IUGR

A.KURDI SYAMSURI
What is the difference between SGA and IUGR?

Can these terms be used interchangeably?

 SGA - small for gestational age infants

• an infant whose weight is lower than the

population norms
• defined as weight below 10th percentile for
gestational age or greater than 2 standard
deviations below the mean
• cause may be pathologic or nonpathologic
 IUGR - intrauterine growth retardation

• defined as failure of normal fetal growth

• caused by multiple adverse effects on fetus
• due to process that inhibits normal growth
potential of fetus
 So what is the difference between SGA and IUGR?

• These terms are related but not synonomous.

• Not all IUGR infants are small enough to fit the
qualifications for SGA.
• Not all SGA infants are small because of a
growth-restrictive process, and therefore, do not
meet criteria for IUGR.
 Incidence
• 3-10% of all pregnancies
• 20% of stillborn infants
• perinatal mortality 4-8 times higher
• half have serious or long-term morbidity
 Epidemiology
• more common in low socioeconomic class
• more common in those of African-
American race
• leading cause in third world countries is
inadequate nutrition of mother
• leading cause in US is uteroplacental
insufficieny
 Causes of IUGR
• maternal factors
• fetal factors
• placental factors
• environmental factors
 Maternal causes of IUGR
• inadequate nutrition of mother
• multiple gestation
• uteroplacental insufficiency
• hypoxia
• drugs
 Mother’s Malnutrition
• lack of adequate food supply
• poor weight gain
• chronic illness
• malabsorption
 Multiple Gestation

• difficult to provide optimal nutrition for

greater than one fetus
• uterine capacity limitations
 Uteroplacental Insufficiency

• preeclampsia
• chronic HT
• renovascular disease
• vasculopathy from diabetes
• drugs
 Hypoxia

• maternal hemoglobinopathies - sickle cell

• maternal anemia
• maternal cyanotic heart disease
• mom living at high altitudes
 Maternal Drug Use and Toxin Exposure

• cigarettes • alcohol
• cocaine • methyl mercury
• • phencyclidine
amphetamines
• phenytoin (Dilantin)
• antimetabolites - MTX
• polychlorinated biphenyls
• bromides
• propanolol
• heroin • steroids - prednisone
• hydantoin • toluene
• isoretinoin (Accutane) • trimethadione
• methadone • warfarin (Coumadin)
 Fetal Causes of IUGR

• genetics
• congenital infection
• inborn errors of metabolism
Chromosome Disorders associated with IUGR

• trisomies 8, 13, 18, 21

• 4p- syndrome
• 5p syndrome
• 13q, 18p, 18q syndromes
• triploidy
• XO - Turner’s syndrome
• XXY, XXXY, XXXXY
• XXXXX
 Syndromes associated with low birth weight
• Aarskog-Scott syndrome • Osteogenesis imperfecta
• anencephaly • Potter syndrome
• Bloom syndrome • Prader-Willi syndrome
• Cornelia de Lange syndrome • Progeria
• Dubowitz syndrome • Prune-belly syndrome
• Dwarfism (achondrogenesis, achondroplasia) • Radial aplasia; thrombocytopenia
• Ellis-van Creveld syndrome • Robert syndrome
• Familial dysautonomia • Robinow syndrome
• Fanconi pancytopenia • Rubinstein-Taybi syndrome
• Hallerman-Streiff syndrome • Silver syndrome
• Meckel-Gruber syndrome • Seckel syndrome
• Microcephaly • Smith-Lemli-Opitz syndrome
• Mobius syndrome • VATER and VACTERL
• Multiple congenital anomalads • Williams syndrome
 Congenital Infections associated with IUGR

• rubella • hepatitis B
• cytomegalovirus • coxsackie
• toxoplasmosis • Epstein-Barr
• herpes • parvovirus
• syphilis • Chagas disease
• varicella • malaria
Metabolic disorders associated with low birth weight

• agenesis of pancreas
• congenital absence of islets of Langerhans
• congenital lipodystrophy
• galactosemia
• generalized gangliosidosis type I
• hypophosphatasia
• I cell disease
• leprechaunism
• maternal and fetal phenylketonuria
• maternal renal insufficiency
• maternal Gaucher disease
• Menke syndrome
• transient neonatal diabetes mellitus
 Placental Causes of IUGR
• placental insufficency
– very important in the 3rd trimester
• anatomic problems
– infarcts
– aberrant cord insertions
– umbilical vascular thrombosis
– hemangiomas
– premature placental separation
– double vessel cord
• microscopic changes
– villous necrosis
– fibrinosis
 Environmental Causes of IUGR

• high altitude - lower environmental

oxygen saturation

• toxins : smoke, alcohol

 IUGR classification
• SYMMETRIC
• height, weight, head circ
proportional
• early pregnancy insult:
commonly due to congenital
infection, genetic disorder, or
extrinsic factors
• normal ponderal index
• low risk of perinatal asphyxia
• low risk of hypoglycemia
• ASYMMETRIC
• head=height, both > weight
• brain growth spared
• later in pregnancy: commonly
due to uteroplacental
insufficiency, maternal
malnutrition, hypoxia, or
extrinsic factors
• low ponderal index
• increased risk of asphyxia
• increased risk of hypoglycemia
 Ponderal Index
• The ponderal index is used determine those
infants whose soft tissue mass is below
normal for their stage of skeletal
development. Those who have a ponderal
index below the 10th % can be classified as
SGA.
• Ponderal Index = birth weight x 100
crown-heel length
 Diagnosis
Prior to delivery, it is necessary to determine the
correct gestational age.

• last menstrual period - most precise

• size of uterus
• time of quickening (detection of fetal movements)
• early ultrasound - the earlier the better accuracy
– biparietal diameter
– abdominal circumference - best sensitivity
– ratio of head to abdominal circumference
– femur length
– placental morphology and
– amniotic fluid
 Diagnosis
after delivery (OUR JOB!)
• low birth weight - this parameter alone misses big IUGR
infants and overdiagnoses constitutionally small infants
• appearance - thin with loose, peeling skin; scaphoid
abdomen; disproportionately large head; may be
dysmorphic
• ponderal index
• Ballard/Dubowitz - accurate within 2 weeks of gestation if
birth weight >999g, most accurate within 30-42 hrs of age
• birth/weight curves
 Complications
• hypoxia • hypothermia
– perinatal asphyxia • neurological
– more tremulous
hematologic -polycythem
– more easily startled
• meconium aspiration
– less visual fixation
• metabolic – less activity
– hypoglycemia – less oriented to visual
– hypocalcemia and auditory stimuli
– acidosis
 Management
in utero

• serologic testing if desired by parents

• decrease mother’s activity
• stop or decrease risk factors if possible
• closely monitor with biophysical profile or nonstress
testing or amniotic fluid measurements
• ultrasound every 10-21 days
• teach mom fetal kick counting
• deliver if reaches 36 weeks
 Management
after birth

• obtain history of risk • check hematocrit

factors • screen for congenital
• appropriate resuscitation infections
• prevent heat loss • screen for genetic
• watch for hypoglycemia abnormalities
– check glucoses • check calcium
– early feeding
– parenteral dextrose
 Outcome

• depends on cause of IUGR/SGA and neonatal course

• symmetric IUGR - poor outcome because early insult
• asymmetric IUGR - better outcome because brain spared
• very bad if brain growth failure starts at < 26 weeks
• school performance influenced by social class
• 25-50% likelihood of neurodevelopmental problems
The End