1. Intrauterine Growth Restriction IUGR

2. Normal Intrauterine Growth
Stage 1
Stage 2
Stage 3
Hyperplasia
Hyperplasia/ hypertrophy
Hypertrophy
4-20 weeks
20-28 weeks
28-40 weeks
Rapid mitosis
Declining mitosis
Rapid hypertrophy
Increasing DNA content
Increasing cell size
Rapid increasing cell size
rapid accumulation of fat, muscle, connective tissue
Symmetric
Mixed- asymmetric
Asymmetric

3. Symmetric - Stage I growth inhibition
Fewer cells but normal size
- weight, head, length all < 10th percentile
Perinatal problems?
Higher
Lower
Growth potential?

4. Asymmetric - Stage II/III growth inhibition
Decrease in cell size, less effect on total cell number
- weight below 10th percentile,head and length preserved
Perinatal problems?
Higher
Lower
Growth potential?

5. What factors affect fetal weight?
Sex
term males 150 gm heavier and 0.9 cm longer than females
Parity
1st born infants smaller
effect loss after 3rd birth
Race, ethnicity, nationality
Altitude
Denver population growth curves under estimate weights of infants born at sea level
Maternal size
maternal pre-pregnancy weight and pregnancy weight gain correlate with fetus size

6. “Maternal constraint”- non-genetic
Number of fetuses
Reduced rate of fetal growth of multiples
Small breed embryo transplanted into large breed uterus will grow larger

7. Hormonal Factors Insulin Major hormone for in utero growth
Produced by fetus
Promotes fetal adipose deposition, glycogen stores

8. Etiology- Overlapping
Maternal, Fetal, Placenta
Maternal factors
Medical disease (US)
Malnutrition (world-wide)
Multiple pregnancy
Drugs
Hypoxemia
Small stature/ low pre-pregnancy weight
Teen pregnancy
Low SES
Prima gravida
Grand multiparity

9. Fetal Genetic Congenital malformations
Genetic/ chromosomal (trisomies, syndromes)
Cardiovascular disease
Congenital infection
Inborn errors of metabolism

10. Placenta placental insufficiency anatomic post dates
abnormal insertion
hemangiomas
infarcts
abruption

11. Diagnosis Algorithm IUGR TORCH stigmata  work-up? no
yes
TORCH stigmata  work-up? no
Dysmorphic features  work-up?

12. Case # 3
Infant is delivered at 38 weeks to mom who presents with headaches and epigastric pain
BW: 2.1 kg
HC: 50th%tile
Lt: 30th%tile
Pre-eclampsia/ HELLP

13. Case # 3- What if?
Mom with no prenatal care delivers undiagnosed twins at EGA 34 weeks
Discordant twins

14. Case # 3- What if?
An infant is delivered at 42 weeks via c- section due to NRHTs after induction
Post dates
- decreased subcutaneous fat
- skin desquamation
- wizened facies
- large AF(diminished membranous bone formation)
- meconium staining

15. Diagnosis Algorithm IUGR yes TORCH stigmata  work-up? no
Dysmorphic features  work-up?
Maternal/placental explanation work-up?

16. Case # 3- What if?
Infant delivered at EGA 34 weeks to mom with no prenatal care and positive tox screen

17. Diagnosis Algorithm IUGR yes TORCH stigmata  work-up? no
Dysmorphic features  work-up?
Maternal/placental explanation work-up?
Maternal drug use tox screen
Unknown cause

18. True or False True IUGR infants are prone to asphyxia Why or why not?
Perinatal hypoxia
Chronic and acute
Increased C/S rate, decreased Apgar, increased resuscitation need

19. An IUGR infant is at risk for
Hypothermia?
Hypoglycemia? Or
Hypocalcemia?
decreased subcutaneous fat, increased surface- volume ratio, decreased heat production
decreased glycogen stores/ glycogenolysis/ gluconeogenesis
increased metabolic rate
deficient catecholamine release
Associated with perinatal stress, asphyxia, prematurity

20. Which lab result(s) would not be associated with IUGR?
WBC 4, S8 & B1
H & H 11/ 33
Plt 65
PT 16
PTT 56
Direct bilirubin 4.5
Neutropenia
Polycythemia
Elevated erythropoietin
Thrombocytopenia
Elevated coags
TORCH

21. Which CxR is more consistent with IUGR?
Increased meconium aspiration
Decreased surfactant deficiency

22. Perinatal problems Perinatal asphyxia Hypothermia Hypoglycemia
Hypocalcemia
Polycythemia, hyperviscosity
Thrombocytopenia
Neutropenia
Elevated coags
Decreased surfactant deficiency
Increased meconium aspiration syndrome
Direct hyperbilirubinemia

23. Evaluation and Management
Physical exam
Labs
- blood sugar - urine shell vial (CMV)
- calcium - viral cultures (HSV)
- CBC diff/plt - syphilis w/u
- bilirubin - tox screen
- head ultrasound - chromosomes
- total IgM vs specific

24. Quick algorithm

25. Evaluation and Management
Monitor postnatal weight gain/ head growth
needs may exceed cal/kg/d
catch- up by 6-12 months
Hypersomatotropism- accelerated growth velocity
? Safety of aggressive feeding
rapid weight gain may predispose to childhood obesity highest risk for developing type 2 DM

26. IUGR- Outcome Neurodevelopment etiology and adverse event dependent
lower intelligence, learning/ behavioral disorders, neurologic handicaps
symmetric, chromosomal disorders, congenital infections--- poorer outcome
school performance influenced by social class

27. World’s smallest…..