Intra Uterine Growth Restriction (IUGR)

INTRAUTERINE GROWTH RESTRICTION (IUGR)

INTRODUCTION

Intrauterine growth restriction (IUGR) is a term used to describe a condition in which the fetus is smaller than expected for the number of weeks of pregnancy. Another term for IUGR is fetal growth restriction. Newborn babies with IUGR are often described as small for gestational age (SGA).

A fetus with IUGR often has an estimated fetal weight less than the 10th percentile. This means that the fetus weighs less than 90 percent of all other fetuses of the same gestational age. A fetus with IUGR also may be born at term (after 37 weeks of pregnancy) or prematurely (before 37 weeks).

Newborn babies with IUGR often appear thin, pale, and have loose, dry skin. The umbilical cord is often thin and dull-looking rather than shiny and fat. Babies with IUGR sometimes have a wide-eyed look. Some babies do not have this malnourished appearance but are small all-over.

CAUSES OF IUGR

Intrauterine growth restriction results when a problem or abnormality prevents cells and tissues from growing or causes cells to decrease in size. This may occur when the fetus does not receive the necessary nutrients and oxygen needed for growth and development of organs and tissues, or because of infection. Although some babies are small because of genetics most IUGR is due to other causes. Some factors that may contribute to IUGR include the following:

Maternal factors:

 

§  high blood pressure
§  chronic kidney disease
§  advanced diabetes
§  heart or respiratory disease
§  malnutrition, anemia
§  infection
§  substance abuse (alcohol, drugs)
§  cigarette smoking

Utero placental factors :

§  decreased blood flow in the uterus and placenta
§  placental abruption (placenta detaches from the uterus)
§  placenta previa (placenta attaches low in the uterus)
§  infection in the tissues around the fetus

Fetal factors:

§  multiple gestation (twins, triplets, etc.)
§  infection
§  birth defects
§  chromosomal abnormality

COMPLICATIONS OF IUGR

IUGR can begin at any time in pregnancy. Early-onset IUGR is often due to chromosomal abnormalities, maternal disease, or severe problems with the placenta. Late-onset growth restriction (after 32 weeks) is usually related to other problems.

With IUGR, the growth of the baby's overall body and organs are limited, and tissue and organ cells may not grow as large or as numerous. When there is not enough blood flow through the placenta, the fetus may only receive low amounts of oxygen. This can cause the fetal heart rate to decrease placing the baby at great risk.

Babies with IUGR may have problems at birth including:

§  decreased oxygen levels

§  low Apgar scores
§  meconium aspiration (inhalation of the first stools passed in utero), which can lead to difficulty breathing
§  hypoglycemia
§  difficulty maintaining normal body temperature
§  polycythemia (increased red blood cells)

Severe IUGR may result in stillbirth. It may also lead to long-term growth problems in babies and children.

Intrapartum Asphyxia

Because the fetus is compromised with IUGR, its ability to tolerate the stress of labor is decreased. Therefore, when uterine contractions occur and the flow of blood to the fetus is diminished with each contraction, the fetus with IUGR may not be able to adapt. This leads to an imbalance between the ability of the placenta to supply the fetus with oxygen and nutrients and the need for these substances. When an imbalance occurs, this may lead to an accumulation of byproducts resulting in acidosis which can be harmful. If intrapartum asphyxia is allowed to progress, irreversible brain damage can occur.

Neonatal Hypoglycemia and Hypocalcemia

As the result of IUGR, a newborn may be deficient in glucose (sugar) and calcium. The lack of these important substances can result in significant compromise to the newborn and result in neurological damage.

Meconium Aspiration

This occurs when the fetus defecates in the uterus resulting in the appearance of a brown, murky substance. Meconium aspiration is of major concern. In severe forms, the newborn may develop lung disease resulting in respiratory and cardiovascular complications that could lead to neonatal death.

Neurodevelopmental Delay

A number of studies have shown that fetuses with significant IUGR are at higher risk for developmental delays, cardiovascular disease, and other problems later in life. For these reasons, and those stated above, it is important to identify the fetus with IUGR and manage the pregnancy accordingly

DIAGNOSIS OF IUGR

§  Fundal Height

The height of the fundus can be measured from the pubic bone. This measurement in centimeters usually corresponds with the number of weeks of pregnancy after the 20th week. If the measurement is low for the number of weeks, the baby may be smaller than expected.

§  Ultrasound
Ultrasound is a more accurate method of estimating fetal size. Measurements include the diameter of the head (Biparietal Diameter or BPD), the circumference of the head, the circumference of the abdomen, and the length of the femur bone of the leg. The fetal abdominal circumference is a helpful indicator of fetal nutrition.

§  Doppler flow

Another way to interpret and diagnose IUGR during pregnancy is Doppler flow, which use sound waves to measure blood flow. The sound of moving blood produces wave-forms that reflect the speed and amount of the blood as it moves through a blood vessel. Blood vessels in the fetal brain and the umbilical cord blood flow can be checked with Doppler flow studies.

§  Mother's weight gain

A mother's weight gain can also indicate a baby's size. Small maternal weight gains in pregnancy may correspond with a small baby.

MANAGEMENT OF IUGR

Management of IUGR depends on the severity of growth restriction, and how early the problem began in the pregnancy. Generally, the earlier and more severe the growth restriction, the greater the risks to the fetus. Careful monitoring of a fetus with IUGR and ongoing testing may be needed.

Some of the ways to watch for potential problems include the following:

§  Fetal movement counting - keeping track of fetal kicks and movements. A change in the number or frequency may mean the fetus is under stress.

§  Non Stress Testing - a test that watches the fetal heart rate for increases with fetal movements, a sign of fetal well-being.

§  Biophysical profile - a test that combines the non stress test with an ultrasound to evaluate fetal well-being.

§  Ultrasound - Ultrasounds are used to view internal organs as they function, and to assess blood flow through various vessels. Ultrasounds are used to follow fetal growth.

§  Doppler flow studies - a type of ultrasound which use sound waves to measure blood flow.

 

TREATMENT OF IUGR

Although it is not possible to reverse IUGR, some treatments may help slow or minimize the effects. Management will be determined based on:

§  Maternal and fetal overall health, and medical history

§  the extent of the condition
§  tolerance for specific medications, procedures

Nutrition
Some studies have shown that increasing maternal nutrition may increase gestational weight gain and fetal growth.

Bedrest
Bedrest in the hospital or at home may help improve circulation to the fetus.

Delivery
If IUGR endangers the health of the fetus, then an early delivery may be necessary.

 

PREVENTION

Intrauterine growth restriction may occur, even when the mother is in good health. However, some factors may increase the risks of IUGR, such as cigarette smoking and poor maternal nutrition. Avoiding harmful lifestyles, eating a healthy diet, and getting prenatal care may help decrease the risks for IUGR. Early detection may also help with IUGR treatment and outcome.

 

 

 

 

Cervical Encirclage

Cervical Encirclage

Introduction

Cervical cerclage (tracheloplasty), also known as a cervical stitch, is used for the treatment of cervical incompetence, a condition where the cervix has become slightly open and there is a risk of miscarriage because it may not remain closed throughout pregnancy. Treatment for cervical incompetence by a cervical cerclage, was first described in 1950 by Dr. Lash. 

Principle

A non-absorbable encircling suture is placed around the cervix at the level of internal os. It operates by interfering with the uterine polarity, preventing the internal os and the adjacent lower segment from being taken up.

Purpose

• A woman with an incompetent cervix is 3.3 times more likely to deliver prematurely.
• a previous preterm delivery
• previous second trimester abortions
• previous trauma or surgery to the cervix
• early rupture of membranes
• abnormalities of the uterus or cervix
• exposure as a fetus to diethylstilbestrol (DES), a synthetic hormone

Indications

• Poor obstetrical history — An elective (prophylactic or history-indicated) cerclage is typically placed at the end of the first trimester (12 to 14 weeks of gestation) to prevent recurrence of early preterm delivery.
• Cervical changes on ultrasound — An urgent (ultrasound-indicated) cerclage is performed when cervical shortening is visualized on ultrasound evaluation of the cervix.
• An emergent (rescue, physical examination indicated) cerclage is placed when advanced cervical changes are noted on digital and visual examination.

Contraindications 

• fetal anomaly incompatible with life
• intrauterine infection,
• active bleeding,
• active preterm labor,
• premature rupture of membranes
• fetal demise
• presence of fetal membranes prolapsing through the external cervical os is a relative contraindication to the procedure because the risk of iatrogenic rupture of the membranes is high

Timing of Cervical Encirclage

• The best time for the cervical cerclage procedure is in the third month (12-14 weeks) of pregnancy
• or atleast 2 weeks earlier than the lowest period of previous wastage.
• emergent cerclage is necessary after changes such as opening or shortening of the cervix have already begun. If an emergent cerclage is required, future pregnancies will probably also require a cervical cerclage.

 Removal of cervical encirclage

Generally the suture is removed at the 37th week of pregnancy, but it can be removed before if membranes rupture or at initiation of labour contractions.

 

Types of Cervical Encirclage

• McDonald’s technique
• Shirodkar technique

Mc Donanld’s Circlage

•        The non absorbable suture (Merseline) material is placed as a purse string suture as high as possible at the junction of the rugose vaginal epithelium and the smooth vaginal part of the cervix below the level of the bladder.

•        The suture starts at the anterior wall of the cervix.
•        Taking successive deep bites (4-5 sites) it is carried around the lateral and posterior walls back to the anterior wall again where the two ends of the suture are tied.

Shirodkar’s cerclage

•        Step I: The patient is put under light general anaesthesia and placed in lithotomy position with good exposure of the cervix by a posterior vaginal speculum. The lips of the cervix are pulled down by sponge holding forceps.

•        Step II: A transverse incision is given anteriorly below the base of the bladder on the vaginal wall and the bladder is pushed up to expose the level of the internal os. A vertical incision is given posteriorly on the cervico- vaginal junction
•        Step III: The non absorbable suture (No. 4 braided nylon or Merseline Dacron) material is passed submucously with the help of a cervical needle so as to bring the suture ends through the posterior incision.
•        Step IV: the ends of the suture are tied up posteriorly by a reef knot. The bulging membranes if present, must be reduced beforehand into the uterine cavity. The anterior and posterior incisions are repaired by interrupted stiches using chromic catgut.

 

Other methods of cerclage

• Hefner (or Wurm) cerclage :usually reserved for later in pregnancy when there is little cervix to work with.
• Abdominal cerclage :a permanent stitch performed through an abdominal incision instead of the vagina; reserved for when a vaginal cerclage has failed or is not possible)
• Lash cerclage :a permanent stitch performed before pregnancy because of trauma to the cervix or an anatomical abnormality

Diagnosis

Diagnosis of an incompetent cervix is usually done by medical history or by examination manually during a pelvic exam or by ultrasound scan. Some symptoms of an incompetent cervix used to decide if a cerclage is necessary are:

•cervical dilation
•shortening of the cervix
•funneling of 25% or more
•Women who are more than 4 cm dilated, who have already experienced rupture of membranes, or whose fetus has died are ineligible for cerclage.

 

Patient Preparation

·        A complete medical history will be taken.

·        A cervical exam by a transvaginal ultrasound will be performed.
·        The patient is kept on NPO after midnight before the day of surgery 
·        The patient will also be instructed to avoid sexual intercourse, tampons, and douches for 24 hours before the procedure.
·        Before the procedure is performed, an intravenous (IV) catheter will be placed in order to administrate fluids and medications.
·        Take a consent after explaining to the patient that she may have to stay in the hospital for a few hours or overnight to be monitored for premature contractions or labor.
·        Immediately after the procedure she may experience light bleeding and mild cramping, which should stop after a few days. This may be followed by an increased thick vaginal discharge, which may continue for the remainder of the pregnancy. She may receive medications to prevent infection or preterm labor.

Aftercare

• After the cerclage has been placed, the patient will be observed for at least several hours (sometimes overnight) to ensure that she does not go into premature labor.
• The patient will then be allowed to return home, but will be instructed to remain in bed or avoid physical activity for two to three days.
• Isoxsuprine (Tocolytic) 10mg tablet is given thrice daily to avoid uterine irritability.
• On discharge she is adviced to avoid intercourse, to avoid rough journey and to report if there is vaginal bleeding or abdominal pain.

Report immediately if one or more of the following signs appear:

• Contractions or cramping
• Lower abdominal or back pain that comes and goes like labor pain
• Vaginal bleeding
• A fever over 100 F or 37.8 C, or chills
• Nausea and vomiting
• Foul-smelling vaginal discharge
• Your water breaking or leaking

 Risks

• risks associated with regional or general anesthesia
• premature labor
• premature rupture of membranes
• infection of the cervix
• infection of the amniotic sac (chorioamnionitis)
• cervical dystocia (inability of the cervix to dilate normally in the course of labor)
• cervical rupture (may occur if the stitch is not removed before onset of labor)
• injury to the cervix or bladder
• bleeding

Alternatives for Cervical Encirclage

• Bed rest. The idea of bed rest is to avoid putting unnecessary pressure on the cervix.
• Tocolytics. These are drugs that are designed to stop or delay labor. Ritrodrine, terbutaline, and magnesium sulfate are some common tocolytics.
• Antibiotics. Some infections are associated with a high risk of preterm labor (e.g., upper genital tract infection). Antibiotics may be successful in preventing preterm labor from occurring by treating the infection.

 

Abortion

Abortion

Abortion is the removal or destruction of an embryo or fetus before birth. It may be spontaneous or induced. Abortion is an extraction or expulsion of an embryo which is capable of independent survival weighing 500 grams or less before the 20^th week of gestation.

Causes of Abortions

1.      Genetic Causes

·         Of all chromosomal abnormalities 50% are autosomal trisomies ( most common trisomy is 16 )

·         Second most common cause of chromosomal anomolies is monosomy X (45XO) 15-20% of all spontaneous ABs
·         Couples that share HLA antigens have increase ab rates

2.      Environmental causes of Abortion

·         Infections: Endometritis, Toxoplasmosis, Herpes

·         Smoking
·         Alcohol
·         Radiation
·         Toxins: Anesthetic agents, Lead, Arsenic, Formaldehyde, Benzene, Ethylene oxide

3.      Uterine Causes

·         Leiomyoma of the uterus: fibroids

·         Uterine anomalies: DES exposure- T shaped uterus, Uterine adhesions, Malformation of the uterus- Uterus didelphys, unicornate uterus, bicornate uterus, uterine septum, Incompetent cervix- congenital or acquired

4.      Medical conditions:

·         Diabetes, Severe malnutrition, Hyperthyroidism

5.      Immunological causes:

·         Client with recurrent fetal loss have antiphospolipid antibodies 80% of the time

6.      Endocrinologic causes:

·         Progesterone deficiency, Hypo or Hyper thyroidism, Diabetes mellitus

 

Types of Abortion

Spontaneous abortion or miscarriages - is a type of abortion that occur without medical or other intervention. About 25% of all pregnancies result in miscarriages, women older than 35 or younger than 17 years old and couples who have difficulty in achieving pregnancy; and women who have had at least two miscarriages has a higher chance of experiencing miscarriage. About 90% of miscarriages occur during the first trimester (first three months, or 12 weeks of pregnancy). Some cases of miscarriages happen even before a woman realizes that she is pregnant, and she even may not realize that she has aborted.

Symptoms of Miscarriage:

§  A typical 10^th week miscarriage is characterized by a very heavy menstrual period. A pregnant woman may experience several days of bleeding and cramps before the contents of the uterus are removed, followed by a short period of bleeding until the lining of the uterus heals.

§  Miscarriage after the 12^th week is like a mild version of the labor of during childbirth, with strong contractions that dilate the cervix and expel the fetus.

§  Miscarriages between the 13^th and 24^th weeks (second trimester) are most often caused by faulty attachment of the placenta to the walls of the uterus or from a weak cervix that dilates too soon.

 

Types of Spontaneous Abortion

§  Threatened abortion is a condition of pregnancy, occurring before the 20^th week of gestation, the patient usually experiences vaginal bleeding with or without some cramps, and the cervix is closed. Bed rest is usually the only treatment needed. In a few cases the symptoms disappear and the rest of the pregnancy is normal.

§  Inevitable abortion is when the bleeding continues and becomes heavy, it usually means that the cervix is dilating and the contents of the uterus are being expelled. Pregnant women will experience lower abdominal cramping and bleeding.

§  Complete abortion is when all the contents are expelled. There is no treatment other than rest is usually needed. All of the tissues that came out should be saved for examination by a doctor to make sure that the abortion is complete. The laboratory examination of the saved tissue may determine the cause of abortion.

§  Incomplete abortion is a name given to abortion where the uterus retains part or all of the placenta. Bleeding may occur because part of the placenta may adhere to the uterine wall and the uterus does not contract to seal the large blood vessels that feed the placenta. The usual treatment is a drug that induces labor by stimulating uterine contractions, a surgical procedure called curettage can also be done to remove the remaining material from the uterus, the goal of this treatment is to prevent prolonged bleeding or infection.

§  Missed abortion - is a case in which an intrauterine pregnancy is present but is no longer developing normally. Before widespread use of ultrasonography, the term missed abortion was applied to pregnancies with no uterine growth over a prolonged period of time, typically 6 weeks after its (fetus) death. A missed abortion is usually indicated by the disappearance of the signs of pregnancy except for the continued absence of menstrual periods. Missed abortions are usually treated by induction of labor by dilation (or dilatation) and curettage (D & C).

Induced abortion - this type of abortion uses drugs or instruments to stop the normal course of pregnancy.

Different methods for performing abortions

§  Menstrual Extraction (endometrial or vacuum aspiration). This method is used for most abortions performed during the first trimester. It is done by suctioning out the lining of the uterus (endometrium) through a thin opening of the undilated cervix. It is a method used after a woman has just missed a period, or anytime up to about the eight week or pregnancy. It can be performed safely in the doctor's office and has a very low rate of mortality.

§  Dilation and Evacuation (D & E) (also called vacuum suction or suction curettage) and Dilation and Curettage (D & C). This method is commonly used for late first trimester or early second trimester abortions. In this method suction is used to remove the fetus and placenta. The cervix is first dilated under local anesthesia using a suction tube that is firm, and a stronger suction is used than in menstrual extraction. Another way of dilating the cervix is the use of a type of dried seaweed, called laminaria, which expands as it absorbs moisture. Some doctors use a hollow, spoon-shaped knife, or curette, to ensure that all the placental tissues are removed by scraping the uterine walls. If curettes are used throughout the procedure instead of suction, the method is called dilation and curettage (D&C). Before the 12^th week of pregnancy, D&E is preferred over D&C because it does not require general anesthesia, causes less discomfort and is less costly. D&C can be used up to the 12^th week of pregnancy. The mortality rate for both D&E and D&C is approximately 3 per 100,000 abortions.

 

§  Prostaglandin or Saline Administration. This method is done by injecting prostaglandins or saline solution through the uterine wall and into the amniotic sac holding the fetus to induce labor and delivery of a nonviable fetus. This procedure is commonly used for second trimester abortions. Prostaglandins may cause nausea, elevated temperatures, and vomiting but are safer than the saline solution. Mortality rate for second trimester abortions performed by this method is approximately 20 per 100,000 abortions.

§  Hysterotomy. This method is similar to caesarian section, the uterus is opened through a small abdominal incision and the fetus is removed. Hysterotomy is usually performed only when other methods have failed repeatedly, it is performed under general anesthesia. It is used between the 12^th and the 24^th week of pregnancy. This method has the greatest risk of complications out of all the abortion procedures, maternal mortality rate is approximately 200 per 100,000 abortions.