EFFECT OF SMOKING ON INTRAUTERINE

GROWTH RESTRICTION IN PREGNANCY

PRADITA ADININGSIH
030.09.182
FACULTY OF MEDICINE TRISAKTI UNIVERSITY
JAKARTA
2013
0
PREFACE
This paper, titled Effects of Smoking on Intrauterine Growth Restriction in Pregnancy,
created in order to complete an English assignment for Medical English III class in Trisakti
University, Faculty of Medicine. Discussed inside is the information related to Cigarette
materials and Intrauterine ro!th "estriction, #oth as individual and related topics.
My token of gratitude to those helped in the process of making this paper, from
conceptuali$ing to actuali$ing it. I also thanks to dr. %&. Martiem Ma!ie, M', !ith his guidance
and assisstance, this paper is the #est that it can #e. I #eg many thanks for my parents and my
friends !ho help me to finish my paper of English.
(nd my most sincere apologies if there are errors, technical or other!ise, contained in this
paper.
)akarta, )anuary *
th
,

+,-.
/radita (diningsih
1
ABSTRACT
The #urden of IU" is concentrated mainly in (sia !hich accounts for nearly *01 of all
affected infants. (frica and 2atin (merica account for +,1 and 01 cases respectively. In
developed countries, appro3imately -01, and in developing countries, appro3imately 41 of
!omen smoke cigarettes, and adolescents and !omen from lo!er socioeconomic groups are
more likely than other !omen to smoke !hile pregnant. Maternal smoking during pregnancy is
the largest modifia#le risk factor for intrauterine gro!th restriction. To#acco5smoke to3ins
readily cross the placental mem#rane, damage the placenta and may lead to nutritients
insufficiency to fetus then #ecome restiricted in gro!th. These effects to smoking may #e dose5
related, as there is good evidence that mean #irth!eight decreasements are greater !ith increased
num#ers of cigarettes smoked during pregnancy. Interventions to control maternal smoking are
also considered.
K!"#$%&' Cigarette, Intra uterine gro!th restriction, 'moking, /regnancy, 2o! #irth!eight
2
CHAPTER I
INTRODUCTION
'moking during pregnancy is considered the largest preventa#le cause of fetal and infant ill
health and death. To#acco e3posure during pregnancy remains a ma&or pu#lic health pro#lem
like IU", as there are more than - #illion individuals glo#ally using to#acco products. The
/regnancy "isk (ssessment Monitoring 'ystem 6/"(M'7 survey reported a prevalence of -8
percent in +,,0 in the United 'tates. 'moking prevalence !as highest in !omen under age +0,
single !omen, lo! income !omen, and (merican Indian9(laska :ative !omen. The overall rate
of smoking during pregnancy declined #y ; percent #et!een +,,, and +,,0. The e3act
prevalence of smoking during pregnancy is difficult to #e calculated, not only #ecause of
incomplete records, #ut also #ecause most studies rely on self5reported smoking #ehavior and are
therefore su#&ect to underreporting.
6-7
Each year, appro3imately +, percent of the almost 8 million infants in the United 'tates are
#orn at the lo! e3tremes of fetal gro!th as the results from IU". (lthough most of lo!5
#irth!eight infants are preterm, appro3imately . percent of the lo!5#irth!eight infants are term.
Most of perinatal mortality cases !ere caused #y IU" that resulted in lo!5#irth !eight #a#y
!ith premature organ development. In +,,<, U' stated 4,. percent of infants !eighed less than
+0,,g at #irth. The proportion of those =+0,,g has increased #y 4 percent since +,,, to +,,;.
Follo!ing conditions such as maternal !eight less than -,, pounds, poor nutrition during
pregnancies, use of cigarettes and alcohol, placental a#normalities, and hypertension may #e at a
greater risk for developing fetal gro!th restriction in pregnancy.
6+7
3
CHAPTER II
DISCUSSION
N#$()* F+)* G$#"+,
%uman fetal gro!th is characteri$ed #y se>uential patterns of tissue and organ gro!th,
differentiation, and maturation. Development is determined #y maternal provision of su#strate,
placental transfer of the su#strates, and fetal5gro!th5potential governed #y the genome.
The initial phase of hyperplasia occurs in the first -< !eeks and is characteri$ed #y a
rapid increase in cell num#er. The second phase, !hich e3tends up to .+ !eeks, includes #oth
cellular hyperplasia and hypertorphy. (fter .+ !eeks, fetal gro!th is #y cellular hypertrophy, and
it is during this phase that most fetal fat and glycogen deposition takes place.
6+7
In early fetal life, the ma&or determinant is the fetal genome, #ut later in pregnancy,
environmental, nutritional, and hormonal influences #ecome increasingly important. F-./$ 1
sho!s intrauterine complications during organ development in neonates.
4
6Figure 17 Fetal organ development and Intrauterine complications.
6.7
I0+$) U+$-0 G$#"+, R&+$-1+-#0
Intrauterine gro!th restriction 6IU"7 refers
to a condition in !hich a fetus is una#le to achieve its
genetically determined potential si$e. This functional
definition seeks to identify a population of fetuses at
risk for modifia#le #ut other!ise poor outcomes.
This definition intentionally e3cludes of fetuses that
are small for gestational age 6'(7 #ut are not
pathologically small. '( is defined as gro!th at the
-,th or less percentile for !eight of all fetuses at that
gestational age. :ot all fetuses that are '( are pathologically gro!th restricted and, in fact,
may #e constitutionally small. 'imilarly, not all fetuses that have not met their genetic gro!th
potential are in less than the -,th percentile for estimated fetal !eight.
607
The term retardation has
#een discarded #ecause ?retardation@ implies a#normal mental function, !hich is not the intent.
6+7
The #urden of IU" is concentrated mainly in (sia !hich accounts for nearly *01 of all
affected infants. (frica and 2atin (merica account for +,1 and 01 cases respectively.
6<7
/regnancies that have any of the follo!ing conditions such as maternal !eight less than -,,
pounds, poor nutrition during pregnancies, use of cigarettes and alcohol, placental a#normalities,
and hypertension may #e at a greater risk for developing fetal gro!th restriction.
6+7
C-.)$++ C#0+0+&
To#acco smoke and its meta#olites, especially nicotine, have an irritant, genoto3ic,
neuroto3ic, mutagenic, teratogenic, cancerogenic, and psychoactive effect. To#acco smoke
contains around 8.,,, su#stances, most of !hich are descri#ed as to3ic 6e.g sterols, cotinine,
nicotine, nitro$amine7. Car#onmono3ide effects the fetus most. Cigarette smoking is one of the
most significant and modifia#le risk factors associated !ith adverse perinatal outcome.
6*7
S#1-#1#0#(-1 F)1+#$&
5
6Figure 27 Body sie difference
!etween a full"term growth"restricted
and normal !a!y.
687
( social class5dimension model has #een suggested related to the to#acco epidemic. The
study sho!ed that -01 in developed countries and 41 in developing countries smoking !omen
!ere reported as more likely to #e younger, single and of lo!er educational achievement.
647
In
vie! of these associations, socioeconomic factors and maternal age could !ell #e confounding
influences on the association #et!een smoking, IU", and pregnancy outcome.
P)+#2,!&-#*#.!
Impaired fetal o3ygen delivery is the #est5studied cause of adverse outcome in pregnant
!omen !ho smoke. /athologic evaluations of the placentas of smokers have sho!n structural
changes, including a reduction in the fraction of capillary volume and increased thickness of the
villous mem#rane !hen compared to nonsmokers. Aoth of these factors may contri#ute to
a#normal gas e3change !ithin the placenta. E3posure to cigarette smoke also acutely decreases
intervillous perfusion, possi#ly via 0-1#+-03-0%/1% 4)&#&2)&(.
6;7
(nother pro#lem is that 1)$5#0 (#0#6-% 62#&/$ from smoking causes the formation
of car#o3yhemoglo#in, !hich has multiple effects on systemic and fetal o3ygen delivery.
Car#o3yhemoglo#in is cleared slo!ly from the fetal circulation, and diminishes tissue
o3ygenation via competitive inhi#ition !ith o3yhemoglo#in. Bhen a pregnant !oman is
e3posed to car#on mono3ide, her fetus !ill eventually come to have a higher 6CC%#7 level than
her o!n 6maternal7 circulation. Initially the rise in CC%# in the fetus lags #ehind that of
maternal CC%#, since the CC has to pass through the maternal circulation #efore reaching the
fetal circulation. Eventually, ho!ever, the higher affinity of the fetusD hemoglo#in 6a mi3ture of
fetal %# and adult %#7 for CC means the fetal CC%# level !ill e3ceed the maternal CC%# level.
For this reason and others, the damaging effects of CC on the fetus are likely to #e greater.
6-,7

'moking may also result in direct %)(). +# 7+)* .0+-1 ()+$-)*. Evidence is
mounting that supports a geneEenvironment interaction !here !omen !ho have polymorphisms
in genes encoding proteins involved in to3in meta#olism are at the greatest risk for developing
infants !ith IU". Cne study compared the chromosomal insta#ility of amniocytes from
smokers and non5smokers, and noted an increased incidence of structural chromosomal
a#normalities among !omen !ho smoked regularly.

Most of these a#normalities !ere the result
6
of deletions or translocations, and many !ere locali$ed to the -->+. region, !hich is also
associated !ith several hematologic malignancies.
6--7
N-1#+-0 in cigarette smoke increases the maternal heart rate and induces vasoconstriction.
6-+7
Elevated concentrations of other to3ic chemicals in cigarette smoke, such as cyanide and
cadmium occur in the #lood and urine of smoking mothers and interfere !ith fetal gro!th
restriction, contri#uting to lo! #irth!eight.
6-.7
The negative impact of cigarette smoking on fetal
health is !ell esta#lished. Cigarette smoking has #een associated !ith numerous adverse
outcomes. Bhile the pathophysiology is not completely understood, as discussed a#ove, several
possi#le mechanisms related to impaired gas e3change, direct to3icity, and sympathetic
activation have #een proposed.
CHAPTER III
7
SMOKING EFFECTS IN IUGR
(n analysis of the -;04 Aritish /erinatal Mortality 'urvey sho!ed that smoking during
pregnancy !as associated !ith a +41 increase in the perinatal mortality rate and a -*,5g
reduction in #irth!eight, even after #alancing other socioeconomic factors. This lead to a num#er
of studies investigating the effects of smoking in pregnancy on #irth!eight. In an (la#aman
study, a survey of -080 !omen sho!ed a relationship #et!een smoking in thin !omen and
IU". It is clear that maternal smoking in pregnancy is associated !ith a reduction in
#irth!eight, and !ith the advent of modern ultrasound technology, the effects of maternal
smoking can #e further evaluated in utero.
6-87

In smokers, lo! #irth!eight !as #est predicted #y third trimester ultrasonographic
detection of IU". First and second trimester ultrasound did not predict !hich infants !ould
have lo! #irth!eight. This suggests that the primary direct effects of smoking do not occur until
the third trimester, and ultrasound may #e a useful tool to identify fetuses at risk of lo!
#irth!eight in the early third trimester. Further investigation of smoking on fetal gro!th can #e
achieved #y utili$ing ultrasound technology to measure other anthropometric data as sho!n as
F-./$ 3.
L#" B-$+,"-.,+ -0 F+)* G$#"+, R&+$-1+-#0
8
8Figure 39 8A9 ro!th of fetal femur length is demonstrated for fetuses of smoking and nonsmoking mothers.
There !as no difference #et!een groups in estimated rate of femur gro!th. 8B9 ro!th of fetal thigh muscle area is
demonstrated for fetuses of smoking and nonsmoking mothers. There !as a significantly slo!er gro!th of thigh
muscle mass in fetuses of smoking mothers. 8C9 ro!th of fetal a#dominal circumference is demonstrated for
fetuses of smoking and nonsmoking mothers. There !as a significantly slo!er gro!th of a#dominal circumference
in fetuses of smoking mothers. 8D9ro!th of fetal thigh fat area is demonstrated for fetuses of smoking and
nonsmoking mothers. There !as a significantly slo!er gro!th of thigh fat in fetuses of smoking mothersF ho!ever,
there !as no a#solute difference #et!een the groups at ..E.* !eeksG gestation.
6-87
(Figure 4) Birthweight for gestational age #$th% &$th and '$
th
percentiles for !a!ies !orn to smoking (!lack lines) and nonsmoking
(dotted lines) mothers.
687
Maternal smoking during pregnancy is the largest modifia#le risk factor for intrauterine
gro!th restriction 6IU"7, !hich in turn influences infant mortality and the long5term health
outcomes of surviving infants. F-./$ : illustrates the lo!er #irth!eight percentile curves in
smoking mothers at different gestational ages, compared !ith others !ho did not smoke during
pregnancy.
( longitudinal study in the U'(, !hich compared patterns of to#acco use during
pregnancy over time and across population su#groups, has reported a higher incidence of lo!
#irth!eight among singletons #orn to smoking compared !ith nonsmoking mothers
6-07.
(nother
longitudinal study in Aristol 6UH7 demonstrated that infants of smoking mothers !ere
symmetrically small at #irth, compared !ith those of nonsmokers.
6-<7
S(#;-0. D#& A&&#1-)+-#0&
:icotine dependence leading to smoking addiction is also strongly associated !ith the
num#er of cigarettes smoked per day. irls and !omen !ho smoke appear to #e nicotine
dependent in relation to the num#er of cigarettes smoked per day. The important thing is that the
risk of IU" and adverse #irth outcomes increases along !ith the enhancement num#er of
cigarettes smoked daily, !ith heavy smokers delivering #a#ies lighter than nonsmokers.
9
( study reported that mothers !ho !ere light smokers 6= -, cigarettes9day7 delivered
#a#ies !eighing on average of ;< g less than infants of nonsmokers.
6*7
Cther research has sho!n
that even light maternal smoking during pregnancy 6= 0 cigarettes9day7, !as significantly
associated !ith elevated rates of lo! #irth!eight.
6-*7
The dose5response effects of maternal
cigarette smoking in pregnancy outcomes is illustrated in F-./$ < and F-./$ = for several
thousand !omen in UH.
The graphic sho!s that there !ere no differences in #irth outcomes #et!een nonsmoking
and light5smoking mothers. It also sho!s a trend to!ards greater reductions of #irth!eight !ith
increased num#er of cigarettes smoked daily.
687
I0+$40+-#0& +# C#0+$#* M)+$0)* S(#;-0.
Cnly nonsmoking is the right !ay to protect the fetus and child. (dvantages of smoking5
cessation programs include the #enefits of population health gains through reductions in smoking
10
(Figure 57 *ean gestational age% and num!er of maternal
cigarettes smoked+day.
687
6Figure 67 *ean !irthweight and num!er of maternal
cigarettes+day.
687
prevalence, reduction in the risk of dying from smoking5related diseases, as !ell as reduction in
the risk of infant illness.
Bomen may #e more likely to stop smoking during pregnancy than at other times due to
their a!areness of the additional ha$ards to their #a#y.
6-47
( meta5analysis of randomi$ed clinical
trials in pregnant smokers demonstrated that the active delivery of smoking cessation methods in
prenatal care increased the >uitting rate #y 0,1, although these cessation rates !ere still modest.
687
The study approved that smoking cessation in prenatal care program is very recommended
and should #e sociali$ed to every smoking mothers.
Iuitting smoking at any point during pregnancy is more #eneficial than continuing to
smoke throughout the entire ; months of pregnancy, especially if it is done !ithin the first
trimester 6!ithin the first -+ !eeks of pregnancy7. ( recent study suggests, ho!ever, that !omen
!ho smoke anytime during the first trimester put their fetus at a higher risk for #irth defects,
particularly congenital heart defects 6structural defects in the heart of an infant that can hinder
#lood flo!7 than !omen !ho have never smoked. That risk only continues to increase the longer
into the pregnancy a !oman smokes, as !ell as the larger num#er of cigarettes she is smoking.
6-;7
Many !omen !ho succeed in stopping smoking during pregnancy later return to smoking
after the #irth of their #a#y. Cf mothers !ho gave up smoking in the year #efore or during
pregnancy, ++1 relapsed < !eeks postpartum.
687
(n (merican study reported that 0<1 of !omen
!ho >uit smoking during pregnancy started again !ithin - month of delivery.
6-;7
'imilar relapse
rates are reported #y others, !ith up to t!o5thirds of !omen !ho stopped smoking during
pregnancy returning to smoking !ithin < months of delivery.
6+,7
In vie! of the high relapse rates after delivery among !omen !ho have >uit during
pregnancy, specific intervention programs provided through pediatric consultations during child
follo!5up visits should #e strongly recommended. 'uggested methods to do this include various
forms of smoking5cessation programs, nicotine5replacement therapy and educational self5help
program.
6+-7
C#/0&*-0. should #e aimed at developing #ehavioral aids to ena#le >uitting, address
specific concerns a#out >uitting, such as fear of !eight gain or !ithdra!al symptoms, and #e
11
responsive to individual needs. Cognitive #ehavioral counseling programs ho! the highest
success rates. The t!o main factors associated !ith success appeared to #e involvement in an
intense counseling program administered #y medical, nursing or other trained clinicians.
6+-7
N-1#+-0 $2*)1(0+ +,$)2! involves the use of products that provide lo! doses of
nicotine #ut does not contain the to3ins found in smoke. The goal of therapy is to relieve
cravings for nicotine and ease the symptoms !hen someone stops using cigarettes and smokeless
to#acco. In general, nicotine replacement therapy #enefits moderate5to5heavy smokers 6people
!ho smoke more than -0 cigarettes a day7 the most. There are several types such as skin patch,
che!ing gum, nasal spray, and inhalers, #ut most people are more likely to use skin patch or
che!ing gum.
6++7
There has #een much concern a#out using nicotine during pregnancy #ecause of
kno!n to3icity and as !e kno!, nicotine is classified as a class D drug, indicating that there is
positive evidence of human risk in pregnancy.
6+.7
%uman data sho! that e3posure to cigarettes or
to nicotine che!ing gum results in a state of sympathetic activation. %o!ever, there is no strong
evidence that pregnant smokers !ho use nicotine replacement therapy are at higher risk of
adverse perinatal events than pregnant smokers not using this therapy.
6-,7
GENERAL GUIDELINES
The Clinical /ractice uidelines released #y the ,nited States -epartment of .ealth and .uman
Services (,S-..S) made three recommendations for treating to#acco use during pregnancy
O77$ 2&!1,#&#1-)* -0+$40+-#0 J Aecause of the serious risks of smoking to the pregnant
smoker and the fetus, pregnant smokers should, !henever possi#le, #e offered e3tended or
augmented psychosocial interventions that e3ceed minimal advice to >uit.
O77$ -0+$40+-#0 +,$#/.,#/+ 2$.0)01! J (lthough a#stinence early in pregnancy !ill
produce the greatest #enefits to the fetus and mother, >uitting at any point in pregnancy can
yield #enefits. Thus, clinicians should offer effective smoking cessation interventions to
pregnant smokers at the first prenatal visit as !ell as throughout the course of pregnancy.
O77$ 2,)$()1#+,$)2! J /harmacotherapy such as Aupoprion and Kaseclinine should #e
considered !hen a pregnant !oman is other!ise una#le to >uit, and !hen the likelihood of
12
>uitting, !ith its potential #enefits, out!eighs the risks of the pharmacotherapy and potential
continued smoking. (lthough pharmacotherapy has not #een recommended for all !omen
during pregnancy #ut is primarily targeted for !omen !ho are unlikely to >uit, it appears
reasona#le to offer pharmacotherapy to pregnant !omen !ho are at high risk for continued
smokingL heavy smokers 6M-, cigarettes per day7F those smoking later in pregnancyF and
those !ho have attempted to stop previously.
CHAPTER IV
CONCLUSION
'moking during pregnancy is considered the largest preventa#le cause of IU" and
adverse #irth outcomes in developed countries. Noung teenage mothers have a significantly
higher risk of having IU" #a#y and delivering a lo!5#irth!eight #a#y than other age groups.
13
Fetal gro!th, as determined #y antenatal ultrasound assessment, is also affected #y smoking. The
smoking patient has a high5risk pregnancy, and as the risk factor is modifia#le, measures and
smoking cessation on every smoking mothers should #e taken to decrease the possi#ility of
perinatal mor#idity and mortality.
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16