PBL 2: Poor Intrauterine Growth

Question 1

What is Intrauterine Growth Restriction?

Answer 1

• Small for gestational age (SGA) = <10th centile for gestation

Question 2

What is low birth weight?

Answer 2

<2,500g at any gestational age.

Question 3

Why does IUGR occur?

Answer 3

blood or nutrient supply to the foetus is not sufficient

Question 4

Risk factors of IUGR?

Answer 4

• Alcoholism.
• Clotting disorders.
• Drug addiction.
• Hypertension or heart disease.
• Kidney disease.
• Poor nutrition.
• Smoking.

Question 5

3 types of causes of IUGR?

Answer 5

Foetal
Maternal
Placental

Question 6

Foetal causes of IUGR?

Answer 6

• Chromosomal disorders (trisomy 18 = Edwards syndrome).
• Structural malformations.
• Congenital infections (CMV, rubella, syphilis).
• Normal!

Question 7

Maternal causes of IUGR?

Answer 7

• Undernutrition (low BMI).
• Maternal hypoxia (heart disease).
• Drugs.
• Infection (TB, malaria).

Question 8

Placental causes of IUGR?

Answer 8

• Reduced vascular supply (pre-eclampsia, hypertension, diabetes).
• Placental thrombosis.
• Twin-twin transfusion syndrome (Monochorionic).

Question 9

Investigations into IUGR?

Answer 9

• Symphysis fundal height.
• Ultrasound.
• Foetal movement assessments.
• Cardiotocography (TCG).
• Amniotic fluid volume.
• Doppler blood-flow studies.

Question 10

What is symphysis fundal height?

Answer 10

• Distance in cm (+/-2) from the symphysis pubis and the fundus corresponds to the gestational week roughly.

Question 11

When is symphysis fundal height done from?

Answer 11

24 weeks

Question 12

Doppler ultrasound for umbilical artery?

Answer 12

• Blood flowing through the umbilical arteries is coming from the foetus to the placenta.

Question 13

What happens to umbilical artery in IUGR?

Answer 13

Increased umbilical artery resistance

Question 14

what is normal for MCA?

Answer 14

little flow during diastole

Question 15

What happens to MCA in IUGR?

Answer 15

• Increased resistance due to IUGR will increase flow during diastole

Question 16

What is most reliable way of measuring foetal growth?

Answer 16

Ultrasonography

Question 17

How does ultrasonography work?

Answer 17

Foetal growth corresponds to foetal weight

Question 18

What is issue with ultrasonography?

Answer 18

• Only issue is high incidence of false-positive results.

Question 19

What does US measure?-

Answer 19

• Biparietal Diameter (BPD).
• Head circumference (HC).
• Transabdominal circumference (AC).
• Femur length.

Question 20

Classification of IUGR?

Answer 20

Symmetrical

Asymmetrical

Question 21

Is symmetrical or asymmetrical more common?

Answer 21

Asymmetrical

Question 22

what happens in symmetrical?

Answer 22

• Head circumference and transabdominal circumference both low.
• HC:AC = 1.

Question 23

What happens in assymmetrical?

Answer 23

• The head is spared in the expense of the liver.

- HC:AC >1.

Question 24

What does symmetrical indicate?

Answer 24

• Indicates earlier cause for IUGR; congenital or infection.

Question 25

What does asymmetrical indicate?

Answer 25

- Indicates later cause for IUGR due to placental insufficiency of oxygen (pre-eclampsia or diabetes).

Question 26

Management for IUGR?

Answer 26

* Intensify existing antenatal care. * If the foetus becomes compromised induce labour or perform a C section. * A glucocorticoid injection is given at least 24 hours prior to delivery to reduce the effects of prematurity.

Question 27

What does glucocorticoids do?

Answer 27

- Stimulates surfactant production by type 2 pneumocytes to enhance foetal lung. - Protect the foetus from intracranial haemorrhage and necrotizing enterocolitis.

Question 28

Neonatal IUGR complications?

Answer 28

* Perinatal hypoxia. * Respiratory distress. * Hypothermia. * Intrauterine death. * Increased risk of infection. * Prematurity.

Question 29

What is barker hypothesis?

Answer 29

* IUGR is associated with later in life diseases. * Hypertension, T2D and CVD are all increased. * There is also an increased risk of neurological damage like cerebral palsy.

Question 30

When does pre-eclampsia appear?

Answer 30

20 weeks gestation

Question 31

What characterises pre-eclampsia?

Answer 31

- Hypertension. - Proteinuria may be present. - Oedema may be present.

Question 32

Cause of pre-eclampsia?

Answer 32

* Pre-eclampsia is caused by failure of the trophoblasts to proliferate and invade. * The spiral arteries become fibrous and are too narrow for proper blood supply.

Question 33

Pathophysiology of pre-eclampsia?

Answer 33

* The placenta does not receive adequate perfusion and so releases inflammatory proteins. * These cause endothelial cell dysfunction.

Question 34

Why is there oedema in pre-eclampsia?

Answer 34

• Endothelial cell dysfunction increases vascular permeability

Question 35

Why is there proteinuria in pre-eclampsia?

Answer 35

• Lack of perfusion also causes glomerular damage

Question 36

Why is there hypertension in pre-eclampsia?

Answer 36

• There is vasoconstriction and the kidneys retain more salt

Question 37

Risk factors for pre-eclampsia?

Answer 37

* >40. * Multiple pregnancy. * Obesity. * Nullparity (never given birth). * Diabetes. * Family history. * Previous pre-eclampsia.

Question 38

Management of pre-eclampsia?

Answer 38

* Women who are at high risk of pre-eclampsia should take 75mg of aspirin from the 12th week until full term. * Labetalol is an oral anti-hypertensive which can be used.

Question 39

When does monitor of pre-eclampsia last until?

Answer 39

37/38 weeks

Question 40

What happens if condition worsens before 37th week (pre-eclampsia)?

Answer 40

Early delivery

Question 41

Complications of pre-eclampsia?

Answer 41

Eclampsia | HELLP syndrome

Question 42

What is HELLP?

Answer 42

``` H = haemolysis EL = elevated liver enzymes LP = low platelets ```

Question 43

What is eclampsia?

Answer 43

- Onset of seizures in pregnant women with pre-eclampsia. | - Caused by cerebral oedema.

Question 44

How to treat eclampsia?

Answer 44

Magnesium sulphate