بسم الله الّرحمن الّرحیم. Definition: fetus uniforfmly small for gestational...
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Transcript of بسم الله الّرحمن الّرحیم. Definition: fetus uniforfmly small for gestational...
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بسم اّلله اّل�رحمن اّل�رحیم
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• Definition: fetus uniforfmly small for gestational age
• Etiologies of symmetric IUGR:• Genetic disorders( e.x: trisomy 18,13,10 )• Fetal infections (e.x: cmv, para
virus ,Rubella)• Congenital malformations • Syndromes( e.x: AIDS embryopathy,
Cornelia de lange )
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Ultrasonographic findingsin Symmetric IUGR
1-size less than expected for dates 2- structural survey more likely to be abnormal than with asymmetric IUGR ( aneuploidy ) 3- second trimester finding of echogenic bowel associated with IUGR in 10-20% cases.4- usually a primary fetal abnormality ,not placental insufficiency 5-DOPPLER is not as helpful as in asymmetric IUGR .6- Does not exhibit “ head sparing “ flow in M.C.A .
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Imaging Recommendations
1- know accurate dating 2- early ultrasound is more accurate than LMP or clinical assessment of GA .3- First trimester CRL measurments accurate to within +/- 0.7 weeks.4- second trimester dating base on composite of several measurments ( BPD, HC,AC, FL )5- second trimester dating accurate to within +/- 1.5 weeks .6-Third trimester dating accurate to within +/- 3-4 weeks .7- Look at ossification centers, helps verify dating when patient present late in gestation .Distal femoral epiphysis > 32 wProximal tibial epiphysis > 35 w
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8- Evaluate amnotic fluid volume IUGR + polyhydramnios high risk for trisomy 18 Low fluid poor outcome 9- look at anomalies :Symmetric IUGR has strong associated with aneploidy Multiple anomalies + early onset IUGR triploidy ,trisomy 13,1810- Look at fetal hands :Clenched fingers trisomy 18 Postaxial ploydactyly trisomy 13Syndactyly triploidy
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Asymmetric IUGR
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Causes of UPI
1)Placental Disorders
• Chronic placental abruption • Placenta previa • Mosaicism ( e.x: localized placental trisomy 16 ) • Marginal or Velamentous cord insertion • Primary placental disorders • Poor placentation
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2) Maternal Etiologies A: Behavioral states • Smoking • Cocaine abuseB: Chronic medical condition • Chronic lung disease (chronic obstructive pulmonary disease ,
Emphysema)• Diabetes mellitus• Chronic hypertension• Collagen vascular disorders ( e.x: lupus ) • Acquired thrombophilias ( e.x: Antiphospholipid antibody
syndrome)• Inherited thrombophilias ( e.x: Factor 5 leiden ,prothrombin
20210A mutution)
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Development of placenta
1)First trimester :
A: Placental attachmentB: AngiogenesisC: Cellular transport mechanismD: Onset of distribution & disposal of various substances between the maternal- fetal circulation by the onset of fetal cardiac activity .
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2) The second trimester : A: Trophoblastic invasion in to the uterine B: Vascular remodeling C: Massive increase in total villous sureface area Capacity for maternal – fetal exchange Fetal cardiac output
3) The tird trimester : Establishment of fetal stress especially body fat because of fetus extra uterine existence
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Doppler Velocimetry
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Fetal Arterial Doppler
1)Umbilical Artery
2) Middle Cerebral Artery
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(2) Middle cerebral artery• MCA is the most accessible cerebral vessel in
ultrasound imaging in the fetus.
• MCA carries 80% of cerebral flow.
• Cerebral circulation is a High-impedance circulation( reverse of Umbilical artery)
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Brain Sparing Reflex( fetal adaptation to oxygen deprivation)
Fetal hypoxemia
Increase blood flow to the brain ,heart and adrenals
Reduction in flow to the peripheral and placenta
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Clinical applications of uterine artery Doppler
• In vitro fertilization o uterine receptiveness for implantation• Risk assessment for maternal complications of
pregnancyo PIHo Pre-eclamptic toxemia• Risk assessment of poor fetal outcomeo IUGRo SGA infant
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Treatment• Randomised controlled trials are currently in progress o Aim to see if abnormal uterine artery Doppler in early
pregnancy can be effectively treated before onset of pregnancy complications
• Treatment options:o Aspirineo Vitamins E/Co Low molecular weight Heparine
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Fetal venus Doppler• Obtain from fetal central venus circulation
• Reflect the physiology status of the right ventricle.
• Inferior vena cava and ductus venosus are the most important
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