20
Fetal Growth Retardation
Chin-Chu Lin
Fetal growth retardation remains an important
problem in obstetrics and gynecology in the
1990s. In recent years, studies of this subject
have grown considerably. Improvements in
new technology for prenatal fetal diagnosis,
such as ultrasound and Doppler studies, gen-
etic evaluations, and fetal umbilical blood
sampling, have contributed tremendously to
our understanding of the pathophysiology of
this high-risk fetal condition.
In this chapter, the author offers compre-
hensive reviews of the literature as well as
commentary based on the author's clinical
experience with intrauterine fetal growth
retardation. 1- 9 This chapter also discusses the
incidence, epidemiology, high- risk factors,
diagnosis, management, and prognosis of the
fetus associated with intrauterine growth re-
tardation.
Epidemiology
The incidence of intrauterine growth retarda-
tion (IUGR) is dependent on (1) the study
population, (2) the criterion being used for di-
agnosis of IUGR, and (3) whether or not the
retarded preterm infant is included. For exam-
ple, Villar and Belizan lO estimated the world-
wide incidence of low-birth-weight (LBW) in-
fants (:52500 g) at 17% during 1979. They use
the criterion of less than 2500 g birth weight at
37 weeks of gestational age or older to define
IUGR. They found that IUGR births consti-
360
C.-C. Lin et al. (eds.), The High-Risk Fetus
Springer-Verlag New York Inc. 1993
tute 30 to 40% of LBW infants in the de-
veloped countries (the incidence of total LBW
infants ranged from 3 to 10%), whereas the in-
cidence of IUGR was 40 to 70% of total LBW
infants in the developing countries (where the
incidence of LBW infants ranged from 10 to
40%). In developing countries a linear correla-
tion was observed between the incidence of
LBW and that of IUGR (r = .95, P < .001); in
contrast, prematurity was not significantly
associated with the incidence of LBW. Data
from the developed countries showed results
exactly opposite to those described for de-
veloping countries; therefore, when the inci-
dence of LBW is higher than 10%, it is almost
exclusively due to the increase in IUGR
infants, whereas the rate of prematurity re-
mains almost unchanged (5 to 7%). When
LBW incidence is less than 10% (mean = 6%),
preterm infants represent the major compo-
nent of LBW. The study of Villar and Belizan
did not include the growth-retarded preterm
infant in the category of IUGR. In the United
States and Canada, most investigators use the
definition of less than the 10th percentile by
weight for gestational age for IUGR. Lin and
Evans 1 reported an incidence of 6%, and Gal-
braith et aP1 reported an incidence of 4.7%. In
Sweden, based on the growth curve developed
by Enstrom et al,12 IUGR was defined as two
standard deviations (SD) below the mean birth
weight for gestational age. Using these criteria,
the incidence of IUGR ranged from 1% to
1.5%.13,14. In Japan, the incidence of IUGR
was reported to be 3.7%,15 defined as those in-
20. Fetal Growth Retardation
98 195
100
80
-
c 60
Q)
0
~
Q)
Cl.
40
20
501- 751- 1001- 1251- 1501- 1751 - 2001- 2251- 2501- 2751 - >3000
750 1000 1250 1500 1750 2000 2250 2500 2750 3000
Birthweight (gm)
FIGURE 20.1. Percentages of infants in various birth
weight categories classified as term and not growth
retarded (TD NIUGR), preterm and not growth re-
tarded (PTD NIUGR), term and growth retarded
(TD IUGR), and preterm and growth retarded
(PTD IUGR). Preterm IUGR constituted 20% of
fants who were 1.5 SD below the mean birth
weight for gestational age on the Nishida
growth curve. l6
Recently, many investigators have paid spe-
cial attention to the growth-retarded preterm
infant because, in general, infants in this cate-
gory have the worst prognosis. 17 .l8 Many of
the high-risk factors that cause IUGR, such
as hypertension, preeclampsia, multifetal preg-
nancy, and sickle cell anemia, can also cause
preterm delivery. Galbraith et aPl reported an
incidence of 11% IUGR among 314 preterm
infants. At the Chicago Lying-In Hospital,
University of Chicago, 426 IUGR infants
among a total of 7177 infants were delivered
between January 1979 and May 1981,17 Break-
ing these down into differential gestational age
groups revealed an increasing incidence of
361
Q~I D
TO PTO TO PTO
NIUGR NIUGR IUGR IUGR
the population of birth weight between 500 and
1500 g, and term IUGR constituted 50% of the
population of birth weight between 2251 and 2750 g.
Reprinted, with permission, from Goldenberg et
al. 19
IUGR in the earlier preterm gestations. The
incidence of IUGR was 13.1% for 28 to 30
weeks, 9.4% for 31 to 33 weeks, 7.4% for 34 to
36 weeks, 5.5% for 37 to 40 weeks, and 5.7%
for 41 weeks and over. In Sweden, Laurin7 re-
ported an incidence of lUG R of 10.1 % among
preterm delivered infants, as compared with
2.3% among term delivered infants. Golden-
berg et aP9 have described the relationship
between low birth weight, intrauterine growth
retardation, and preterm delivery. Between
20 and 30% of infants born weighing 500 to
2000 g, and nearly 50% of infants born weigh-
ing 2001 to 2750 g, had IUGR (Fig 20.1);
however, most reports studying preterm in-
fants do not separate preterm IUGR from pre-
term appropriate-for-gestational-age (AGA)
infants.