IUGR, Fetal Distress dan Fetal Death

dr. Hydrawati Sari, MCE, SpOG

Definisi

Intrauterine growth restriction (IUGR) adalah berat janin dibawah BB persentil ke-10 pada umur kehamilannya. Janin dipengaruhi oleh keadaan patologi sehingga

mengganggu kemampuannya utk tumbuh.

BBLRBBLR: BB lahir bayi < 2500 gram yg dapat

terjadi karena IUGR atau prematuritas

Insidensi

3-10% dari seluruh kehamilan 20% dari bayi stillbirth Kematian perinatal: 4-8 kali lebih tinggi

Karakteristik

SimetrisSimetris AsimetrisAsimetris

Disproporsi pada Disproporsi pada pertumbuhan abdomen, pertumbuhan abdomen, kmk problem terjadi stlh kmk problem terjadi stlh perkembangan janin yg sdh perkembangan janin yg sdh lanjut. lanjut.

kepala dan badan bayi kepala dan badan bayi kecil, kmk terjadinya kecil, kmk terjadinya problem pd awal problem pd awal perkembangan janinperkembangan janin

In a normal infant, the brain weighs about three times more than the liver. In In a normal infant, the brain weighs about three times more than the liver. In

asymmetrical IUGR, the brain can weigh five or six times more than the liver.asymmetrical IUGR, the brain can weigh five or six times more than the liver.

Simetris Early onset Constitutional or “normal” small Decreased growth potential Normal ponderal index Lower risk for transitional problems Brain symmetrical to body

Contoh: Genetic causes, chromosomal

Karakteristik IUGR

Karakteristik IUGR

Asimetris Late onset

Environmental

Growth arrest

Higher risk for transitional problems

Brain sparing

Contoh:

Hipoksia kronik

Preeklamsia

Hipertensi kronik

Malnutrisi

Simetris Asimetris

Kecil dan simetris Kepala > abdomen

Ponderal indeks normal Ponderal indeks rendah

Rasio H/A dan F/A normal Rasio H/A dan F/A meningkat

Kelainan Genetik, infeksi Insufisiensi vaskuler plasenta

Prognosis jelek Prognosis lebih baik jika komplikasi dapat dicegah atau tx adekuat

IUGR

Etiologi

1. Maternal

2. Fetal

3. Plasenta

Faktor maternal Genetik Demographics

Umur (extremes of reproductive age)RasStatus sosioekonomi

BB kurang sblm hamil atau malnutrisi Penyakit kronik Terpapar teratogen (obat-obatan,

radiasi, dll.)

Faktor maternal

Penyakit jantung Penyakit ginjal Hipertensi Penyakit paru Hemoglobinopathies Penyakit Collagen-

vascular Diabetes

Postmatur Kehamilan multipel Thrombotic disease High altitude

environment Merokok Drug abuse (kokain)

Faktor-faktor yg mempengaruhi aliran dan fungsi plasenta

Faktor fetal

Constitutional – genetically small, but genetically normal

Kelainan kromosom Malformasi – SSP, skeletal, gastroschisis Infeksi kongenital – CMV, rubella

Faktor plasenta

Malformasi – vaskular Infark Solusio plasenta Plasenta previa Invasi trofoblas yg abnormal

Faktor plasenta

Insufisiensi Uteroplasental Ketidaksesuaian/tidak adekuatnya invasi trophoblast dan

plasentasi pada trimester pertama. Berkurangnya aliran darah maternal ke placental bed.

Insufisiensi Fetoplasental Kelainan vaskular plasenta dan tali pusat Menurunnya fungsi plasenta

Plasenta kecil, solusio plasenta, plasenta previa, kehamilan posterm

1. Identifikasi pasien risiko tinggi Pasien dgn faktor risiko tinggi Pasien dgn usia kehamilan tdk jelas TFU tidak sesuai

Riwayat keluarga atau penyakit Pemeriksaan fisik

Manajemen

2. Membedakan IUGR dgn small and healthy fetus USG

F/A ratio H/A ratio The fetal PI Rasio S/D umbilikalis:

menunjukkan IUGR Aliran diastole terbalik atau absen

Manajemen

Diagnosis

Indeks ponderal rendah Berkurangnya lemak subkutan Tdp keadaan sbb:

Hipoglikemia Hiperbilirubinemia, Necrotizing enterocolitis, Hyper viscosity syndrome

Neonatal -

Neonate and Placenta in IUGR

Normal & IUGR Newborn babies

Normal & IUGR Placentas

Antepartum surveillance of the IUGR fetus (Biophysical Profile)

Electronic monitoring of the fetal heart

Non stress test Contraction stress test

Pemeriksaan cairan amnion Amniosentesis: menilai maturasi paru

Manajemen

1. Antepartum Stillbirth Oligohidramnion:

urine output janin menurun karena perfusi renal menurun

Intrapartum fetal acidosis: Deselerasi lambat Penurunan variabilitas Bradikardi

Komplikasi

Deselerasi lambat

2. Neonatal Asfiksia dan asidosis perinatal

Aspirasi mekoneum Hypoxic-ischemic encephalopathy Gangguan metabolik: hipoglikemi, hipokalsemi,

sindrom hiperviskositas, dan hipotermi

Komplikasi

Pencegahan

Strategies include Perawatan prenatal Suplementasi protein/energy Terapi anemiavitamin/mineral supplementation, Pencegahan dan terapi

hipertensi infeksi

Treatment

IUGR has IUGR has many causes, therefore, there is causes, therefore, there is not one treatment that always works. not one treatment that always works.

Treatment Persalinan atau memperbaiki aliran darah ke uterus

Jika IUGR disebabkan oleh kelainan plasenta dan janin msh baik, diagnosis dan penanganan awal akan mengurangi kmk hasil yg jelek

Tidak ada terapi yg dpt memperbaiki pertumbuhan janin, ttp janin IUGR yg sdh cukup bulan akan memberikan outcome yg lbh baik jika dilahirkan segera.

Short Term Risks of IUGR Morbiditas dan mortalitas perinatal meningkat

Intra uterine / Intrapartum death. Intrapartum fetal asidosis ditandai dengan:

Late deceleration. Severe variable deceleration. Beat to beat variability. Episodes of bradicardia.

Intrapartum fetal asidosis dp terjadi pada 40% kasus IUGR shg meningkatkan kejadian bedah Sesar

Bayi IUGR berisiko lbh besar utk tjd kematian krn komplikasi neonatal: - asfiksia, asidosis, sindrom aspirasi mekoneum, infeksi, hipoglikemia, hipotermi, dll.

Bayi IUGR lebih rentan thd infeksi krn terganggunya imunitas

Long term Prognosis

Bayi IUGR berisiko utk tjd nya gangguan perkembangan, risiko ini meningkat seiring dgn beratnya growth restriction.

Setiap kasus adl unik. Tdk dpt diprediksi scr akurat progres yg akan datang. Beberapa bayi akan berkembang scr normal, sementara yg lain mempunyai komplikasi sistem saraf/intelectual problems

Fetal distress

LIN QI DE

2005.9.5

Fetal distress: berkurangnya oksigen dan

akumulasi CO2 shg terjadi “hypoxia dan

acidosis ” intra uterin.

Definisi

Maternal factors Iskemia mikrovaskuler (PIH) Anemia Perdarahan akut (placenta previa, placental

abruption) Shock and acute infection

Etiology

Placenta-umbilical factors Obstructed of umbilical blood flow Disfungsi plasenta Fetal factors Malformations of cardiovascular system Intrauterine infection

Etiology

Hypoxia 、 accumulation of carbon dioxide ￬

Respiratory Acidosis￬

FHR ￪ → FHR ￬→ FHR ￪￬

Intestinal peristalsis￬

Relaxation of the anal sphincter￬

Meconium aspiration￬

Fetal or neonatal pneumonia

Pathogenesis

Acute fetal distress

Chronic

Fetal

distress

Pathogenesis

IUGR(intrauterine

growth retardation)

Clinical manifestation

Acute fetal distress (1)FHR FHR>160 beats/min (tachycardia) <100 beats/min (bradycardia) (LD) Repeated Late deceleration Placenta dysfunction (VD) Variable deceleration Umbilical factors

FHR:120~160 bpm / FHR variability

Early deceleration

Late deceleration

Variable deceleration

Clinical manifestation

Acute fetal distress (2) Meconium staining of the amniotic fluid (3) Fetal movement Frequently→decrease and weaken (4) Acidosis FBS (fetal blood sample) pH<7.20

pO2<10mmHg (15~30mmHg)

CO2>60mmHg (35~55mmHg)

Clinical manifestation

Chronic fetal distress

(1) Placental function

(2) FHR

(3) BPS

(4) Fetal movement

(5) Amnioscopy

Management

Remove the induced factors actively

Koreksi acidosis: 5%NaHCO3 250ML

Terminasi kehamilan (1) FHR>160 or <120 bpm, mekoneum stain (2) Meconium staining grade III amniotic fluid volume<2cm (3) FHR<100 bpm continually

Management

Terminasi kehamilan (4) Repeated LD and severe VD

(5) Baseline variability disappear with LD

(6) FBS pH<7.20

Forceps delivery

Caesarean section

Treatment for Fetal Distress

Reposition patient: miring kiri Berikan oksigen Pemeriksaan vaginal utk mengetahui ada/tdk prolaps tali

pusat Ensure that qualified personnel are in attendance for

resuscitation and care of the newborn. Note: each institution shall define in writing the term

qualified personnel for resuscitation and care of the newborn.

Each of the following actions should be performed and documented prior to starting a Cesarean section for fetal distress: Perform vaginal exam to rule out imminent

vaginal delivery; Initiate preoperative routines; Monitor fetal heart tones (by continuous fetal

monitoring or by auscultation) immediately prior to preparation of the abdomen;

Ensure that qualified personnel are in attendance for resuscitation and care of the newborn (each institution shall define in writing the term qualified personnel for resuscitation and care of the newborn).

Stop using oxytocin, because oxytocin can strengthen the contraction of uterine which affects the baby's heart rate.