Case presentation&

Lecture On iugr

PRESENTED BY : DR.NEHA JAINJnmch, amu aligarh

Mrs.X,

Wife of Mr. Y,

Age 23yrs

Resident of N district.

Unbooked case

Presented with complaint of :

Cessation of menses- 81/2 mths

Ghabrahat- 3 days

History of present illness:

Patient was apparently all right 81/2 mths back when she developed cessation of menses.

1st TRIMESTER: No H/O

excessive nausea & vomitting

bleeding p/v

fever with or without rashes

drug intake

radiation exposure

2nd TRIMESTER: H/O poor weight gain

No H/O headache

epigastric pain

blurring of vision

bleeding or leaking p/v

Pain abdomen

Quickening @ around 5th mth

3rd trimester: H/O Ghabrahat on & off

No H/O headache

epigastric pain

blurring of vision

bleeding or leaking p/v

Menstrual History:LMP-01/12/2013

By Dates-36 wks 3 days(dates sure)

By 30 wks scan-32 wks 4 days

No H/O prolonged menstrual cycles/

normal flow

Obstetric history:G2P1+0L0 0 / IUD delivery @

8mths GA / Govt.hospital / 1yr. back / cause N/K

Past history: No H/O Hypertension

Renal disease

Diabetes mellitus

Heart disease

Asthma

Thrombophilias

Personal history: Sleep-N,Bladder/Bowel-N

No H/O smoking

alcoholism

drug abuse

Dietary history:2-3 chapatis/day

1 small bowl of dal

1 small bowl of vegetables

Rice occasionally

1 spoon ghee, 2 spoons oil

Calorie intake-1200kcal./day(Requirement-1900kcal.)

Iron tablets not regular

No calcium tablets

Socio economic status:Poor

Kuppuswamy class-Upper lower(IV)

Family history: No H/O HTN/DM/Asthma/TB

No H/O genetic disorder in family

General examination:Thin built

Poor nutritional status

Height -152cm.

Weight - 55kg.

BMI- 22.9 Kg/m2

Pallor + (clinically 8g%)

Cyanosis & Icterus -nt

Cervical lymphadenopathy-nt

Pedal edema +nt

EXAMINATION

Vitals:Pulse - 94/min, regular, good volume,

no radiofemoral delay

Bld. Pressure- 110/70mmHg.

Resp.rate- 20/min

Temp.- Afebrile

Systemic examination:

CNS

CVS WNL

RESP.

Abdominal examination:Distended

Skin loose

Uterus 30-32wks

SFH-30cms

cephalic

Liquor clinically normal

FHS+nt, 132/min. regular

Uterus relaxed X 10 min.

Hb% - 8.5

Bld grp.- A+ve

TLC - 7800/cu mm.

DLC - P70L28M02

Platelets- 1.8 lacs/cu mm.

Bld Sugar ®- 124 mg/dl.

S.Urea - 30mg%

S.Creatinine- 0.42 mg%

HIV, HBsAg, VDRL- NR

INVESTIGATIONS

• Wrong Dates• Small for Gestation Age(SGA) fetus• Pathological Fetal Growth Restriction(PFGR)• Intra Uterine Fetal demise• Oligohydraminos

DIFFERENTIAL DIAGNOSIS

next investigation

to confirm…???ULTRASOUND WITH

COLOUR DOPPLER

Doppler effect:• Change in the apparent frequency due to relative

motion between the source & the observer.

(Doppler probe & RBCs)• When the sound wave strikes a moving target,

the frequency of sound waves reflected back is proportionate to the velocity & direction of moving object.

• Used to determine the volume & rate of blood flow through maternal vessels

DOPPLER VELOCIMETRY

Types: 1) CONTINUOUS WAVE DOPPLER:

Two crystals are used, one transmits & other receives wave

Used in M-mode echocardiography

2) PULSE WAVE DOPPLER:

Only one crystal that

Transmits-wait-Receives-wait-Transmits

Allows precise targeting & visualization of the vessel of interest

Have software that displays blood flow-

Towards transducer as RED

Away from transducer as BLUE

• Angle of Insonation: Between doppler beam & direction of flow

• Higher the angle lesser the frequency & more the error.

Frequency change relative to angle of insonation

• To minimize error we use RATIOS, to cancel off the cosϴ

Arterial Doppler indices S/D Ratio: Peak systolic flow(S)

End diastolic flow(D)

PULSATILITY INDEX : S-D

Mean RESISTANCE INDEX : S-D

S

Venous Doppler indices:

PRELOAD INDEX :

Peak velocity during atrial contraction

Peak systolic velocity

PEAK VELOCITY INDEX :

Peak Systolic – Peak velocity atrial contraction

Peak Diastolic velocity

PERCENTAGE REVERSE FLOW :

Systolic time averaged velocity

Diastolic time averaged velocity

PULSATILITY INDEX :

X 100

COLOUR DOPPLER

MATERNAL COMPARTMENT

•Uterine Artery

FETAL COMPARTMENT

•Umblical Artery

•Middle Cerebral Artery

•Venous Doppler

Uterine artery Doppler:

• High diastolic flow velocities

• Its main use is in screening.• Early diastolic notch in the uterine artery

@ 12-14 wks. suggest delayed trophoblastic invasion (JAMES)

• Persistence of notch beyond 24 wks confirms & indicates an increase risk of Pre-eclampsia,

Placental abruption & Early onset IUGR. (JAMES)

• Increase impedence of flow in Uterine artery

@ 16-20 wks was predictive of superimposed

pre-eclampsia developing inwomen with chronic hypertension. (WILLIAMS)

Umbilical ARTERY DOPPLER

• The amount of flow during diastole increases as gestation advances• Thus the S/D ratio dec. from 4 @ 20 wks to 2 @ 40 wks. (WILLIAMS)

• Umbilical A. S/D ratio is generally < 3 after 30 wks. (WILLIAMS)

• Umbilical A. Doppler indices should be measured only after 23 wks (STUDD)

• It is useful adjunct in the management of pregnancies complicated by fetal-growth restriction. (ACOG-2008)

• It is not recommended for screening of low-risk

pregnancies or for complications other than growth restriction. (WILLIAMS)

• Umbilical artery Doppler becomes abnormal when at least 30% of the fetal villous structure is abnormal. (JAMES)

•In extreme cases of growth restriction, end-diastolic flow may become absent or even reversed (AREDF).

•AREDF occurs when 60-70% of the fetal villous structure is abnormal.

•About ½ of the cases of AREDF are associated with aneuploidy or a major anomaly (WILLIAMS)

•Fetuses of preeclamptic women who had AREDF were more likely to have hypoglycemia & polycythemia. (WILLIAMS)

ABNORMAL Umbilical ARTERY WAVEFORM

Resistance index & S/D ratio is increasing

ABNORMAL Umbilical ARTERY WAVEFORM

Perinatal mortality rate in AEDF- 9-41% (IAN DONALD’S)

ABNORMAL Umbilical ARTERY WAVEFORM

Reversal of the End Diastolic FlowPerinatal mortality rate of REDF- 33-73% (IAN DONALD’S)

• Abnormal Umbilical artery flow pattern indicate an increased risk of hypoxemia & acidemia proportionate to severity of Doppler abnormality. (JAMES)

• Umbilical artery Doppler can also be used to distinguish b/w the high risk small fetus that is truly growth restricted that needs inc. monitoring & the low risk small fetus. (IAN DONALD’S)

• When Umbilical artery Doppler are incorporated into management algorithm of growth restricted fetus, perinatal death is reduced as much as 29%. (STUDD)

• In summary UA Doppler in suspected IUGR pregnancies improves perinatal outcome & should be used to monitor these fetuses

Ductus arteriosus doppler• Primarily used to monitor fetuses exposed to

indomethacin and other NSAIDs.

• Indomethacin was used for tocolysis

• They causes Premature closure of Ductus Arteriosus Increased pulmonary flow Reactive hypertrophy of pulmonary arterioles Pulmonary Hypertension.

WILLIAMS 23rd EDITION

MIDDLE CEREBRAL ARTERY(MCA) DOPPLER

• It was used for assessment of-

Fetal Anemia

Growth restriction FETAL ANEMIA: (In Rh isoimmunisation)

With increasing anemia cardiac output increases

& blood viscosity decreases increase flow to

brain Elevated peak systolic velocity WILLIAMS 23rd EDITION

Normal MCA WAVEFORM

MCA DOPPLER IN FETAL ANEMIA

INCREASED PEAK SYSTOLIC VELOCITY

Why only Middle Cerebral Artery is used in assessing fetal anemia…???

• Other vessels have high insonating angles

• MCA is an exception because anatomically, the path of this artery is such that flow velocity approaches the transducer "head-on," and the fontanel allows easy insonation

(WILLIAMS 23RD EDITION)

GROWTH RESTRICTION:

It is involved in severely growth restricted fetus after involvement of Umbilical artery.

It is the progression of the Doppler finding & is due to the adaptive compensatory mechanism in the fetus against increasing hypoxia (Brain sparing effect)

Umbilical artery involved

Increasing hypoxia

Inc. blood flow to Vital Organs(Brain, Heart&

Adrenals)BRAIN SPARING EFFECT

OrCEPHALISATION

Dec. blood flow to Abdominal Organs(Liver &

Kidneys)

OLIGOHYDRAMINOSMCA DOPPLER- Inc. Diastolic Flow

Dec. RI/PI/SD ratio & abn MCA-PSV

MCA WAVEFORM IN IUGR

INCREASED FLOW DURING DIASTOLE

CEREBRO-PLACENTAL RATIO(CPR):

MCA Pulsatility Index

Umbilical A. Pulsatility Index

It is more sensitive index for detecting poor perinatal outcome than UA or MCA Doppler alone, but due to non standardized technique of calculating CPR limit its clinical utility. (STUDD)

• Abnormal MCA reflects inc risk of adverse perinatal outcome(PTL, Intrapartum acidemia & inc NICU admission)

• Not superior to Umbilical artery Doppler

• High negative predictive value for adverse outcome

• Normal UA & MCA Doppler indices & normal AFI in growth restricted fetus <32 wks have negative predictive value of 97% for adverse outcome

Umbilical artery involved

Increasing hypoxia

Inc. blood flow to Vital Organs(Brain, Heart&

Adrenals)BRAIN SPARING EFFECT

OrCEPHALISATION

Dec. blood flow to Abdominal Organs(Liver &

Kidneys)

OLIGOHYDRAMINOSMCA DOPPLER- Inc. Diastolic Flow

Dec. RI/PI/SD ratio & Abn MCA-PSV

INCREASING HYPOXIA

DECOMPENSATION

NORMALSATION OF MCA DOPPLER INDICES EXCEPT

FOR MCA-PSV

MCA-PSV IS THE BETTER

TOOL TO FOLLOW THE PROGRESSION

OF THE DISEASE(STUDD)

SUMMARY OF MCA:

Despite the association of abn. MCA & adverse perinatal outcome, there are no specific interventions to improve outcome based on abn. findings.

However abn. values should prompt more frequent fetal survillence

Venous Doppler studies• Reflects fetal cardiac function• Most commonly used Venous Doppler indices:

Ductus Venosus

Inferior vena cava

Hepatic vein

Umbilical vein(Intra abdominal portion)

VENOUS DOPPLER

All venous Doppler have this type of waveform except for Umbilical vein waveform

Ductus venosus doppler

PERINATAL MORTALITY IN ABSENT OR REVERSE FLOW OF DV IS 63-100% (IAN DONALD’S)

HYPOXIA

INC BLOOD SHUNTING THROUGH DV B/W UMBILICAL VEIN & IVC

INC. PULSATILITY INDEX FOR VEINS (PIV)

PSV-ATRIAL CONTRACTION VELOCITY

Avg. Vel. Drng cardiac cycle

REVERSED a WAVE IN

DV PULSATION

PULSATIONS IN THE UMBILICAL VEIN

REVERSAL OF FLOW IN IVC DURING ATRIAL

CONTRACTION

ABNORMAL WAVEFORM IN UMBILICAL VEIN

Important points on venous Doppler

• Especially useful in early onset IUGR

Reason: In Term /near term fetuses there is shorter interval & delivery is often indicated

With advancing GA cardiac activity becomes more efficient slow Steady decline in Doppler indices

• When DV & Umbilical vein Doppler- Sensitivity inc to 70-80%.

Current areas in research & investigation

• POST TERM PREGNANCY:

Pregnancy >41 wks

Abn. CPR & MCA indicate adverse outcome

• DETERMINATION OF PLACENTATION: To identify Placenta Accreta, Increta,Percreta

Specific sonographic findings:

Absence of hypo echoic zone retro placental zone

Presence of numerous placental lakes

interruption of bladder-myometrium interface

Sensitivity is low

Negative predictive value-95%

3D power Doppler: Sensitivity-97%; Specificity-92%

• PREDICTION OF INTRAPARTUM ACIDEMIA:

• OXYGEN THERAPY FOR IUGR FETUSES:

Continuous oxygen therapy for AEDF fetuses

30% reduction in perinatal mortality

PERINATAL MORTALITY RATES

DOPPLER PARAMETER PERINATAL MORTALITY

INC. UMBLICAL A. RESISTANCE 5-6%

ABSENT UMBLICAL A. EDF 11-13%

REVERSED UMBLICAL A. EDF 20-24%

DECREASED MCA 21%

ABN. DV a WAVE 30-38%

INTRA ABD. UMBLICAL VEIN PULSATIONS

35%

BACK TO THE CASE

What is

your diagnosis???...

G2P1+0L0 with 36wks 3 days pregnancy with moderate anemia with IUGR

INTRAUTERINE GROWTH

RESTRICTION

Tissue & organ growth

differentiation

maturation

Normal growth

hyperplasia

• First 16 wks• Rapid mitosis• Inc. in DNA content

Hyperplasia & hypertrophy

• 17-32 wks• Dec. mitosis• Inc. in cell size

hypertrophy

• After 32 wks• Inc. in cell size, fat

deposition, muscle mass & connective tissue

Phases of growth

WILLIAMS OBSTETRICS -23rd EDITION

34 wks - 30-35g/day

24 wks - 10-20g/day

15 wks - 5g/day

GENETIC POTENTIAL• Derived from both parents• Mediated through factors like insulin like growth factor

SUBSTRATE SUPPLY• Derived from placenta• Depend upon Uterine & Placental vascularity

Growth depends upon:

glucose

Amino acids

oxygen

Fetal growth

Substrate transport

Fetal growth restriction

BIRTH WEIGHT <10thPERCENTILE OF

THAT GESTATION(OR)

WEIGHT <2SD of THE MEAN

FETAL GROWTH RESTRICTION(Or)

SMALL FOR GESTATION AGE(SGA)(3-10%)

CONSTITUTIONALPATHOLOGICAL

(IUGR)

Classification of IUGR

• TYPE 1/ SYMMETRICAL /INTRINSIC: (20-30%):

• Growth inhibition early in the pregnancy (4-20 wks)• Affects Hyperplastic stage• Causes are: Intrauterine infections (TORCH)• Congenital malformations• HC, AC, FL & Weight below 10th percentile for GA • Hence Ponderal Index Wt.(gm)is normal

FL(cm)3

• Causative factor is usually uncorrectable.

Classification(Cont…)

TYPE 2/ aSYMMETRICAL /exTRINSIC:(70-80%):

• Occurs later, usually after 28 wks of GA• Affects hypertrophic stage• Due to restriction of nutrient supply in utero• Associated with maternal d/s.- Chronic Htn., Renal d/s.,

Vasculopathy etc.• Brain Sparing Effect• HC & FL- normal, AC- decreased• Ponderal index- low

Classification(Cont…)

TYPE 3/ intermediate iugr(5-10%)

• Combination of Type-1 & type-2• Affects both Hyperplasia & Hypertrophy• Associated with Chronic Htn., Lupus nephritis,

vascular d/s. in early 2nd trimester

PLACENTAL

FETAL

MATERNAL

UTERINE

PFGR/IUGR

Aetiology of iugr

PLACENTAL CAUSES

• Placenta Previa• Abruptio Placentae• Placental thrombosis or infarction• Deciduitis, Placentitis, Vasculitis, Edema• Chorioamnionitis• Placental Cyst• Chorioangioma

FETAL CAUSES

• Infections• Malformations• Heart Disease• Chromosomal abnormalities• Osteogenesis Imperfecta

Maternal causes

• Race, Weight, Height• Cardiovascular disease• Renal disease, Acidosis• Anemia• Fever• Drug intake(DES, Anticancer, Narcotics)• Smoking• Alcohol

Uterine Causes

• Decreased uteroplacental blood flow• Atheromatosis or Arteriosclerosis of the

decidual spiral arteries• Chronic Hypertension• Preeclamsia• Diabetes Mellitus• Connective tissue disorders• Fibromyomas• Morphologic abnormalities

• Perinatal morbidity & mortality of IUGR infants

is 3-20 times greater than normal infants(IanDonalds)

Complications of iugr

• Risk is increased 3times at 26 weeks compared with only a 1.13-fold increased risk at 40 weeks.(Williams 23rd edition)

Antenatal Period:• Oligohydraminos• Fetal Distress• IUD

During labour:• Still birth• Meconium aspiration• Fetal distress• Acidosis

Complications (Cont…)

neonatal period:

• Hypoxic Ischemic Encephalopathy• Persistent Fetal circulation• Difficulty in temperature regulation• Hypoglycemia• Polycythemia• Necrotising Enterocolitis

Childhood:

• Infectious Diseases• Congenital Anomalies• Cerebral Palsy(4-6 times higher)[Ian Donalds]• Subtle impairment in cognitive improvement• Educational underachievement

Long term:

Inc. risk of • Coronary Heart Disease• Hypertension• Type II Diabetes Mellitus• Dyslipidaemia• Stroke

History:

• Correct gestational age• History of Previous IUGR baby• History of disorders affecting placental function• Obstetric history• Dietary history• Drug / Radiation exposure / Addiction• Family history• Socioeconomic status

Diagnosis of iugr

Examination: General examination Systemic examination Obstetrical examination-SFH /AG

• After 20 wks SFH corresponds to the no. of wks. of gestation. (JAMES)

• Between 18-30wks. SFH coincides within 2wks of GA & a lag of 2-3cms. Denotes growth restriction (WILLIAMS)

• SFH increases by 1cm/wk b/w 14-32wks. A lag of > 4 wks denotes moderate IUGR & > 6wks denotes severe IUGR. (IAN DONALD’S)

• AG increases by 1 inch/wk. after 30 wks. It is 30inch @ 30 wks

Investigations:

Routine ANC investigations ULTRASOUND: Most useful inv.• Gestation age determination- prior to 24 wks, but most

accurate @10-12 wks

CRL is the most accurate parameter(WILLIAMS)

There is an error of around:

7days in 1sttrimester

10-11 days in 2ndtrimester

21 days in 3rdtrimester (JAMES)

• Determination of EFW: AC & EFW inc the sensitivity • Determination of multiple gestation• Determination of Fetal wellbeing

• Determination of Congenital anomalies:

@ 16-20 wks of gestation (WILLIAMS)

• Determination of placenta:

• Assessment of fetal growth:

Repeat @ 32-34 wks

BPD(Bi Parietal Diameter)- Most accurate for dating in 2ndtrimester (14-26wks) [WILLIAMS]

Proximally-outer table, Distally-inner table

WILLIAMS 23rd EDITION

MEASURED@ THE LEVEL OF THALAMUS & CAVUM SEPTUM PELLUCIDUM

HC(Head Circumference):

More accurate than BPD in

Dolicocephalic or Brachycephalic head

CEPHALIC INDEX:

Ratio of BPD to Occipitofrontal diameter.

FL(Femur Length):

Measured @ the level perpendicular to shaft excluding the epiphysis

Correlates well with the BPD & Gestational age

AC(Abdominal Circumference):

Single best parameter for detection of IUGR because it is related to the liver size which reflects fetal glycogen storage (JAMES)

Its sensitivity is further inc. by serial measurements atleast 14 days apart (JAMES)

We should not not label as growth restricted fetus unless AC is far below normal or unless other parameters correlate. (JAMES)

DONALD SCHOOL OF ULTRASOUND

ABDOMINAL CIRCUMFERENCE

TCD(Trans Cerebellar Diameter): Correlates well with the gestation age

Relatively spared in mild to moderateUteroplacental dysfunction.

Upto 25 wks TCD in cms. = GA (IAN DONALD’S)

Age independent ratios

HC/AC: Decreases linearly from 16-40wks. normally.

Ratio>2SD is suggestive of IUGR (IAN DONALD’S)

FL/AC:Normal value = 22 + 2% in second half of preg.

Ratio above23.5% is abnormal (IAN DONALD’S)

• Determination of Amniotic Fluid Volume:

Type II IUGR causes Oligohydraminos

Amniotic Fluid Index(AFI) = 5-18 cms.

Maximum Liquor Pocket = 2-8 cms.

Other investigations

Amniocentesis Karyotyping Colour doppler TORCH test Antiphospholipid antibody Thrombophillia screen Thyroid function test Detailed level II ultrasound Biophysical Profile(BPP) Cardiotocography

Presumptive diagnosis of iugr

• SFH not increasing at a normal rate

• Fetuses with small AC• Flattening of growth curve on two consecutive occasion

14 days apart

• Beyond 24 wks., an elevated umbilical artery Doppler index• After 34 wks umbilical artery Doppler index may be normal

& a dec. CPR or MCA Doppler index may be the only supporting evidence of placental-based IUGR

Based on the above findings, the fetus may have one of the four diagnosis:

• Aneuploidy• Viral infection• Placental dysfunction (Most Common)• Non Aneuploidy fetal Syndrome

Diagnostic work-up

• It is imp. to decide the cause of IUGR before delivering the fetus

Clinical suspicion of IUGR

AC/EFW<10 th PERCENTILE

Anatomical survey & AFI

•Aneuploidy•Syndromes•Viral infections

Normal / oligohydramin

os

Anomaly/polyhydra

minos

Umbilical Artery Doppler / MCA Doppler

Dec./AREDF/

brain sparing effect Placental

insufficiency

Normal

Cerebro-Placental ratio

Repeat USG after 14 days constitutional

Normal

Abnormal

Maternal & fetal therapy• Reduce/ Eliminate the potential external contributors(Stress/ smoking)• Encourage maternal rest daily in LLL• Low dose aspirin-75mg/day

Used for mild placental dysfunction

Found useful when started in 1st trimester• Fetal therapy:

Maternal Hyper oxygenation

Intra vascular volume expansion

Hyperailmentation JAMES 4th edition

• Antenatal administration of corticosteroids in <

34wk to hasten fetal lung maturity.

• Delivery of the fetus in an institution having

Neonatal care unit that can carry complex

management of the neonate with IUGR

JAMES 4th edition

Timing & mode of delivery• Frequent surveillance of growth-restricted fetuses is

essential to optimize timing of delivery & maximizing GA while minimizing the risk of neonatal morbidity & mortality

• More than 60% of the fetus with abnormal heart rate are already hypoxemic or acidemic. (STUDD)

• Doppler findings precede Biophysical profile & Non Stress Test by several wks. (STUDD)

• Umbilical A. MCA venous Doppler BPP CTG• Integrated fetal testing is used to monitor timing.

• Management algorithm depends heavily on

Gestation age(upto 29 wks)

Umbilical A. Doppler

Difficult extrauterine environment

Hostile intrauterine environment

PREMATURITY IUGR

IUGR> 24 WKS

UMBILICAL A. DOPPLER

•NST twice weekly•BPP weekly•AFI Weekly•Umbilical A. Doppler wkly•Fetal growth 3 wkly

•Hospitalise the pt.•Continuous /frequent fetal monitoring•Corticosteroids•MCA Doppler wkly•DV Doppler every 3-4days •BPP daily•Fetal growth every 3 wks

Deliver @ 37-39wksDeliver @34-36 wks

Normal / mildly

elevated

AREDF

ABNORMAL

NORMAL

NORMAL

STUDDRCOG 2013- 37wks RCOG 2013- 32wks

MODE OF DELIVERYUMBILICAL A. DOPPLER

RAISED AREDF

VAGINAL CAESAREAN

CAESAREAN

THANK YOU