Rafat Mosalli MDRafat Mosalli MD

Abnormal Gestation

Objectives

What is Normal gestation?What is Normal gestation? Newborn classification according to age Newborn classification according to age

and Weight.and Weight. How to assess for Gestational age?How to assess for Gestational age? Causes of abnormal gestationCauses of abnormal gestation Complications of abnormal Gestation.Complications of abnormal Gestation.

- - LGA & SGALGA & SGA

-Premature & Post mature-Premature & Post mature

Definitions Full TermFull Term : 37- 42W GA : 37- 42W GA PrematurityPrematurity : < 37 W GA : < 37 W GA Post termPost term : > 42W GA : > 42W GA Large for gestational age (LGALarge for gestational age (LGA):):

BWT >2 SD from the mean of GA(>90 BWT >2 SD from the mean of GA(>90 percentile)percentile)

Small for gestational age( SGASmall for gestational age( SGA): ): BWT<2SD from the mean of GA(<10 BWT<2SD from the mean of GA(<10 percentile)percentile)

Low birth weight (LBW):Low birth weight (LBW):

Bwt <2500gmBwt <2500gm Very low birth weight (VLBW):Very low birth weight (VLBW):

Bwt<1500gmBwt<1500gm Extremely-very-low-birth-weight (ELBW)Extremely-very-low-birth-weight (ELBW) : :

Bwt < 1000 gBwt < 1000 g

LBW could be both!

- An infant of birth weight 1.8 kg born at 36 - An infant of birth weight 1.8 kg born at 36 weeks is classified as weeks is classified as preterm and LBWpreterm and LBW

Gestational age assessment

LMPLMP UltrasoundUltrasound Balllard score :Balllard score :

-Physical -Physical andand neuromuscular maturity neuromuscular maturity

-correlate the cumulative score with a -correlate the cumulative score with a gestational age (usually lies within gestational age (usually lies within 2weeks)2weeks)

Large for gestational age (LGA)

Bwt > 90% for their ageBwt > 90% for their age Causes:Causes:

-Familial-Familial

-IDDM-IDDM

-Others-Others

LGA(IDM) :Complications

-Prematurity - GIT-Prematurity - GIT

-Birth injuries - Prenatal death -Birth injuries - Prenatal death

-CNS - Congenital anomalies-CNS - Congenital anomalies

-Respiratory -Respiratory

-CVS-CVS

-Metabolic-Metabolic

-Hematologic-Hematologic

-Renal-Renal

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Fetal growth has been divided into three phases.

1-cellular hyperplasia1-cellular hyperplasia

2- hyperplasy & 2- hyperplasy & hypertrophyhypertrophy

3- hypertrophy3- hypertrophy

cell size.cell size. fat depositionfat deposition fetal weight as much fetal weight as much

as 200 G.r. per as 200 G.r. per week.week.

Normal Intrauterine Growth Pattern

95% of fetal weight gain occurs during the 95% of fetal weight gain occurs during the last 20 weeks of gestationlast 20 weeks of gestation

Late insult will affect weight the mostLate insult will affect weight the most

Intrauterine Growth Retardation (IUGR)

Is deviation from expected Is deviation from expected fetal growthfetal growth patternpattern

a fetus is unable to grow to its genetically determined potential size to a degree that may affect the health of the fetus.

A late pregnancy insult such A late pregnancy insult such

as placental insufficiency as placental insufficiency

would affect cell sizewould affect cell size . .

Asymmetrical

symmetrical

An early insult due to : chemical viral aneuploidy

Cell sizeCell num.

Proportionate reduction in head & body

Symmetric Vs Asymmetric IUGR

Symmetric IUGRSymmetric IUGR Entire body is proportionally small.Entire body is proportionally small.

Asymmetric IUGRAsymmetric IUGR

A fetus who is undernourished (A fetus who is undernourished (“Head sparing” “Head sparing” effect)effect)

IUGR vs SGA

SGA :

A fetus that has failed to achieve a expected weight by a specific gestational age(Bwt Bwt <2SD from the mean of GA (<10 %)<2SD from the mean of GA (<10 %)

IUGR: a fetus is unable to grow to its

genetically determined potential size to a degree that may affect the health of the fetus.

IUGR vs SGA

50–70% of fetuses with a BWT <10% For GA are constitutionally small, and the lower the centile for defining SGA, the higher the likelihood of IUGR

Not all fetuses who are SGA (<10th percentile) have IUGR, and not all fetuses who have IUGR are SGA.

Small for gestational age (SGA)

Causes : Causes : FetalFetal MaternalMaternal Placental Placental and Uterine Abnormalitiesand Uterine Abnormalities

impaired nutrient deliveryimpaired nutrient delivery

Fetal

impaired fetal uptake impaired fetal uptake

GeneticsGenetics

Congenital anomalies/ InfectionsCongenital anomalies/ Infections

Multiple gestationMultiple gestation

Maternal

InfectionInfection Pre- eclampsia, Diabetes, HypoxemiaPre- eclampsia, Diabetes, Hypoxemia Drug misuse / SMOKINGDrug misuse / SMOKING Chronic medical illnessChronic medical illness impaired nutrient uptakeimpaired nutrient uptake

Uterine &Placental

impaired nutrient delivery impaired nutrient delivery Short cervix,Incompetent cervix Short cervix,Incompetent cervix Placenta Previa ,Abruptio PlacentaePlacenta Previa ,Abruptio Placentae

Others

Premature rupture of membranePremature rupture of membrane

HydramniosHydramnios

IatrogenicIatrogenic

Trauma/Trauma/

Which is common?

Vascular disease (HTN, DM, etc) 35%Vascular disease (HTN, DM, etc) 35% Chromosomal and congenital anomalies 10%Chromosomal and congenital anomalies 10% Normal variation 10%Normal variation 10% Congenital infections 5%Congenital infections 5% Drug misuse 5%Drug misuse 5% Placenta and cord defect 2%Placenta and cord defect 2% Uterine defects 1%Uterine defects 1% Others : Low socioeconomic status, unknownOthers : Low socioeconomic status, unknown

Problems of SGA

SGA: associated problems

Intrauterine deathIntrauterine death AsphyxiaAsphyxia Meconium aspirationMeconium aspiration Persistent pulmonary Persistent pulmonary

hypertensionhypertension Polycythemia/Polycythemia/

hyperviscosityhyperviscosity

HypothermiaHypothermia Hypo-er glycemiaHypo-er glycemia Acute renal failureAcute renal failure Gastrointestinal Gastrointestinal

perforationperforation ImmunodeficiencyImmunodeficiency Neonatal death(1%)Neonatal death(1%)

IUGR : long term problems!

Depend on the causes &Type?Depend on the causes &Type? The asymmetrically GR is more likely to The asymmetrically GR is more likely to

catch up after birthcatch up after birth Impaired neurodevelopment, CPImpaired neurodevelopment, CP type 2 diabetes type 2 diabetes hypertension. hypertension.

Prematurity

< 37W GA< 37W GA

Prematurity

Incidence: 6-8 % all birthIncidence: 6-8 % all birth Causes:Causes:

IdiopathicIdiopathic

MaternalMaternal

fetalfetal

Prematurity complications

Affect every system !Affect every system !

Short termShort term

Long termLong term

Neurologic &Ophthalmologic

Immature temperature regulation Immature temperature regulation hypothermiahypothermia

AsphyxiaAsphyxia IVHIVH PVLPVL CP and neurodevelopment delayCP and neurodevelopment delay

ROPROP

Respiratory and CVS

RDSRDS Apnea of prematurityApnea of prematurity BPDBPD pneumoniapneumonia HypotensionHypotension PDAPDA

GIT and Nutrition

Feeding difficultyFeeding difficulty

NECNEC

Renal and Metabolic

Immature kidneysImmature kidneys Electrolyte dist.Electrolyte dist. AcidosisAcidosis Hypo-er glycemiaHypo-er glycemia HypocalcemiaHypocalcemia Osteopenia of prematurity Osteopenia of prematurity

Hematologic &Immunology

Anemia of prematurity Anemia of prematurity

JaundiceJaundice

InfectionInfection

Post maturity

> 42 weeks GA> 42 weeks GA C/PC/P Complications:Complications: MAS and related complicationsMAS and related complications Hypoxic ischemic encephalopathy(HIE Hypoxic ischemic encephalopathy(HIE

sequences)sequences) MetabolicMetabolic PolycythemiaPolycythemia

We Talked about

What is Normal gestation?What is Normal gestation? Newborn classification according to age Newborn classification according to age

and Weight.and Weight. How to assess for Gestational age?How to assess for Gestational age? Causes of abnormal gestationCauses of abnormal gestation Complications of abnormal Gestation.Complications of abnormal Gestation.

- - LGA & SGALGA & SGA

-Premature & Post mature-Premature & Post mature