Intrauterine Growth Restriction

1. OBSTETRICS AND
GYNAECOLOGY
CASE PRESENTATION

2. A CASE PRESENTATION ON IUGR
MODERATOR:
DR. MANOJ MAZUMDAR
ASSISTANT PROFESSOR
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
GMCH

3. PRESENTED BY:
Roll nos. Name
8 NAYANMANI SARMA
9 GAYATRI SHARMA
10 ANANDARUP DAS
11 PAYAL DEY
12 JAYASHREE PATHAK
13 KIRTI CHHABRA
14 IMDADUL HOSSAIN

4. HISTORY TAKING

5. PATIENT’S PARTICULARS
Name – Anima Bibi Hospital no. – 28586/16
Age – 23 years Ward – ANW
Sex – Female Unit – IV
Address – Dharapur Bed no. – 19
Azara MRD no. – 6715
Kamrup (M)
Assam
Occupation – Housewife
Religion – Muslim
Marital status – Married
Duration of marriage – 5 years
Date of admission – 01.02.2016
Date of examination – 05.02.2016
Husband’s name – Tahar Ali
Husband’s occupation – Carpenter

6. PATIENT’S PARTICULARS
• LMP –04.05.2015
• EDD – 11.02.2016
• Gravida and Parity– G2P1+0L0

7. CHIEF COMPLAINTS
Routine antenatal checkup at 9 months of pregnancy.

8. H/O PRESENT ILLNESS
The patient complains of cessation of menstruation
for the last 9 months. She labeled herself pregnant
after a positive urine pregnancy test after she was
one and a half months amenorrhoeic.

9. PREGNANCY EVENTS (PRESENT
OBSTETRIC HISTORY)
1ST TRIMESTER:
• The pregnancy was confirmed by urine pregnancy test after
she missed her periods for one and a half months.
• There are no antenatal checkups in the first trimester.
• There is no history of vomiting or increased frequency of
micturition.
• There is no history of fever, burning micturition, loin pain or
difficulty in micturition.
• There is no history of any drug intake or exposure to
radiation.
• There is no history of vaginal discharge or bleeding per
vagina.
• There is no history of any abdominal pain, breast discomfort.
• Bowel and bladder habits are normal.
• Sleep is normal but Appetite is reduced.
• There are no medical or surgical events in the first trimester.
• There is no history of trauma.

10. 2ND TRIMESTER:
• The patient says that there was progressive enlargement
of the abdomen.
• The First fetal movements were perceived at around 5th
month of gestation, exact date could not be specified,
since then she has been perceiving till date.
• She went for her first antenatal checkup at 5th month at
Azara Community Health Centre and then regularly at
monthly interval.
• Total two antenatal checkups were done in 2nd trimester.
• Iron and folic acid tablets have been consumed regularly
from the 5th month.
• Calcium supplements have been taken.
• No Tetanus Toxoid has been administered.
• There is no history of fever, burning micturition.
• Frequency of micturition was normal.

11. 2ND TRIMESTER (contd)
• The patient does not give history of swelling of legs
or other parts of the body like face, abdomen, vulva
or whole body or tightness of ring of the finger.
• There is no history of headache, dizziness or blurring
of vision or abnormal body movements.
• There is no history of pain abdomen or vomiting.
• There is no history of vaginal discharge or bleeding
per vagina.
• Bowel and bladder habits are normal.
• Sleep is normal but Appetite is reduced.
• There are no medical or surgical events in the second
trimester.
• There is no history of trauma.

12. 3RD TRIMESTER:
• Fetal movements can be felt regularly @ 10-12/12-hr
period.
• Total no. of antenatal checkups in 3rd trimester is three.
• Tetanus toxoid, one dose, was received at 8th month.
• There is no history of breathing difficulty.
• Frequency of micturition is normal.
• There is no history of fever, swelling of legs, pain
abdomen or vomiting.
• There is no history of vaginal discharge or bleeding per
vagina.
• There is no history of exposure to caffeine.
• The patient does not give history of breaking of water
yet.
• Bowel and bladder habits are normal.
• Sleep is normal but Appetite is reduced.
• There are no medical or surgical events in the third
trimester.
• There is no history of trauma.

13. PREVIOUS ANTENATAL
CHECKUPS (as per MCP card)
Sl.
No
Week Place Fetal
movement
FHR BP (mm
Hg)
Weight
(kg)
Medication
1 21st Azara
CHC
Present 120 110/70 35 IFA, Ca2+
supp.
2 24th Azara
CHC
Present 136 120/76 36 -
3 28th Azara
CHC
Present 140 110/70 38 -
4 32nd Azara
CHC
Present 130 108/72 40 -
5 39th GMCH Present 130 110/70 40 -

14. PAST OBSTETRIC HISTORY
Duration of marriage is 5 years.
Gravida 2 Parity 1 with no living issue.
Sl.
No
Year of
birth
Pregnancy
events
Labour events Place and
mode of
delivery
Puerperium Baby
1. December
2014
1) Duration of
pregnancy = 28
weeks.
2) Antenatally
cared.
3) Premature
rupture of
membrane at
7th month and
early onset of
labour.
1) Onset =
spontaneous
and early.
2) Duration of
labour =
normal, not
prolonged.
3) There is
history of
PROM.
1) Mode of
delivery =
normal.
2) Place of
delivery =
transit.
1)Uncomplicat
ed
2) No H/O
blood
transfusion.
3) Hospital
stay = 9 days.
Live birth,
Female,
Birth weight
is 1.3 kg,
Preterm,
Admitted to
NICU
immediately
after birth,
Death on
10th day of
birth.

15. MENSTRUAL HISTORY
• L.M.P. – 04.05.2015
• E.D.D. – 11.02.2016
• Period of amenorrhoea – 9 months.
• Age of menarche – 12 years.
• Duration of menstruation – 4-5 days.
• Interval in days – 28+/-2 days.
• Regularity of cycle – regular.
• Amount of bleeding – Moderate (as suggested by
the use of 2-3 packs/day)
• Pain during period – none
• Clots – absent
• L.M.P. lasted for lasted for 4 days with normal
flow of blood and no clots were present.

16. PAST MEDICALAND SURGICAL
HISTORY
There is no significant past medical history.
• There is no history of hypertension, diabetes
mellitus, tuberculosis, bronchial asthma, heart
disease, renal disease or vascular disease in the
past.
• There is no history of blood transfusion in the
past.
• There is no previous history of surgical
intervention in the past.
• There is no previous history of MTP.

17. PERSONAL HISTORY
• The patient is a non-smoker and non-alcoholic.
• She does not consume betelnut or tobacco.
• She consumes an average non-vegetarian
Assamese diet.

18. FAMILY HISTORY
• The patient lives with her husband.
• There is no history of diabetes mellitus,
hypertension, bleeding disorders or TB in other
members of the family.
• There is no history of repeated abortions, still
births, congenital anomalies, multiple pregnancy
in the family.

19. SOCIOECONOMIC HISTORY
• The patient lives in a pucca house with 2 rooms, a
separate kitchen and sanitary latrine.
• Total income of the family is Rs. 6000/- per
month, suggesting lower socioeconomic strata.
• The family consumes filtered water and the source
of water is tubewell.

20. CONTRACEPTIVE HISTORY
• There is no history of usage of any
contraceptive.

21. IMMUNISATION HISTORY
• BCG scar is present.
• In her first pregnancy 2 years back, she
received two doses of Tetanus toxoid at 5th
and 6th months of pregnancy.
• In the current pregnancy, she received one
dose of Tetanus toxoid at 8th month of
gestation.

22. DRUG HISTORY
• The patient has been prescribed iron and
folic acid tablets along with Calcium
supplements which she has been taking
regularly from 5th month.
• No history of intake of any other
medications.

23. ALLERGY HISTORY
• The patient is not allergic to any known
allergen.

24. GENERAL EXAMINATION

25.  Consciousness – Patient is alert and conscious.
 Orientation – Well oriented to time, place and person.
 Appearance & Facies – Normal.
 Decubitus – Of choice.
 Build – Average.
 Nutrition – Poor.
 Height – 147 cm.
 Weight – 40 kg.
 Gait – Normal.
 Skin – Normal, stretch marks present on abdomen.
 Icterus – Absent.
 Pallor – Absent.
 Dehydration- absent
 Cyanosis – Absent.
 Edema – Absent.
 Clubbing – Absent.
 Oral cavity – Oral hygiene is maintained, no features of
malnutrition, no dental caries, gums, tongue is moist with
normal papillae.
• Neck veins – Not engorged.
 Neck glands – Not enlarged.
 Leg Veins- No varicose vein , tortuosity

26. VITALS
 Pulse -
Rate- 90 bpm
Rhythm- regular
Volume-Normal
Character-Normal
No radio-radial and Radio-femoral delay
All peripheral pulses are palpable
 Blood pressure - 110/70 mm Hg in Left arm
taken in supine position
 Respiratory Rate - 18/min, Regular
• Temperature - 98.40 F

27. SYSTEMIC
EXAMINATION

28. CENTRAL NERVOUS SYSTEM
a) Higher function: The patient is alert, conscious,
cooperative and well oriented to time, place and
person.
b) Cranial Nerves: Functions of all the cranial
nerves are intact.
c) Motor system: Tone, power and bulk of muscles
of all four limbs are normal. Coordination is
normal. No abnormality detected. All the
superficial and deep reflexes are intact.
d) Sensory and autonomic functions are normal.

29. CARDIOVASCULAR SYSTEM
a) Inspection: Precordium is normal. No visible
pulsations or engorged veins seen. No scar is seen.
b) Palpation: Apex beat is palpable just medial to
mid-clavicular line in the left 5th intercostal space.
It is normal in character.
c) Auscultation: Heart sounds are normal. No added
sounds heard.

30. RESPIRATORY SYSTEM
a) Inspection: Shape and symmetry of chest is normal and
symmetrical. Respiratory movements are bilaterally
symmetrical. Respiratory rate is 18/minute and regular
in rhythm. No deformity detected.
b) Palpation: Trachea is in midline. Chest expansion is
normal and bilaterally symmetrical. Vocal fremitus is
bilaterally symmetrical and normal.
c) Percussion: Resonant in all the areas. No abnormality
detected.
d) Auscultation: Normal breath sounds are heard in all the
areas. Vocal resonance is normal and bilaterally
symmetrical in all the areas. No added sounds heard.

31. OBSTETRIC
EXAMINATION

32. PER ABDOMINAL EXAMINATION
1. INSPECTION:
 Size – enlarged.
 Shape – globular.
 Ovoid – longitudinal.
 Flanks – not full.
 Fundus – Convex.
 Suprapubic Region – Convex.
 Condition of Skin – Healthy.
 Skin - Presence of stria gravidarum and linea nigra.
 Umbilicus – everted, midline in position.
 Venous prominence – none.
 Scar mark of previous operation – none.
 Visible pulsation – none.

33. PER ABDOMINAL EXAMINATION
2. PALPATION
 Local rise of temperature = none
 Tenderness = none
 Abdominal girth = 70cm.
 Symphysio-fundal height = 28cm.
 Uterus = soft, relaxed and non-tender.
 Fetal movements = felt.
 Fundal height= corresponds to 28 weeks of pregnancy.

34. PER ABDOMINAL EXAMINATION
 Obstetric grips:
a) Fundal grip: Soft, broad, irregular and non-
ballotable mass felt, suggestive of buttocks.
b) Lateral grip: Smooth, curved, resistant surface
felt on the right side of the abdomen suggestive of
back. Small knob like structures felt on the left
side, suggestive of legs.
c) First pelvic grip: Hard, globular and smooth
mass felt suggestive of head. Head is not engaged.
d) Second pelvic grip: Confirmation of the findings
of first pelvic grip is done. Head is not engaged. It
is ballotable.

35. PER ABDOMINAL EXAMINATION
3. AUSCULTATION
 Fetal heart sound – present.
 Site – right spinoumbilical line.
 Rate – 130/min.
 Rhythm – irregular.

36. PERINEAL EXAMINATION
1. INSPECTION
 Vulva is healthy.
 No active bleeding or discharge seen.
2. PALPATION:
 No tenderness elicited.
 No local rise of temperature.

37. EXAMINATION OF BREAST
1. INSPECTION
 Both breasts are uniformly enlarged in size.
 Skin over the breasts = healthy.
 Nipples =everted
 Areola =hyperpigmented.
 Montgomery tubercles are seen.
 No nipple discharge seen.
2. PALPATION
 No lump present.
 No tenderness felt.
 No local rise of temperature.

38. PER VAGINAL EXAMINATION
Not done.

39. DIFFERENTIAL
DIAGNOSIS

40. DIFFERENTIAL DIAGNOSIS
1. Wrong calculation of LMP
2. Small for gestational age.
3. Intrauterine growth restriction.

41. INVESTIGATIONS

42. 1. Blood Group- A-
2. Haemoglobin- 10 g/dL of blood
3. Total Leucocyte Count (T.L.C.) - 7.58x103/µL of blood
4. Differential Leucocyte Count(D.L.C.)-
*Neutrophils- 74%
*Lymphocytes- 21.9%
*Monocytes- 3.3%
*Eosinophils- 0.8%
5.Platelet Count- 1.7 lacs/µL of blood
6. Random Blood Sugar (R.B.S.) - 86 mg/dL of blood
7. Serum Creatinine- 0.63 mg/dL of serum
8. Serum T.S.H. - 2.92 mIU/cc of serum
9. Urine R/E- No abnormality detected
10. Urine C/S- No growth
11.H.I.V. - Non-reactive
12. V.D.R.L. - Non-reactive
13. HBsAg- Non-reactive.

43. 14. Radiology: Ultrasonography- (as on
01.02.2016)
Single live foetus in cephalic presentation
Calculated Gestational Age- 30 weeks
Foetal movements seen; Daily foetal movement score- 12
Foetal Heart Rate- 130 beats/minute
a)Placenta: Fundo-body Posterior; Grade- II
b) Amniotic Fluid Index (A.F.I.) = 2.1+2.4+1+1.6=7.1 cm
c) Foetal Biometry- Not available
d) Femur Length- Single femur epiphysis seen
e) Estimated Foetal Weight(E.F.W.) - 1.4 kg
f) Ponderal Index- Not measured
g) Doppler Ultrasound Velocimetry-
i) Umbilical Artery Systole/Diastole ratio (U.A. S/D) - 3.2
ii) U.A. R.I. (Resistance Index) - 0.51
iii) U.A. P.I. (Pulsatility Index) - Not measured

44. DIAGNOSIS

45. DIAGNOSIS
“The patient, 23 years old, G2P1 with no
living issue, at 39weeks of gestation, with
longitudinal lie with cephalic presentation
and non-engaged head, with severe IUGR
with Oligohydraminos ,not in labour.”

46. MANAGEMENT

47. GOAL OF ANTENATAL CARE
Healthy mother and a healthy baby.

48. PRINCIPLES OF MANAGEMENT
1. Identify the cause of growth restriction.
2. Treat the cause.
3. General management.
4. Delivery of the baby.

49. ANTEPARTUM EVALUATION
1. Gestational age : 39 weeks 1 day - term
pregnancy.
2. Present weight – No weight gain during last
two months.
3. Symphysio-fundal Height - 26cm (> 3cm
difference)
4. Abdominal girth – 70 cm.
5. Amniotic Fluid Index - 7.1 cm
6. Estimated Foetal Weight - 1.4 kg
7. Umbilical Artery Systole/Diastole Ratio -
3.2
8. Placenta - Fundo-body posterior; Grade II.
9. Daily foetal movement score - 12 (Normal)

50. DELIVERY OF THE BABY
ELECTIVE CAESAREAN SECTION

51. IMMEDIATE CARE OF THE
BABY AFTER BIRTH
• Paediatrician should be present at the time
of delivery.
• If required, baby is shifted to NICU

52. CASE SUMMARY