IUGR

1. Intrauterine growth restriction (IUGR)
Dr. P Usha Devi
AMC/VGH

2. Intrauterine growth restriction (IUGR)
• IUGR is a common complication of pregnancy and
carries an increased risk of perinatal mortality and
morbidity.
• Definition - Birth weight below 10th percentile of
the average for the gestational age
• Incidence
– 5% in term
– 15% in post term

3. SGA vs IUGR
• Small Fetuses
–Physiological
–Pathological
• Type I or Symmetrical
• Type II Asymmetrical

4. IUGR vs SGA
Characteristics IUGR SGA
Definition Growth of a fetus is restricted
or retarded while in the uterus
Size of the fetus is small for
gestational age
Appearance Babies always appear
malnourished
Babies appear small, and do not
always appear to be malnourished
Diagnosis Ultrasound & Doppler of blood
flow, measurements of the
fundus to the pubic bone
Ultrasound and measurements of
the fundus to the pubic bone
Measurement Measure is based on the change
in growth over time
Measure is based on a one-time
measurement that fails below
statistical value
Growth Rate in Utero Always slower than normal Can be normal or slower than
normal
Birth Weight Sometimes lower than normal,
but not always
Always lower than normal
Pathological
Conditions
Always due to some sort of
problem or disorder
Not always due to a disorder or a
problem. Sometimes the cause is a
small-size mother

5. IUGR – Types
• Symmetric or primary IUGR: In this condition all
internal organs are reduced in size. It is found in
20%-30% of all cases of IUGR.
• Asymmetric or secondary IUGR: In this condition
the head and brain are normal in size, but the
abdomen is smaller. It is evident mostly in the
3rd trimester. It is more common and found in
70% to 80% of total IUGR cases.

6. Symmetrical Vs Asymmetrical
Symmetrical Asymmetrical
Uniformly small Head larger than abdomen
Total cell number less, cell size
normal
Total cell number normal, cell size
decreases
Ponderal index = wt/ crown heel
length3 x 100 – Normal
PI low
HC : Ac
FL : Ac Ratio (N)
HC : Ac
FL : Ac Ratio elevated
Intrinsic : Eg: genetic or
Infections
Extrinsic: Eg: Maternal diseases
Neonatal prognosis – Good Bad

7. Causes of IUGR
• Causes :- Maternal, fetal, placental, Unknown
• Maternal
– Constitutional,
– Nutritional,
– Maternal diseases
• Anemia,
• PIH,
• HTN,
• Heart Diseases,
• Renal Disease’
• Thrombotic Diseases,
• Collagen Vascular diseases
– Toxins – Alcohol, smoking, cocaine, heroine, drugs

8. Causes of IUGR
• Fetal
– Structural Anomalies Eg: CVS, Renal
– Chromosomal : Trisomy, Turners
– Infections : TORCH, Malaria
– Multiple Pregnancies
• Placental :
– Chronic Placental insufficiency
– Placenta Previa,
– Abruption,
– Circumvallate Placenta
– Infarction,
– Mosaicism

9. Predictors of IUGR
• High Risk Factors
– Obstetric
– Medical
• PAPP – A
• Uterine Artery Notching
• Fetal Echogenic bowel
• Pathophysiology of IUGR …….

10. Diagnosis
• Clinical :-
–Examination
–Symphysio fundal height > 3 cm lag
–Abdominal girth measurement
–Maternal weight

11. Diagnosis
• Ultrasound :-
–HC /AC > 1, 1, < 1
–Transcerebellar diameter
–Alone AC & EFW Serial Measurement
–FL / AC > 23.5
–AFI
–TIFFA

12. Diagnosis
• USG Doppler
– SD Ratio, RI, PI
– Uterine Artery – Diastolic Notch
– Umbilical Artery Doppler
• S/D Ratio due to decreased EDV
• AREDV
– Middle Cerebral Artery : Brain Sparing Effect
– Umbilical Venus Pulsations
– Ductus Venosus Doppler

13. Post Natal Diagnosis
• Low APGAR score
• Low Birth weight
• Height
• HC > AC
• Dry wrinkled skin, scaphoid abdomen,
meconium stain, old man look
• Baby is alert, active, eyes open

14. Complications
• Antenatal :
– Chronic Fetal distress
– Acute fetal distress
• Postnatal :
– Asphyxiated,
– RDS
– Hypoglycemia,
– MAS
– Hypothermia,
– Polycythemia, Anemia, Thrombocytopenia, DIC
– IVH

15. Complications
Continued …..
Postnatal :
– Hyper Viscosity Syndrome
– Hypocalcemia, Hypokalemia
– Hyperbilirubinemia
– Increased Perinatal morbidity, mortality

16. Late Complications
• Retarded Neurological, Intellectual
Development
• Increased chances of Metabolic Syndrome
like Obesity, HTN, DM, CAD

17. Management
• Constitutional small - No treatment
• Symmetrical IUGR - No treatment
• Asymmetrical IUGR
– Bed rest
– Correct Malnutrition
– Avoid smoking, Alcoholism
– Treat maternal diseases
– LDA
– Oxygen, Amino acid infusion, Volume Expansion
– Antepartum Evaluation
• USG
• Doppler
• BPP

18. Management - Intrapartum
• NICU facility
• Higher Centers
• Term gest:
– Immediate delivery
• Preterm gest:
– Antenatal Steroids
– Mg.SO4
– Then delivery
• Delivery: Vaginal vs LSCS

19. Management - Intrapartum
• Care during delivery:
– Forceps application
– Quick cord clamping
– Cord to be kept long
• After Delivery:
– Clear mucus from air passages
– Baby wrapped in warm sterile towel
– Keep in warmer
– Inj Vit K 1mg IM
– NICU Admission if required
– Early feeds
– More frequent feeds

20. Prevention
Although IUGR can occur even when a mother is perfectly
healthy, still there are some measures to reduce the risk of
IUGR and increase the chances of a healthy pregnancy and
baby.
Care before pregnancy:
• Providing care to women before and between pregnancies
(inter-conception care) improves the chances of mothers
and babies being healthy.
• Advocating healthy eating and physical activity to women
in their daily routine to improve weight and cardiovascular
status before pregnancy.
• Diagnosis and management of chronic diseases such as
hypertension, diabetes before pregnancy.
• Correction of anemia/folic acid supplementation before
pregnancy.

21. Prevention
Care during pregnancy:
• All pregnant mothers should get antenatal checkups as advised
by medical persons/ Pradhan Mantri Surakshit Matritva Abhiyan
(PMSMA)- Programme aims to provide comprehensive and
quality antenatal care, free of cost, universally to all pregnant
women on the 9th of every month throughout the country.
• Pregnant mothers should take only those medicines which are
prescribed by doctors.
• Healthy diet should be advised to pregnant women with
behavior change to encourage healthier eating patterns during
pregnancy. Foods fortified with nutrients can be provided to
pregnant women.

22. Prevention
• Pregnant women are advised to take enough rest with
proper duration of sleep during night and an hour or
two of rest in the afternoon.
• Expectant mothers should follow healthy lifestyle
habits. Tobacco use, smoking and alcohol intake
should be avoided during pregnancy.
• Low dose Aspirin, High dose Calcium

23. Discussion