IUGR (FGR) and SGA

Definition

• SGA ≠ FGR
• SGA is baby less than 10th percentile in intergrowth 21 charts
• FGR is baby not attaining full growth potential due to environmental or genetic factors

Types

Causes

maternal

• <16 yrs or >36 yrs
• low socioeconomic status
• smoking, drug abuse
• diabetes mellitus
• maternal SLE
• use of assisted reproductive techniques
• chronic renal, gastric or gastrointestinal disease

Fetal

• chromosomal anomaly
• congenital malformation
• congenital infection
• multiple infection

Placental

• low placental weight
• placental infections
• placental mosaicism
• vascular anomalies

Endocrine

• insulin deficiency
• decreased IGF1,2, IGFBP-2
• endothelin deficiency
• reduced levels of thyroid hormones

Pathogenesis

• reduction in umbilical blood flow - redistribution of blood from liver - reduction of abdominal circumference
• elevated placental resistance - decreased umbilical artery end-diastolic flow - increased pulsatility index - later can cause absent end-diastolic flow or reversed end-diastolic flow
• redirection of blood to vital organs - end-diastolic flow increases in cerebral arteries - brain sparing effect

difference between early FGR and late FGR

Complication of IUGR

short term complications

• hypoglycemia
• polycythemia
• hypocalcemia
• 3-4x higher risk of feed intolerance
• 2.5x higher risk of necrotizing enterocolitis

Long term complications

• 45% higher risk of BPD
• neurodevelopmental disabilities
• failure to thrive
• hypertension
• insulin resistance
• coronary artery disease
• cerebrovascular stroke

Screening and Diagnosis

Screening

Clinical examination

• symphysio-fundal height
  • more than 3 weeks difference SFH and gestational age is specific marker for FGR
• Continuous weight monitoring of mother
• Uterine artery doppler

Fetal biometry

• abdominal circumference (reduction in AC is the first biometric marker)
• Biparietal diameter
• head circumference
• femur length
• HC/AC ratio
• estimated fetal weight

Doppler studies

• abnormal CPR and UtA velocities for late FGR
• UA velocities for early FGR

Diagnostic criteria - Consensus Definition

Management

Timing of delivery

• If Doppler velocity abnormalities are detected, baby can be delivered at any age after completion of steroids

Neonatal management

• High risk of short and long term complications
• 20-30% of recurrence in subsequent pregnancies
• feed to be started with high index of suspection

Prevention

• optimizing maternal age of delivery
• maternal nutrition
• micronutrient supplementation including calcium
• treatment of maternal diseases like gestational hypertension and diabetes
• cessation of smoking, alcohol and drug abuse
• Aspirin - inhibit platelet aggregation by enhancing nitric oxide - reduce uteroplacental resistance
• aspirin to be given in all women with risk factors of placental insufficiency or pre-eclampsia (81 gms from 12 to 28 weeks of gestation - preferably before 16 weeks)

Principles of Community care

1. Mobilizing all pregnant women to ensure compliance with full antenatal care.
2. Undertake birth planning and birth preparedness with the mother and family to ensure access to safe delivery.
3. Provide newborn care through a series of home visits and performing the following activities:
   • Weighing the newborn;
   • Measuring newborn temperature;
   • ensuring warmth;
   • Supporting early and exclusive breastfeeding, and teaching the mother
   • proper positioning and attachment for initiating breastfeeding;
   • Diagnosing and counselling in case of problems with breastfeeding;
   • Promoting hand washing;
   • Providing skin, cord and eye care;
   • Health Promotion and counselling mothers and families on key messages on newborn care (discouraging early bathing, bottle feeding);
   • Ensuring identification and prompt referral for sepsis or other illnesses.
4. Assessing if the baby is high risk, (preterm or low birth weight), through the use of protocols and managing such LBW or preterm babies by:
   1. Increasing the number of home visits;
   2. Monitoring weight gain;
   3. Supporting and counselling the mother and family to keep the baby warm and enabling frequent and exclusive breastfeeding
   4. Teaching the mother to squeeze breast milk out and feed baby using cup and spoon.
5. Detect signs and symptoms of sepsis, provide first level care and refer the baby to an appropriate center, after counselling the mother to keep the baby warm. If the family is unable to go, the ASHA should ensure that the ANM visits the sick newborn on a priority basis.
6. Detect postpartum complications in the mother and refer appropriately.
7. Counsel the couple to choose an appropriate family planning method.
8. Provide immediate newborn care in case of those deliveries that do not occur in institutions

Kangaroo mother care

• 4 components of kangaroo mother care
  • kangaroo position
    • skin to skin contact
    • semi-reclined position of mother
    • baby should be kept in upright position
    • hips flexed in 'frog' position
    • head should be covered with cap
    • make sure the neck of the baby is not too flexed
  • Exclusive or near exclusive breast feeding
  • early discharge from health facility
  • continued follow up and home care
  • to be continued till baby is 2500 grams

Advantages

• can be done by anyone
• KMC can be initiated early before 24 hours of life if baby is hemodynamically stable (iKMC study)
• should be given 8-24 hours
• no need of any major equipment
• helps to decrease apnea episodes,
• mother can feed the baby while KMC

Disadvantages

• no major disadvantages
• Contraindication include
  • intubated / invasive ventilation
  • shock
  • sepsis
  • seizures
  • severe jaundice
  • major congenital malformations
  • no major illness in care-giver

Feeding of LBW

• Babies are born prematurely and have poor feeding skills
• Initial feeding to be decided based on whether the baby is sick or healthy
  • sick - babies on inotropic supports, babies on ventilator supports, symptomatic hypoglycemia, seizures, electrolyte abnormalities, AKI etc..
  • Sick children are started on IV fluids - shifted to enteral feeding when the child is hemodynamically stable
  • Healthy children are started on enteral feeding
  • 
  • Choice of milk
    • Expressed mother's own milk (MOM) is the best
    • Donor's milk
    • LBW formula
  • Milk Quantity to be given
    • 60 ml/kg/day in ≥ 1.5kg and 80 ml/kg/day < 1.5 kg initially
    • incremented at a rate of 30-40 ml/kg/day
    • max 180 ml/kg/day
  • Supplementation
    • Fortification with HMF and preterm formula
    • preterm babies have inadequate source of following nutrients and hence needs to be supplemented
      • calcium and phosphate - Osteocalcium 5-6 ml/kg/day
      • Vitamin A, B, zinc - Visyneral/ Dexvita 1ml/day
      • Vitamin D3 - Arbivit / sunsips (800/1) - 0.5 ml/day
      • Iron - started at 4-6 weeks of life - Tonoferon 2 drops/kg/day
      • Folate - Folvite / folium 0.1 ml/day
  • Feed intolerance can occur
    

Improving neurodevelopmental outcomes

• Family centric developmentally supportive care
  • positioning of baby 'as if in-utero' - universal flexion, achieved with swaddling, soft boundaries and a padded foot wall
  • clustering of activities like pricking for sample, diaper change, examination of newborn
  • protected sleep - prone positioning, use of dim light, reduced noise levels, use of separate room for each neonate
  • efforts to improve bonding with mother/family and neonate, early initiation of KMC, NNS, oro-motor suckling
  • limiting the number of painful procedures

Discharge criteria

Weight Criteria

• Minimum weight of 1800 grams (some guidelines may accept 1500 grams if the baby is otherwise stable).
• Consistent weight gain of 15–20 grams per day for 3 consecutive days.

Thermal Stability

• Ability to maintain normal body temperature (36.5–37.5°C) in an open environment (without external heat sources) for at least 3 consecutive days.

Feeding Ability

• Baby should be able to breastfeed or take oral feeds adequately.
• No signs of feeding intolerance.
• No need for intravenous fluids or tube feeding.

Clinical Stability

• No signs of infection, respiratory distress, or other acute medical conditions.
• No apneic episodes for at least 5–7 days.
• Normal vital signs (heart rate, respiratory rate, oxygen saturation).

Parental Readiness

• Parents/caregivers trained in:
  • Kangaroo Mother Care (KMC)
  • Breastfeeding techniques
  • Danger signs recognition
  • Hygiene and thermal care
• Confident and capable of caring for the baby at home.

Follow-Up Plan

• A clear follow-up schedule including:
  • Home-Based Newborn Care (HBNC) visits by ASHA workers.
  • Scheduled visits to the nearest health facility or SNCU follow-up clinic.

Immunization

• Baby should have received age-appropriate immunizations before discharge.