PathophysiologyPathophysiology

3) Placental Factors: Placental insufficiency ( most imp in 3rd trimester) Anatomic problems:

– Multiple infarcts– Aberrant cord insertions– Umbilical vascular thrombosis & hemangiomas– Premature placental separation– Small Placenta

Postnatal AssessmentPostnatal Assessment

Growth parameters: weight, height, HCAssess GA with Ballard score.Plotted growth parameters in growth chart

Physical AppearancePhysical Appearance

Physical appearance:Physical appearance:

• Heads are disproportionately large for their trunks and extremities

• Facial appearance has been likened to that of a “wizened old man”.

• Long nails.• Scaphoid abdomen

• Signs of recent wasting - soft tissue wasting - diminished skin fold thickness - decrease breast tissue - reduced thigh circumference

• Signs of long term growth failure - Widened skull sutures, large fontanelles - shortened crown – heel length - delayed development of epiphyses

• Comparison to premature infants,IUGR has brain and heart larger in proportion to the body weight, in contrast the liver, spleen, adrenals and thymus are smaller.

ComplicationComplicationHypoxia

- Perinatal asphyxia- Persistent pulmonary hypertension- meconium aspiration

Thermoregulation- Hypothermia due to diminished subcutaneous fat and elevated surface/volume ratio

ComplicationsComplications

Metabolic - Hypoglycemia

- result from inadequate glycogen stores.- diminished gluconeogenesis.- increased BMR

- Hypocalcemia- due to high serum glucagon level, which

stimulate calcitonin excretion

ComplicationsComplicationsHematologic

- hyperviscosity and polycythemia due to increase erythropoietin level sec. to hypoxia

Immunologic- IUGR have increased protein catabolism and decreased in protein, prealbumin and immunoglobulins, which decreased humoral and cellular immunity.

ManagementManagementAntenatal diagnosis and management is the

key to proper management of IUGRDelivery and Resuscitation

- appropriate timing of delivery- skilled resuscitation should be available- prevention of heat loss

Hypoglycemia- close monitoring of blood glucose- early treatment ( IV dextrose, early feeding )

ManagementManagement Hematological Disorder

- central Hct to detect polycythemia- CBC with diff to r/o leukopenia or thrombocytopenia

Congenital infection- infant should be examined for signs of congenital infection (eg.rash, microcephaly hepatosplenomegaly, lymphadenopathy, cardiac anomalies etc….)- TORCH titer screening- Viral cx of urine, nasopharynx- Head CT to r/o calcification

ManagementManagementGenetic anomalies

- screening as indicated by physical exam- chromosomal analysis (infant with dysmorphic features)

Others- serum calcium to r/o hypocalcemia- fractionated bilirubin sec to polycythmia, congenital infection- urine, meconium tox for substance abuse

ManagementManagement

Early feeding and caloric intake should be 100-120 kcal/kg/d

Developmental and growth f/u in all IUGR infants

OutcomeOutcome

Symmetric vs. Asymmetric IUGR- symmetric has poor outcome compare to asymmetric

Preterm IUGR has high incidence of abnormalities IUGR with chromosomal disease has 100%

incidence of handicap Congenital infection has poor outcome - handicap

rate > 50% IUGR has higher rate of learning disability.

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