- Managment of IUGR

 Managment of IUGR

The initial management of a neonate with fetal growth restriction (FGR) is supportive and is focused on preventing or addressing any associated complications.

Antenatal management

1.  Bed rest: has been used but is now largely abandoned.

2.  Calcium channel blockers: used in pregnancy as tocolytics and to alter cerebral blood flow.

3.  Hormonal therapy: maternal estrogen administration may result in greater uterine blood flow allowing ↑ nutritional supply to improve fetal growth.

4.  Corticosteroid therapy: maternal glucocorticoid administration results in improved fetal doppler waveforms and better outcomes.

 

Perinatal management

A. Assessment of fetal well-being:

-        Fetal movement: All women with pregnancies with risk factors for adverse perinatal outcome should perform daily fetal movements counts and consult their physician if they notice a decrease or change in fetal movements.

-        Non stress test (NST): Frequency of regular NST to assess fetal well-being should be based on severity of IUGR.

-        Biophysical profile (BPP): In presence of decreased fetal movement, abnormal NST, suspicion or diagnosis of IUGR, a BPP or amniotic fluid assessment is warranted.

B. Delivery and resuscitation.

-        The optimal timing for delivery discussed before.

-        Outcomes are more favorable with cesarean delivery because the FGR fetus tolerates the stress of labor poorly and signs of fetal distress are common. In such cases, the already stressed, chronically hypoxic infant is exposed to the acute stress of diminished blood flow during uterine contractions.

-        Skilled resuscitation should be available because of possible complications for example perinatal depression .

A.    Prevention of heat loss.

B.    Hypoglycemia: monitoring of blood glucose levels is essential.

C.    Hematologic disorders. Cbc with differential and HCT reading should be obtained to detect polycythemia.

D.    Calcium monitoring.

E.    If respiratory distress present, ABG and Chest X-ray.

F.    U/S, echo if clinically indicated

G.   Congenital infection.

-        FGR infants should be examined for congenital malformations or signs of congenital infections.

-        Many intrauterine infections are clinically silent, and screening for these should be done routinely in FGR infants.

-        At our institution, we consider evaluation for cytomegalovirus in FGR neonates without an underlying etiology.

-        CMV PCR (urine) This is the most sensitive test for congenital CMV.

I. Genetic anomalies. Screening for genetic anomalies should be done as indicated by the physical examination.

J. Nutrition:

-        Enteral feeding should be started early in infants at volumes appropriate for the infant's weight. It is not certain what the most optimal caloric intake is for infants with FGR.

-        In preterm IUGR infants enteral feeding should progress cautiously because of the increased risk of necrotizing enterocolitis (NEC) due to fetal redistribution of blood away from the gut.

-        Our goal is to provide enough nutrients to achieve postnatal growth similar to a normal fetus of the same gestational age or infant with the same postmenstrual age.

K. The placenta:  should be sent for histopathologic examination and Placental chromosome analysis.

L. LFT, clotting screen Only if evidence of chronic fetal hypoxic–ischaemic injury.