Understanding Intrauterine Growth Retardation: Causes, Diagnosis, and Management

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SEMINAR ON :
INTRA UTERINE GROWTH
RETARDATION
 
OBJECTIVE
 
Introduce the intrauterine retardation
Define the intrauterine retardation
Discuss the incidence of intrauterine retardation
Discuss the normal  fetal growth  incidence of intrauterine retardation
Discuss the etiology of intrauterine retardation
Explain the classification of intrauterine retardation
Explain the pathophysiology of intrauterine retardation
Discuss the symptoms of intra uterine growth retatdation.
Discuss the diagnosis of tntra uterine growth retardation.
Describe the management
 
INTRODUCTION
 
Intrauterine growth restriction
 (
IUGR
) refers to poor
growth of a fetus while in the mother's womb during
pregnancy. The causes can be many, but most often
involve poor maternal nutrition or lack of adequate
oxygen supply to the fetus.The growth of the fetus is
abnormally slow. When born, the baby appears too
small, relative to its dates. Intrauterine growth restriction
is associated with increased risk of medical illness and
death in the newborn.
 
DEFINITION
 
Intra uterine growth restriction is said to be
present in those babies whose birth weight is
below the term the tenth persentile of the average
for the gestational age.
Growth restriction can occur in preterm,term or
post-term babies.
 
Incidence
 
 In developed countries, its overall incidence is about 3-10%
 Term babies- 5% • Post-term babies-15%
 2nd leading contributor to the Perinatal mortality rate
20% of all stillbirths are IUGR.
Incidence of intrapartum asphyxia in cases of IUGR has been
reported to be 50%.
 
NORMAL FOETAL GROWTH
 
 
Cellular hyperplasia.
 
 Hyperplasia and hypertrophy.
 
 Hypertrophy.
 
STAGES
 
 Stage- I (Hyperplasia) - 4 to 20 weeks - Rapid mitosis -
Increase of DNA content
 
Stages - Stage II (Hyperplasia & Hypertrophy) - 20 to 28
weeks - Declining mitosis. - Increase in cell size.
Stages - Stage III ( Hypertrophy) - 28 to 40 weeks - Rapid
increase in cell size. - Rapid accumulation of fat, muscle
and connective tissue. • 95% of fetal weight gain occurs
during last 20 weeks of gestations.
 
CAUSES
 
IUGR has many causes related to mother, foetus and placenta (part
that joins the mother and foetus). Various risk factors for IUGR can
be summarized as-
:
A. Maternal causes 
Before pregnancy
Low pre-pregnancy weight and small maternal size
Poor periconceptual nutrition.
Multiple gestations
 
DURING PREGNANCY
 
Poor weight gain during pregnancy, especially in latter half
Moderate to heavy physical work
Chronic illness – such as malabsorption, diabetes, renal
disease
Use of certain drugs, smoking, and alcohol
Pregnancy induced hypertension
Decreased oxygen availability such as in high altitude, severe
maternal anemia
 
cy
 
B.UTERINE AND PLACENTAL FACTORS
 
Inadequate placental growth
Uterine malformations
Decreased utero-placental blood flow (such as in
toxemias of pregnancy, diabetic vasculopathy)
Multiple gestations
 
C
.FETAL CAUSES
 
1
. 
Congenital Infections:
The growth potential of fetus may be severely impaired
by intrauterine infections.
 The timing of infection is crucial as the resultant effects
depends on the phase of organogenesis.
 Viruses- rubella, CMV, varicella and HIV 
 rubella is the
most embryotoxic virus, it cause capillary endothelial
damage during organogenesis and impairs fetal growth.
 Protozoa- like malaria, toxoplasma, trypanosoma have
also been associated with growth restriction.
 
Conti..
 
2
. Structural Anomalies-
All major structural defects involving CNS,CVS,GIT,
Genitourinary and musculoskeletal system are associated
with increased risk of fetal growth restriction. If growth
restriction is associated with polyhydramnios, the
incidence of structural anomaly is substantially increased.
3. Genetic Causes-
Maternal genes have greater influence on fetal growth.
Inborn errors of metabolism like agenesis of pancreas,
congenital lipodystrophy, galactosemia, phenylketonuria
also result in growth restriction of fetus
 
 
CLASSIFICATION
 
 
Symmetric or primary IUGR
: In this condition all
internal organs are reduced in size. It is found in 20%-
30% of all cases of IUGR.
Asymmetric or secondary IUGR
: In this condition the
head and brain are normal in size, but the abdomen is
smaller. It is evident mostly in the 3
rd
 trimester. It is more
common and found in 70% to 80% of total IUGR cases.
 
 
.
Pathophysiology
 
Reduced availability of nutrients in mother.
 
 
Reduced transfer by placenta to fetus.
 
 
 Reduced utilisation by fetus Brain size (asymmetric) as well
as cell no (symmetric) are reduced Liver glycogen content is
reduced Renal and pulmonary contribution to amniotic fluid
are diminished due to reduced blood flow.
 
 
Conti..
 
 
Oligohydramnios Risk of intrauterine hypoxia and acidosis
 
 
 
death if severe
 
 
Accelerated maturation
 
 
conti...
 
Accelerated fetal pulmonary maturation in complicated
pregnancies associated with growth restriction
 
 
 Fetus responds to a stressed environment by increasing
adrenal glucocorticoid production, which leads to earlier
or accelerated fetal lung maturation
 
Symptoms
 
The main symptom of IUGR is a small for gestational age
baby. During the antenatal checkup, a doctor measures the
height of the uterus from the pubic bone to estimate the
size of the fetus. After about the 20th week, uterine fundal
height in centimeters is usually equal to the number of
weeks of the pregnancy. A lag in fundal height of 4 cm or
more with weeks of pregnancy suggests IUGR, and
additional tests are required to confirm diagnosis.
 
CONTI..
 
During ultrasound, the baby’s estimated weight
with IUGR is below the 10th percentile or less
than that of 90% of babies of the same gestational
age. At term, the birth weight less than 2,500 g (5
lb, 8 oz) is considered as IUGR. Not all babies that
are born small have IUGR. In most severe cases
IUGR can lead to stillbirth.
 
 
Baby is small all over or malnourished.
Thin, pale, loose and dry skin
Umbilical cord is thin and often stained with
meconium
 
 
At term birth, symptoms of
IUGR are:
 
Diagnosis
 
One of the most important things when diagnosing IUGR
is to know accurate gestational age of baby. Gestational
age can be calculated by using the first day of last
menstrual period (LMP) and also by early ultrasound
calculations. Once the gestational age is known the
following methods can be used to diagnose IUGR.
 
F
UNDAL HEIGHT
 
It is the simplest and most common method to diagnose
IUGR. Fundal height is size of uterus measured as the
distance from the pubic bone to the top of the uterus in
centimeters. After the 20th week of pregnancy, the
measure in centimeters usually corresponds with the
number of weeks of pregnancy. A lag in fundal height of 4
cm or more suggests IUGR.
 
WEIGHT CHECKUP
 
Doctors routinely check and record the
mother’s weight at every prenatal
checkup. If a mother is not gaining
weight properly, it could indicate a
growth problem in her baby.
 
ULTRASOUND
 
It is used to measure the baby’s head
and abdomen and compared with
growth charts to estimate the baby’s
weight. Ultrasound can also be used to
determine amniotic fluid.
 
DOPPLER ASSESSMENT
 
 
It is a technique that uses sound waves to measure
the amount and speed of blood flow through the
blood vessels. Doctors may use this test to check
the flow of blood in the umbilical cord and vessels
in the baby’s brain. Abnormal Doppler tests are
diagnostic of IUGR.
 
MANAGEMENT
 
Constitutionally small.
no intervention  symmetric IUGR investigated for
anomalies infections, genetic syndromes .
 Placental disease or reduced placental blood flow
May be given some treatment.
No effective therapy.
 
Conti.
 
A..
General No proven therapy for reversing IUGR once it has
established
 1
. Adequate bed rest specially in left lateral position
 2. Correct malnutrition by balanced diet- 300 extra calories per day
 3. Appropriate therapy for complicating factors likely to produce
IUGR
4. Avoidance of smoking, alcohol
 5. Maternal yperoxygenation at the rate of 2.5 mL/min by nasal
prong ,for short term prolongation of pregnancy 6. Low dose
aspirin (50 mg daily) in selected cases with history of thrombotic
disease, hypertension, pre- eclampsia or IUGR
 
CONTI..
 
Antepartum evaluation Serial evaluations of fetal growth
and assessment of well being should be done-
 • USG- intervals of 3-4 weeks for assessment of BPD,
HC/AC, and fetal weight.
 • Fetal well being- kick count, NST, biophysical profile,
amniotic fluid volume and cordocentesis for blood gases
 • Doppler ultrasound parameters
 
Conti..
 
Time of delivery Factors to be considered:
 1. Presence of fetal abnormality
 2. Duration of pregnancy
3. Degree of growth restriction
 4. Associated complicating factor
 5.Previous obstetric history
 6. Availability of NICU
 
Conti.
.
 
 Severe degree of IUGR-
 • If lung maturation is achieved Presence of phosphatidyl
glycerol and L:S ratio at least 2 from amniotic fluid study 
termination.
 • Lung maturation not yet achieved problems- prematurity,
growth restriction Preterm IUGR requires highest level of NICU
Betamethasone therapy - <34 week Corticosteroid reduce risk of
neonatal HMD and IVH
 
Conti..
 
Methods of delivery Route and time decided considering:
 1. Severity of IUGR .
2. Maternal condition .
3. Any other obstetric complication Low rupture of membranes followed by
oxytoxin.
 • Beyond 34 weeks with favourable cervix and head is deep in pelvis.
 • PGE2 gel when cervix unfavourable Intrapartum monitoring by clinical ,
continuous electronic and scalp blood sampling is needed as risk of
intrapartum asphyxia is high
 
Conti..
 
Care during vaginal delivery-
 
• Equipped institution where intensive intranatal monitoring (clinical
and electronic) is possible and having facilities for NICU.
 • precautions Caesarean section without a trial of labour- when risks
of vaginal delivery are more( fetal acidemia, absent or reversed
diastolic flow in umbilical artery or unfavourable cervix)
 
Conti..
 
First stage-
 • Ensure adequate fetal oxygenation by giving oxygen to mother by mask.
 • Epidural analgesia is of choice.
 • Labour carefully monitored preferably with continuous EFM Second
stage.
 • Birth should be gentle and slow to avoid rapid compression and
decompression of head.
 • Episiotomy may be done to minimise head compression • Tendency to
delay is curtailed by low forceps.
 • Cord is to be clamped immediately at birth
 
 
Management protocol of IUGR-
 
To confirm IUGR and type.
 •To exclude cong malformation.
 •To treat specific cause if found.
 
Conti..
 
Mild IUGR
Increased rest.
 •Folic acid
 •Increased fliud intake
 •Fetal monitoring till 37 weeks Delivery Dual problem
 
Conti..
 
care of low birth weight baby 
immediate management following birth
- the cord is to be clamped quickly to prevent hypervolaemia and
development of hyperbilirubinemia cord length is kept long ( 10-12 cm)
in case exchange transfusion is required.
 Air passage should be cleared of mucus promptly and gently using a
mucus sucker  adequate oxygenation through mask or nasal catheter in
concentration not exceeding 35%  baby should be wrapped including
head in a sterile warm towel (36.5-37.5 ⁰C) . aqueous solution of vitamin
K 1 mg is to be injected i.M. To prevent haemorrhagic manifestations
Hypothermia and sequelae: hypoxia hypoglycemia anaerobic metabolism
metabolic acidosis
 
Conti..
 
Maintaining body temperature • Delivery room dept warm, dry •
With mother- skin to skin contact • Best placed in incubator where
temperature and humidity(50%) can be better stabilised
 Under radiant warmer with protective plastic covers. Baby is
placed naked. • If not possible to maintain for entire room, cot is
kept warm( 30 ⁰C). Rubber hot water ( not boiling) bottles
stoppered and well covered with clothings
 
Conti..
 
Infection- • Respiratory tract, GIT, skin, umbilicus • Poor defensive
power of neonates with low WBC count and poor phagocytic
activity make baby more vulnerable • Prophylactic antibiotic
therapy in premature rupture of membranes • Every precaution to
prevent infection • Ampicillin 100 mg/kg per day or amikacin 10-
15 mg/kg per day i.v. in 2 divided doses for 5-7 days
 
Nutrition -• Enteral feeding depending on gestation age and vigour
• May require gavage feeding/ parenteral nutrition • Human milk is
1st choice.
 
 
Tube/ Gavage:-
 • Fine polythene tube 0.5 mm internal diameter.
 • Through nose down to oesophagus.
 • Expressed milk is started with small volume and gradually build up.
• Continued for about 7 days.
 • Calculated amount is injected with syringe by gravitation/pressure
 
 
 Pipette, dropper, katori and spoon- where baby can swallow but
fails to suck-
 • Bottle- when baby can suck and swallow but can’t manage to
express milk from the breast.
 • I.v. fluids- neonates within incubator/radiant warmer.
 •Net reqt= 60-80 mL/kg/day of 10% dextrose water on 1st day,
increase by 15 mL/kg/day.
 •More amount(10%) if phototherapy
 
 
Additional supplements-
 • Started after 2 weeks.
 • Vitamin A 2500 IU, vitamin D 400 IU,vitamin C 50 mg, folic acid
65 µg, vitamin B1 0.5 mg.
 • Iron- liquid preparation 2-4 mg/kg/d in 2 divided doses • calcium ,
phosphate.
 • I.v. gamma globulin therapy(400 mg/kg/dose) to prevent infections •
<1200 g- parenteral nutrition with a.a, lipids with dextrose and
multivita
 
Conti..
 
Favourable signs of progress-
 • Colour of skin remains pink all the time
 • Smooth and regular breathing
• Increasing vigour –movements of limb, cry
• Progressive gain in weight.
 
 
Conti..
 
 
Discharge-
 • When they attain sufficient weight
 • About feeding schedule
 • Prescribe suitable multivitamin and oral iron preparation
 • To attend child welfare clinic for subsequent check up,
immunisation and guidance Supervision continued at home
by public health nurses or health visitors if possible.
 
COMPLICATION
 
IUGR causes many health problems during pregnancy, delivery, and
after birth. These include:
 
Difficulty during vaginal delivery
Low Apgar scores (a test done immediately after birth to evaluate the
newborn’s physical condition to determine need for special medical care)
Meconium aspiration (inhalation of stools passed while in the uterus),
which can lead to breathing problems
low birth weight
High red blood cell count
Low resistance to infection
 
 
Prevention
 
Care before  pregnancy:
Providing care to women before and between pregnancies (inter-
conception care) improves the chances of mothers and babies being
healthy.
Advocating healthy eating and physical activity to women in their
daily routine to improve weight and cardiovascular status before
pregnancy.
Diagnosis and management of chronic diseases such as
hypertension, diabetes before pregnancy.
Correction of anaemia/folic acid supplementation before pregnancy.
 
Conti..
 
Care during pregnancy
:
Pregnant mothers should take only those medicines which are
prescribed by doctors.
Healthy diet should be advised to pregnant women with behavior
change to encourage healthier eating patterns during pregnancy.
Foods fortified with nutrients can be provided to pregnant women.
Pregnant women are advised to take enough rest with proper
duration of sleep during night and an hour or two of rest in the
afternoon.
Expectant mothers should follow healthy lifestyle habits. Tobacco
use, smoking and alcohol intake should be avoided during
pregnancy.
 
Conti..
 
Care after  delivery-
Delivery should be planned in health facilities
having emergency obstetric care and neonatal care
facilities
.
 
summary
 
Intrauterine growth restriction
(
IUGR
) is a
medical term which refers to a baby who is not
growing normally within the womb. In general,
this label is for babies who weigh less than the
10th percentile for their gestational age, or period
of pregnancy
.
 
BIBLIOGRAPHY
 
Ghai, O.P. (2008).Ghai essentials of paediatrics.(ed.6
th
).Delhi. O.P
Ghai publishers.
Gupta,P.(2004).Essentials of paediatric nursing.(ed.1
st
).New
Delhi:A.P Jain &Co Publishers.
Marlow.& Redding.(2008).Text book of paediatric
nursing.(ed.6
th
).Philadelphia: Elsevier publications.P.NO.-57,58
Wong, D.L& Hockenberry.(2001).Wong’s essentials of paediatric
nursing.(ed.7
th
).Missouri: Mosby publications
 Parul Dutta, “Paediatric nursing” 2nd. edition P.No.23
 
 
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Intrauterine growth restriction (IUGR) refers to poor fetal growth in the womb, often due to maternal factors or inadequate oxygen supply. This condition can lead to increased risks for the baby. Topics covered include definition, incidence, normal fetal growth, stages, causes, diagnosis, and management of IUGR.


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  1. SEMINAR ON : INTRA UTERINE GROWTH RETARDATION

  2. OBJECTIVE Introduce the intrauterine retardation Define the intrauterine retardation Discuss the incidence of intrauterine retardation Discuss the normal fetal growth incidence of intrauterine retardation Discuss the etiology of intrauterine retardation Explain the classification of intrauterine retardation Explain the pathophysiology of intrauterine retardation Discuss the symptoms of intra uterine growth retatdation. Discuss the diagnosis of tntra uterine growth retardation. Describe the management

  3. INTRODUCTION Intrauterine growth restriction (IUGR) refers to poor growth of a fetus while in the mother's womb during pregnancy. The causes can be many, but most often involve poor maternal nutrition or lack of adequate oxygen supply to the fetus.The growth of the fetus is abnormally slow. When born, the baby appears too small, relative to its dates. Intrauterine growth restriction is associated with increased risk of medical illness and death in the newborn.

  4. DEFINITION Intra uterine growth restriction is said to be present in those babies whose birth weight is below the term the tenth persentile of the average for the gestational age. Growth restriction can occur in preterm,term or post-term babies.

  5. Incidence In developed countries, its overall incidence is about 3-10% Term babies- 5% Post-term babies-15% 2nd leading contributor to the Perinatal mortality rate 20% of all stillbirths are IUGR. Incidence of intrapartum asphyxia in cases of IUGR has been reported to be 50%.

  6. NORMAL FOETAL GROWTH Cellular hyperplasia. Hyperplasia and hypertrophy. Hypertrophy.

  7. STAGES Stage- I (Hyperplasia) - 4 to 20 weeks - Rapid mitosis - Increase of DNA content Stages - Stage II (Hyperplasia & Hypertrophy) - 20 to 28 weeks - Declining mitosis. - Increase in cell size. Stages - Stage III ( Hypertrophy) - 28 to 40 weeks - Rapid increase in cell size. - Rapid accumulation of fat, muscle and connective tissue. 95% of fetal weight gain occurs during last 20 weeks of gestations.

  8. CAUSES IUGR has many causes related to mother, foetus and placenta (part that joins the mother and foetus). Various risk factors for IUGR can be summarized as- :A. Maternal causes A. Maternal causes Before pregnancy Low pre-pregnancy weight and small maternal size Poor periconceptual nutrition. Multiple gestations

  9. DURING PREGNANCY Poor weight gain during pregnancy, especially in latter half Moderate to heavy physical work cy Chronic illness such as malabsorption, diabetes, renal disease Use of certain drugs, smoking, and alcohol Pregnancy induced hypertension Decreased oxygen availability such as in high altitude, severe maternal anemia

  10. B.UTERINE AND PLACENTAL FACTORS Inadequate placental growth Uterine malformations Decreased utero-placental blood flow (such as in toxemias of pregnancy, diabetic vasculopathy) Multiple gestations

  11. C.FETAL CAUSES 1. Congenital Infections: The growth potential of fetus may be severely impaired by intrauterine infections. The timing of infection is crucial as the resultant effects depends on the phase of organogenesis. Viruses- rubella, CMV, varicella and HIV rubella is the most embryotoxic virus, it cause capillary endothelial damage during organogenesis and impairs fetal growth. Protozoa- like malaria, toxoplasma, trypanosoma have also been associated with growth restriction.

  12. Conti.. 2. Structural Anomalies- All major structural defects involving CNS,CVS,GIT, Genitourinary and musculoskeletal system are associated with increased risk of fetal growth restriction. If growth restriction is associated with polyhydramnios, the incidence of structural anomaly is substantially increased. 3. Genetic Causes- Maternal genes have greater influence on fetal growth. Inborn errors of metabolism like agenesis of pancreas, congenital lipodystrophy, galactosemia, phenylketonuria also result in growth restriction of fetus

  13. CLASSIFICATION Symmetric or primary IUGR: In this condition all internal organs are reduced in size. It is found in 20%- 30% of all cases of IUGR. Asymmetric or secondary IUGR: In this condition the head and brain are normal in size, but the abdomen is smaller. It is evident mostly in the 3rdtrimester. It is more common and found in 70% to 80% of total IUGR cases.

  14. .Pathophysiology Pathophysiology Reduced availability of nutrients in mother. Reduced transfer by placenta to fetus. Reduced utilisation by fetus Brain size (asymmetric) as well as cell no (symmetric) are reduced Liver glycogen content is reduced Renal and pulmonary contribution to amniotic fluid are diminished due to reduced blood flow.

  15. Conti.. Oligohydramnios Risk of intrauterine hypoxia and acidosis death if severe Accelerated maturation

  16. conti... Accelerated fetal pulmonary maturation in complicated pregnancies associated with growth restriction Fetus responds to a stressed environment by increasing adrenal glucocorticoid production, which leads to earlier or accelerated fetal lung maturation

  17. Symptoms The main symptom of IUGR is a small for gestational age baby. During the antenatal checkup, a doctor measures the height of the uterus from the pubic bone to estimate the size of the fetus. After about the 20th week, uterine fundal height in centimeters is usually equal to the number of weeks of the pregnancy. A lag in fundal height of 4 cm or more with weeks of pregnancy suggests IUGR, and additional tests are required to confirm diagnosis.

  18. CONTI.. During ultrasound, the baby s estimated weight with IUGR is below the 10th percentile or less than that of 90% of babies of the same gestational age. At term, the birth weight less than 2,500 g (5 lb, 8 oz) is considered as IUGR. Not all babies that are born small have IUGR. In most severe cases IUGR can lead to stillbirth.

  19. At term birth, symptoms of IUGR are: Baby is small all over or malnourished. Thin, pale, loose and dry skin Umbilical cord is thin and often stained with meconium

  20. Diagnosis One of the most important things when diagnosing IUGR is to know accurate gestational age of baby. Gestational age can be calculated by using the first day of last menstrual period (LMP) and also by early ultrasound calculations. Once the gestational age is known the following methods can be used to diagnose IUGR.

  21. FUNDAL HEIGHT It is the simplest and most common method to diagnose IUGR. Fundal height is size of uterus measured as the distance from the pubic bone to the top of the uterus in centimeters. After the 20th week of pregnancy, the measure in centimeters usually corresponds with the number of weeks of pregnancy. A lag in fundal height of 4 cm or more suggests IUGR.

  22. WEIGHT CHECKUP Doctors routinely check and record the mother s weight at every prenatal checkup. If a mother is not gaining weight properly, it could indicate a growth problem in her baby.

  23. ULTRASOUND It is used to measure the baby s head and abdomen and compared with growth charts to estimate the baby s weight. Ultrasound can also be used to determine amniotic fluid.

  24. DOPPLER ASSESSMENT It is a technique that uses sound waves to measure the amount and speed of blood flow through the blood vessels. Doctors may use this test to check the flow of blood in the umbilical cord and vessels in the baby s brain. Abnormal Doppler tests are diagnostic of IUGR.

  25. MANAGEMENT Constitutionally small. no intervention symmetric IUGR investigated for anomalies infections, genetic syndromes . Placental disease or reduced placental blood flow May be given some treatment. No effective therapy.

  26. Conti. A..General No proven therapy for reversing IUGR once it has established 1. Adequate bed rest specially in left lateral position 2. Correct malnutrition by balanced diet- 300 extra calories per day 3. Appropriate therapy for complicating factors likely to produce IUGR 4. Avoidance of smoking, alcohol 5. Maternal yperoxygenation at the rate of 2.5 mL/min by nasal prong ,for short term prolongation of pregnancy 6. Low dose aspirin (50 mg daily) in selected cases with history of thrombotic disease, hypertension, pre- eclampsia or IUGR

  27. CONTI.. Antepartum evaluation Serial evaluations of fetal growth and assessment of well being should be done- USG- intervals of 3-4 weeks for assessment of BPD, HC/AC, and fetal weight. Fetal well being- kick count, NST, biophysical profile, amniotic fluid volume and cordocentesis for blood gases Doppler ultrasound parameters

  28. Conti.. Time of delivery Factors to be considered: 1. Presence of fetal abnormality 2. Duration of pregnancy 3. Degree of growth restriction 4. Associated complicating factor 5.Previous obstetric history 6. Availability of NICU

  29. Conti.. Severe degree of IUGR- If lung maturation is achieved Presence of phosphatidyl glycerol and L:S ratio at least 2 from amniotic fluid study termination. Lung maturation not yet achieved problems- prematurity, growth restriction Preterm IUGR requires highest level of NICU Betamethasone therapy - <34 week Corticosteroid reduce risk of neonatal HMD and IVH

  30. Conti.. Methods of delivery Route and time decided considering: 1. Severity of IUGR . 2. Maternal condition . 3. Any other obstetric complication Low rupture of membranes followed by oxytoxin. Beyond 34 weeks with favourable cervix and head is deep in pelvis. PGE2 gel when cervix unfavourable Intrapartum monitoring by clinical , continuous electronic and scalp blood sampling is needed as risk of intrapartum asphyxia is high

  31. Conti.. Care during vaginal delivery- Equipped institution where intensive intranatal monitoring (clinical and electronic) is possible and having facilities for NICU. precautions Caesarean section without a trial of labour- when risks of vaginal delivery are more( fetal acidemia, absent or reversed diastolic flow in umbilical artery or unfavourable cervix)

  32. Conti.. First stage- Ensure adequate fetal oxygenation by giving oxygen to mother by mask. Epidural analgesia is of choice. Labour carefully monitored preferably with continuous EFM Second stage. Birth should be gentle and slow to avoid rapid compression and decompression of head. Episiotomy may be done to minimise head compression Tendency to delay is curtailed by low forceps. Cord is to be clamped immediately at birth

  33. Management protocol of IUGR- To confirm IUGR and type. To exclude cong malformation. To treat specific cause if found.

  34. Conti.. Mild IUGR Increased rest. Folic acid Increased fliud intake Fetal monitoring till 37 weeks Delivery Dual problem

  35. Conti.. care of low birth weight baby immediate management following birth - the cord is to be clamped quickly to prevent hypervolaemia and development of hyperbilirubinemia cord length is kept long ( 10-12 cm) in case exchange transfusion is required. Air passage should be cleared of mucus promptly and gently using a mucus sucker adequate oxygenation through mask or nasal catheter in concentration not exceeding 35% baby should be wrapped including head in a sterile warm towel (36.5-37.5 C) . aqueous solution of vitamin K 1 mg is to be injected i.M. To prevent haemorrhagic manifestations Hypothermia and sequelae: hypoxia hypoglycemia anaerobic metabolism metabolic acidosis

  36. Conti.. Maintaining body temperature Delivery room dept warm, dry With mother- skin to skin contact Best placed in incubator where temperature and humidity(50%) can be better stabilised Under radiant warmer with protective plastic covers. Baby is placed naked. If not possible to maintain for entire room, cot is kept warm( 30 C). Rubber hot water ( not boiling) bottles stoppered and well covered with clothings

  37. Conti.. Infection- Respiratory tract, GIT, skin, umbilicus Poor defensive power of neonates with low WBC count and poor phagocytic activity make baby more vulnerable Prophylactic antibiotic therapy in premature rupture of membranes Every precaution to prevent infection Ampicillin 100 mg/kg per day or amikacin 10- 15 mg/kg per day i.v. in 2 divided doses for 5-7 days Nutrition - Enteral feeding depending on gestation age and vigour May require gavage feeding/ parenteral nutrition Human milk is 1st choice.

  38. Tube/ Gavage:- Fine polythene tube 0.5 mm internal diameter. Through nose down to oesophagus. Expressed milk is started with small volume and gradually build up. Continued for about 7 days. Calculated amount is injected with syringe by gravitation/pressure

  39. Pipette, dropper, katori and spoon- where baby can swallow but fails to suck- Bottle- when baby can suck and swallow but can t manage to express milk from the breast. I.v. fluids- neonates within incubator/radiant warmer. Net reqt= 60-80 mL/kg/day of 10% dextrose water on 1st day, increase by 15 mL/kg/day. More amount(10%) if phototherapy

  40. Additional supplements- Started after 2 weeks. Vitamin A 2500 IU, vitamin D 400 IU,vitamin C 50 mg, folic acid 65 g, vitamin B1 0.5 mg. Iron- liquid preparation 2-4 mg/kg/d in 2 divided doses calcium , phosphate. I.v. gamma globulin therapy(400 mg/kg/dose) to prevent infections <1200 g- parenteral nutrition with a.a, lipids with dextrose and multivita

  41. Conti.. Favourable signs of progress- Colour of skin remains pink all the time Smooth and regular breathing Increasing vigour movements of limb, cry Progressive gain in weight.

  42. Conti.. Discharge- When they attain sufficient weight About feeding schedule Prescribe suitable multivitamin and oral iron preparation To attend child welfare clinic for subsequent check up, immunisation and guidance Supervision continued at home by public health nurses or health visitors if possible.

  43. COMPLICATION IUGR causes many health problems during pregnancy, delivery, and after birth. These include: Difficulty during vaginal delivery Low Apgar scores (a test done immediately after birth to evaluate the newborn s physical condition to determine need for special medical care) Meconium aspiration (inhalation of stools passed while in the uterus), which can lead to breathing problems low birth weight High red blood cell count Low resistance to infection

  44. Prevention Care before pregnancy: Providing care to women before and between pregnancies (inter- conception care) improves the chances of mothers and babies being healthy. Advocating healthy eating and physical activity to women in their daily routine to improve weight and cardiovascular status before pregnancy. Diagnosis and management of chronic diseases such as hypertension, diabetes before pregnancy. Correction of anaemia/folic acid supplementation before pregnancy.

  45. Conti.. Care during pregnancy: Pregnant mothers should take only those medicines which are prescribed by doctors. Healthy diet should be advised to pregnant women with behavior change to encourage healthier eating patterns during pregnancy. Foods fortified with nutrients can be provided to pregnant women. Pregnant women are advised to take enough rest with proper duration of sleep during night and an hour or two of rest in the afternoon. Expectant mothers should follow healthy lifestyle habits. Tobacco use, smoking and alcohol intake should be avoided during pregnancy.

  46. Conti.. Care after delivery- Delivery should be planned in health facilities having emergency obstetric care and neonatal care facilities.

  47. summary Intrauterine growth restriction(IUGR) is a medical term which refers to a baby who is not growing normally within the womb. In general, this label is for babies who weigh less than the 10th percentile for their gestational age, or period of pregnancy.

  48. BIBLIOGRAPHY Ghai, O.P. (2008).Ghai essentials of paediatrics.(ed.6th).Delhi. O.P Ghai publishers. Gupta,P.(2004).Essentials of paediatric nursing.(ed.1st).New Delhi:A.P Jain &Co Publishers. Marlow.& Redding.(2008).Text book of paediatric nursing.(ed.6th).Philadelphia: Elsevier publications.P.NO.-57,58 Wong, D.L& Hockenberry.(2001).Wong s essentials of paediatric nursing.(ed.7th).Missouri: Mosby publications Parul Dutta, Paediatric nursing 2nd. edition P.No.23

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