Intrauterine Growth Restriction

Dr. Majed Alshammari, FRSCS

Objectives
 Normal fetal growth and factors
 Definition, incidence and significance of IUGR
 Causes
 Diagnosis & types
 Management & follow-up
 Long-term sequelae
Factors of Fetal Growth
 Race
 Gender
 Number of fetuses
 Socioeconomic environment
 Altitude
 Maternal weight and height
 Maternal weight gain
Birthweight in Kuwait Ethnic Groups
3400

Gulf
3300
Medetaranian
African
3200 Indian Subcontinents
Middle Asia
Southeast Asia
3100
EuroAmericans

3000

Alshammari, et al, 2002

Factors of Fetal Growth
 Race
 Gender
 Number of fetuses
 Socioeconomic environment
 Altitude
 Maternal weight and height
 Maternal weight gain
Birthweight and Gender in Kuwait

Alshammari, et al, 2002

Factors of Fetal Growth
 Race
 Gender
 Number of fetuses
 Socioeconomic environment
 Altitude
 Maternal weight and height
 Maternal weight gain
Twins vs. Singletons
Factors of Fetal Growth
 Race
 Gender
 Number of fetuses
 Socioeconomic environment
 Altitude
 Maternal weight and height
 Maternal weight gain
Factors of Fetal Growth
 Race
 Gender
 Number of fetuses
 Socioeconomic environment
 Altitude
 Maternal weight and height
 Maternal weight gain
Factors of Fetal Growth
 Race
 Gender
 Number of fetuses
 Socioeconomic environment
 Altitude
 Maternal weight and height
 Maternal weight gain
Factors of Fetal Growth
 Race
 Gender
 Number of fetuses
 Socioeconomic environment
 Altitude
 Maternal weight and height
 Maternal weight gain
Alshimmiri, et al, 2002
Fetal growth acceleration
 14-19 weeks: 5 g/d
 20-29 weeks: 10 g/d
 30-35 weeks: 30-35 g/d
 > 35 weeks: rate decreases
Terminology
 IUG Restriction
 Small for gestational age
 Low Birth Weight
 Very Low Birth Weight
 Prematurity
Definition
 Less than 10th percentile. Most commonly
used. Includes non-specific cases.

 Less than 2 standard deviations of the

mean (  < 3rd percentile). Clinically more
relevant.
IUGR
 Incidence: 3-10%
 In Kuwait 9.8% of all births are < 10th
percentile
Perinatal morbidity and mortality
 Fetal demise: 1% vs. 0.2% in normal growth
 Birth asphyxia
 Meconium aspiration
Perinatal morbidity and mortality
 Neonatal hypoglycemia and hypothermia
 Abnormal neurological development
 Effects of cause e.g viral, genetic &
congenital malformations.
Causes of IUGR-Summary
 Fetal  Maternal
 Chromosomal Abn
 Congenital malform
 Malnutrition
 Multiple gestation  Vascular/renal dis
 Infection
 Thrombophilias
 Placental  Drugs/lifestyle
 Smaller placenta  Altitude/hypoxia
 Circumvallate
 Chorangioma
Chromosomal Abnormalities &
Congenital Abnormalities
 Incidence in IUGR: 20%
 Trisomy 18, 13, and 21, deletions & sex
chromosome disorders.
 Risk is higher if early IUGR (<26 weeks).
 Risk is higher if polyhydramnios is present.
Viral Infections
 Primary infection before 20 weeks
 CMV, Toxplasmosis, rubella & parvovirus
Multiple gestations
 Growth curve of twins is different from
singletons
 15-30% of twin gestations may be IUGR
 IUGR more in monochorionic twins with
the fetal transfusion syndrome
 Discordant growth may be observed in
dichorionic twins
Placenta in IUGR
 Significantly smaller
 Abnormal terminal villi
 Circumvallate placenta and chorangiomas
have more IUGR
Causes of Placental Insufficiency
 Hypertensive diseases of pregnancy.
 Maternal chronic disease e.g. cardiac, renal
 Autoimmune disease
 Smoking
Maternal Vascular Disease
 Responsible for 30% of IUGR
 The most common cause of IUGR
 Preeclampsia and superimposed
hypertension are most more frequent
causes.
Thrombophylic Disorders
 Lupus Anticogulant
 Anticardiolipin antibodies
 Protein S & C & Anti Thrombin III
deficiencies
 Prothrombin gene mutation
Maternal Nutrition
 Severe caloric restriction
 Severe inflammatory bowel disease
 Low pre-pregnancy weight
 Inadequate weight gain
 IUGR is uncommon in obese women
Drugs & Lifestyle
 Maternal smoking may decrease fetal
weight by 135-300 g
 Drugs such as cocaine, heroin, alcohol,
anticonvulsants, and the warfarin & other
teratogens
Diagnosis
Gestational Age Calculation
 Reliable menstrual dates
 Early ultrasound
 Menstrual date reliable if
 LMP is known for certain
 Regular & normal menses
 No oral contraceptives or lactation
 Ultrasound establishment of gestational age

< 8 weeks 3 days Sac diameter

8-13 weeks 7 days Crown-rump length

14-22 weeks 10 days

23-35 weeks 14 days BPD + HC + AC + FL

>35 weeks 21 days

Diagnosis
Fetal Weight Estimation
 Clinical: symphysis-fundal heigh
 Accuracy only 50%
 Varies with maternal habitus
 Help to screen for weight abnormality
Fetal Weight Estimation
 Ultrasound
 Is the standard
 Use of BPD+HC+AC+FL
 Different international formulae
 Standard deviation varies according to
gestational age
Diagnosis
Ultrasound in IUGR
 Key test for diagnosis
 Rule out congenital abnormalities
 Monitoring of fetal well-being
 Symmetrical vs. Asymetrical
IUGR
Symmetrical Assymetrical

Gest. Age (wks) 32 32

Head circumf. (wks) 27 30

Abdomen circumf (wks) 27 27

Femur length (wks) 27 28

Symmetrical vs. Asymetrical
IUGR
 Head: abdominal circumference ratio
 Timing of insult
 Cause
 Prognosis
 Symmetrical IUGR
 Early intrinsic insult at time of cell division
 Equally small head & abdominal dimensions
 Chromosomal abnormalities, congenital
malformations, drugs or other chemical
agents, or infection
 Generally poor prognosis
 Asymmetrical IUGR
 Late extrinsic factors at time of cell
hypertrophy
 Inadequate availability of substrates for fetal
metabolism. Head sparing & liver is small so
HC >AC
 Maternal vascular disease and decreased
uteroplacental perfusion
 More optimistic prognosis
Symmetrical Vs. Asymetrical
IUGR; Exception to Rules
 Long-standing maternal disease in
pregnancy may present as symmetrical
IUGR
 Symmetric IUGR with a normal growth
rate may simply represent a
constitutionally small and otherwise
normal fetus
Management
 A 22 year old primigravid, 28 weeks by
dates, presented with small for gestational
age uterine size.
Discuss her management.
Management
 Full history and physical exam
 Determine risk factors
 Confirm gestational age
Management
 Lab tests according to type of IUGR
 Symmetrical.
 Prenatal genetic diagnosis
 Viral studies: CMV, Toxoplasm., Parvo

 Assymetrical
 Thrombophilias: ACL, lupus AC, AT-III, protein
S&C
 Investigate vascular causes e.g. Pre-eclampsia
Management
 Serial ultrasound every 2-3 weeks for
growth assessment
 Weekly BPP and doppler flow studies
 Advice home rest if placental insufficiency
 Instruct on fetal movement counts
 Treat underlying cause
 Biophysical profile (BPP)
No Yes
Fetal movement  3 times 0 2
Breathing movement  30 seconds 0 2

Tone:  1 limb flexion-extension 0 2

Amniotic fluid  2 cm perpendicular 0 2

Reactive Non-stress test 0 2

Total 10
70 mm 60 mm

70 mm 60 mm
Non-stress Test
Degrees of Placental Insufficiency

Normal Flow

Decreased diastolic flow (Mild)

Absent diastolic flow (Moderate)

Reversed diastole (Severe)

Management
 Time of delivery
 Term or near term especially if hypertensive
 Lack of growth
 Evidence of fetal compromise
 Abnormal NST
 Abnormal BPP

 Significant doppler changes

Management
 Optimize the timing of delivery
 Avoid progressive hypoxia during labor
 Provide immediate skilled neonatal care
Neonatal Complications and Long-Term
Sequelae
 Outcome is dependent on etiology
 Unfavorable prognosis with chromosomal
or congenital malformation
 Outcome is more difficult with premature
birth
Neonatal Complications and Long-Term
Sequelae
 Antepartum, intrapartum or neonatal
hypoxia
 Neonatal ischemic encephalopathy
 Meconium aspiration
Neonatal Complications and Long-Term
Sequelae
 Polycythemia
 Hypoglycemia
 Other metabolic abnormalities
Treatment of IUGR
 None of the following proven effective
 Nutritional supplementation
 Plasma volume expansion
 Low-dose aspirin
 Maternal oxygen therapy
 Steroids
Evaluation and Management
Constitutionally small Malformation/ Placental insufficiency
chromosomal/Infection

Pattern symmetric Symmetric Asymmetric

Growth rate Below but parallel to Markedly below normal variable

normal

Anatomy Normal Abnormal Normal

Evaluation and Management
Constitutionally small Malformation/ Placental insufficiency
chromosomal/Infection

Amniotic fluid volume Normal Normal- Low

polyhydramnios

Additional evaluation None Prenatal diagnosis for Fetal lung maturity as

chromosomes/virology indicated

BPP & doppler study Normal BPP variable, normal BPP and doppler
doppler become abnormal

Follow-up & delivery None-anticipate term Dependent upon BPP/doppler/fetal lung

delivery etiology maturity. Delivery
dependent on GA and
tests findings