Post on 13-Jan-2016
Rafat Mosalli MDRafat Mosalli MD
Abnormal Gestation
Objectives
What is Normal gestation?What is Normal gestation? Newborn classification according to age Newborn classification according to age
and Weight.and Weight. How to assess for Gestational age?How to assess for Gestational age? Causes of abnormal gestationCauses of abnormal gestation Complications of abnormal Gestation.Complications of abnormal Gestation.
- - LGA & SGALGA & SGA
-Premature & Post mature-Premature & Post mature
Definitions Full TermFull Term : 37- 42W GA : 37- 42W GA PrematurityPrematurity : < 37 W GA : < 37 W GA Post termPost term : > 42W GA : > 42W GA Large for gestational age (LGALarge for gestational age (LGA):):
BWT >2 SD from the mean of GA(>90 BWT >2 SD from the mean of GA(>90 percentile)percentile)
Small for gestational age( SGASmall for gestational age( SGA): ): BWT<2SD from the mean of GA(<10 BWT<2SD from the mean of GA(<10 percentile)percentile)
Low birth weight (LBW):Low birth weight (LBW):
Bwt <2500gmBwt <2500gm Very low birth weight (VLBW):Very low birth weight (VLBW):
Bwt<1500gmBwt<1500gm Extremely-very-low-birth-weight (ELBW)Extremely-very-low-birth-weight (ELBW) : :
Bwt < 1000 gBwt < 1000 g
LBW could be both!
- An infant of birth weight 1.8 kg born at 36 - An infant of birth weight 1.8 kg born at 36 weeks is classified as weeks is classified as preterm and LBWpreterm and LBW
Gestational age assessment
LMPLMP UltrasoundUltrasound Balllard score :Balllard score :
-Physical -Physical andand neuromuscular maturity neuromuscular maturity
-correlate the cumulative score with a -correlate the cumulative score with a gestational age (usually lies within gestational age (usually lies within 2weeks)2weeks)
Large for gestational age (LGA)
Bwt > 90% for their ageBwt > 90% for their age Causes:Causes:
-Familial-Familial
-IDDM-IDDM
-Others-Others
LGA(IDM) :Complications
-Prematurity - GIT-Prematurity - GIT
-Birth injuries - Prenatal death -Birth injuries - Prenatal death
-CNS - Congenital anomalies-CNS - Congenital anomalies
-Respiratory -Respiratory
-CVS-CVS
-Metabolic-Metabolic
-Hematologic-Hematologic
-Renal-Renal
Fetal growth has been divided into three phases.
1-cellular hyperplasia1-cellular hyperplasia
2- hyperplasy & 2- hyperplasy & hypertrophyhypertrophy
3- hypertrophy3- hypertrophy
cell size.cell size. fat depositionfat deposition fetal weight as much fetal weight as much
as 200 G.r. per as 200 G.r. per week.week.
Normal Intrauterine Growth Pattern
95% of fetal weight gain occurs during the 95% of fetal weight gain occurs during the last 20 weeks of gestationlast 20 weeks of gestation
Late insult will affect weight the mostLate insult will affect weight the most
Intrauterine Growth Retardation (IUGR)
Is deviation from expected Is deviation from expected fetal growthfetal growth patternpattern
a fetus is unable to grow to its genetically determined potential size to a degree that may affect the health of the fetus.
A late pregnancy insult such A late pregnancy insult such
as placental insufficiency as placental insufficiency
would affect cell sizewould affect cell size . .
Asymmetrical
symmetrical
An early insult due to : chemical viral aneuploidy
Cell sizeCell num.
Proportionate reduction in head & body
Symmetric Vs Asymmetric IUGR
Symmetric IUGRSymmetric IUGR Entire body is proportionally small.Entire body is proportionally small.
Asymmetric IUGRAsymmetric IUGR
A fetus who is undernourished (A fetus who is undernourished (“Head sparing” “Head sparing” effect)effect)
IUGR vs SGA
SGA :
A fetus that has failed to achieve a expected weight by a specific gestational age(Bwt Bwt <2SD from the mean of GA (<10 %)<2SD from the mean of GA (<10 %)
IUGR: a fetus is unable to grow to its
genetically determined potential size to a degree that may affect the health of the fetus.
IUGR vs SGA
50–70% of fetuses with a BWT <10% For GA are constitutionally small, and the lower the centile for defining SGA, the higher the likelihood of IUGR
Not all fetuses who are SGA (<10th percentile) have IUGR, and not all fetuses who have IUGR are SGA.
Small for gestational age (SGA)
Causes : Causes : FetalFetal MaternalMaternal Placental Placental and Uterine Abnormalitiesand Uterine Abnormalities
impaired nutrient deliveryimpaired nutrient delivery
Fetal
impaired fetal uptake impaired fetal uptake
GeneticsGenetics
Congenital anomalies/ InfectionsCongenital anomalies/ Infections
Multiple gestationMultiple gestation
Maternal
InfectionInfection Pre- eclampsia, Diabetes, HypoxemiaPre- eclampsia, Diabetes, Hypoxemia Drug misuse / SMOKINGDrug misuse / SMOKING Chronic medical illnessChronic medical illness impaired nutrient uptakeimpaired nutrient uptake
Uterine &Placental
impaired nutrient delivery impaired nutrient delivery Short cervix,Incompetent cervix Short cervix,Incompetent cervix Placenta Previa ,Abruptio PlacentaePlacenta Previa ,Abruptio Placentae
Others
Premature rupture of membranePremature rupture of membrane
HydramniosHydramnios
IatrogenicIatrogenic
Trauma/Trauma/
Which is common?
Vascular disease (HTN, DM, etc) 35%Vascular disease (HTN, DM, etc) 35% Chromosomal and congenital anomalies 10%Chromosomal and congenital anomalies 10% Normal variation 10%Normal variation 10% Congenital infections 5%Congenital infections 5% Drug misuse 5%Drug misuse 5% Placenta and cord defect 2%Placenta and cord defect 2% Uterine defects 1%Uterine defects 1% Others : Low socioeconomic status, unknownOthers : Low socioeconomic status, unknown
Problems of SGA
SGA: associated problems
Intrauterine deathIntrauterine death AsphyxiaAsphyxia Meconium aspirationMeconium aspiration Persistent pulmonary Persistent pulmonary
hypertensionhypertension Polycythemia/Polycythemia/
hyperviscosityhyperviscosity
HypothermiaHypothermia Hypo-er glycemiaHypo-er glycemia Acute renal failureAcute renal failure Gastrointestinal Gastrointestinal
perforationperforation ImmunodeficiencyImmunodeficiency Neonatal death(1%)Neonatal death(1%)
IUGR : long term problems!
Depend on the causes &Type?Depend on the causes &Type? The asymmetrically GR is more likely to The asymmetrically GR is more likely to
catch up after birthcatch up after birth Impaired neurodevelopment, CPImpaired neurodevelopment, CP type 2 diabetes type 2 diabetes hypertension. hypertension.
Prematurity
< 37W GA< 37W GA
Prematurity
Incidence: 6-8 % all birthIncidence: 6-8 % all birth Causes:Causes:
IdiopathicIdiopathic
MaternalMaternal
fetalfetal
Prematurity complications
Affect every system !Affect every system !
Short termShort term
Long termLong term
Neurologic &Ophthalmologic
Immature temperature regulation Immature temperature regulation hypothermiahypothermia
AsphyxiaAsphyxia IVHIVH PVLPVL CP and neurodevelopment delayCP and neurodevelopment delay
ROPROP
Respiratory and CVS
RDSRDS Apnea of prematurityApnea of prematurity BPDBPD pneumoniapneumonia HypotensionHypotension PDAPDA
GIT and Nutrition
Feeding difficultyFeeding difficulty
NECNEC
Renal and Metabolic
Immature kidneysImmature kidneys Electrolyte dist.Electrolyte dist. AcidosisAcidosis Hypo-er glycemiaHypo-er glycemia HypocalcemiaHypocalcemia Osteopenia of prematurity Osteopenia of prematurity
Hematologic &Immunology
Anemia of prematurity Anemia of prematurity
JaundiceJaundice
InfectionInfection
Post maturity
> 42 weeks GA> 42 weeks GA C/PC/P Complications:Complications: MAS and related complicationsMAS and related complications Hypoxic ischemic encephalopathy(HIE Hypoxic ischemic encephalopathy(HIE
sequences)sequences) MetabolicMetabolic PolycythemiaPolycythemia
We Talked about
What is Normal gestation?What is Normal gestation? Newborn classification according to age Newborn classification according to age
and Weight.and Weight. How to assess for Gestational age?How to assess for Gestational age? Causes of abnormal gestationCauses of abnormal gestation Complications of abnormal Gestation.Complications of abnormal Gestation.
- - LGA & SGALGA & SGA
-Premature & Post mature-Premature & Post mature