Retardation of intrauterine development of the fetus treatment. Intrauterine growth retardation: causes, treatment and prevention

Obstetric pathologies and some somatic diseases can affect the course of pregnancy. In severe disorders, intrauterine delay fetal growth. This condition can be corrected with timely treatment, so pregnant women at risk are under observation.

Features of the pathology

delay prenatal development fetus (or IUGR) is considered to be below the 10th percentile in birth weight. The condition is diagnosed during pregnancy, so it includes those children who do not correspond in size to this period gestation.

This condition occurs with varying frequency, which depends on the social stratum, living conditions and nutrition. According to the literature, fetal growth retardation syndrome occurs in 5-17% of all pregnancies.

The intrauterine development of the child is completely dependent on the state of the mother's body. Therefore, a woman's nutrition, working conditions, somatic and infectious diseases can affect the course of gestation. Most of the adverse factors are removable, therefore, to prevent the development of pathology, pregravid preparation and proper management of pregnancy are necessary.

Why is this happening

The placenta is the main organ that maintains the life of the unborn child. It performs the function of supplying nutrients and oxygen, filters harmful substances, microorganisms. Therefore, placental insufficiency becomes the main factor of deviations in development. But the reasons that lead to pathology are diverse:

The risk of developing fetal retention is high with an initially low mother's body weight (less than 50 kg). The complicated obstetric and gynecological anamnesis matters. Unfavorable factors include:

infantilism of the uterus;
anomalies in the development of the genital organs;
menstrual dysfunction;
spontaneous interruption in the past;
complications in past births or pregnancies.

In half of the cases, the exact cause cannot be established, so a woman needs to know about the likelihood of a pathological condition with her risk factors.

Types and severity

The form of malnutrition is determined by the ratio of the lag in the development of different parts of the fetal body:

Symmetrical form (hypoplastic) - the proportions of the child are preserved, there is no lag or predominance of any parts of the body. But the overall dimensions are reduced, according to the gestational age. This form develops at the beginning of gestation. The mechanism of development of a symmetrical form is due to the fact that in the early period the growth of the fetus depends on cell hyperplasia - their increased division. Hypoxia inhibits this process, so there is a lag in height and weight.
Asymmetric form (hypotrophic) - the child has a normal body length, but there is a significant lag in growth. Measurement of the volume of the abdomen will show its decrease relative to the week of gestation. This is due to a decrease in the volume of cells of internal organs that do not receive the right amount oxygen and nutrients.
Mixed form - there is a lag in the size of the abdomen by 2 weeks from the norm for a given gestational age, the remaining indicators of fetometry are slightly reduced.

The degree of malnutrition is also determined. Delayed fetal development of the 1st degree is characterized by a delay of 2 weeks from the norm. This condition is referred to as mild deviations. Intrauterine growth retardation of the 2nd degree is manifested by a lag of 3-4 weeks from the norm. In severe cases, when the fetus is 4 weeks less than the due date, the 3rd degree of IUGR is set.

Development mechanism

The probability of the formation of the IGR is laid already in the first trimester. A woman under the influence of various pathological factors the process of trophoblast germination in spiral uterine arteries- the basis of the future placenta. The consequence is hemodynamic disturbances in the uterus-placenta system. There is a slowdown in blood flow in the vessels, which leads to a decrease in the rate of gas exchange between the mother and fetus. In the period up to 22 weeks, the mechanisms that are able to compensate for hypoxia have not yet been developed, therefore, a symmetrical form of developmental delay develops.

In the second half of pregnancy, the occurrence of malnutrition occurs due to impaired functioning of the placenta under the influence of many factors. This causes chronic hypoxia. The body of the fetus is trying to save a vital part - the nervous system, so the main blood flow is directed to the brain. suffering from hypoxia internal organs, therefore, an asymmetric form of malnutrition is formed.

Manifestations of a pathological condition

By outward signs it is impossible to establish the pathological condition of the fetus. In the 3rd trimester of pregnancy, this can be suspected by a slight weight gain or a small size of the abdomen when measuring its circumference and the height of the uterine fundus. But these indicators are non-specific. Similar processes are observed in oligohydramnios, which does not always accompany developmental delay.

Only the presence of risk factors, the low social status of a woman, the lack of normal nutrition and living conditions, as well as bad habits, can allow the doctor to suggest a violation of the condition.

Indirectly, hypoxia and possible IUGR can be judged by the motor activity of the child. A sudden increase in tremors indicates an acutely developed intrauterine. The almost complete cessation of movements is an indicator of chronic hypoxia and suffering of the child.

Complications

The consequences of malnutrition depend on the cause that led to it. Fetoplacental insufficiency can become a factor that will lead to the threat of termination of pregnancy or premature birth, abnormalities in labor.

As one of the causes of IUGR, it can be complicated by placental abruption and the death of the child, and for the mother this threatens to develop DIC.

infections on early dates lead to non-developing pregnancy, and in the later ones - to the formation of congenital malformations or antenatal death.

In children who were born with a weight lag, adaptive capabilities are reduced. They get sick more often postpartum period, tolerate physiological jaundice and other body changes worse. They need special attention from the pediatrician.

With an asymmetric form of malnutrition, the development of the following complications after birth is characteristic:

large weight loss after birth and slow recovery;
prolonged hyperbilirubinemia;
no hormonal crisis;
slow healing umbilical wound;
metabolic disorders: decreased protein-synthetic function of the liver;
blood clotting disorders;
asphyxia of the newborn, often - damage to the brain and spinal cord;
hyperexcitability syndrome.

With a symmetrical form, stigmas of disembryogenesis are often detected:

reduced skull size, overhanging eyebrows;
small facial features, its asymmetry;
saddle-shaped, Mongoloid nose;
epicanthus, eye asymmetry;
dystopia of the auricles;
anomalies of the ear curl, antihelix;
brachydactyly, arachnodactyly;
cryptorchidism or phimosis in boys;
enlargement of the clitoris in girls;
violation of skin pigmentation;
excessive hair growth in certain areas of the body.

Maternal and fetal examination

At each visit to the obstetrician-gynecologist, the height of the fundus of the uterus and the circumference of the abdomen are measured. Their increase, regardless of the constitution of the mother, occurs according to certain standards. With a lag of 2 cm or more, there is reason to suspect malnutrition, especially if the woman is at risk. But accurate data can be obtained during dynamic ultrasound. To assess growth retardation, a minimum of two studies with an interval of 14 days is required.

The symmetrical form occurs in 10-30% of cases. In this case, there is a proportional decrease in all sizes of the child: head, abdomen, length of the femur. IUGR of this type begins to manifest itself from the 2nd trimester. Violation placental blood flow registered from 20 weeks. For such women, a lot of or oligohydramnios is characteristic, a combination with malformations is often detected.

Fetal cardiotocography (CTG)

For accurate diagnosis, it is necessary to know the gestational age in order to correctly correlate the data and standards obtained during the study. The ratio of the head and the circumference of the abdomen in the fetus with a symmetrical shape is reduced evenly. Therefore, these data are not informative. The ratio of the length of the thigh and the circumference of the abdomen is applied. If it is more than 24.0, this gives the right to consider that the fetus is lagging behind in development.

Exceptions are cases when the small size of the child is genetically determined, is a constitutional feature of the parents.

The asymmetric form is detected in 70-90% of cases. Diagnosis of pathology is usually not in doubt. The ratio of the circumference of the head and abdomen is taken as the basis. For an asymmetric form, this figure exceeds the norm for age. The following numerical values are taken as a normal ratio:

up to 32 weeks - more than 1.0;
from 32 to 34 weeks - approaches 1.0;
from 34 to childbirth - less than 1.0.

The asymmetric form of IGR develops in the 3rd trimester. Blood flow disorders in the placenta appear after 30 weeks of gestation, the volume of amniotic fluid is reduced or normal, and malformations are rarely detected.

Also, during the diagnosis, the severity is established, which determines further medical tactics.

Ultrasound includes conducting dopplerometry of the vessels of the placenta. At the same time, blood flow disturbances are detected in the following fetal vessels:

umbilical artery;
aorta;
cerebral artery;
venous duct.

All women after 27-30 weeks perform CTG (what kind of procedure it is and how it is done, read in). This allows you to assess the presence and severity of fetal hypoxia. Deviations from the norm are considered to be a decrease in heart rate variability, a non-stress test of an areactive type.

The biophysical profile of the fetus is assessed. He gives objective information only after 30 weeks of pregnancy. The duration of the procedure is at least 30 minutes. A number of indicators are evaluated in real time using ultrasound. They and CTG data are assigned a certain number of points, which are then summed up. 6 indicators matter:

non-stress test (heart contractions in response to fetal movements);
respiratory movements;
fetal tone;
physical activity;
volume of amniotic fluid;
maturity of the placenta.

It is considered normal to receive from 8 to 12 points. If the sum is equal to 7-6 points, the condition is doubtful and requires observation. At 5-4 points - pronounced fetal distress.

Correction methods

Treatment of intrauterine growth retardation takes place in two directions:

Correction of blood flow disorders in the placenta.
Treatment of concomitant diseases that could cause violations.

Nowhere in the world have developed unified effective treatment regimens for IUGR. Clinical recommendations for intrauterine growth retardation are based on the treatment regimen developed by Savelieva G.M. It includes:

protein diet enriched with vitamins and minerals;
alternation of 10 sessions of diathermy of the perirenal region with 10 sessions of ultraviolet irradiation;
injections into a vein of glucose with Korglikon, alternating every other day;
cocarboxylase into the muscle daily for 10-14 days;
taking Euphyllin inside or in the form of suppositories rectally;
tablets Trental or Isadrin in combination with Fenoptil.

This therapy regimen cannot help with severe IUGR. But with moderate severity, it stops the deterioration and supports the fetus. According to some studies, the use of Phlebodia-600 venotonic, which is pure diosmin, gives an effect.

Venotonic Phlebodia-600

This substance has an affinity for the venous wall and allows for the prevention of pregnancy complications caused by placental insufficiency. For women at risk, it is prescribed from the second trimester, if there are signs of IUGR, then the medication is recommended from the moment the condition is diagnosed. Diosmin eliminates venous stasis in the uterine-placental complex, improves microcirculation, increases the compensatory-adaptive reactions of the fetus.

Improper nutrition is one of the causes of pathology, but the condition can only be improved with the help of food. Biological additives do not have a significant effect on the condition of the fetus.

When IUGR is combined with infection, the method of therapy has not been developed. Bacteria never cause stunting, this condition develops under the influence of viruses.

Preservation of pregnancy and delivery

Pregnancy is prolonged for a woman if there are no signs of chronic hypoxia at 1-2 degrees of developmental delay.

If there are symptoms of hypoxia, regardless of the severity of the condition, which is amenable to medical correction, the pregnancy is prolonged to at least 32-34 weeks.

In the absence of a fetal response to the ongoing therapy (it does not grow), the deterioration of the mother's condition and the threat to her life, early delivery is performed.

Fetal growth retardation before 37 weeks of gestation does not always result in a caesarean section. It is carried out according to the following indications:

critical deterioration of the child's condition;
ZVUR 3 degrees;
2 degree of delay in combination with obstetric pathology;
unpreparedness of the cervix for childbirth;
complicated history.

The operation is performed under epidural anesthesia in order to prevent the depressing effect of narcotic anesthetics on the child.

If, with existing malnutrition during childbirth, the condition began to worsen, a decision may be made on an emergency caesarean section.

Delayed fetal development leads to deviations in physical and neuropsychic development during the first years of life. Therefore, it is necessary to avoid conditions that can adversely affect the development of the child.

In every tenth case of pregnancy, a diagnosis is made - intrauterine growth retardation (the pathology is also known under the abbreviation IUGR). The doctor determines the deviations, which are characterized by a discrepancy between the size of the child and the normal indicators for a particular week of pregnancy. How dangerous this pathology is and what exactly you should be afraid of, it is useful for everyone to know future mother, because no one is immune from such a phenomenon.

Causes of the disease

Intrauterine growth retardation of the fetus is diagnosed at the most different stages pregnancy. This happens if the baby does not receive enough nutrients and oxygen, which are actively involved in the formation of a small organism. The reasons for this can be very different:

placental pathology: incorrect presentation or detachment;
chronic diseases mothers: high blood pressure, problems with the cardiovascular system, anemia, wrong job respiratory tract;
deviations in the chromosome set: Down syndrome;
pathologies of intrauterine development: malformation of the abdominal wall or kidneys;
mother's bad habits;
infectious diseases suffered by a woman during pregnancy: rubella, toxoplasmosis, syphilis, cytomegalovirus;
inadequate or malnutrition;
constant stress;
gynecological diseases;
independent reception medicines during pregnancy without a doctor's prescription;
multiple pregnancy;
climatic conditions: living in an area that is located high above sea level.

Smoking and alcoholism during childbearing can lead to such a phenomenon as asymmetric fetal growth retardation, when, according to ultrasound, the child's skeleton and brain correspond to the term, but the internal organs remain undeveloped. It is especially important to supply the fetus with everything necessary in the last weeks of pregnancy so that it successfully adapts to the new environment.

Symptoms of IUGR

The first signs of the IUGR syndrome are detected already in the early stages of pregnancy (at 24–26 weeks), but the woman is not able to determine them on her own. This can only be done by a doctor. Symptoms are considered non-compliance with the norm of the following indicators:

abdominal circumference at a certain level, the height of the fundus of the uterus (palpable by hand by a gynecologist);
the size of the head, femur, belly of the baby;
growth with constant monitoring;
the amount of amniotic fluid;
violations of the functioning of the placenta (the size or structure may change);
blood flow velocity in the placenta and umbilical cord;
baby's heart rate.

Even doctors are often mistaken in the diagnosis, because sometimes the discrepancy between these parameters is nothing more than a genetic or hereditary predisposition. To avoid misdiagnosis, a survey of parents is conducted, with what weight they were born. Whereas a delay in fetal development for 2 weeks or more already gives serious reasons to believe that the diagnosis is accurate.

Treatment Methods

Treatment largely depends on the degree of observed abnormalities:

intrauterine growth retardation of the 1st degree - a lag of 2 weeks (therapy can be quite successful and negate the negative consequences for the further development of the baby);
2 degrees - a delay of 3-4 weeks (strong treatment will be required, and the results can be completely unpredictable);
3 degrees - a lag of more than a month (even the most intensive therapy will not be able to equalize such a large lag, and the child may be born with serious deviations from the norm).

Treatment includes:

therapy for maternal diseases;
treatment of pregnancy complications;
increasing the resistance of a small organism to hypoxia;
normalization of placental insufficiency (as a rule, drugs are prescribed to dilate blood vessels to improve the blood supply to the fetus and uterus, as well as means to relax the muscles of the uterus).

Treatment is carried out on a stationary basis so that mother and child are constantly under medical supervision. The timing and methods of delivery depend on the well-being of the mother and the condition of the fetus.

Consequences of intrauterine growth retardation

The consequences that the syndrome of fetal growth retardation entails can be very different. Children with this diagnosis after birth may experience serious problems with health.

In infancy:

obstetric complications during childbirth: hypoxia, asphyxia, neurological disorders;
poor adaptation to new living conditions;
hyperexcitability;
increased or decreased muscle tone;
poor appetite;
small weight gain;
psychomotor retardation in development;
inability to maintain body temperature constant within the normal range;
insufficient degree of development of internal organs;
high susceptibility to infectious diseases.

At older age:

diabetes;
tendency to corpulence;
high blood pressure.

In adulthood:

cardiovascular diseases;
obesity;
non-insulin dependent diabetes mellitus;
elevated blood lipid levels.

However, many babies diagnosed with intrauterine growth retardation over time may not differ at all from their peers, catching up with them in terms of both height and weight, without any consequences for their health at any age.

Approximately every tenth woman in position, the doctor diagnoses "fetal growth retardation" (IUGR). The specialist determines the presence of deviations, characterized by a discrepancy between the size of the baby and the normative indicators for a particular week of development. How dangerous this pathology is in reality and how it threatens the child, it is important for every mother to know, because absolutely no one is immune from such a phenomenon.

What is a ZVUR?

Retardation of intrauterine development of the fetus is usually diagnosed on the basis of an ultrasound examination. Pathology is determined if the weight of the baby is less than the normative indicators characteristic of this period of development. In medical practice, specially designed tables are used that indicate the weight of the fetus in accordance with its gestational age, that is, the time since fertilization. This indicator is usually determined in weeks. In other words, there are certain norms for each stage of pregnancy. The basic unit of measure in such tables is the percentile. If the fetus is less than 10 percentiles on this table, the doctor confirms the presence of pathology.

Fetal growth retardation: causes

Sometimes, when diagnosed with IUGR, parents do not need to worry. It happens that a baby is born small in size, since his father and mother are not very tall. This physiological feature does not affect the activity of the child, his mental and physical development. During pregnancy and after birth, such a baby does not need narrowly targeted therapy.

In all other situations, special attention should be paid to the diagnosis. This condition can lead to deviations in the development of the child or even death of the fetus. IUGR may indicate that the baby in the womb is not eating well. This means that he does not receive sufficient volumes nutrients and oxygen. Nutritional deficiencies are usually attributed to the following reasons:

Wrong chromosome set.
Bad habits of the mother (smoking, drinking alcoholic beverages and drugs).
Pathogenic diseases (hypertension, anemia, diseases of the cardiovascular system).
Incorrect location and subsequent formation of the placenta.

In addition, doctors call whole line other reasons that can also provoke intrauterine growth retardation syndrome:

Multiple pregnancy.
The use of drugs without a doctor's prescription.
Childbirth after 42 weeks.
Not balanced diet. Many women do not want to get better during pregnancy, so they exhaust themselves with diets. By this they provoke the exhaustion of the body, which leads to the development of pathology.
Diseases of an infectious nature (toxoplasmosis, rubella, syphilis).

Clinical picture

What are the symptoms of intrauterine growth retardation? Signs of pathology appear most often in the early stages (approximately 24-26 weeks). A woman is not able to determine them on her own, this can only be done by a doctor. IUGR syndrome is diagnosed when the following indicators do not meet the standards:

The size of the head and femur of the baby.
Abdominal circumference at a certain level, the height of the fundus of the uterus.
Volume of amniotic fluid.
Violation of the functioning of the placenta (its structure and size change).
Fetal heart rate.
Blood flow velocity in the placenta and umbilical cord.

In some cases, the pathology develops quite quickly and progresses without any special disturbances, that is, it is asymptomatic.

Severity

I degree. The intrauterine growth retardation of the 1st degree is considered relatively mild, since the developmental lag from the anthropometric data corresponding to a certain gestational age is only two weeks. Timely therapy can be effective and minimize the likelihood of developing negative consequences for the baby.
II degree. The delay in development is approximately 3-4 weeks, serious treatment is required.
III degree. It is considered the most severe form due to the delay in fetal parameters by one month or more. This condition is usually accompanied by so-called organic changes. Delayed intrauterine development of the fetus of the 3rd degree often ends in death.

Asymmetric form of pathology

In this case, there is a significant decrease in the weight of the fetus with its normal growth. The child is diagnosed with a lag in the formation of soft tissues of the chest and abdomen, and an abnormal development of the trunk. Available uneven growth systems of internal organs. In the absence of adequate therapy, a gradual decrease in the size of the head and a lag in the development of the brain begin, which almost always leads to the death of the fetus. The asymmetric variant of the IUGR syndrome occurs mainly in the third trimester against the background of general placental insufficiency.

Symmetrical form of pathology

With a symmetrical form, a uniform decrease in the mass, size of organs and growth of the fetus is observed. This pathology most often develops on early stages pregnancy due to fetal diseases (infection, chromosomal abnormalities). Symmetrical intrauterine growth retardation increases the likelihood of having a child with an imperfectly formed CNS.

Diagnostic measures

If you suspect this pathology a woman is recommended to undergo a complete diagnostic examination. First of all, the doctor collects the patient's medical history, clarifies the previous gynecological diseases, the features of the course of the previous pregnancy. Then a physical examination is carried out with the obligatory measurement of the circumference of the abdomen, the fundus of the uterus, the height and weight of the woman.

Additionally, ultrasound, dopplerometry (assessment of blood flow in the arteries and veins) and cardiotocography (continuous recording of the fetal heart rate, its activity and directly uterine contractions). Based on the results of the tests, the specialist can confirm the diagnosis or refute it.

What treatment is required?

To determine the subsequent management of pregnancy after confirming the diagnosis of intrauterine growth retardation, the causes of the pathology, the form and degree of the disease should be taken into account. The main principles of therapy should be focused on improving blood flow in the uterus-placenta-fetus system. All therapeutic measures are carried out in stationary conditions. First of all, a woman needs to ensure peace, rational nutrition and a good long sleep. An important element therapy is considered to be monitoring the current state of the fetus. For these purposes, ultrasound is used every 7-14 days, cardiotocography and blood flow dopplerometry.

Drug treatment includes the use of angioprotectors to protect blood vessels, tocolytics against uterine muscle tension (Papaverine, No-shpa), general tonic. In addition, all women, without exception, are prescribed drugs that reduce neuropsychic excitation (tincture of motherwort, valerian) and improve blood flow in the placenta (Actovegin, Curantil).

Depending on the severity of the pathology, the results of treatment may vary. Delayed intrauterine development of the fetus of the 1st degree usually responds well to therapy, the likelihood of further negative consequences is minimized. With more serious pathologies a different approach to treatment is needed, while its results are quite difficult to predict.

Abortion

Early delivery, regardless of the gestational age, is recommended in the following cases:

Lack of fetal growth for 14 days.
A noticeable deterioration in the condition of the baby inside the womb (for example, a slowdown in blood flow in the vessels).

Pregnancy is maintained up to a maximum of 37 weeks if, due to drug therapy, there is an improvement in performance, when it is not necessary to talk about the diagnosis of intrauterine growth retardation.

Consequences and possible complications

Babies with such a pathology after birth may have deviations of varying severity, their subsequent compatibility with ordinary life will largely depend on their parents.

The first consequences appear already during delivery (hypoxia, neurological disorders). The intrauterine growth retardation of the fetus inhibits the maturation of the central nervous system and its functions, which affects all systems. In such children, the body's defenses are usually weakened; at a more mature age, there is increased likelihood occurrence of diseases of the cardiovascular system.

In children under five years old, slow weight gain, psychomotor retardation in development, improper formation of internal organ systems, and hyperexcitability are often diagnosed. AT adolescence high risk diabetes disease. Such children are usually overweight, they have problems with blood pressure. This does not mean that their daily existence will be reduced to taking medications and living in hospitals. They just need to pay a little more attention to their own nutrition and daily physical activity.

Some children who have been diagnosed with grade 2 intrauterine growth retardation and treated appropriately do not differ from their peers. They drive habitual image life, play sports, communicate with friends and get an education.

How can IUGR be prevented?

The best prevention of this pathology is the planning of an upcoming pregnancy. In about six months, future parents must undergo a comprehensive examination and treat all existing chronic diseases. Refusal of addictions, proper lifestyle, rational nutrition and daily dosed physical activity - the best option prevention of IUGR.

visit antenatal clinic plays on a regular basis after registration important role with a diagnosis of intrauterine growth retardation. Treatment of a timely detected pathology minimizes the risk of negative consequences.

Pregnant women should have a well-organized work and sleep schedule. correct and good rest implies 10 hours of sleep at night and 2 hours during the day. This mode allows you to improve blood circulation and transport of nutrients between mother and child.

Daily walks in the fresh air, dosed physical activity not only improve general well-being pregnant, but also normalize the condition of the fetus inside the womb.

Conclusion

Do not ignore such a pathology as intrauterine growth retardation, the consequences of which can be the most sad. On the other hand, parents should not take this diagnosis as a sentence. If it is delivered in a timely manner, the future woman in labor will take everything necessary measures to eliminate its cause and will follow all the recommendations of the doctor, the prognosis may be favorable. There are no obstacles in the world that cannot be overcome. It is important to remember that the happiness of motherhood is incomparable!

Throughout pregnancy, the expectant mother and the development of the fetus are carefully monitored by doctors. This observation includes not only a general examination at the reception, measuring the circumference of the abdomen and the height of the uterus, probing the parts of the fetus and analyzes. One of the important examinations, which are carried out at least three times during gestation, is an ultrasound scan of the fetus and placenta, as well as the uterus. Sometimes, after such a study, the ultrasound doctor writes the abbreviation "IUGR" or "intrauterine developmental delay" in the conclusion. Such diagnoses greatly frighten expectant mothers, who suspect the worst thing - something is wrong with the baby. How justified are the fears of pregnant women, what threatens such a diagnosis, and where does developmental delay come from, what needs to be done to eliminate it?

Table of contents: The concept of IUGR: terms, definitions How often is intrauterine growth retardation diagnosed? How is IUGR formed? Danger of IUGR for fetal development Causes of intrauterine growth retardation Problems of the placenta in the genesis of IUGR, the course of pregnancy Classification, degrees of intrauterine growth retardation Types of IUGR according to the features of fetal development Diagnosis of IUGR: tests and ultrasound Instrumental methods for assessing IUGR Doctors' actions in the presence of IUGR

The concept of IUGR: terms, definitions

In articles on obstetrics, various terms flicker, in fact, reflecting approximately the same conditions associated with deviations from normal development fetus inside a woman's uterus. Doctors use the concepts of “fetal hypotrophy”, or “intrauterine growth retardation”, “small growth and weight by gestational age”, “fetal retardation”, and many other terms. According to the international classification (ICD-10), such concepts are included in the general heading of pathologies of pregnancy (P05), and they are united by a single term - "growth retardation and malnutrition of the fetus".

Such a frightening, incomprehensible term IUGR will mean the problems and pathologies of the fetus associated with negative influence external and internal factors, which leads to a reduced supply of oxygen molecules and nutrients necessary for growth to the crumbs. A similar diagnosis is made when, according to ultrasound or at birth, the body weight of a child by the gestational age is reduced by 10% or more. Among other things, a similar diagnosis will be made to those children who are immature for their gestational age (in other words, they look at a shorter gestational age, with a deviation of at least two weeks or more).

How often is intrauterine growth retardation diagnosed?

According to obstetricians, starting from the regions and the type of maternity institution (ordinary maternity hospital or a specialized perinatal center), a similar condition is recorded in 5-18% of pregnant women, while up to 20% of stillbirths occur precisely in this pathology. These children have an 8-fold increased risk of early mortality in the first days of life due to complications and developing pathologies compared to healthy children.

note

Approximately half of children born with IUGR have acute infections or chronic pathologies at least once after birth. It is important to note that the number of children born with such a diagnosis depends on how long and often the harmful factor affects the mother's body and indirectly the fetus.

Currently, the number of children with IUGR has increased due to the general deterioration in the health of mothers and the practice of maintaining pregnancy in those women who were previously simply forbidden to give birth.

As a result, if the health of the mother herself is unsatisfactory, this leads to a pathological course of pregnancy, in which the baby grows more slowly than usual due to the fact that he is supplied with less oxygen and nutrition. About 10% of children diagnosed with IUGR are born to mothers who had no health complaints and any risk factors, young and quite strong, without the presence of chronic somatic diseases. In connection with this fact, observation by doctors from an early date is always necessary in order to detect deviations in the development of the crumbs in time and correct them.

How is IUGR formed?

Throughout pregnancy, the baby feeds on glucose, vitamins and other elements, "breathes" oxygen dissolved in the blood due to the uninterrupted supply of these substances from the mother's body by the placenta. The placenta is a unique organ that occurs only during pregnancy in order to communicate between mother and baby in both directions. It filters dangerous compounds that can enter the fetus, removes metabolic products, delivers oxygen from the mother's red blood cells and all the substances necessary for growth, while not mixing the fetal and maternal blood with each other.

If for some reason the placenta cannot fully cope with its functions, a special pathology is formed - FPI (fetoplacental insufficiency). It gradually forms a state when the fetus receives less and less oxygen, and also “starves” due to the lack of amino acids, carbohydrate and fat molecules. This leads to a slowdown in his growth rates and weight gain.

If the fetus is behind the standards regulated by the results of ultrasound, experts expose its malnutrition, the presence of IUGR. Such a term does not mean that this is a disease, rather it is a complication of pregnancy that occurs under the influence of various negative factors that affect the structure and functions of the placenta.

Danger of IUGR for fetal development

But, it is worth noting right away the fact that, as a complication of pregnancy, the presence of IUGR in crumbs threatens him with the development of serious diseases, which will be dangerous after birth. The consequences for various departments in nervous system as the most sensitive to hypoxia. The easiest thing that can be expected from a child with IUGR is a violation of the processes of adaptation to new living conditions, which threatens with a decrease in immunity and frequent illnesses of the child after childbirth.

Also, IUGR is one of the components in the complex of genetic and chromosomal abnormalities or fetal malformations. It is quite natural that a fetus with defects will grow and develop worse. Therefore, if IUGR is detected, a mandatory detailed screening (both ultrasound and laboratory) is shown to detect chromosomal and gene anomalies and the presence of defects in the brain and spinal cord, and internal organs.

Causes of intrauterine growth retardation

If we talk about all the negative factors that can lead to IUGR, there are a lot of them, ranging from bad habits and lifestyle of the future mother, ending with serious health problems, both reproductive and somatic.

note

It is worth mentioning right away that the small size of the fetus on ultrasound is not always the reason for the diagnosis of IUGR. A slender young mother of short stature with the same spouse, by definition, will not have a 4-kilogram child.

If we talk about harmful factors, they are divided into three groups:

maternal factors,
Problems related to the uterus and placenta, reproductive system and hormones,
fruit factors.

If we talk about the condition of the mother, many factors can become influencing factors:

Early age for pregnancy, from 13-14 years to 17,
The age of a woman after 35 years, when a load of mutations and somatic pathologies accumulates,
Low socio-economic status, poor nutrition, inability to provide medicines,
Features due to race and ethnicity, consanguineous marriage,
Constitutional features - mass, height, heredity.

Also, acute and prolonged illnesses of the mother during pregnancy, exacerbation of chronic pathology, work in hazardous and hazardous industries, overwork, various nutrition systems (veganism, diets, fasting), bad habits, as well as taking certain medications during gestation can also lead to the formation of developmental delays. .

The fetal risk factors for IUGR include:

hereditary diseases, genetic abnormalities, chromosomal pathology,
Defects of the heart, digestion, kidneys,
Problems in the development of the neural tube (anencephaly, spina bifida and others),
Intrauterine infection of the crumbs,
Multiple pregnancy with the syndrome of stealing one fetus from another.

Problems of the placenta in the genesis of IUGR, the course of pregnancy

A frequent reason for the development of IUGR is problems in the structure and functioning of the uterus and placenta. So, this includes uterine malformations (bicornuate, saddle-shaped, with partitions), fibroids and other tumors, defects in the structure of the placenta and umbilical cord, its presentation (full or partial), heart attacks in the thickness of the placenta, calcifications or detachments with the formation of hematomas and bleeding. Threats of abortion, the development of anemia and Rhesus conflict, incompatibility by blood group or other factors also have an impact.

Whatever the initial causes of IUGR, they all eventually lead to a violation of the delivery of oxygen and nutrition through the placenta, from which the baby suffers.

Classification, degree of intrauterine growth retardation

By origin, primary developmental delay and secondary are distinguished. Primary is present initially, from an early date, and is associated with severe influencing factors - poor nutrition, malformations, bad habits and the influence of drugs, it is diagnosed from the very first ultrasound. It is formed as an initial deficiency of nutrition and oxygen, usually has a severe degree.

Secondary type ZVUR they are detected not earlier than 2-3 trimesters, and often it occurs when the mother is ill, the presence of preeclampsia, severe anemia, or problems with the location of the placenta.

Three degrees can be identified according to the severity of the delay.. First degree IUGR characterized by a baby lagging behind in terms of 2-3 weeks from the expected, with second degree the lag reaches a period of 4 weeks, and when heavy third the fetus lags behind the terms of development by 5 or more weeks.

Types of IUGR according to the features of fetal development

According to ultrasound studies, it is customary for doctors to divide two types of IUGR: symmetrical and asymmetric, for which there are different features course of pathology.

Symmetric delay type typical with a proportional decrease in height and weight, and this is usually associated with heredity and chromosomal abnormalities, the presence of intrauterine infection and fetal malformations, especially in the brain area. Mothers with bad habits, starving and not looking after their health can have similar problems. These phenomena can be detected after the second trimester, and in the presence of such a picture, additional screenings are necessary to exclude gene and chromosomal pathologies.

Asymmetric Delay manifests itself in the uneven development of the fetus, its head usually corresponds to the terms in size, and the body in development lags behind the terms. This is detected after 30 weeks of pregnancy, often associated with pathologies of the mother and complications of gestation (preeclampsia, hypertension, diabetes, multiple pregnancy). For such an IUGR, even if the baby’s body is 3-4 weeks behind in development, with timely treatment, the problem is quickly eliminated, the fetus grows and gains weight.

At mixed form, combining both previous forms, the prognosis is the most unfavorable.

Diagnosis of IUGR: tests and ultrasound

Suspicions of the presence of IUGR may arise from an obstetrician-gynecologist who conducts a woman's pregnancy based on the results of examinations and the dynamics of changes in the size of the uterus and abdominal circumference by weeks. Starting from 15 weeks, when the uterus is palpable above the pubis, the height of its fundus is measured in centimeters. If the growths are less than the due date, the doctor will prescribe tests and ultrasound to confirm fetal malnutrition and the presence of IUGR.

Only ultrasound can show accurate data, since the size of the abdomen and the height of the fundus of the uterus depend on the physique, pelvic capacity and many other conditions. When a small size of the fetus is detected in time, the family is analyzed and heredity is assessed, defects and health problems are excluded. If IUGR is suspected, additional ultrasound with Doppler fetal and placenta to assess blood circulation.

Instrumental methods for assessing IUGR

An ultrasound scan can easily and painlessly diagnose and assess the severity of developmental delay, a form of pathology. According to ultrasound, based on the actual gestational age and the size of the fetus, compliance or developmental delay is determined, as well as the form of pathology. If necessary, dopplerometry will show problems with blood flow in the umbilical cord and placenta, which will make it possible to find out both the causes and the severity of IUGR.

Along with these methods, such modern studies are carried out as determining the level of placental hormones in the mother's blood: this is placental lactogen, the level of alkaline phosphatase, and some others. By the amount of these hormones, you can assess the degree of damage to the placenta. To assess the well-being of the fetus, CTG (cardiotocography) is performed with an assessment of the fetal heart rate, its reactions to uterine tone and movement, this shows whether the fetus has enough nutrition and oxygen for normal development.

Actions of doctors in the presence of IUGR

If, according to the data of all studies, a developmental delay is revealed, both general regimen measures and good nutrition and medical support. This leads to the enrichment of the placenta and uterus with oxygen, which helps the fetus to receive enough nutrients for development and growth, weight gain.

With a mild degree of fetoplacental insufficiency, a woman is treated at home, under the supervision of a antenatal clinic doctor, severe degrees of IUGR require inpatient treatment.

To date, there is a group of drugs that increase blood flow in the vessels of the fetoplacental complex, increase the resistance of the fetus to hypoxia and eliminate IUGR. The most basic treatment is to eliminate the cause that leads to developmental delay and fetal distress. The earlier the problem is identified and treatment is started, the better the prognosis for the baby will be.

They use drugs that reduce the tone of the uterus and eliminate vasospasm, reduce blood viscosity and saturate the blood with oxygen, as well as vitamins, iron and minerals necessary for the full functioning of the mother's body. The choice of drugs always remains with the doctor, based on the clinical situation, the tolerability of a particular treatment and the severity of FPI.

Monitoring the effectiveness of treatment is carried out every 2 weeks according to ultrasound and fetal cardiotocography, with the elimination of the causes that led to IUGR, usually growth and weight gain of the fetus quickly return to normal.

Alena Paretskaya, pediatrician

Fetal growth retardation is intrauterine retardation physical development fetus.

These babies are often referred to as "underweight". In 30% of cases, they are born as a result of premature birth (up to 37 weeks of gestation) and only in 5% of cases at full-term pregnancy (at 38-41 weeks).

There are two main forms of intrauterine growth retardation (abbreviated as IUGR): symmetrical and asymmetric. How do they differ from each other?

If the fetus has a deficiency in body weight, it lags behind in terms of growth length and head circumference from the normal values for a given gestational age, then a symmetrical form of IUGR is diagnosed.

The asymmetric form of IUGR is observed in those cases when the fetus, despite the lack of body weight, does not lag behind the normal indicators of growth length and head circumference. The asymmetric form of IUGR is more common than the symmetrical form.

There are also three degrees of severity of IUGR:

I degree - lag of the fetus for 2 weeks;
II degree - a lag of 2-4 weeks;
III degree - a lag in the development of the fetus for more than 4 weeks.

What causes can lead to the development of IUGR?

If we talk about symmetrical IUGR, then, as a rule, it occurs due to fetal chromosomal abnormalities, genetic metabolic disorders, hypofunction thyroid gland and pituitary dwarfism. An important role is also played by viral infections (rubella, herpes, toxoplasmosis, cytomegalovirus).

The asymmetric form of IUGR is caused by pathologies of the placenta in the third trimester of pregnancy, or rather, fetoplacental insufficiency (abbreviated FPI). FPI is a pathology in which the placenta cannot fully supply the fetus nutrients that circulate in the mother's blood. As a result, FPI can cause fetal hypoxia, that is, oxygen starvation.

FPI can occur due to: late preeclampsia, anomalies in the development of the umbilical cord, multiple pregnancy, placenta previa, vascular lesions of the placenta.

To provoke IUGR of any form can be unfavorable external factors- taking medications, exposure to ionizing radiation, smoking, consumption of alcohol and drugs. Also, the risk of IUGR increases with a history of abortion.

In many cases true reason ZVRP still fails to install.

Symptoms of growth retardation and fetal development

Unfortunately, the symptoms of IUGR are quite erased. A pregnant woman is unlikely to be able to suspect such a diagnosis on her own. Only regular observation by an obstetrician-gynecologist throughout the pregnancy helps to diagnose and treat IUGR in a timely manner.

It is widely believed that if a pregnant woman gains little weight during pregnancy, then most likely the fetus is small. This is partly true. However, this is not always true. Of course, if a woman restricts food intake to 1500 calories per day and is fond of diets, then this can lead to FGR. But FGR also occurs among pregnant women who, on the contrary, have too much weight gain. Therefore, this sign is not reliable.

With a pronounced IUGR, the expectant mother may be alerted by more rare and sluggish than usual fetal movements. This is the reason for an emergency visit to the gynecologist.

Examination for fetal growth retardation

When examining a pregnant woman with IUGR, the doctor may be alerted by the discrepancy between the height of the fundus of the uterus and the standards for this period of pregnancy, that is, the uterus will be slightly smaller in size than normal.

The most reliable method for diagnosing IUGR is an ultrasound examination of the fetus, during which the ultrasound doctor measures the circumference of the fetal head, the circumference of the abdomen, hips, and the estimated weight of the fetus. In addition, with the help of ultrasound, you can determine how the internal organs of the fetus function.

If IUGR is suspected, a Doppler study (a type of ultrasound) is mandatory to assess blood flow in the vessels of the fetus and placenta.

An important method of research is cardiotocography (CTG) of the fetus, which also makes it possible to suspect IUGR. With the help of CTG, the baby's heartbeat is recorded. Normal fetal heart rate ranges from 120 to 160 beats per minute. If the fetus experiences a lack of oxygen, then the heartbeat quickens or slows down.

Regardless of the gestational age and the severity of the disease, IUGR must be treated in any case to maintain the vital functions of the fetus. In some cases, if there is a slight lag of the fetus from the norm (approximately 1-2 weeks according to ultrasound), then this should be considered as a variant of the norm or as a “tendency to VRT”. In this case, dynamic monitoring is carried out.

Treatment for growth retardation and intrauterine development of the fetus

For the treatment of IUGR in obstetrics, a large arsenal is used medical preparations that improve uteroplacental blood flow.

These include:

Tocolytic drugs that help relax the uterus: beta-agonists (Ginipral, Salbutamol), antispasmodics (Papaverine, No-shpa);
- infusion therapy with the appointment of glucose, blood substitute solutions to reduce blood viscosity;
- drugs to improve microcirculation and metabolism in tissues (Actovegin, Curantil);
- vitamin therapy (magne B6, vitamins C and E).

The drugs are prescribed for a long period with careful monitoring of CTG for the condition of the fetus.

The nutrition of a pregnant woman with IUGR should be balanced. Food should contain proteins, fats and carbohydrates. No need to "lean" on certain products. You can and should eat everything. Especially do not neglect meat and dairy products, because they contain the largest number proteins of animal origin, the need for which increases by 50% by the end of pregnancy.

However, do not forget that the main goal of the treatment of IUGR is not to “fatten” the child, but to provide him normal growth and development. Therefore, overeating is not necessary.

Pregnant women are recommended daily walks in the fresh air, emotional peace. It is traditionally believed that an afternoon nap (if there is a desire, of course) has a beneficial effect on the physical condition of the fetus and mother.

From non-drug methods hyperbaric oxygen therapy (inhalation of air enriched with oxygen) and medical ozone are used to treat IUGR.

The issue of delivery in the presence of IUGR is relevant. In each case, it should be decided individually, based on the condition of the fetus according to ultrasound and CTG, as well as on the state of health of the mother. If there is no certainty that a weakened child will be able to be born on his own, then preference is given to caesarean section. In severe cases, surgery is performed on an emergency basis.

Complications of IUGR:

Intrauterine fetal death;
- hypoxia (oxygen starvation) of the fetus;
- Anomalies in the development of the fetus.

Prevention of IUGR:

A healthy lifestyle, giving up bad habits before a planned pregnancy;
- refusal of abortions;
- timely examination and treatment infectious diseases at the gynecologist before the planned pregnancy.

Consultation of an obstetrician-gynecologist on the topic of fetal growth retardation:

1. According to ultrasound, the placenta is too small, but the height, weight of the fetus and head circumference are normal. The doctor said that I have FPI. Is it so?
No. Only on the basis of the size of the placenta, such a diagnosis is not made.

2. Is it possible to cure IUGR if there is a lot?
Unless FGR is associated with chronic malnutrition. In other cases balanced diet should be in combination with the main treatment.

3. Does the weight of the fetus depend on the weight of the mother?
In part, the weight of the fetus depends on many factors, including the weight of the mother.

4. If parents vertically challenged and weight, then the child should be small?
Most likely, and this is the norm. The diagnosis of IUGR is not made in such cases.

5. I was diagnosed with fetal hypotrophy by ultrasound. What does it mean?
Fetal hypotrophy and IUGR mean the same thing - a lag in the development of the fetus.

6. Is it necessary to go to the hospital if I have IUGR?
This should be decided by your obstetrician-gynecologist, based on the data of ultrasound and CTG in dynamics. With IUGR, if there are no signs of fetal hypoxia, hospitalization is not necessary. With IUGR II or III degree hospitalization is required.

7. I am 35 weeks pregnant, but on examination, the height of the fundus of the uterus corresponds to 32 weeks. What's this? ZVRP?
There may be small errors in the doctor's measurement of the height of the uterine fundus. If no abnormalities were detected during ultrasound and CTG, then everything is in order.

8. At the last ultrasound, I was told that the fetus's abdominal circumference is 3 weeks behind the due date, but all other indicators are normal. Is this a ZVRP? Need to be treated?
Most likely, this idiosyncrasy fetus if other parameters are within normal limits. If Doppler and CTG do not reveal any abnormalities, then there is no IUGR and there is no need for treatment.

9. What is the “count to 10” test that is recommended for IUGR?
The “count to 10” test is a test for assessing fetal movements. It is recommended for all pregnant women from 28-30 weeks, and with IUGR it is especially relevant. A woman needs to count fetal movements every day between 9:00 am and 21:00 pm every day. Normally, there should be 10 or more. If there are fewer of them, this indicates oxygen starvation of the baby.

10. According to the ultrasound data, the child is 2 weeks behind in terms of parameters. CTG and dopplerometry are normal. Whether it is necessary to be treated?
A slight delay in fetal parameters by 1-2 weeks is possible and normal. You need to look at dynamics.

Obstetrician-gynecologist, Ph.D. Christina Frambos.

Intrauterine growth retardation (IUGR)) is a lag in the size of the fetus from normal indicators at a given gestational age.

The main reasons for the development of IUGR

Fetal growth retardation can occur at any stage of pregnancy (more often in the third trimester) and is caused by the following reasons:

mother's bad habits(alcoholism, drug addiction);
Extragenital diseases of a woman(diseases of the urinary, respiratory and circulatory systems, arterial hypertension, infectious diseases);
Obstetric and gynecological diseases(violations menstrual cycle, primary infertility, complicated course of previous pregnancies, anomalies in the structure of the uterus);
Complications of real pregnancy(early and late gestosis, multiple pregnancy, anemia, etc.);
Fetal pathologies (intrauterine infection, ).

IUGR classifications

information There are two forms of intrauterine growth retardation, which differ in clinical signs, causes of development and prognosis of further development and viability of the fetus: symmetrical and asymmetric form.

With a symmetrical shape characterized by a uniform decrease in the mass, growth of the fetus and the size of all its organs. This form often develops in the early stages and is caused by fetal diseases (chromosomal abnormalities, intrauterine infection), bad habits of the mother. Symmetrical lag can lead to the threat of the birth of a child with an inferior development of the central nervous system.

With an asymmetrical shape there is a decrease in body weight with normal growth of the fetus ( underweight baby). The child has a lag in the development of the soft tissues of the abdomen and chest, insufficient development of the body with normal head sizes. Perhaps the appearance of uneven development of internal organs. If left untreated, a decrease in the size of the head and a lag in the development of the brain begin, which can lead to the death of the fetus. The asymmetric form often occurs in the third trimester against the background of placental insufficiency and is caused by extragenital diseases of the mother and complications of pregnancy.

There are three severity of IUGR:

First degree(easy). The size of the fetus is no more than two weeks behind the normal indicators characteristic of a given gestational age;
Second degree. Delay in fetal development within 2-4 weeks;
Third degree(heavy). The size of the fetus is four weeks or more behind normal. As a rule, IUGR of the third degree is irreversible and leads to fetal death.

The main symptoms and diagnosis of IUGR

The main diagnostic methods fetal developmental delays are:

Measurement of abdominal circumference and fundal height. When IUGR is characterized by a lag of these parameters from normal indicators;
ultrasound. helps to determine the form of IUGR and its severity, assess the condition of the placenta;
Doppler (additional method Ultrasound, which allows you to explore the nature and speed of the uteroplacental and fetal-placental blood flow). When IUGR is often characterized by the appearance of circulatory disorders in the arteries of the umbilical cord, aorta, venous duct of the fetus;
cardiotography(). This is a method of functional diagnostics of the state of the fetus, which studies the frequency and nature of its heartbeat, changes in heart rate under the influence of external factors, motor activity of the fetus itself and uterine contractions. IUGR is characterized by an increase or decrease in the fetal heart rate.

Treatment of IUGR

Treatment of intrauterine growth retardation should be carried out only in a hospital:

A state of complete physical and emotional rest;
Full sleep;
Balanced diet;
Drugs that reduce

Fetal growth retardation is intrauterine retardation of the physical development of the fetus.

There are two main forms of intrauterine growth retardation (abbreviated as IUGR): symmetrical and asymmetric. How do they differ from each other?

There are also three degrees of severity of IUGR:

I degree - lag of the fetus for 2 weeks;
II degree - a lag of 2-4 weeks;
III degree - a lag in the development of the fetus for more than 4 weeks.

What causes can lead to the development of IUGR?

If we talk about symmetrical IUGR, then, as a rule, it occurs due to fetal chromosomal abnormalities, genetic metabolic disorders, hypothyroidism and pituitary dwarfism. An important role is also played by viral infections (rubella, herpes, toxoplasmosis, cytomegalovirus).

The asymmetric form of IUGR is caused by pathologies of the placenta in the third trimester of pregnancy, or rather, fetoplacental insufficiency (abbreviated FPI). FPI is a pathology in which the placenta cannot fully supply the fetus with nutrients that circulate in the mother's blood. As a result, FPI can cause fetal hypoxia, that is, oxygen starvation.

FPI can occur due to: late preeclampsia, abnormalities in the development of the umbilical cord, multiple pregnancies, placenta previa, vascular lesions of the placenta.

To provoke IUGR of any form can be adverse external factors - taking medications, exposure to ionizing radiation, smoking, alcohol and drug consumption. Also, the risk of IUGR increases with a history of abortion.

In many cases, the true cause of IUGR remains undetermined.

Symptoms of growth retardation and fetal development

With a pronounced IUGR, the expectant mother may be alerted by more rare and sluggish than usual fetal movements. This is the reason for an emergency visit to the gynecologist.

Examination for fetal growth retardation

If IUGR is suspected, a Doppler study (a type of ultrasound) is mandatory to assess blood flow in the vessels of the fetus and placenta.

Treatment for growth retardation and intrauterine development of the fetus

For the treatment of IUGR in obstetrics, a large arsenal of medications is used that improve uteroplacental blood flow.

These include:

The drugs are prescribed for a long period with careful monitoring of CTG for the condition of the fetus.

The nutrition of a pregnant woman with IUGR should be balanced. Food should contain proteins, fats and carbohydrates. No need to "lean" on certain products. You can and should eat everything. Especially do not neglect meat and dairy products, since they contain the largest amount of animal proteins, the need for which increases by 50% by the end of pregnancy.

However, do not forget that the main goal of the treatment of IUGR is not to "fatten" the child, but to ensure normal growth and development. Therefore, overeating is not necessary.

Of the non-drug methods of treatment of IUGR, hyperbaric oxygenation (inhalation of air enriched with oxygen) and medical ozone are used.

The issue of delivery in the presence of IUGR is relevant. In each case, it should be decided individually, based on the condition of the fetus according to ultrasound and CTG, as well as on the state of health of the mother. If there is no certainty that a weakened child will be able to be born on his own, then a caesarean section is preferred. In severe cases, surgery is performed on an emergency basis.

Complications of IUGR:

Intrauterine fetal death;
- hypoxia (oxygen starvation) of the fetus;
- Anomalies in the development of the fetus.

Prevention of IUGR:

A healthy lifestyle, giving up bad habits before a planned pregnancy;
- refusal of abortions;
- timely examination and treatment of infectious diseases by a gynecologist before the planned pregnancy.

Consultation of an obstetrician-gynecologist on the topic of fetal growth retardation:

1. According to ultrasound, the placenta is too small, but the height, weight of the fetus and head circumference are normal. The doctor said that I have FPI. Is it so?
No. Only on the basis of the size of the placenta, such a diagnosis is not made.

2. Is it possible to cure ZVRP if there is a lot?
Unless FGR is associated with chronic malnutrition. In other cases, a balanced diet should be in combination with the main treatment.

3. Does the weight of the fetus depend on the weight of the mother?
In part, the weight of the fetus depends on many factors, including the weight of the mother.

4. If the parents are small in stature and weight, then the child must be small?
Most likely, and this is the norm. The diagnosis of IUGR is not made in such cases.

5. I was diagnosed with fetal hypotrophy by ultrasound. What does it mean?
Fetal hypotrophy and IUGR mean the same thing - a lag in the development of the fetus.

6. Is it necessary to go to the hospital if I have an IUGR?
This should be decided by your obstetrician-gynecologist, based on the data of ultrasound and CTG in dynamics. With IUGR, if there are no signs of fetal hypoxia, hospitalization is not necessary. With IUGR II or III degree hospitalization is required.

7. I am 35 weeks pregnant, but on examination, the height of the fundus of the uterus corresponds to 32 weeks. What's this? ZVRP?
There may be small errors in the doctor's measurement of the height of the uterine fundus. If no abnormalities were detected during ultrasound and CTG, then everything is in order.

8. At the last ultrasound, I was told that the fetus's abdominal circumference is 3 weeks behind the due date, but all other indicators are normal. Is this a ZVRP? Need to be treated?
Most likely, this is an individual feature of the fetus, if other parameters are within the normal range. If Doppler and CTG do not reveal any abnormalities, then there is no IUGR and there is no need for treatment.

9. What is the "count to 10" test that is recommended for IUGR?
The “count to 10” test is a test for assessing fetal movements. It is recommended for all pregnant women from 28-30 weeks, and with IUGR it is especially relevant. A woman needs to count fetal movements every day between 9:00 am and 21:00 pm every day. Normally, there should be 10 or more. If there are fewer of them, this indicates oxygen starvation of the baby.

10. According to the ultrasound, the child is 2 weeks behind in terms of parameters. CTG and dopplerometry are normal. Whether it is necessary to be treated?
A slight delay in fetal parameters by 1-2 weeks is possible and normal. You need to look at dynamics.

Obstetrician-gynecologist, Ph.D. Christina Frambos.

METHODOLOGICAL INSTRUCTIONS FOR TEACHERS

Department of Pediatrics, Medical and Dental Faculties

Learning theme number 2.

Name learning topic: Diseases of the newborn. Retardation of intrauterine development. Modern ideas about the causes of intrauterine growth retardation. Formation mechanisms. Forms of developmental delay. Problems of diagnostics. Approaches to therapy and nursing of children with intrauterine growth retardation.

The purpose of studying the educational topic. To acquaint students with diseases of newborn children. To study modern ideas about intrauterine growth retardation. To give students an understanding of approaches to therapy and nursing of children with intrauterine growth retardation

Chronocard, calculation of organizational potential

The name of the stage of the lesson	Duration of the stage of the lesson in minutes	Monodidactic systems
The name of the stage of the lesson	Duration of the stage of the lesson in minutes
Attendance accounting
Introductory speech of the teacher on the relevance and significance of the topic under study
Programmed control of the initial level of knowledge
Demonstration of the patient with a group discussion
Work of students with teaching materials
Independent work with supervised children, mothers
Analysis of tasks on the topic of the lesson
Control of the final level of knowledge

Topic study plan:

Definition of IUGR
Clinical manifestations of IUGR
IUGR forms
Differential Diagnosis
Approaches to therapy
IUGR forecast

Presentation of educational material.

Growth Retardation(IUGR) is a synonym for the obstetric diagnosis of "intrauterine growth retardation of the fetus", which is established when there are lags in the parameters of the hearth from the average size corresponding to its gestational age.

Epidemiology. In the Russian Federation, the incidence of IUGR varies from 3.5 to 17%, in the USA - from 3 to 7%, in Western Europe - about 4%. According to perinatal diagnostics, the incidence of IUGR in premature babies is 15.7-22%. This is due to the presence of common pathogenetic mechanisms of intrauterine growth retardation and miscarriage.

Risk factors for IUGR include:

Unfavorable socio-economic conditions - low socio-economic status of parents; unavailability of medical care; professional hazards of parents; bad habits (smoking, alcohol, drugs); maternal malnutrition during pregnancy; insufficient weight gain of the mother during pregnancy; low maternal body weight;

Chronic diseases of the mother - chronic arterial hypertension; diabetes; chronic diseases; autoimmune diseases; severe anemia; congenital heart defects with signs of circulatory failure;

Congenital infections - viral (rubella, cytomegaly); bacterial (listeriosis, tuberculosis, syphilis); protozoan (toxoplasmosis, malaria);

Burdened obstetric history - the birth of children with signs of IUGR; stillbirth; mother's age is less than 16 and older than 35;

Complications of this pregnancy - preeclampsia (preeclampsia); bleeding in the second and third trimesters; delayed pregnancy; anomaly of the umbilical cord and placentation; multiple pregnancy;

Congenital malformations of the fetus - trisomy on the 13th, 18th, 21st chromosomes; Turner syndrome; neural tube defects; congenital heart defects.

Etiology and pathogenesis. In the development of the embryo and fetus, three phases are conditionally distinguished:

1) first 16 weeks pregnancy - processes occurring in tissues are mainly associated with cell hyperplasia;

2) second 16 weeks (weeks 16 to 32)- along with cell hyperplasia, there is an increase in their size (cellular hypertrophy);

3) last 8 weeks of pregnancy- hypertrophic processes dominate over hyperplastic ones.

At early onset IUGR decreases the relative number of cells, which is clinically manifested by a symmetrical lag of fetometric parameters from the normative indicators.

Later development IUGR is typical for an asymmetric form and is characterized by a lower rate of cell hypertrophy, which leads to a relative decrease in the size of those organs, the mass of which increases mainly in late pregnancy (for example, the liver).

About 10% of IUGR cases are associated with a pathological karyotype, another 10% with congenital infection (cytomegalovirus infection, rubella, toxoplasmosis, syphilis).

In other cases, the cause of IUGR is uteroplacental insufficiency associated with somatic or obstetric pathology of the mother.

IUGR - the reaction of the fetus to the impact of adverse factors. Among the mechanisms underlying the formation of IUGR, a large role is played by chronic fetoplacental insufficiency, manifested by a violation of the uteroplacental and fetal blood flow, resulting in impaired diffusion of oxygen, urea and carbon dioxide. Violation of the fetoplacental blood flow leads to insufficient supply of oxygen, energy and plastic substances to the fetus, to a violation of hormonal homeostasis. There is a direct relationship between the degree of decrease in placental blood flow, placental weight and fetal IUGR. The development of the placenta slows down before the growth of the fetus. In smoking mothers, the formation of IUGR is also associated with a decrease in the level of oxyhemoglobin in the blood as a result of increased formation of carboxyhemoglobin.

A direct relationship has been established between a decrease in the level of estriol in the blood and urine of a pregnant woman and a slowdown in fetal growth. In the development of IUGR, insulin-like growth factor -1 (somatomedin) also plays a role. In newborns with IUGR, its plasma content is reduced. There is evidence of a relationship between antiphospholipid syndrome in a pregnant woman and the formation of fetal IUGR.

Adverse effects on the fetus are caused by intrauterine infections, the use of pregnant alcohol, drugs, certain medications (valproic acid) and chemicals.

Classification

According to the nature of changes in fetometric parameters in obstetric practice, they distinguish symmetrical and asymmetrical forms of IUGR, and by the time of occurrence - early and late forms.

In neonatological practice, there are: hypotrophic, hypoplastic and dysplastic variants of IUGR.

By severity: mild, moderate, severe.

Research. General analysis of blood and urine, hematocrit, CBS, blood glucose, bilirubin and its fractions, proteinogram, blood electrolytes (potassium, sodium, calcium, magnesium), ultrasound, consultations of an ophthalmologist, neurologist, orthopedist.

Anamnesis, clinic. IUGR can be diagnosed in children of any gestational age. In anamnesis in children with IUGR, it is necessary to identify causative factors (see above).

When examining such children, there are clinical signs of malnutrition, a lag in the score of morphofunctional maturity from gestational age by approximately 2 weeks. Usually these children are prone to a large loss of the initial weight and to its slower recovery, however, with severe IUGR, the transient loss of the initial body weight is small (1-3%) and may even be completely absent. Children with IUGR are characterized by a protracted course and severity of physiological jaundice, slow healing of the umbilical wound, and the absence of manifestations of a hormonal crisis. After a period of hyperexcitability, these infants often have a symptom complex of "energy deficiency", manifested by a decrease in blood levels of glucose, calcium, magnesium. Even the normal course of childbirth in the presence of IUGR in the fetus is often traumatic for the child, so they often develop asphyxia, birth trauma of the brain and spinal cord.

Children with IUGR may experience polycythemia, hypocalcemia, hyperbilirubinemia, as well as hypomagnesemia, hyponatremia, and hypoglycemia. In the early neonatal period, respiratory disorders, manifestations of vitamin K deficiency (hemorrhagic disease of the newborn) and infection are possible.

Hypotrophic variantIUGR (asymmetric shape, prenatal malnutrition) are established at the birth of children with low weight and normal indicators of body length and head circumference. In this case, the mass-height indicator will be reduced, and body weight will be below the 10th percentile in relation to the child's body length. Normally, the mass-height index in full-term children is 60-80. With malnutrition of the first degree - 59-55; II degree - 54-50; III degree - less than 50. The assessment of the severity of this option is carried out according to the degree of body weight deficiency, the thickness of the subcutaneous fat layer, tissue turgor, head circumference and the presence of trophic skin disorders. The asymmetric form often develops in late pregnancy.

The vast majority of children with this form of IUGR do not have antenatal brain lesions, its mass and structure correspond to gestational age. This variant in the English-language literature is also called asymmetric IUGR or the phenomenon of "economical brain" (brain-sparing), since body weight is reduced disproportionately with respect to body length and head circumference. These children appear lean and have a smaller belly circumference than their head due to shrinking livers and depleted glycogen stores.

Hypoplastic variant (symmetrical shape) IUGR. It is detected in newborns with a uniform lag in weight, body length and head circumference from the normative ones for a given gestational age. All parameters of physical development in these children are reduced by 1.5 or more sigma (below the 10th percentile), the weight-height index is within the normal range. Such children look proportionately built, but small. The ratio between the circumferences of the head and chest is not disturbed, the edges of the sutures and fontanelles are soft, supple, the sutures are not closed, often there is no ossification point in the femoral head.

Dysplastic variant of IUGR diagnosed in children who, in addition to weight lag, also have a violation of body proportions, therefore, typical manifestations for this variant of IUGR are the presence of malformations, physique disorders, dysembryogenetic stigmas (detection of five or more stigmas in a patient has a diagnostic value). These children are characterized by severe neurological disorders, metabolic disorders, a tendency to develop anemia and infection.

Diagnosis. Prenatal diagnosis of IUGR is based on a comparison of individual fetometric parameters obtained as a result of ultrasound examination of the fetus with standard values.

In the antenatal period, the following is taken into account:

Insufficient increase in body weight in a pregnant woman;

Stop or insufficient increase in the size of the fetus (according to ultrasound);

Changes in the area and volume of the placenta and a decrease in uteroplacental and fetal blood flow;

Presence of signs of intrauterine suffering of the fetus: changes in heart rate, absence of accelerations, occurrence of deceleration, persistent bradycardia - according to cardiotocography with a non-stress test;

Increased or increased respiratory movements of the fetus (according to ultrasound scanning) (normal 30-70 / min. for a period of 36-40 weeks);

Elevated levels of AFP and hCG in the blood of a woman in the II-III trimesters of pregnancy;

In newborns, IUGR set on the basis of a comparison of the parameters of his physical development at birth with the proper parameters for the gestational age at which the child was born, the assessment of the morphological index of maturity

In many Western countries, for the diagnosis of IUGR, specialists use Lyubchenko's percentile curves (L.O. Lubchenko).

The diagnosis of IUGR is established on the basis of anthropometric data in children with insufficient body weight at the first weighing in relation to the norm for a given gestational age. The diagnosis of IUGR is considered valid if the birth weight of the child is more than 1.5 standard deviations below the mean for the given gestational age (or below the 10th percentile).

Taking into account the degree of decrease in the main parameters of physical development, there are three degrees of IUGR in newborns:

- Idegree, light, a decrease in body weight by 1.5-2 standard deviations (or below the 10th centile), with normal or moderately reduced body length (height). In 80% of these children, the size of the head circumference does not go beyond the normal fluctuations for gestational age. All of these children have clinical signs of malnutrition.

- IIdegree - a decrease in both body weight and length of more than 2 standard deviations (below the 3rd centile). 75% of these children have reduced head circumference. These children have the appearance of proportionately small children. There are no clinical signs of malnutrition, but more often there is an increase in the stigma of dysembryogenesis.

- IIIdegree, severe, - a decrease in all parameters of physical development (by 3 or more standard deviations or ≤ 1st centile), the presence of body disproportion, trophic disorders of the skin, a lot of dysembryogenesis stigmas.

The greater the deviation of the child's body weight from the normative values, the worse both the perinatal and long-term prognosis.

Early diagnosis of IUGR, both in the antenatal and postnatal periods, is very important, due to the fact that its presence leads to an increased risk of intrauterine and intranatal death of the fetus, impaired adaptation of the child in the neonatal period and various deviations in health in subsequent years of life .

Treatment,treatment goals: prevention of cold stress, hemorrhagic disease of the newborn, polycythemia, hypoglycemia, hypocalcemia, infectious complications.

Treatment regimen: Mandatory treatment: administration of vitamin K, stay in an incubator, enteral nutrition if possible.

Auxiliary treatment: relief of electrolyte disturbances, hypoglycemia, polycythemia.

Indications for hospitalization in the OPN: the presence of II-III degree IUGR, dysplastic variant of IUGR.

Methods of treatment for IUGR depend on the stage of development of the fetus and newborn.

prenatal period. In modern obstetrics, there are two main approaches to the prevention and treatment of IUGR in the prenatal period:

1) improvement of blood flow in the mother-placenta-fetus system (impact on peripheral and organ hemodynamics, correction of vascular tone, rheological and hemostasiological disorders);

2) pathogenetic treatment of concomitant diseases of the mother, exacerbating placental insufficiency.

The scheme for the treatment of placental insufficiency and IUGR, developed by G. M. Savelyeva, has become widespread in our country. The treatment regimen provides for complex therapy of pregnant women both in the conditions of the antenatal clinic and in the obstetric hospital.

Among the methods of pharmacological treatment of placental insufficiency of IUGR, the following drugs are currently used in obstetric clinics: beta-adrenomimetics, blood substitutes, heparin, trental, hormones, aspirin, solcoseryl / actovegin.

At the same time, from the point of view of evidence-based medicine, none of the proposed methods of prenatal prevention and treatment of IUGR is sufficiently effective.

Among the activities for prenatal prevention of IUVR great attention nutritious food for pregnant women. However, malnutrition is rarely the sole cause of IUGR, and the use of various biological and food additives does not significantly affect perinatal outcomes. However, if a pregnant woman has nutritional deficiencies and hypovitaminosis, then they certainly need to be corrected in a timely manner.

The timing and methods of delivery of a pregnant woman with IUGR are determined taking into account the biophysical profile of the fetus and the dynamics of fetometric parameters against the background of ongoing therapy.

early neonatal period. At the first stage, the treatment of children with IUGR is in many ways similar to the treatment of premature babies. Immediately after birth, such children should be placed under a source of radiant heat, given their tendency to rapidly cool. The need for primary resuscitation and the volume of intensive care are determined by assessing the severity of the condition at birth and based on dynamic observation data in the first hours of life.

In a satisfactory condition (the presence of a sucking reflex, the absence of pronounced neurological changes, normal motor function of the gastrointestinal tract), a child weighing over 2000 g is applied to the chest in the delivery room, children weighing over 1800 g begin to be fed with expressed breast milk from a bottle, in the rest cases, tube feeding with expressed breast milk is started no later than two hours after birth. The required amount of milk is determined according to the same rules as for premature babies. For children weighing over 2 kg, the calculation of nutrition can be carried out according to the formula: V times \u003d 3 x m (kg) x n, where n is the number of days of life. From the 11th day of life, the calculation can be carried out by the volumetric method - 1/5 of the body weight. In the future, the feeding regimen (exclusively breastfeeding, breastfeeding + bottle feeding, bottle feeding, tube and parenteral nutrition), as well as the timing of breastfeeding in newborns who are not attached in the delivery room, depend on the ability of the infant to suck out and retain the required amount of nutrition, from birth weight, neonatal condition, comorbidities and complications.

All children with IUGR, regardless of the severity of the condition at birth, receive 1-2 mg of vitamin K parenterally in the first hours of life.

Further volume of therapy depends on the presence of complications and concomitant diseases.

In children with IUGR in the early neonatal period, hypoglycemia, hypocalcemia, and blood clotting syndrome are often detected.

The complex of treatment also includes the treatment of trophic, cerebral disorders, correction of orthopedic disorders.

Forecast depends on the clinical variant of IUGR and its severity.

At hypotrophic and hypoplastic variants IUGR of the 1st degree, children, as a rule, catch up with their peers in physical development by the end of the first or the beginning of the second half of the year. Their psychomotor development may lag behind. Infectious morbidity does not exceed the morbidity of peers without IUGR.

At IUGRIIdegrees most children catch up with the physical development of their peers by the year, some have an increased infectious morbidity and a lag in psychomotor development in terms of pace in the first 2 years of life. In the future, iron deficiency anemia, rickets, mild brain dysfunction (neurotic reactions, mental infantilism, neuropathic disorders) may develop.

In children with IUGRIIIdegree, and also with its dysplastic variant, the prognosis is often unfavorable. In the first 3 years, there is a lag in physical and psychomotor development. In 10-15% of these children, signs of organic damage to the central nervous system develop (cerebral palsy, epilepsy, progressive hydrocephalus, mental retardation). These children already in the neonatal period have a very high infectious morbidity, every 3-4th child develops a bacterial infection.

Mortality among term infants with IUGR exceeds that of infants with normal physical development. Newborns with IUGR are susceptible to infectious and inflammatory diseases. IUGR of the fetus and newborn makes a significant contribution to the development of critical forms of pathology and childhood disability. The main causes of disability are due to severe damage to the central nervous system - cerebral palsy, epilepsy, progressive hydrocephalus.

In children with IUGR, there was a lag in physical development in early and adolescence, sometimes persistent malnutrition persists.

Prevention IUGR involves the treatment of genital and extragenital pathology in pregnant women, elimination of bad habits (smoking, alcohol, drugs), timely treatment of pregnancy complications, genetic counseling, normalization of pregnant women's nutrition, reduction of the harmful effects of environmental factors.

Educational and methodical material:

Tab. 2.4.Estimation of the gestational age of the child according to the totality of morphological criteria(Bollard J. et al., 1991)

sign	Points							Maximum rating
sign								Maximum rating
Leather	Sticky, loose, transparent	Transparent, red, impregnated	Thin, pink, pronounced venous network	With superficial "scaly" or rash, mild venous network	Cracking, venous network is almost not expressed	Parchment-like, cracking, venous network is not expressed	Rough, cracked, wrinkled
Lanugo		Missing	Abundant		Bare areas	Mostly missing
Plantar folds	Heel toe 40-50 mm: -1 < 40 мм: –2	No folds	Weak, red	Only on the front third of the sole	On the front two-thirds of the sole	Numerous throughout the sole
Thoracic gland	imperceptible	Barely noticeable	flat areola without nipple	"Grainy" areola, nipple 1 - 2 mm	Protruding areola, nipple 3 - 4 mm	Fully formed areola, nipple 5–10 mm
Eye/Auricle	Eyelids closed Loose -1 Tight -2	Flat, inelastic	Begins to bend, slight elasticity	Partially curved, good elasticity	Fully curved, fairly tight, very good elasticity	With strong cartilage, the ear is tight
Genitals	The scrotum is flat, smooth	The scrotum is empty, no wrinkles		The testicle descends, the furrows on the scrotum are weakly expressed	The testicle is lowered, the furrows are well defined	Testicles "hung", deep folding of the scrotum
Genitals ♀	The clitoris protrudes, the labia is even	The clitoris and small lips protrude		Large and small lips protrude equally	Big lips protrude more	The clitoris and small lips are completely covered
Overall assessment of morphological maturity