Eric H Dellinger MD Greenville Hospital System IUGR Introduction IUGR 2nd leading contributor to PNM rate PNM rate increased 610 fold PNM rate 81000 background 1201000 for all IUGR 60801000 when anomalies excluded ID: 486240
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Slide1
Intrauterine Growth Restriction
Eric H. Dellinger, MD
Greenville Hospital SystemSlide2Slide3
IUGR: Introduction
IUGR 2nd leading contributor to PNM rate
PNM rate increased 6-10 fold
PNM rate 8/1000 background:
120/1000 for all IUGR
60-80/1000 when anomalies excludedSlide4
IUGR: Introduction
40% of stillbirths have IUGR
53% of preterm stillbirths
26% of term stillbirths
Intrapartum asphyxia reported in up to 50% of IUGR fetuses
> 60% of IUGR fetuses with FHR tracing abnormalities have hypoxia/acidosis
Pardi, NEJM 328:692, 1993Slide5
When is small, too small? Defining IUGRSlide6
IUGR: Definition
Birth weight < 10th percentile used to define growth restriction at birth
Definition carried over to fetuses using ultrasound measurements (+/- 15%)
Using 10th percentile, 70% will be constitutionally small (no increase risk)
Two SD = less than 3rd percentile
AC < 2.5th percentile has 95% sensitivitySlide7
IUGR: PNM and EFWSlide8
Background InformationSlide9
Normal Versus AbnormalSlide10
Normal Versus Abnormal
< 10
th
Percentile
70% Normal
30% Abnormal
(Constitutional IUGR) (Pathological IUGR)Slide11
IUGR: Etiology
Fetal / Placental
Maternal
Chromosomal / Genetic
History
of IUGR
Twins
Hypertension
Congenital malformation
Diabetes
Infectious disease
MSAFP
increase
CMV
APS
Toxoplasmosis
Chronic
illness
Rubella
Weight
< 90% IBW
Placental pathology
Hemoglobinopathy
Previa
Substance
abuse
Abruption
Anemia/Hypoxia
Mosaiacism
Infarction
Slide12
Past History of IUGR
Prior history #1 risk factor for subsequent IUGR
1 prior episode: 25% recurrence
2 episodes: Fourfold increase
1/3 population “at risk”: 2/3 IUGR babies
2/3 population “low risk”: 1/3 of the IUGR babies, but most are constitutionalSlide13
IUGR: Diagnosis
The Fundal Height Myth:
best from 20-32 weeks: lightening
lag of 4 cm suspicious
Sensitivity of 27%, PPV of 18%
Fundal height of limited value
risk factors more predictiveSlide14
IUGR: Fetal Measurements
Have you weighed a fetus lately?
EFW derived indirectly
“Normal” growth curves difficult to establish
PTL strongly associated with IUGR
BW derived charts inaccurate
U/S growth curves more accurate over preterm age rangesSlide15
IUGR: Fetal Growth Patterns
When did you last watch a fetus grow?Slide16
StrategySlide17
Strategy
Normal versus abnormal
Symmetric versus asymmetric
Fetal causes
Anomalies, arrhythmias, infection
Placental problems
Amniotic fluid
Dopplers
Fetal surveillanceSlide18
HC/AC Ratios
Weeks
Ratio
<32
>
1.0
32-34
~
1.0
>34
<
1.0
Asymmetric HC preserved, ratio > 1.0
Symmetric HC, AC both small, ratio ~ 1.0Slide19
IUGR: HC/AC Ratios
Asymmetric Symmetric
HC
HC
AC
AC
HC/AC
HC/ACSlide20
Asymmetric vs. Symmetric
Asymmetric
Utereo
-placental
Symmetric
Constitutional
Aneuploidy
InfectionSlide21
Fetal Causes
Aneuploidy
Anomalies
Arrhythmias
InfectionSlide22
AneuploidySlide23
AnomaliesSlide24
ArrhythmiasSlide25
InfectionSlide26
Placental CausesSlide27Slide28Slide29
Amniotic Fluid VolumeSlide30Slide31
IUGR: Oligohydramnios
Initial harbinger of doom
IUGR, preeclampsia
may precede abnormal HC/AC
Fluid pocket of BPP:
>2 cm 6% IUGR
1-2 cm 20% IUGR
<1 cm 39% IUGR
also predicts intrapartum distress