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PERTU MBUHAN JANIN

TERHAMBAT (PJT)

A. Kurdi Syamsuri

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IUGR - INTRAUTERINE GROWTH

RETARDATION

defined as failure of normal fetal growth

caused by multiple adverse effects onfetus

due to process that inhibits normal

growth potential of fetus

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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

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SO WHAT IS THE DIFFERENCE

BETWEEN SGA AND IUGR?

These terms are related but non

synonimuous.

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.

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INCIDENCE

3 - 10 % of all pregnancies

10 % of general obstetric population

4-7 % of all infants born in developed countries 6-30 % of all infants born in developing countries

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IUGR : SO WHAT!

2nd leading contributor to perinatal mortality!!!

1/3 of infants with BW < 2800 gms are growth retarded and not premature.

9 - 27 % have anatomic and/or genetic abnormalities

Perinatal mortality : x 6-10

Intrapartum asphyxia : up to 50%

As many as 40% stillborn are IUGR

A portion of perinatal complication is preventable (morbidity and mortality)

Association with mutiple sequelae (short and longterm morbidity)

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PATTERNS OF GROWTH

Three phases of fetal growth and development :

1. Occurring from 4 to 20 weeks gestation, is characterized by

proportional increases in fetal weight, protein content, and DNA

content (cellular hyperplasia).

2. From 20 to 28 weeks gestation, is characterized by increases inprotein and weight and lesser increases in fetal DNA content

(hyperplasia and concomitant hypertrophy).

3. From 28 weeks to term, is characterized by continued increases

in fetal protein and weight but no increase in DNA content

(hypertrophy).

Enid Gilbert-Barness, Diane Debich-Spicer, BS. Embryo and Fetal Pathology 2004 ; 310-20.

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FETAL GROWTH CHARTSSingle Fetus

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FETAL GROWTH CHARTS

Multiple Fetus

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FETAL GROWTHRESTRICTION

Fetal :-Chromosomal (trisomy 18,13, 21)

- Mendelian single gen disorder

- Congenital structural abnormalities

- Other syndromes

Extrinsic :

-Cigarette smoking

- Alkohol / cocaine

- viral infection

Maternal :

- Hypertension

- Preeclampsia

- APS

- Trombhophilia

Placental factor :

- placental mosaicsm

- abnormal placentation

- uterine abnormality

- chronic placental

abruption

Baschat AA, Pathophysiology of Fetal

Growth Restriction: Implications for

Diagnosis and Surveillance; CME

Review Article, Vol.59 No.8 2004, 617-

627

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1. Normal small fetuses- have no structural abnormality, normal umbilical

artery & liquor but wt., is less.They are not at risk and do not need any

special care.

2. Abnormal small fetuses- have chromosomal anomalies or structuralmalformations.

3. Growth restricted fetuses- are due to impaired placental

function.Appropriate & timely treatment or termination can improve

prospects.

Classification

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Symmetrical growth restriction :

comprises 20 to 30 percent,

all fetal organs are decreased proportionally

due to impairment of early fetal cellularhyperplasia (early onset)

such as chromosomal abnormalities and

congenital malformations, drugs or other

chemical agents, or infection

Robert Resnik, MD Intrauterine Growth Restriction. AMJOG vol. 99; 3; march 2002 : 490-6

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Asymmetrical growth restriction :

comprises 70 to 80 percent

extrinsic factors, limited fetal metabolic substrate

availability (most commonly maternal vascular disease

and decreased uteroplacental perfusion)

the skeletal dimensions and head circumference are

spared and the abdominal circumference is decreased

because of subnormal liver size and a paucity of

subcutaneous fat late onset

Robert Resnik, MD

Intrauterine Growth Restriction. AMJOG vol. 99; 3; March 2002 : 490-6

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BARKER: BAYI YANG MENDERITA PJT LEBIH BANYAK YANG

MENDERITA KELAINAN METABOLIK, HIPERTENSI DAN

KELAINAN JANTUNG DI MASA DEWASA

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ULTRASOUND DIAGNOSTIC

The most common determination of fetal growth

restriction is based on the EFW, determined from a

combination of BPD and AC (Campbell,1975)

Fetal measurements using formulas of BPD, HC, AC and

FL, have the highest accuracy for in utero weight

estimation

The best interval for serial scanning is every 2-3 weeks.

Dr. Helen Kay, Professor of OB-GYN , Director, Division of Maternal-Fetal Medicine ,

University of Wisconsin Meriter Hospital, Madison, Wisconsin

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DIAGNOSTIC

- Last Menstrual Period (menstrual diary)

- Curvilinear fundal height measurements in centimetersfrom the symphysis pubis could be closely correlatedwith gestational age: a lag of 4 cm or more suggestsgrowth restriction (Belizan et al)

- A sensitivity of only 27 percent and a positivepredictive value of 18 percent using carefullyperformed fundal height measurements to detect IUGR(Persson et al)

- Additional studies have confirmed the lack ofsensitivity of fundal height measurements for detectingfetal growth restriction.

Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed.

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ULTRASOUND DIAGNOSTIC

Ratio of HC/AC, which normally exceeds 1.0 before 32

weeks, 1.0 at 32-34 weeks and falls below 1.0 after 34 weeks

In asymmetric IUGR, the HC remains larger compared to theAC because of the brain sparing growth phenomenon

In symmetric IUGR, the HC and AC are both reduced and

therefore, the HC/AC ratio is not helpful

Dr. Helen Kay, Professor of OB-GYN , Director, Division of Maternal-Fetal Medicine ,

University ofWisconsin Meriter Hospital, Madison, Wisconsin

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ULTRASOUND DIAGNOSTIC

One other ratio that may be useful is the FL/AC ratio. In

asymmetric IUGR, the FL is spared in comparison to the

AC measurements from 21 weeks on and therefore, a ratio

greater than 23.5 suggests the presence of IUGR.

Dr. Helen Kay, Professor of OB-GYN , Director, Division of Maternal-Fetal Medicine ,

University ofWisconsin Meriter Hospital, Madison, Wisconsin

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ULTRASOUND DIAGNOSTIC

Fluid measurements

Decreased amniotic fluid volume has been associated with IUGR

This is due to poor perfusion of the fetal kidneys and therefore

decreased urine production.

A 2-cm vertical pocket was considered normal, 1 to 2 cm

marginal, and less than 1 cm decreased. Manning et al observed :

6 percent incidence of IUGR with a pocket 2 cm or larger, 20

percent with a pocket 1 to 2 cm, and 39 percent with a pocket less

than 1 cm. One may also use the amniotic fluid index to quantitate

amniotic fluid volume

Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed.

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ULTRASOUND DIAGNOSTIC

Doppler SonographySystolic/diastolic flow velocity ratios correlate with

placental resistance :

a. Decrease over the course of pregnancy

b. Increased values for gestational age indicate increased placental

resistance

c. Absent or reversed end diastolic flow is often associated with

imminent fetal compromise

Enid Gilbert-Barness, Diane Debich-Spicer, BS. Embryo and Fetal Pathology 2004 ; 310-20.

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EARLY NEONATAL MORBIDITY

RDS

Meconium aspiration

Hypoglycemia

Hypocalcemia

Hypothermia

Polycythemia, hyperbilirubinemia Thrombocytopenia

Pulmonary hemorrhage

Necrotizing enterocolitis

Sepsis

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LONG-TERM OUTCOME

Depend on underlying cause Poor cognitive function

Adverse neurological outcome in

childhood Impaired gross motor development,

hyperactivity, poor concentration, lower IQ,

speech and reading disabilities (Gembruch

& Gortner 1998)

Cerebral palsy

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LONG-TERM OUTCOME

David Barker, epidemiologist from England

Fetal origin of adult diseases: The risk of coronary artery

disease, stroke and hypertension Intrauterine conditions could program development

of the cardiovascular system later in life

Infants with birth weight less than 5.5 lb had a 3x increasein death due to coronary artery disease later in life.

Other risks: Abdominal obesity, type 2 diabetes mellitus,

hyperlipidemia

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Reported associations between impaired fetal growth with various outcomes

Increased cardiovascular disease (CVD) mortality and possible CVD risk factors:

Raised blood pressure (Barker and Martyn, 1997)

Impaired glucose tolerance/type 2 diabetes/gestational diabetes (Barker, 1999a)

Dyslipidaemia: higher cholesterol, LDL-cholesterol and triglycerides levels (Barker,

1999b)

Obesity (Fall et al., 1995)

Higher plasma levels of fibrinogen, Factor VII and other blood-clothing factors (Martyn etal., 1995)

Renal disease/increased mean albumin:creatinine ratio (Garrett et al., 1993)

Reduced arterial compliance (Leeson et al., 1997)

Higher plasma leptin concentrations (Lissner et al., 1999)

Increased thryroid function (Phillips et al., 1993) Higher sympathetic nervous system activity (Philips and Barker, 1997)

Higher plasma cortisol levels (Phillips et al., 2000)

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Reported associations between impaired fetal growth with various outcomes

Psychological disorders:

Increased risk of schizophrenia (Hoek et al., 1996) Increased risk of depression (Thompson et al., 2001) Increased risk of suicide (Barker et al., 1995a)

Respiratory disorders:

Increased risk of asthma (Xu et al., 2002) Increased risk of chronic obstructive pulmonary disease (Barker et al., 1991)

Early menarche (dos Santos Silva et al., 2002)

Early menopause (Cresswell et al., 1999)

Ovarian cancer (Barker et al., 1995b)

Osteoporosis (Dennison et al., 2001)Lower IQ scores (Sorensen et al., 1997)

Lower rates of marriage (Phillips et al., 2001)

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MANAGEMENT

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SKORE PROFIL BIOFISIK

5 variabel : skore 0 10

NST, FBM, FM, FT, AF

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MANAJEMEN

Nilai BBP 8-10 observasi 7 hari

Nilai BPP 6 observasi tiap 3-4 hari, bila

usia > 34 minggu /paru matang - induksi,

awasi persalinan, KTG berkala

Nilai BPP

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MANAGEMENT

If delivery is not elected, or indication for delivery is notcertain, the patient should undergo continuous monitoring

of fetal condition

Evidence of fetal lung maturity may provide sufficient

reassurance to proceed with delivery in many instances

Robert Resnik, MD

Intrauterine Growth Restriction. AMJOG vol. 99; 3; march 2002 : 490-6

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MANAGEMENT

The term or near-term IUGR fetus should be delivered ifthere is evidence of :

- maternal hypertension, or

- failure of apparent growth over a 24 week period, or

- the BPP score is low (less than 6), and/or- umbilical arterial Doppler velocimetry reveals absence

or reversal of flow

Robert Resnik, MD

Intrauterine Growth Restriction. AMJOG vol. 99; 3; march 2002 : 490-6

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DELIVERY IS INDICATED IN FOLLOWING

CONDITIONS

When end diastolic flow is present (PED), andother surveillance findings are normal, delaydelivery to 37 weeks.

When end diastolic flow is absent or reversed,deliver at 34w regardless of biophysical tests

When end diastolic flow is absent or reversed andother surveillance results (biophysical profile,venous Doppler) are abnormal, delivery is indicatedat any time

RCOG 2002, Evidence Level IIA

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ANTEPARTUM FETAL

MONITORING

Doppler velocimetry of the

umbilical arteries

40% of combined ventricular

output is directed to the placenta

by umbilical arteries. Assessment of umbilical blood

flow provides information on

blood perfusion of the

fetoplacental unit.

Volume of flow increases and

vascular impedance decreaseswith advancing gestational age.

Low vascular impedance allows

a continuous forward blood flow

throughout the cardiac cycle.

Th k h

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Thank you very much