IUGR Flashcards
What is the definition of IUGR?
Intra uterine growth restriction refers to fetus that fails to reach full growth potential, where the growth slows or stops completely. Intrauterine growth restriction is further classified as symmetrical and asymmetrical.
Asymmetrical: late presentation from the 3rd trimester, larger head, maternal and placental risk factors. Circulatory changes occur to protect the main functions, and the oxygenated blood gets distributed towards the brain, myocardium, and adrenal that undergo vasodilatation. On the other hand, vasoconstriction occurs in limbs, subcutaneous tissue, kidneys (leading to oligohydramnios) and partially in livers.
Symmetrical: has a greater mortality and morbidity and incidence of 20-30 %, characterised by early presentation from the 1st or 2nd trimester, usually caused by fetal factors such as congenital abnormalities, drugs, infections, preeclampsia. This is where the whole fetus is suffering from reduced cellular hyperplasia and hypertrophy and decrease in cells and their size.
What is the aetiology for IUGR?
Maternal - Hypertension, Pre-eclampsia, Diabetes, drug abuse/ smoking – due to calcification of placenta, advanced maternal age, maternal malnutrition
Fetal – congenital defect or chromosomal abnormalities trisonomy 21, 18 or 13, metabolic disorders such as phenylketonuria, infections such as Toxoplasmosis, Tuberculosis, HIV, Malaria, Syphilis, and Cytomegalovirus, twin pregnancy
Placental- abnormal placental vasculature, placental infraction, placental dysfunction
Incidence is 6x higher in underdeveloped world due to high levels of poverty, poor access to food and clean water, low maternity care
Speak through the anatomy and physiology of IUGR
The leading cause of IUGR is reduced uteroplacental supply of gases and nutrients to the fetus, causing retardation of fetal growth (Haroun, 2017). At approximately ten weeks following the fertilisation, the placenta is functioning and performing several physiological roles to sustain the fetus. It acts as an exchange mechanism between the mother and the fetus for respiration, nutrition, storage, excretion, endocrine regulation, and protection. The fetus cannot use the pulmonary function when in the uterus; therefore, it relies on the maternal oxygen supply through the placenta and umbilical vein. It excretes the carbon dioxide and bilirubin back to the mother through the mother umbilical arteries and placenta. Growth hormones Oestrogens, nutrients, amino acids and Glucose for the fetus are also supplied by the maternal circulation and through the placenta. To prepare for the extrauterine transition, In the last trimester, a healthy fetus will build up in their liver, muscle and lungs stores of fat and glycogen that will be later converted by the liver to Glucose and used for energy. Glucose is detrimental to normal brain function, and therefore, lack of Glucose and the inability to rely on further lipid stores can cause severe neurological injury.
The reduced uteroplacental flow is caused by an insufficient widening, development, and changes to the spiral arteries in early pregnancy. This results in damage and vasoconstriction of stem and villous capillaries due to increased pressure and incomplete penetration of trophoblastic cells through decidua. This combination results in inadequate nutritional supply. The nutritional deficiency is one of the direct causes of IUGR, where the fetus is unable to lay down the glycogen stores for the glucose energy and fat stores that could otherwise be converted into ketones and act as a temporary energy reserve. IUGR fetus is at higher risk of Intrauterine death or inadequate neurodevelopment (Michaelides, 2021)
Risk Factors: of the scenario:
IUGR in preeclampsia: Hypertension causes damage to the endothelial cells of the spiral arteries and affects the diffusion through the capillary walls. This limits the amount of gas exchange in the placenta and can cause inadequate supply for the fetus.
Speak through the care in Labour
Inform the multidisciplinary team of the midwife in charge, obstetric team anaesthetist and neonatologist and make sure that the plan is made, for neonatologist to be present at birth and team on stand bye as there is high chance of c-section due to fetal compromise. Inform neonatal team to be aware of bed capacity in NNU or consider in utero transfer
Introduction to the woman and birth partner
Establish language needs
Review notes to check for relevant obstetric history
Making sure that dignity is always protected
Woman comfortable and informed of the care and plan
Birth plan discussed
Informed consent obtained prior any care
Teds stockings to prevent DVT
Check the resuscitaire and the room temperature as baby is more likely to suffer from hypothermia and is more vulnerable to respiratory distress
Documentation/ partogram
CTG monitoring is extremely important as the fetus have none or very low energy stores to tolerate stress and disruption of the oxygen supply through placenta during contractions. And can therefore develop asphyxia and hypoxia
Hourly fresh eyes and half hourly documenting on portogram to make sure CTG gets correctly interpreted, contractions frequency every half an hour to assess the progress.
Immediate escalation and obstetric intervention. Try intrauterine resuscitation, left lateral, give, or increased IV fluids
Interpret CTG:
Define risks: IUGR
Contractions: 3 in 10, regular, strong or palpation
Baseline: 110-160bmm
Accelerations: Present 15bpm lasting 15 or more seconds
Variability: above 5 bpm
Deceleretions: Early? Onset of contraction and rapid return to the baseline
Variable? Vary in duration and frequency, caused by cord compression, rapid return to baseline
Late? Uniform and repetitive peak occurs after the peak of contraction, caused by delay of placental perfusion.
Prolonged? Lasting longer than 60 seconds
Overall classification: Normal, Suspicious, Pathological?
Next care
1. 4 hourly vital signs to rule out abnormalities to assess maternal wellbeing
2. Vaginal examination every 4 hours to assess the progress, expecting 2cm in 4 hours. If delayed, inform the team, and consider agumentation in view of the progress and fetal wellbeing. (If no progress and baby already showing signs of distress, oxytocin agumentation might make things worse…maybe Csection?)
3. Checking the colour of amniotic fluid to see if any signs of meconium as this could be also indicative of fetal distress, or any excessive bleeding
4. Bladder care every 4 hours to help with descent, urinalysis to check for ketones, leucocytes, protein
5. Mobilising- Throne position
6. Hydration/ light diet, for example fruit, to make sure the woman is well energised and hydrated
7. Offer pain relief
Second stage:
Continue carefully monitoring CTG, support perineum. Following the birth stimulate the baby, and assess colour, tone, respiratory effort, heartbeat, and grimace. If baby well and crying and no excessive maternal blood loss, delayed cord clamping to provide baby with maximum benefits of the cord blood for transition to extrauterine life, support safe skin to skin. However, if baby in in respiratory distress call for help and immediately begin resuscitation, transfer to NNU.
facilitate 3rd stage – examine placenta and cord to make sure all complete, note the blood vessels in the cord because a single artery is common anomaly in IUGR
Cord gases
Speak through baby care in case of IUGR
Baby care
1. Initial assessment, HC, Weight, Vit K according to weight and dose calculated by peads if lower than 2.5 kg
2. INFECTION, especially if meconium aspiration Vital signs as baby is more likely to develop infection, respiratory distress…
3. HYPOTHERMIA Maintain thermoregulation as baby is more likely to become hypothermic and as result due to inadequate stores of brown fat. This can then lead to hypoglycaemia.
4. HYPOGLYCEAMIA: Monitor Prefeed BMs at least 2.6 mmol/l for 48 to 72 hours and If the blood glucose drops below 2.6 mmol/L despite early feeding), intravenous infusion of 10% dextrose must be given in addition to oral feeds.
Establish early feeding within one hour, supplement with formula if required feeding plan to maintain healthy blood sugar levels.
5. HYPERGLYACEAMIA: Baby is at risk of developing hyperglycaemia due to immature pancreas and low insulin levels. If this happens, it must be treated with infusion of titration and insulin.
6. HYPOCALCEAMIA: Calcium levels also should be monitored due to decreased transfer of calcium in utero or immature parathyroid gland, and calcium supplementation should be given if needed.
- URINE: Observe for passage of urine as kidneys might be compromised due to growth restriction
- JAUNDICE: babies more at risk of polycythemia due to chronic hypoxia that causes elevated heaemoglobin levels. Perform capillary haemocrit at 4-6 hours of age and observe for signs of jaundice.
Neonatologist must follow up on baby`s progress and examine for any congenital abnormalities and make a written plan. Symetrically growth restricted babies will need to be monitored for few years as they can continue having complications and developmental problems into adulthood. Community midwives must ensure that they communicate effectively with health visitors.
All the findings explained to parents and documented.
Speak through the postnatal care for mother in case of IUGR
Postnatal Mother:
Initial postnatal assessment and bleeding
Vital signs to rule out deterioration
Assess and repair perineum
Offer analgesia
Emotional support and mental wellbeing
Monitor lochia/ uterus contracted
Help to mobilise/ signs of dvt/ preeclampsia
Monitor passing urine within 6 hours
Hydration/ diet
Explain signs of unwell baby
Feeding/ Expressing support if baby in NNU
Discharge talk and leaflets
Follow up in community.
