acog practice bulletin no 12, intrauterine growth restriction, january 2000 Summary The general approach to management of the

fetus with ultrasonographically suspected IUGR involves risk factor modification when possible and the initiation of antepartum fetal surveillance, ultrasonography, and delivery when the risks of continued in utero development outweigh the benefits. The risks to the growth-impaired fetus are well documented. Currently, although the incidence of IUGR has not changed appreciably, the prognosis for SGA infants has improved dramatically. It must be emphasized, however, that perinatal morbidity and mortality will continue to occur despite optimal management of the fetus with suspected IUGR. In those fetuses managed expectantly, antepartum injury or death may occur because current methods of fetal surveillance are less than perfect in the prediction of fetal outcome. The following recommendations are based on good and consistent scientific evidence (Level A): The use of Doppler ultrasonography to measure umbilical artery waveforms in the management of IUGR is associated with a reduction in perinatal death, and may be considered a part of fetal evaluation once IUGR is suspected or diagnosed. Nutrient treatment or supplementation, zinc or calcium supplementation, plasma volume expansion, maternal oxygen therapy, antihypertensive therapy, heparin, and aspirin therapy have not been shown to be effective for prevention or treatment of IUGR. The following recommendations are based primarily on consensus and expert opinion (Level C): Antepartum surveillance should be instituted once the possibility of extrauterine survival for the growth-restricted fetus has been determined. This may include Doppler velocimetry, contraction stress testing, NST with amniotic fluid volume assessment, and BPP. Routine screening for IUGR in low-risk patients should comprise classical clinical monitoring techniques. Ultrasound evaluation of the fetus is appropriate in patients determined to be at high risk. BACKGROUND often difficult to distinguish nl and pathologic growth in clinical practice. tho we use 10%ile to define, poor perinatal outcomes are generally confined to those below 5th or even 3rd percentile. DEFINITIONS sga: infant with bw<10th %ile for ga iugr: fetus c est wt <10th %ile for ga

RISK FACTORS FOR iugr maternal medical conditions (htn, renal dz, restrictive lung dz, diabetes c microvascular dz, cyanotic heart dz, antiphospholipid syndrome, collagenvascular dz, hemoglobinopathies), smoking and substance use and abuse, severe malnutrition, primary placental dz, multiple gestation, infections (viral, protozoal), genetic disorders, exposure to teratogens. FETAL MORBIDITY stillbirth rate 3 fold also variable, c-sections, oligo, NEONATAL MORBIDITY polycythemia, hyperbilirubinemia, hypoglycemia, hypothermia, apnea, need for intubation, seizures, sepsis, neonatal death. ANTENATAL DX 2 steps: identifying risk factors and measuring fundal heights, then obtaining ultrasound. supplement with invasive fetal testing for aneuploidy or viral infection in select cases. CLINICAL CONSIDERATIONS AND RECOMMENDATIONS 1. Which pregnancies should be screened for IUGR, and how is screening accomplished? fh=ultrasound as a screening tool, both 80% sensitive. measure fh and obtain us for >2cm lag in fh. obtain us for risk factors, no growth or lagging growth 2. what are the best ways to evaluate and monitor a pregnancy complicated by suspected intrauterine growth restriction? growth ultrasound q 2-4 wks to include estimated wt %ile, AFI, HC/AC ratio, systolic/diastolic ratio in umbi artery. as fetus nears term, obtain weekly doppler velocimetry and either BPP or AFI/NST. 3. what interventions improve pregnancy outcome in cases of intrauterine growth restriction or suspected intrauterine growth restriction? evidence for benefit: smoking avoidance improves bw. tx of malaria in endemic areas also. insufficient evidence for harm or benefit: bed rest, early delivery for pulsatile waveflow, calcium, aspirin, 4. is there any evidence that prenatal diagnosis or suspicion of intrauterine growth restriciton with antenatal surveillance alters outcome? not really. current data suggests that our monitoring helps time delivery but doesn't really change outcome. normal s/d ratio has excellent negative predictive value.

5. how does knowledge of the etiology of intrauterine growth restriciton alter management? maternal medical conditions: only delivery helps (e.g., anti-htnsive tx has no benefit c IUGR), lethal anomaly: one would avoid antepartum surveillance conisder fetal karyotype c early or severe IUGR or when fetus has recognized structural anomaly amniotic fluid analysis can dx viral infections-rubella, cmv, varicella. if toxo identified, treating mother can help prevent spread to baby. 6. when should a growth restricted fetus be delivered? if the risk of fetal death exceeds that of neonatal death usually based on nonreassuring fetal assessment or a complete cessation of fetal growth by us over 2-4 wk interval.