Intrauterine Growth Restriction

Diagnosis – No consensus
EFW (Effective fetal weight) < 10th centile for Gestational age
 Symmetrical IUGR

• EFW < 10 th centile for Gestational age

• Uniformly small for gestational age
• All biometric parameters equally affected
• Multiple anomalies
• Aneuploidy
• Echogenic Bowel
• Doppler – usually normal
• NO Brian sparing flow
 Symmetrical IUGR

• Accurate dating – Essential

• Early USG more accurate than LMP
• CRL more accurate than G sac diameter
• Biological variations don’t manifest untill 13 weeks of
gestation
 Symmetrical IUGR

• Accuracy – USG
• I trimester - ± 0.7 week
• II trimester - ± 1.5 week
• III trimester - ± 3-4 week

• Difficulty –
• Patient usually presents in III trimester
• At 34 weeks; fetus can be normal in range of 31-37 weeks
• Biological variation has maximum effect in III trimester
 Symmetrical IUGR

• Ossification centre
• Distal Femoral - ≥ 32 weeks
• Proximal Tibial - ≥ 35 weeks

• Management
• Karyotype – 5 – 27% babies may have chromosomal
abnormality
• Infection screen
 Constitutional Small fetuses

• By Definition – 10% of pregnancies will be “Too Small”

• Constitutional – Examine Parents
• Ask “Birth-weight” of previous babies
• Interval Growth - Normal
 Asymmetrical IUGR

• EFW < 10 th centile for Gestational age

• Abdomen < other biometric parameters
• HC, BPD – Preserved
• AC – Small; Poor interval growth
• Echogenic bowel – 10 – 20%
• Multiple Gestation – Placental cord insertion
– Significantly increase in Marginal / Velamentous cord insertion
• Oligohydramnios
• Abnormal Doppler
 Asymmetrical IUGR

• Monitor growth –
• Ideal minimum interval 3 weeks
• Biophysical profile
• Acute Hypoxia – Abnormalities of movement and tone
• Chronic Hypoxia – Decrease in amniotic fluid
 Asymmetrical IUGR

• Presentation in late II / early III trimester

• Earlier presentation – Triploidy; Twins or High order gestation
• 4 fold increase in adverse perinatal outcome
• Additional 4 – 8 fold with abnormal Doppler
• Neurodevelopmental morbidity in survivors
• IUGR babies – Higher risk of Hypertension, Diabetes, Stroke
as adults
 Asymmetrical IUGR

• Management
• Infection screen
• Thrombophilia screen ( especially with h/o IUGR fetuses and
Pre – Eclampsia)

• Recurrence –
• Risk of IUGR – upto 25% if past history of IUGR fetus ±
Maternal risk factors
 Management

• Early recognition of Small for gestational age

• Diagnosis of factor inducing delay in growth
• Monitoring
• Determining the time of delivery
 Pathophysiology

• Uteroplacental Insufficiency
• Maternal (Hypertension, Diabetes mellitus, Collagen Vascular disease,
Drugs, Alcohol, Cigarette, Malnutrition)
• Uterine
• Placental (Vascular endothelial growth factor, Leptin, Resistin)
• Fetal Abnormality

• Most Accepted – Failure of trophoblast invasion; Increased

impedance to umbilical artery
 Persistence of Nutritional Deprivation

• Progressive Deterioration
• Hemodynamic changes affecting cardiofuctioning
• Abnormalities in venous system
• Abnormalities in Fetal motor behaviour and Fetal
heart rate patterns
• If NOT delivered in due course- Fetal DEATH
 Determining TIME of delivery

• Based on Biophysical profile or uncontrolled maternal disease

(Pre-Eclampsia)
• Time interval between FIRST doppler abnormality in
umbilical / Fetal circulation (Brain sparing) and delivery is
wide (May Range from 1-9 weeks)
• Ultrasound Obstet Gynecol 18; 564-570; 2001
• After establishment of Brain Sparing; IUGR fetuses with
abnormal heart rate tracings may be Acidotic and exhibit poor
neurologic development at 2 years
• Am J Obstet Gynecol 167; 66-71. 1992
• IUGR babies must be delivered before the onset of abnormal
Fetal heart rate patterns
• Eur J Obstet Gynecol Reprod Bio 42; 573-587, 1991
 Hemodynamic changes and Doppler patterns in
Deteriorating fetus
Hemodynamic Changes
Brain sparing
Change of Cardiac Afterload
Redistribution of Cardiac output
Decreased cardiac output
Increased venous pressure
Decompensation
Doppler Findings
Increase UA / MCA
Increase Pulmonary artery TPV
Decreased Aortic TPV
Decreased RCO/LCO
Decreased Aortic PV
Decreased Pulmonary PV
Increased precent Reversal flow in IVC
Increased S/A in Umbilical artery
UV pulsations
Abnormal fetal heart patterns
 Maternal weight at booking and fetal growth.
Fetuses of heavier mothers display accelerated growth after 26 week
 Maternal height and fetal growth
Fetuses of taller mothers display accelerated growth after 32 weeks
 Parity and fetal growth
Growth is similar untill 36 weeks, then primipare have a slight decelerative course.
 Ethinicity and fetal growth
Growth is slower in Indian fetuses from about 30 weeks
 Effect of smoking in fetal growth
Statistically significant difference noted from 36 weeks.
Preterm delivery and Fetal growth
Birth Weight prediction errors – Customised v/s Non- Customised charts