give a rough idea. Ultrasonography: can calculate the fetal weight
- 8. Hazards Prolonged pregnancy Cephalopelvic disproportion Obstructed labour. Shoulder dystocia. Meconium aspiration syndrome. Nerve and bone injuries.
- 9. Management Proper antenatal care: to prevent macrosomia and diagnose it before labour commences. Cesarean section: is the safest for both mother and fetus.
- 10. IUGR
- 11. Definition ! IUGR is defined as a fetus that has an estimated weight that is less than the 10th percentile for it’s gestational age At term, the cutoff birth weight for IUGR is 2,500 g (5 lb, 8 oz)
- 12. Growth percentiles for fetal weight versus gestational age
- 13. Correlation of birth weight percentile to perinatal morbdity and mortalility
- 14. Is small for gestational age (SGA) the same as IUGR? • IUGR is used synonymously with small for gestational age (SGA) but implies a pathologic condition. EFW at or below 10th percentile is used to identify fetuses at risk However a certain number of fetuses at or below the 10th percentile just may be constitutionally small and not growth restricted
- 15. IUGR VS SGA IUGR: fetus with birth weight <10th percentile for gestational age due to pathologic process. SGA: fetus with birth weight <10th percentile for gestational age in the absence of pathologic process
- 16. 1. Symmetrical growth restriction 20 % of IUGR Infants proportional decrease in all organs HC/AC ratio is normal Occurs in early pregnancy : Cellular hyperplasia Increase risk for long term neurodevelopmental dysfunction Due to Intrinsic factor Chromosomal abnormalities Congenital anomalies Intrauterine infection
- 17. 2.Asymmetrical growth restriction 80% of IUGR Infants Increase HC/AC ratio : decrease in abdominal size Brain sparing effects Occurs in late pregnancy : cellular hypertrophy Risk for perinatal hypoxia, neonatal hypoglycemia Good prognosis Due to extrinsic factors : Uteroplacental insufficiency Maternal vascular disease: hypertension Multiple gestations Placental disease
- 18. 3. Combined type Asymmetrical symmetrical Symmetrical asymmetrical More morbidities and mortalities More long term effects
- 19. Ponderal Index Ultrasound criteria for diagnosis of fetal malnutrition; Gestation age independent; Way of characterizing the relationship of height to mass for an individual. PI = 1000 x Typical values are 20 to 25. PI is normal in symmetric IUGR. PI is low in asymmetric IUGR. Mass (kgs) Height (cms)
- 21. Fetal causes Infection CMV, Rubella, Toxoplasma gondii – severe IUGR Syphilis, Tuberculosis, Malaria, listeriosis Herpes simplex, chicken pox Chromosomal abnormality Trisomy 18,13 –severe IUGR Trisomy 21 Turner syndrome (45,XO), Klinefelter syndrome (47,XXY) Congenital anomalies Congenital Heart diseases Anencephaly
- 22. Case # 1 A baby is delivered at 36 WGA via repeat C- section BW- 2 kg HC- < 10th %tile Lt- < 10th %tile CMV
- 23. Case #2- What if? Toxoplasmosis Rubella
- 24. Case #3- What if? Trisomy 18 Turner syndrome
- 25. Maternal causes • Maternal malnutrition • Poor maternal weight gain • Severe anemia • Chronic hypoxemia • Cardiovascular disease • Drugs and teratogens • Multiple pregnancy • Antiphospholipid antibodies syndrome
- 26. Case #4 Infant is delivered at 38 weeks to mom who presents with headaches and epigastric pain BW: 2.1 kg HC: 50th%tile Lt: 30th%tile Pre-eclampsia/ HELLP
- 27. Case # 5- What if? Mom with no prenatal care delivers undiagnosed twins at EGA 34 weeks Discordant twins
- 28. Case # 6- What if? An infant is delivered at 42 weeks via c- section due to NRHTs after induction Post dates - decreased subcutaneous fat - skin desquamation - wizened facies - large AF(diminished membranous bone formation) - meconium staining
- 29. Placental causes • Placental infarction • Placental abruption • Chorioangioma • Placenta previa , circumvallate placenta • Marginal or velamentous insertion of umbilical cord
- 30. Cause Fetal causes (intrinsic factors) Symmetrical IUGR Maternal causes Plcental causes (extrinsic factors) Asymmetrical IUGR
- 31. IUGR Symmetric IUGR Asmmetric IUGR Small symmetrically. Head is larger than abdomen. Ponderal index is normal. Ponderal index is low. Normal head-abdomen ratio. High head-abdomen ratio. Genetic, infections. Placental vascular insufficiency. Complicated neonatal course. Benign neonatal course if complications are treated adequately.
- 32. Diagnosis • Clinical assessment • Ultrasonic measurement • Doppler velocity
- 33. History for risk factor – Teen age – High altitude – Socioeconomic factor – Smoking , Alcohol , Drugs – Previous IUGR pregnancy history – previous IUGR in family
- 34. Signs: Seldom elicited before 28 weeks of gestation: Failure of fetus and uterus to grow at the normal rate over a 4 week period; Uterine fundal height should be at least 2cm less than expected for the length of gestation; Poor maternal weight gain; Diminished fetal movements.
- 35. Physical examination Uterine fundal height Uterine fundus Pubic symphysis Simple, Safe, Inexpensive for screening Between 18 and 30 weeks, the uterine fundal height in centimeters coincides with weeks of gestation. If the measurement is more than 2 to 3 cm from the expected height or < 1oth percentile from normal curve, inappropriate fetal growth may be suspected
- 36. Errors in Fundal Height Estimation: Inter-observer variations Obese patients Transverse lie Multiple gestation Polyhydramnios / Oligohydramnios Uterine fibroids
- 37. Ultrasonic measurement Initial U/S at 16 to 20 weeks to establish gestational age and identify anomalies and repeated at 32 to 34 weeks to evaluate fetal growth
- 38. Ultrasonography Biometry The measurements most commonly used to measure and follow fetal growth are: Biparietal Diameter Femur Length Head Circumference Abdominal Circumference Ratio :- Head circumference to the abdominal circumference (HC/AC) .
- 39. Amniotic Fluid Index Mild IUGR – Normal amniotic fluid Severe IUGR – Oligohydramnios (AFI is ≤ 5) Incidence 40% On ultrasonography - a pocket of fluid < 1cm is diagnosed as oligohydramnios.
- 40. The amniotic fluid index is obtained by summing the largest cord-free vertical pocket in each of the four quadrants of an equally divided uterus.
- 41. Abnormal umbilical artery Doppler velocimetry A. Normal velocimetry pattern with an S/D ratio of <30. B. The diastolic velocity approaching zero reflects increased placental vascular resistance. C. During diastole, arterial flow is reversed (negative S/D ratio), which is an ominous sign that may precede fetal demise – characterized by absent or reversed end-diastolic flow – associated with fetal growth restriction
- 43. An IUGR infant is at risk for Hypothermia? Hypoglycemia? Or Hypocalcemia? decreased subcutaneous fat, increased surface- volume ratio, decreased heat production decreased glycogen stores/ glycogenolysis/ gluconeogenesis increased metabolic rate deficient catecholamine release Associated with perinatal stress, asphyxia, prematurity
- 44. Management Prepregnancy: to prevent it by identifying risk factors and treat as necessary (e.g. improve nutrition intake, stop smoking or alcohol, ASA in APA syndrome, and Heparin in thrombophilias) Antepartum: identify risk factors that can be changed. Fetal surveillance by ultrasound (BPP) and fetal heart monitoring (Non-Stress Test). To decide on timing and mode of delivery.
- 45. Growth restriction near term Prompt delivery Recommend delivery at 34 weeks or beyond if there is clinically significant oligohydramnios
- 46. Growth restriction remote from term No specific treatment If diagnosed in prior to 34 weeks, and amnionic fluid volume and fetal surveillance are normal Observation is recommended screening for toxoplasmosis,herpes,rubella,CMV and others Specific treatment(causes of IUGR) and supportive care If severe IUGR or bad obstetric conditions Terminate pregnancy should be considered
- 47. IUGR- Outcome Neurodevelopment etiology and adverse event dependent lower intelligence, learning/ behavioral disorders, neurologic handicaps symmetric, chromosomal disorders, congenital infections--- poorer outcome school performance influenced by social class
- 48. Case study
- 49. Case SW a16 years old G1 P0+0 presented early for prenatal care PMH: None PSH: None Allergies: None Medications: Prenatal vitamins Social Hx: + Tobacco 1ppd x > 5 years, No illicit drug use • B average in high school and good support system • Lives in Denver, HIGH ALTITUDE • Poor nutrition
- 50. She followed up regularly and had an uncomplicated 1st trimester….. • At 18 weeks fundal height measured 17 cm • At 22 weeks fundal height measured 20 cm • At 24 weeks fundal height measured 21 cm At this point I am worried about IUGR with this sluggish growth. Although we do not use fundal height to diagnose IUGR, it can be a clue to a developing problem. •A fundal height that lags by more than 3 cm or is increasing in disparity with the gestational age may signal IUGR. • A lag of 4 cm or more certainly suggests growth restriction. • The size of the uterus should be assessed at each prenatal visit.
- 51. So now we have increasing concern over her poor fundal height. What other risk factors for IUGR does AMY have? A) Teen B) Poor nutrition C) Poor abdominal girth growth D) High altitude E) Smoker F)All of the above ANSWER F
- 52. Maternal weight Gain Decreased maternal weight gain is a relatively insensitive sign of IUGR baby…
- 53. Risk Factors of IUGR With all these risk factors, poor weight gain, and an inadequate fundal height… What would you do to further evaluate for potential IUGR? 1)Consult OB now 2) Get an ultrasound 3) Do an NST 4) Continue to watch one more week ANSWER 2
- 54. The result of 32 wks US Comments: a single intrauterine pregnancy. No obvious fetal anatomic abnormalities were seen. Not all malformations of the above mentioned organ systems can be detected by ultrasound. There is an overall growth lag of two weeks, with the head and abdomen lagging three weeks. Amniotic fluid is lower limits of normal measuring 8.5 cm . S/D ratio is slightly elevated. She declined amniocentesis. Recommend follow up growth in three weeks. This appointment was scheduled today
- 55. History of Present Illness • That was her ultrasound at 24 weeks. You repeat it at 27 weeks: 3 week growth lag and AFI 8.5 • Repeat US at 30 weeks: normal growth since last US – 15 day lag; AFI 10.5 • Repeat US at 32 weeks: EFW 9% AFI 5.9 Is this IUGR? What do you do now?
- 56. She has an overall 3 week lag and an EGW 12% at 32 weeks. Is this IUGR? A) Yes ,any growth lag is IUGR B)Yes any EFW<l15% is IUGR C)No ,too early to diagnose IUGR D) No, IUGR is EGW overall lag 4 weeks ANSWER C
- 57. IUGR is usually not detectable before 32-34 weeks (maximal fetal growth). But it must be suspected earlier Signs rarely occur before 28 weeks of gestation
- 58. What is Intrauterine Growth Restriction (IUGR)? A fetus with IUGR often has an estimated fetal weight associated with which of the following? A) Abdominal circumference is below 5th percentile B) Abdominal circumference is below the 2.5th percentile C) Less than the 5th percentile for its gestational age D) Less than the 10th percentile for its gestational age ANSWER D
- 59. What is one of the pathologic Maternal/Placental causes for IUGR? A.Gestational Diabetes B.Hypertension C.Obesity D.Hyperemesis Gravidarum ANSWER B
- 60. Which of the following is not a pathologic FETAL cause for IUGR? D)CMV infection C)Congenital heart disease B)Cleft lip/palateA)Trisomy 21 ANSWER B
- 61. Does SW have symmetrical or asymmetrical IUGR? A)Asymmetrical B) Symmetrical Answer B
- 62. Comments of the ultrasound at 32 weeks. It reads: A complete detailed scan of a single intrauterine pregnancy was performed. No obvious fetal anatomic abnormalities were seen. Not all malformations of the above mentioned organ systems can be detected by ultrasound. There is an overall growth lag of two weeks, with the head and abdomen lagging three weeks. Amniotic fluid is lower limits of normal measuring 5.9 cm . S/D ratio is slightly elevated.
- 63. How else can IUGR be diagnosed in addition to a <10% weight for gestational age? A) US B) Inadequate Maternal Weight gain C) Non-reassuring NST D) Fundal Height ANSWER A
- 64. So SW has had a 32 wk US with EFW 10% and AFI 6.9. What is your next step? A)Repeat US in 8 weeks B)No further US needed C)Repeat US in 4 weeks D)Transfer to OB ANS C
- 65. Yes! Correct Answer: Repeat US in 3-4 weeks Repeat US at 35 weeks: Comments: A repeat ultrasound of this single intrauterine pregnancy was performed. EFW is in the less than 10th percentile in growth. Amniotic fluid is within normal limits for this gestation. Umbilical artery dopplers performed and S/D ratio is normal. Recommendations include: 1. follow up ultrasound in 1 week for AFI and dopplers 2. follow-up ultrasound in 2 weeks for growth 3. NST testing twice weekly.
- 66. SW is in your office to review the results. You explain the results and schedule her for an ultrasound next week and the week after. Any other advice for her? Click for advice 1. Rest as much as possible- she does not work and is out of school. 2. Perform daily kick counts. 3. She will need weekly visits with biweekly NSTs. She asks you: “Why so many ultrasounds?” What do you tell her?
- 67. You tell her: “Ultrasound measurement of the fetus is the gold standard for assessing fetal growth.” AND “We need to follow the amount of fluid around the baby as well. If it is too low, we will need to deliver your baby early.” Click here. Click here next
- 68. When should we (Family Practice) Transfer care to the Obstetricians? A)Whenever you are unsure or uncomfortable with the situation B)Definite need for C-Section C)Worsening fetal status D)Severe/worsening Maternal Disease E)Unsure of IUGR etiology F)All of the above Answer F
- 69. Which of the following may we see after the birth of a baby with IUGR? A) Decreased oxygen levels B) Meconium aspiration C) Hypoglycemia D) Difficulty maintaining normal body temperature E) Polycythemia F) Stillbirth G) All of the Above ANSWER G
- 70. Case Close • SW remained on the family practice service because she remained stable and her biweekly BPP and NST were reassuring. • In the 36th week, she was found to have oligohydramnios by US AFI = 3.2 along with IUGR EFW < 10% • Pt was at this time transferred to OB for care. • She was already known to them because we consulted them at the first signs of IUGR. • Amniocentesis was done to ensure fetal lung maturity and she was induced soon there after. • Patient vaginally delivered a baby with Down’s Syndrome • No other complications at birth
- 71. Thank you