Fetal Growth Restriction
Growth restriction is defines as an infant born at or below the third percentile of mean weight for gestational age, with clinical evidence of dysfunctional or abnormal growth. The perinatal mortality rate of these infants is five times higher than that of normal infants. Approximately one half of growth-restricted babies show wasting of soft tissue and muscle mass, especially in the cheeks, arms, buttocks, and thighs. The skin is often dry, cracked, and peeling. Fetal growth-restricted fetuses often aspirate meconium, are more often acidotic at birth, and are susceptible to massive pulmonary hemorrhage, convulsions, hypoglycemia, polycythemia, hypocalcemia, hypothermia, thrombocytopenia, and, if growth restriction is severe, cerebral or renal damage.
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Depending on the timing of growth restriction, as well as its etiology, infants can be either asymmetrically or symmetrically growth restricted. Asymmetric growth restriction generally occurs late in the second trimester or early in the third trimester of pregnancy. The fetal brain and heart are often spared because of non-reduced blood flow, and these fetuses usually demonstrate normal musculoskeletal growth. Conversely, the symmetrically growth-restricted infant begins the process of growth restriction early, with a decrease in hyperplasia of all cells. The fetus that is symmetrically growth restricted not only shares the growth aberration of the fetus with an asymmetric pattern but also has decreased skeletal dimensions. More recently, two classes of antiphospholipid antibodies have been associated with fetal growth restriction–anticardiolipin antibodies and lupus anticoagulant.
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Asymmetric growth restriction, which generally occurs during the phase of growth termed cellular hypertrophy, is attributed to placental insufficiency secondary to maternal hypertensive disorders, renal disease, heavy cigarette smoking, or diabetes with vascular disease. Factors associated with symmetrical growth restriction include chromosomal abnormalities (ie, trisomy 18 and 13), developmental abnormalities secondary to teratogens (eg, anticonvulsants, narcotics, cocaine), and intrauterine fetal infections (eg, rubella, CMV, malaria, hepatitis A and B, toxoplasmosis, listeriosis, syphilis, tuberculosis). In addition, cyanotic heart disease, heavy cigarette smoking, and other causes of prolonged fetal hypoxia may result in a symmetrically growth-restricted infant.