IUGR

Question 1

What are the risks of IUGR?

Answer 1

• increased risk of: hypothermia, hypoglycemia, pulmonary hemorrhage, infection, encephalopathy, NE
• asphyxia, meconium aspiration, MR
• operative delivery
• higher risk of stillbirth

Question 2

What are the types of IUGR?

Answer 2

• type I - symmetrical IUGR <28 weeks
• type II - asymmetrical IUGR >28 weeks

Question 3

What are the causes of symmetric IUGR?

Answer 3

fetal causes (20%)
- structural or chromosomal abnormalities (trisomy 13, 18, 21)
- Dwarf syndrome: Osteogenesis imperfecta
- Congenital malformation: structural defects
- early congenital/fetal infections: TORCH

Question 4

What are the risk factors for chromosomal anomalies?

Answer 4

• maternal age > 35 years
• history of previous child with chromosomal disorder
• abnormal parent (carrier)
• consanguinity (first cousins) -> risk 6%
• presence of gene defects -> risk 50%
• diabetic mothers
• hemoglobinopathies
• inborn error of metabolism

Question 5

What are the infections that lead to symmetric IUGR?

Answer 5

Viral
- Rubella
- Cytomegalovirus
- hepatitis
- varicella
- influenza

Bacterial
- Listeriosis
- TB
- Syphilis

Protozoal
- toxoplasmosis

Question 6

What are the causes of asymmetric IUGR?

Answer 6

Maternal disease (chronic causes of placental insufficiency)
1- inadequate maternal nutrition
2- decreased utero-placental blood flow: (HTN, DM vasculopathy, post-dated pregnancy)
3- decreased oxygen carrying capacity: (sickle cell, cyanotic heart defect)
4- Brain sparing effect -> decreased urine output -> oligohydramnios
5- vascular diseases
6- chronic renal diseases
7- chronic hypoxia: living at high altitudes or cyanotic heart disease
8- placental & cord abnormalities

Question 7

What are the types of placental & cord abnormalities?

Answer 7

• placental abruption
• extensive infarctions
• placental calcifications
• true knots
• marginal & velamentous insertion of the cord

Question 8

How will diagnosis of IUGR be suspected in ANC visits?

Answer 8

1- Poor maternal weight gain
2- uterine fundal heights (if < 2 cm from expected height)

Question 9

How is diagnosis of IUGR diagnosed using ultrasound assessment?

Answer 9

1- abnormal BPD & abdominal circumference
2- associated oligohydramnios
3- accelerated placental aging

Question 10

How is detection of CFMF diagnosed?

Answer 10

1- screening tests (noninvasive)
- PGD
- maternal serum cell-free fetal DNA (10w)
- serum PAPP-A, hCG + fetal NT ultrasound (11-13w)
- quadruple test: AFP, hCG, Estriol, Inhibin-A (15-20w)

2- confirmatory tests (invasive)
- chorionic villous sampling: TA (14-16w) TV (11-13w)
- amniocentesis (14-16w)
- cordocentesis (20w)

3- Screening for TORCH antibodies
4- detailed anomaly scanning (18 - 20w)

Question 11

How is assessment of fetal wellbeing done?

Answer 11

1- daily fetal movement count
2- non-stress test
3- oxytocin challenge test
4- biophysical profile
5- doppler study for UA & MCA -> high resistance in UA & low resistance in MCA (ominous sign)

Question 12

How is IUGR managed?

Answer 12

1- Prevention
- stop smoking & alcohol with proper dietary intake & vitamins
- control underlying pathology
- low dose aspirin (100mg) + anticoagulants (APS)

2- Near term (37w)
- early delivery
- IOL + continuous CTG monitoring
- emergency CS

3- Remote from term (<37w)
- in cases with trisomy 13 or 18 -> TOP
- expectant management + corticosteroids + MgSO4
- if severe placental insufficiency (fetal distress) -> TOP

4- Care of newborn baby
- examine to rule out congenital anomalies & infections
- monitor blood glucose levels (hypoglycemia is common)
- care for hypothermia & hyperbilirubinemia