UPDATES IN INTRA UTERINE GROWTH RESTRICTION

1. INTRAUTERINE GROWTH
RESTRICTION
PRESENTED AND PREPARED BY DR . DERAR I . I . ISMERAT
OBSTETRICS AND GYNECOLOGY RESIDENT DOCTOR AT AL-AHLI HOSPITAL

3. Intrauterine growth restriction (IUGR) is a poorly understood complication of pregnancy,
affecting up to 10% of live-born infants.
It is characterized as a rate of fetal growth less than normal for the gestational-age appropriate
growth potential Quantitatively, this poor fetal growth has been defined by the American
College of Obstetricians and Gynecologists as estimated fetal weight of <10th percentile for
gestational age, often times with ultrasound evidence of growth deceleration late in gestation or
abnormal Doppler indexes in the umbilical artery or middle cerebral artery.

4. Fetal growth restriction, (IUGR), is a common complication of pregnancy.
• Pathologic condition where there is a restriction of growth in utero, and the fetus does not attain
its full growth potential.
• Complicates ≈5-10% of pregnancies
• Third leading cause of perinatal mortality after anomalies
and prematurity
Perinatal mortality inversely proportional to percentile growth:
1.5% <10%
2.5% < 5th %

6. Correlation of birth weight percentile to
perinatal morbdity and mortalility

7. IUGR (Intrauterine Growth
Restriction)
SGA (Small for Gestation Age)
30% babies with birthweight <10th
percentile
70% babies with birthweight <10th
percentile
Growth restricted Not growth restricted
Constitutionally and anatomically
abnormal
Constitutionally small but
anatomically normal
↑ Obstetric/neonatal risk NO obstetric/neonatal risk
{Variable} Normal subcutaneous fat

8. • Stage I (Hyperplasia)
• - 4 to 20 weeks
• - Rapid mitosis
• - Increase of DNAcontent
• Stage II (Hyperplasia & Hypertrophy)
• - 20 to 28 weeks
• - Declining mitosis.
• - Increase in cell size.
• Stage III ( Hypertrophy)
- 28 to 40 weeks
- Rapid increase in cell size.
- Rapid accumulation of fat, muscle and connective tissue.
• 95% of fetal weight gain occurs
during last 20 weeks of gestations.

9. • 15 weeks = 5 grams/day
• 20 weeks = 10 grams/day
• 30 weeks = 25 grams/day
• 35 weeks = 35 grams/day
• 40 weeks = 15 grams/day
• May vary by race, gender, multiple gestation

10. Reduce fetal growth support..
EXTRINSIC CAUSES
Reduce fetal growth potential..
INTRINSIC CAUSES
PALCENTAL FACTORS
MATERNAL FACTORS
ANEUPLOIDY
INTRA UTERINE INFECTION
More morbidities and mortalities More long term effects

12. Infection
 CMV, Rubella, Toxoplasma gondii – severe IUGR
 Syphilis, Tuberculosis, Malaria, listeriosis
 Herpes simplex, chicken pox
Chromosomal abnormality
 Trisomy 18,13 –severe IUGR
 Trisomy 21
 Turner syndrome (45,XO(
 Klinefelter syndrome (47,XXY(
Congenital anomalies
 Congenital Heart diseases
 Anencephaly

13. • Maternal malnutrition
• Poor maternal weight gain
• Severe anemia
• Chronic hypoxemia
• Cardiovascular disease
• Drugs and teratogens
• Multiple pregnancy
• Antiphospholipid antibodies syndrome

14. • Placental infarction
• Placental abruption
• Twin-twin transfusion syndrome
• Placenta previa , circumvallate placenta
• Marginal or velamentous insertion of umbilical cord

15. : proposed in 1990 by the British epidemiologist
David Barker (b. 1939) that intrauterine growth retardation will increase :.
• Increased risk of adult metabolic syndrome
• Obesity
• Type 2 diabetes mellitus
• Coronary artery disease
• Stroke
• Up to 50% cognitive disability
• Increased risk of cerebral palsy
• <10th percentile at 8 years
• Early IUGR less likely to catch up

16. • Clinical assessment
• Ultrasonic measurement
• Doppler velocity

17. – Teen age
– High altitude
– Socioeconomic factor
– Smoking , Alcohol , Drugs
– Previous IUGR pregnancy history
– previous IUGR in family

18. Seldom elicited before 28 weeks of gestation:
. Failure of fetus and uterus to grow at the normal rate over a 4 week period;
.Uterine fundal height should be at least 2cm less than
expected for the length of gestation;
.Poor maternal weight gain;
. Diminished fetal movements.

19. Uterine fundal height
 Uterine fundus  symphysis Pubic
 Simple, Safe, Inexpensive for screening
 Between 18 and 30 weeks,
 the uterine fundal height in centimeters coincides with weeks of
gestation.
 If the measurement is more than 2 to 3 cm from the expected height or <
1oth percentile from normal curve, inappropriate fetal growth may be
suspected

20.  Inter-observer variations
 Obese patients
 Transverse lie
 Multiple gestation
 Polyhydramnios / Oligohydram
 Uterine fibroids
nios

21. Initial U/S at 16 to 20 weeks to establish gestational age
and identify anomalies and repeated at 32 to 34 weeks
to evaluate fetal growth

22. The measurements most commonly used to
measure and follow fetal growth are:
Biparietal Diameter
HeadCircumference
Femur Length
Abdominal Circumference
Used between 15-42 weeks. Normal ratio:
<36 weeks = 1:1
>36 weeks - ratio decreases as the AC increases.

23. Mild IUGR – Normal amniotic fluid
Severe IUGR – Oligohydramnios (AFI is ≤ 5) Incidence
40%

24. • Blood flowing through the umbilical arteries originates
from the fetus and enters the placenta.
• The flow of blood through the arteries is dependent upon the strength of the fetal heart contraction and the
health of the placenta.
• Blood returning from the placenta goes throughthe umbilical vein to the fetus.

25. • Doppler principle based on changes in sound waves related to the flow velocity of blood traveling
through these vessels.
• The umbilical artery was first used to study this flow velocity in in 1977.
• The umbilical arterial waveform usually has a "saw tooth" type pattern with flow always in the
forward direction
•The umbilical artery is evaluated by measuring the blood flow velocity at peak
systole (maximal contraction of the heart) and peak diastole (maximal relaxation of
the heart).
• These values are then
computed to derive a
ratio.

26. • As GA advances, increase blood flow at diastole means placenta
less resistant.

27. • In growth-retarded fetuses and fetuses developing intra- uterine distress, there is more
placental resistance and the umbilical artery blood velocity waveform usually changes
in a progressive manner.
• Increased resistance, absent end diastolic flow, reverse flow.
• Increasing RI values and S:D ratios if blood flow during diastole is decreased.

28. • Absent End Diastolic flow

29. • reversal of end diastolic flow (REDF)

30. • notching in late in pregnancy is an indicator of increased uterine
vascular resistance and impaired uterine circulation’

31. :
– characterized by absent or reversed end-diastolic flow
– associated with fetal growth restriction
A. Normal velocimetry pattern with an S/D ratio of <
3.0
B. The diastolic velocity approaching zero reflects
increased placental vascular resistance.
C. During diastole, arterial flow is reversed (negative
S/D ratio), which is an ominous sign
precede fetal demise

32. Hypothermia?
Hypoglycemia?
Or
Hypocalcemia?
decreased subcutaneous fat, increased
surface- volume ratio, decreased heat
production
decreased glycogen stores/
glycogenolysis/ gluconeogenesis
increased metabolic rate deficient
catecholamine release
Associated with perinatal stress, asphyxia,
prematurity

33. Prepregnancy: to prevent it by identifying risk factors and treat as necessary
(e.g. improve nutrition intake, stop smoking or alcohol, ASA in APA syndrome,
and Heparin in thrombophilias)
Antepartum: identify risk factors that can be changed. Fetal surveillance by
ultrasound (BPP) and fetal heart monitoring (Non-Stress Test). To decide on
timing and mode of delivery.

34. Near term
 Prompt delivery
Recommend delivery at 34 weeks or beyond if there is clinically significant
oligohydramnios
• Growth Restriction Intervention Trial
• Only published randomized trial to assess the timing of delivery of the early preterm (less
than 34 weeks of gestation) growth-restricted fetus.
• Randomized to either the early delivery group (delivery within 48 hours) or to the
expectant management group (with antepartum surveillance until it was felt that delivery
should not be delayed any longer)
• Betamethasone administration were the same in both groups

35. • Prospective Observational Trial to Optimize Pediatric Health in
Intrauterine Growth Restriction (IUGR) (PORTO STUDY)
• National prospective observational multicenter study
• Evaluate which sonographic findings were associated with perinatal
morbidity and mortality in pregnancies affected by growth restriction
(defined as estimated fetal weight (EFW) <10th centile)
• Am J Obstet Gynecol. 2013Apr;208(4)

36. • STUDY DESIGN:
• Over 1100 consecutive ultrasound-dated singleton pregnancies with EFW <10th centile
were recruited from January 2010 through June 2012.
• A range of IUGR definitions were used, including EFW orabdominal
circumference <10th, <5th, or <3rd centiles
• with or without oligohydramnios
• with or without abnormal umbilical arterial Doppler
• Adverse perinatal outcomes included intraventricular hemorrhage, periventricular
leukomalacia, hypoxic ischemic encephalopathy, necrotizing enterocolitis,
bronchopulmonary dysplasia, sepsis, and death
• Am J Obstet Gynecol. 2013Apr;208(4)

37. • RESULTS:
• N=1116 fetuses
• 312 (28%) were admitted to neonatal intensive care unit
• 58 (5.2%) were affected by adverse perinatal outcome including 8
mortalities (0.7%)
• The presence of abnormal umbilical Doppler was significantly associated with adverse outcome,
irrespective of EFW or abdominal circumference measurement.
• The only sonographic weight-related definition consistently associated with adverse outcome
was EFW <3rd centile (P = .0131), all mortalities had EFW <3rd centile.
• Presence of oligohydramnios was clinically important when combined with EFW <3rd centile
(P = .0066).
• Am J Obstet Gynecol. 2013 Apr;208(4)

38. • CONCLUSION:
• Abnormal umbilical artery Doppler and EFW <3rd centile were strongly
and most consistently associated with adverse perinatal outcome.
• Stricter IUGR cutoffs may be warranted and future studies should
comparing various definitions of IUGR and management strategies

39. • Management
• Serial US q 2-4 weeks is indicated
• Antenatal surveillance with umbilical artery Doppler velocimetry and
antepartum testing (NST,BPP)
• Delivery depends on the underlying etiology and estimated
gestational age
• Eunice Kennedy Shriver National Institute of Child Health and Human Development/Society
for Maternal-Fetal Medicine/American College of Obstetricians and Gynecologists Joint
Conference
• Dx fetal growth restriction:
• Delivery at 38 0/7–39 6/7 weeks of gestation isolated fetal growth restriction
• Delivery at 34 0/7–37 6/7 weeks of gestation in cases of fetal growth restriction with additional
risk factors for adverse outcome (eg, oligohydramnios, abnormal umbilical artery Doppler
velocimetry results, maternal risk factors, or co- morbidities)

40. • Delivery for fetal growth restriction before 34 weeks:
• Planned at a center with a neonatal intensive care unit and consultation
with a maternal–fetal specialist.
• Antenatal corticosteroids should be administered
• For cases in which delivery occurs before 32 weeks:
• Magnesium sulfate should be considered for fetal and neonatal
neuroprotection.

42. • Heads are disproportionately
large for their trunks and
extremities
• Facial appearance has been
likened to that of a “wizened
old man”.
• Long nails.
• Scaphoid abdomen

43. • Way of characterizing the relationship of height to mass for an individual.
• PI = 1000 x cubed root of Mass (kgs)
Height (cms)
• Typical values are 20 to 25.
• PI is normal in symmetric IUGR.
• PI is low in asymmetric IUGR