Case Presentation onIntrauterine Growth RestrictionModerator

Dr M. K. Majumdar Asst. Professor, Dept. of Obstetrics and Gynaecology,Gauhati Medical College & Hospital

Presented by

Students of 8th semesterRoll no. 29, 30, 31, 32, 33, 34, 35

Intrauterine Growth Restriction (IUGR) or,Foetal Growth Restriction (FGR)IUGR is said to be present in those babies whose birth weight is below the 10th percentile of the average for the gestational age.

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Dutta D. Fetal Growth Restriction (FGR). In: Konar H, editor. DC Dutta’s Textbook of Obstetrics. 8th ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2015. p. 533.

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Salient features of SGA & IUGR foetusesIUGR (Intrauterine Growth Restriction)

SGA (Small for Gestation Age)

30% babies with birthweight <10th percentile

70% babies with birthweight <10th percentile

Growth restricted Not growth restricted

Constitutionally and anatomically abnormal

Constitutionally small but anatomically normal

↑ Obstetric/neonatal risk No obstetric/neonatal risk

{Variable} Normal ponderal index

{Variable} Normal subcutaneous fat

{Variable} Uneventful neonatal course

Dutta D. Fetal Growth Restriction (FGR). In: Konar H, editor. DC Dutta’s Textbook of Obstetrics. 8th ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2015. p. 533.

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Features of Symmetrical and Asymmetrical IUGR Foetuses Symmetrical Asymmetrical

Incidence 20% 80%

Onset Early, during cellular hyperplasia

Late, during cellular hypertrophy

Size Uniformly small Head larger than abdomen

Ponderal IndexBirth weight/Crown-heel length3

Normal Low

HC:AC & FL:AC ratios Normal Elevated

Etiology Genetic disease or infection (TORCH), involving all organs including headIntrinsic to foetus

Chronic placental insufficiency Extrinsic to foetus

Total cell number Less Normal

Cell size Normal Smaller

Neonatal course Complicated with poor prognosis

Usually uncomplicated having good prognosis

Dutta D. Fetal Growth Restriction (FGR). In: Konar H, editor. DC Dutta’s Textbook of Obstetrics. 8th ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2015. p. 534.

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EtiologyA. MATERNAL

Constitutional Nutrition Diseases Toxins

B. FETAL Non-utilisation of resources by the foetus.

Due to:1. Structural anomaly2. Chromosomal anomaly3. Infection4. Multiple pregnancy

C. PLACENTAL

D. UNKNOWN

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Predictive Factors1. Presence of high-risk factors (obstetric, medical)

2. Low level of 1st trimester PAPP-1 value

3. Abnormal uterine artery Doppler value (notching) at 20-24 weeks of pregnancy

4. Foetal echogenic bowel based on USG

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Pathophysiology• Due to,

Reduced availability of nutrients, or Reduced transfer by placenta to foetus, or Reduced utilisation by the fetus.

• ↓ Brain cell size (Asymmetric-SGA) and cell number (Symmetric-SGA)

• ↓ Liver glycogen

• Oligohydramnios Due to ↓ renal and pulmonary contribution

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Morphology• Old man look

Weight deficit: 600g below the minimum in percentile standard. Length unaffected.

HC relatively larger than body in asymmetric variety

Dry and wrinkled skin due to less SC fat Scaphoid abdomen, thin meconium, stained vernix caseosa

and thin umbilical cord Pinna: Cartilaginous ridges Plantar creases: Well defined

• Baby is alert, active and having a normal cry. Eyes are open.

• Reflexes: Normal, including Moro-reflex

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Case Study

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Patient Particulars

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Patient Particulars• Name: Majoni Begum• Age: 20 years• Sex: Female• Religion: Islam• Educational Status: Class IX• Occupation: Housewife• Marital Status: Married• Husband

Name: Bubul Ali Occupation: Mechanic Educational status: Matriculate

• Address: C/o Bubul Ali, Baihata Chariali, Kamrup (Rural), Assam• Date of admission: 21-02-2017, 3:30 PM• Date and time of examination: 22-02-2017• Date of last menstrual period: 25-05-2016• Estimated date of delivery: 27-02-2017• Duration of pregnancy: 39 weeks 5 days

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Chief Complaints• Cessation of menstruation for 9 months

For safe hospital confinement

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History of Present Illness• Patient came to know that she was pregnant when she missed

her periods for 2 months, after which she did pregnancy kit test and later got her pregnancy confirmed via the doctor at the local hospital.

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Antenatal History

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First Trimester• The patient complains of cessation of menstruation. She complains

of increased frequency of micturition by about 7 to 8 times a day in comparison to 4 to 5 times a day normally. However, it was not associated with any burning sensation or any pain during voiding.

• The patient gives history of constipation, nausea and vomiting. There was no history of fever, headache, giddiness, cold, cough, weakness, abdominal discomfort, discharge or bleeding-par-vagina.

• She went for her first antenatal check-up in the month of August. She was given Folic Acid tablets to be consumed daily which she did. There is no history of consumption of any other drug, There is no history of exposure to any radiological investigation but to ultrasonography in the month of August.

• Her sleep and appetite was normal.

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Second Trimester• Cessation of menstruation continued and she noticed gradual

enlargement of the abdomen. She perceived the first foetal movements in the month of October (5th Month). She went for her next antenatal check-up in the month of October where she received her 1st dose of Tetanus Toxoid, and the next dose in the following month.

• She was given Iron and Folic Acid (IFA) Tablets to be consumed regularly. There is no history of fever, headache, abdominal discomfort, swelling of legs, blurring of vision, discharge or bleeding-par-vagina. She did not consume any other drug or was exposed to any kind of radiological investigation. She couldn’t specify her weight gain. Her sleep and appetite was normal, and her bladder and bowel habits were regular.

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Third Trimester• Cessation of menstruation continued and so did the gradual

enlargement of abdomen.

• The foetal movements intensified. There was an increased frequency of micturition which was about 7-8 times per day. There is no history of fever, headache, abdominal discomfort, swelling of legs, blurring of vision, discharge or bleeding-par-vagina. Her sleep and appetite was normal, and her bladder and bowel habits were regular.

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Past obstetrics historyYear and month

Pregnancy events

Labour events

Mode of delivery

Puerperium period

Baby

26-06-2012

Duration of pregnancy:9 months

Elective Caesarian Section

Elective LSCS Uncomplicated

LivingAge: 4 years 7 months

Antenatally cared:3ANC

Bezera Hospital

No history of blood transfusion

Birth wt. 2.8 kg

Complications:Absent

Conducted by: Gynaecologist

Hospital stay: 9 days

Sex: Male

Treatment:IFA + 2 TT

Breastfed within 1 hourCompletely immunised till date

• Patient is G2P1 with 1 living issue (L1)

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Menstrual History• The patient attained menarche at the age of 13. Her cycle was

regular (28 ± 2 days) with a flow for 4-5 days. She used 2-3 pads per day. There is no history of passage of discharge or clots and there is no associated pain.

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Past medical and surgical history• The patient did not give history of hypertension, asthma,

diabetes mellitus, heart disease, tuberculosis, kidney disease or any other major illnesses in the past.

• She did not undergo any surgeries in the past.

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Personal History• The patient had studied up to IXth standard.

• She is a non-vegetarian and takes three major meals a day consisting of a rice-based Assamese diet.

• She is a non-smoker, non-alcoholic and does not chew betel nut.

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Family History• The patient lives with her husband, child and father-in-law. All

members are enjoying good health.

• There is no history of TB, heart disease, blood dyscrasias, diabetes, congenital malformation, still birth, recurrent abortion or twin pregnancy in the family.

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Socio-economic History• Patient belongs to lower middle class family with a total income

of ₹6000 per month.

• She lives in a kutcha house with unsanitary latrine.

• She drinks water from tube well without filtering or boiling.

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Contraceptive History• She has not used any contraceptives till date.

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Drug History• The patient took IFA Tablets during her pregnancy.

• There is no history of use of other drugs during her pregnancy.

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Immunisation History• BCG scar is absent.

• She had taken 2 doses of TT in her 4th and 5th month of pregnancy.

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Allergy History• She is not known to be allergic to any inhalant, contactant, or

ingestant.

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General Examination

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• Appearance: Patient looks well.• Decubitus: Left lateral position,

as advised by the doctor.• Build: Average• Weight: 53kg• Height: 155cm• Nutrition: Fair• Har and skin: Normal in colour

and texture• Dehydration: Absent• Icterus: Absent• Pallor: Present

• Cyanosis: Absent• Teeth and gums: Healthy• Tongue: Moist and smooth

papillae• Neck vein: Not engorged• Neck glands: Not palpable• Clubbing: Absent• Koilonychia: Absent• Oedema: Present

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Vitals• Respiratory rate: 18/min.

Regular in rhythm, and thoracic type.

• Blood pressure: 110/70 mm Hg in right upper arm in supine position.

• Pulse: 84 beats/min. Regular in rhythm, normo-volumic, normal arterial wall condition with

normal character. No radio-radial and radio-femoral delay found. All other peripheral pulses are bilaterally and symmetrically palpable.

• Temperature: 98⁰F

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Systemic Examination

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A. Central Nervous System• Higher mental functions

Patient is conscious, alert and cooperative. Patient is oriented to time, place and person. Her speech is normal and memory is intact.

• Cranial nerves are intact.

• Motor system is normal.

• Reflexes and jerks are normal.

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B. Respiratory System• Inspection:

Shape and size of chest is normal. Movement of chest is bilaterally symmetrical.

• Palpation: Trachea is in the midline. Chest expansion is normal. Vocal fremitus is bilaterally symmetrical and normal.

• Percussion: Lung field is uniformly resonant in all areas.

• Auscultation: Normal vesicular breath sounds are heard and no additional

sounds are heard. Vocal resonance is normal on both sides.

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C. Cardiovascular System• Inspection:

Precordium is normal. No bulging o visible pulsations are seen.

• Palpation: Apex breath is felt in the 5th intercostal space just medial to

the mid-clavicular line.

• Auscultation: 1st and 2nd heart sounds are heard normally. No additional heart sounds are heard.

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Obstetric Examination

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A. Breast Examination• INSPECTION:

Size: Uniformly enlarged. Skin over breast: Normal Nipples: Everted Areola: Hyperpigmented Montgomery tubercles seen No secretions from nipples seen

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B. Par-abdominal Examination• INSPECTION:

Size: Uniformly enlarged Shape: Longitudinally ovoid Flanks: Not full Umbilicus: Everted, in the midline Linea nigra seen extending from pubic symphysis to umbilicus Stria gravidum seen No visible peristalsis or pulsations seen No engorged veins seen Scar of previous C-section seen

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Par-abdominal Examination (Contd.)• PALPATION:

No local rise in temperature felt. Tenderness: Absent Abdominal girth: 87cm/34” Symphysiofundal height: 28 cm Fundal height corresponds to 34 weeks of gestation Foetal movements perceived Uterine contractions felt

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Par-abdominal Examination (Contd.)• Fundal grip:

Soft, broad, irregular, non-ballotable mass felt, suggestive of foetal buttocks

• Lateral grip: Smooth, curved, resistant surface felt on the right side suggestive of back of

foetus and multiple knob –like structures felt on the left side, suggestive of foetal limbs.

• First pelvic grip: A hard, globular and smooth mass felt, suggestive of foetal head. Lie: Longitudinal Attitude: Flexion Presentation: Vertex Engagement: Head is engaged

• Second Pelvic Grip: Findings of first pelvic grip are confirmed. Head is flexed and engaged.

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Par-abdominal Examination (Contd.)• AUSCULTATION:

Foetal heart sounds heard on right spino-umbilical line Foetal heart rate: 132 beats/min

Regular in rhythm

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Provisional diagnosisThe patient Majoni Begum, 20 year Muslim female, a married housewife hailing from Baihata Chariali, Kamrup (R) is a post C/S multigravida G2P1L1 presenting with a cessation of menstruation for 9 months is provisionally diagnosed to be a case of 39 weeks 5 days of pregnancy with single live foetus in a longitudinal lie, cephalic presentation, and not in labour with intrauterine growth restriction.

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Investigations

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A. Blood Tests• ABO Grouping: B+

• Rh Typing: Positive

• Haemoglobin: 9.2 g/dl

• TLC: 11,910/mm3

• DLC Neutrophil: 82% Lymphocyte: 12.6% Monocyte: 4.2% Eosinophil: 1.2%

• Platelet: 1.36 lacs/mm3

• Random Blood Sugar: 74 mg/dl

• Serum creatinine: 0.93 mg/dl

• TSH: 0.37 µIU/l

• Hbs Ag: Negative

• HIV: Non reactive

• VDRL: Non reactive

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B. Urine Examination• PHYSICAL:

Quantity: 50 ml Colour: Pale yellow Sediment: Nil Appearance: Clear Reaction: Acidic Specific gravity: 1.010

• CHEMICAL: Albumin: Nil Sugar: Nil Phosphate: Nil Microscopy:

Pus cells: 1-2 cells/HPF Epithelial cells: 1-2/HPF RBC: Nil Crystals: Nil Cast: Nil

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C. Stool Examination• No ova or cyst seen.

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D. Ultrasonography

Parameter Measurement (mm)

GA

BPD 85 34w2d

HC 305 34w0d

AC 301 34w1d

FL 65 33w4d

As on 12-02-2017

Single live foetus with head in the lower pole with longitudinal lie. Foetal cardiac pulsations seen normal and heart rate measures 143 bpm.• Foetal intracranium, stomach, kidney, spine and

urinary bladder are normal. Foetal limbs, to the extent visualised appear normal. No evidence of gross congenital anomalies.

• Foetal movements are normal. • Four chambered view of heart is normal.• Placenta has Grade III maturity and is in anterior

upper segment.• There is no evidence of placenta previa.• Amniotic fluid adequate.• No cord seen around neck.• Cervix normal.

GA EDD

Ultrasound 34w0d 26-Mar-17

Menstrual 38w2d 24-Feb-17

Foetal biometry:

Biometry Calculations (LMP=20-May-16)

Impression1. Single live foetus in cephalic presentation and longitudinal lie with gestational age of

34 weeks corresponding to dates.2. Approximate foetal weight 2306 g

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Final DiagnosisOur patient, Mrs. Majoni Begum, 20 year old Muslim female, a married housewife hailing from Baihata Chariali, Kamrup (R), belonging to lower middle class family, is a post C/S multigravida G2P1L1 with 39 weeks 5 days of gestation, presenting with a cessation of menstruation for 9 months, is finally diagnosed to be a case of 39 week 5 days of gestation with a single live foetus in cephalic presentation and longitudinal lie with gestational age of 34 weeks corresponding to dates and an approximate foetal weight 2306 g.

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Case Summary

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• Mrs Majoni Begum, a 20 year old Muslim female, of G2P1L1 married for last 5 years, coming from a low socioeconomic status, admitted on 21st February, 2017 for safe hospital confinement following a cessation of menstruation for 9 months. Her LMP was 25th May, 2016 and EDD is 27th February, 2017 and duration of gestation is 39 week 5 days. Her menstrual period was regular with an average of 28-30 days duration. She used to attend antenatal clinic regularly and had taken Iron Folic acid and TT injection as advised. She had no significant past and family history.

• On physical examination, her height was 155cm and weight was 53 kg. Her BP was 110/70 mm and pulse was 84 beats/min. No abnormality was detected during systemic examination.

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• On obstetric examination, height of fundus corresponds to 34 weeks, longitudinal lie, vertex presentation, head engaged. SFH is 28 cm (usually less than expected) and abdominal girth is 87 cm. Foetal heart rate 132 bpm and regular, situated on right spino umbilical line.

• USG report showed a single live foetus in cephalic presentation and longitudinal lie with gestational age of 34 weeks corresponding to dates and an approximate foetal weight of 2306 g, which is suggestive of intrauterine growth restriction.

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Management

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General• Bedrest

• Diet

• Maternal hyperoxygenation

• Hyperalimentation

• Maternal Volume Expansion

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Mode of Delivery• Since the last delivery was LSCS and there is history of decrease

contraction which was cause of caesarean section, therefore elective LSCS will be done in this case to prevent any complication.

• Immediate care of baby after birth is taken care of.

Thank You