Small For Gestational Age Presentation 3rd Year Medicine

SMALL FOR
GESTATIONAL AGE
SGA definition
SGA refers to size of infant at birth: IUGR is not
synonymous, although the two may be
associated.
Avergage weight at birth is 7 lbs.
LBW < 2500g [5lb 8oz]
VLBW <1500g
ELBW <1000g
Appropriate for Gestational Age (AGA) = birth

weight and length within +\- 2 Standard
deviations (SD) of the mean gestational age of
a reference population
SGA < 3rd percentile in birth weight and/or
length [SGAW, SGAL, SGAWL]
Subsets of SGA may have different causes and
treatment protocols
Calculating Gestational Age
Factors Associated With

Increased Incidence of Infants
Who Are Born SGA
Fetal factors
Karyotypic abnormalities
Trisomy 21 (Down syndrome)
Trisomy 18 (Edward syndrome)
Monosomy X (Turner syndrome)
Trisomy 13 (gonadal dysgenesis)
Other chromosomal abnormalities
Autosomal deletions
Ring chromosomes
Genetic diseases
Achondroplasia
Bloom syndrome
Congenital anomalies
Potter syndrome
Cardiac abnormalities
Associated Factors Contd
Maternal factors
Medical conditions
Hypertension
Renal disease
Diabetes (advanced stages) mellitus
Collagen vascular diseases
Maternal hypoxemia
Infection
Toxoplasmosis
Rubella
Cytomegalovirus
Herpesvirus
Malaria
Trypanosomiasis
Human immunodeficiency virus

Nutritional status
Low prepregnancy weight
Low pregnancy weight with poor weight gain during pregnancy

Substance use/abuse
Cigarette smoking
Alcohol
Illicit drugs
Therapeutic drugs (eg, warfarin, anticonvulsants, antineoplastic agents, folic acid

antagonists)

Uterine/placental factors
Gross structural placental factors
Single umbilical artery
Velamentous umbilical cord insertion
Bi-lobate placenta
Placental hemangiomas
Infarcts, focal lesions
Insufficient uteroplacental perfusion
Suboptimal implantation site
Placenta previa
Low-lying placenta
Placental abruption

Demographic factors
Maternal age
Very young age
Older age
Maternal height
Maternal weight
Maternal and paternal race
Parity
Nulliparity
Grand multiparity
Maternal history
Previous delivery of SGA infants
Multiple gestation
Complications
Immediate complications in hospital include:
Neonatal Respiratory Distress Syndrome

Cerebral or pulmonary hemorrhage
Infection/sepsis
Hypoglycemia
Newborn jaundice
Necrotizing enterocolitis
Patent ductus arteriosus
Longterm risks include:
impaired neurologic development

behavioral and social problems
development of metabolic syndrome as adults
Bronchopulmonary dysplasia
Retinopathy of prematurity, blindness
Postpartum Care
Preterm labor may be induced if fetus is
determined to be at risk.
Infant taken to high risk nursery, placed
under a warmer or incubator. Breathing,
heart rate, O2 sat are monitored
constantly.
Feeding tube if necessary (usually
unable to coordinate sucking and
swallowing before 34 weeks gestation).
If the baby is very premature or sick, IV
nutrition instead of feeding tube
Nursery care until baby can breath on
its own, feed by mouth, has stable or
Long Term Treatment

Growth Hormone Therapy before puberty may
accelerate linear growth in children. However, it is
not indicated until at least 2-3 years of age (end
of spontaneous catch-up growth period).
FDA has approved doses between 0.24 0.48
mg/kg/wk
Children who begin GH therapy in the 9th or 10th
year of life may benefit from treatment, but show
a mean lower growth velocity than those who
start treatment earlier.
Target height (estimated genetic potential for
height) is a strong predictor of response to GH
therapy, and is commonly estimated as midparental height corrected for gender.
Estimates based on bone age to predict adult height are
Karamvir Sidhu
LARGE FOR
GESTATIONAL AGE
LGA definition
LGA = birth size/weight >90th percentile
for gestational age.
Average baby weighs 7 lbs. Babies
weighing > 8 lbs 13 oz ( >4000g ) are
considered LGA.
Macrosomia defined as weight > 9 lb 15
oz ( >4500g ), or above the 97th
percentile.
During pregnancy, estimate height of
the fundus from the pubic bone. This
value in centimeters usually correlates
with the # of weeks of pregnancy.
Evaluating Macrosomia
Ultrasound is less accurate
If the fetus dates are known,
the best measurement to
evaluate macrosomia is
mothers abdominal
circumference. Initial
abdominal circumference
above 70th percentile is
strongly associated with
delivery of an infant that is
LGA.
If the fetus dates are
unknown, the Femur
LGA Risk Factors

MCC: Diabetic mother, especially poor
glycemic control in third trimester. Maternal
insulin resistance in 2nd half of pregnancy
due to hPL, cortisol and prolactin
Maternal obesity - associated with a 3- to 4fold increased likelihood of fetal macrosomia
Pregnancies lasting beyond 40 weeks
Male sex - male fetuses are an average of
150 g heavier than appropriately matched
female fetuses at each gestational week
during late pregnancy
Increased maternal age
Multiparity
Genetic growth disorders:
Beckwith-Wiedemann syndrome, Sotos
LGA complications
Higher incidence of stillbirth
Polycythemia - significantly higher absolute
nucleated red blood cell counts, lymphocyte
counts, and packed cell volumes (due to chronic
intrauterine hypoxia)
Higher risk of dystocia. Depends on size of
baby, head circumference and pelvic diameter
of the mother
Erbs palsy, Klumpkes paralysis
Usually C-section to safely deliver baby
Complications of low blood sugar in baby

postpartum
Check babys blood sugar [FIRST] and feed early if

hypoglycemic [SECOND]
Increased incidence of birth defects

Feeding difficulties
Hyperbilirubinemia
References
1.) Peter A. Lee, Steven D. Chernausek, Anita C. S.
Hokken-Koelega and Paul Czernichow. International
Small for Gestational Age Advisory Board
Consensus Development Conference Statement:
Management of Short Children Born Small for
Gestational Age. Pediatrics 2003. 111:1253-1261.
2.) Landon MB, Catalano PM, Gabbe SG. Diabetes
mellitus complicating pregnancy. In: Gabbe SG,
Niebyl JR, Simpson JL, eds.Obstetrics: Normal and
Problem Pregnancies. 5th ed. Philadelphia, Pa: Elsevier
Churchill Livingstone; 2007:chap 37.
3.) Michael A. Berk,Francis Mimouni,Menachem
Miodovnik, Vicki Hertzberg,andJennifer Valuck.
Macrosomia in Infants of Insulin-Dependent
Diabetic Mothers. Pediatrics1989;83:61029-1034
4.) Williams Obstetrics: 23rd Edition: F.
Cunningham, Kenneth Leveno, Steven Bloom, John

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SMALL FOR

Appropriate for Gestational Age (AGA) = birth

Calculating Gestational Age

Factors Associated With

Associated Factors Contd

Diabetes (advanced stages) mellitus

Collagen vascular diseases

Human immunodeficiency virus

Low prepregnancy weight

Low pregnancy weight with poor weight gain during pregnancy

Therapeutic drugs (eg, warfarin, anticonvulsants, antineoplastic agents, folic acid

Associated Factors Contd

Associated Factors Contd

Neonatal Respiratory Distress Syndrome

Longterm risks include:

impaired neurologic development

Long Term Treatment

LGA Risk Factors

Complications of low blood sugar in baby

Check babys blood sugar [FIRST] and feed early if

Increased incidence of birth defects

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