Intra-Uterine Growth Restriction

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Intra-uterine Growth Restriction

Dr Shantala Vadeyar
Advanced Obstetric Ultrasound (RCOG / RCR) Subspecialist Fetal & Maternal Medicine (RCOG)
MD, FRCOG, DM
Consultant Obstetrician, Fetal & Maternal Medicine Kokilaben Dhirubhai Ambani Hospital, Mumbai
Definition
IUGR is failure to achieve the fetal growth potential Difference between size and growth Size - one measurement Growth multiple measurements plotted on a graph Growth charts important in fetuses like in children
Size v/s Growth

Small for gestational age - <2.5 kg Preterm gestation and small Term gestation and small Healthy but small Constitutionally small Pathologically small IUGR
Chronic maternal conditions

Renal disease Hypertension Long standing Diabetes Congenital heart disease
Causes of IUGR 1. Maternal
Smoking Alcohol Anemia - severe
Causes of IUGR 2. Fetal

Infection TORCH
Toxoplasma, Rubella, CMV
Malformation
Gastroschisis
Chromosomal abnormalities
Trisomy 18 (Edward syndrome)
Multifetal pregnancy
Chorionicity determination is vital MC Twins, Twin twin transfusion syndrome
Causes of IUGR 3. Placental

Placental thrombosis / infarctions Antiphospholipid syndrome Chorioamnionitis Abruptio placentae usually acute, but sometimes, small recurrent bleeds Placenta previa
Causes of IUGR 4. Uterine

Poor uterine blood flow Poor placental blood flow Large fibroids leading to poor placentation Uterine anomalies septate or subseptate uterus
IUGR screening
Whom to screen? Ideally Symphysis Fundal Height performed regularly for all pregnancies SFH in cms = weeks of gestation High risk cases will need ultrasound for growth, liquor volume, umbilical artery Doppler and Biophysical Profile Umbilical Artery Doppler is the best test!
Diagnosis
Accurate dating is vital!
< 20 weeks of gestation, preferably < 14 wks
Suspect clinically
Uterus palpates small Less amniotic fluid Reduced fetal movements
High risk maternal, placental, uterine or fetal factors

Ultrasound diagnosis of IUGR

Growth Measure the fetus biometry
Head circumference Abdominal circumference Femur length
Measure the amniotic fluid- AF index, SDP Evaluate the blood flows- Dopplers!
Uterine Artery Doppler

Screening test in pregnant women High resistance waveform- notching indicates poor placentation Notches are present in early gestation but disappear 24 weeks onwards Bilateral notches are significant
Uterine A DopplerNormal
Uterine Artery Doppler

Notching indicates a high risk pregnancy Increased risk of
Pre-eclampsia Growth restriction Placental abruption Intrauterine fetal death
Increased monitoring- growth scans, Umbilical artery Doppler

Uterine A DopplerNotching
Umbilical Artery Doppler

Indicates resistance in the feto-placental vascular bed Angle of insonation should be <60o From 16 weeks onwards- positive end diastolic flow (EDF) Reduced EDF, Absent EDF and Reversed EDF represent increasing resistance in the vascular bed
Umbilical Artery Doppler
Umbilical A: AEDF
Umbilical A: REDF
Fetal growth
Serial assessments are important Growth trajectory is important, not size! Symmetrically small fetus
Constitutionally small Genetic syndromes/ chromosomal abn Very early onset IUGR
Asymmetric- HC>AC suggests growth restriction due to placental insufficiency
Clinical history
Interpretation of Ultrasound findings in IUGR
Previous poor outcome Antepartum haemorrhage Reduced fetal movements
Gestation- how accurate? Viability? U/S- Growth, Biphysical profile, Umbilical Artery and Uterine Dopplers CTG (NST)
Antenatal Surveillance in IUGR

Watch fetal movements Maternal health pre-eclampsia Biophysical Profile Score Comprises 2 points each for Fetal body movements Fetal tone Fetal breathing movements Amniotic fluid volume CTG
Fetal Middle Cerebral Artery Doppler

22-28 weeks- no EDF in MCA 28w to term- some EDF seen- normal Increased EDF ( low PI) suggests brain sparing redistribution in IUGR Worsening hypoxia- fetal acidemia- paradoxical rise in resistance (high PI) Cerebro-placental ratio increases this is indicative of IUGR
MCA Doppler
MCA Doppler- IUGR
What does NOT help

Duvadilan / Bricanyl Amnioinfusions Oxygen therapy Amninoacid preparations Bed rest ??
Timing of delivery
>34 weeks good neonatal outcome <34 weeks - Betamethasone inj should be given to the mother Fetal pulmonary maturity Reduces risk of intra-ventricular haemorrhage Very preterm gestation - <28 weeks ? To wait or to deliver
Preterm labour in IUGR

Often IUGR fetuses / pregnancies tend to go into preterm labour Natures way of resolving the problem Important to recognise this and avoid prolongation of pregnancy!
Mode of delivery
Labour is a stressful process for the fetus Every contraction reduces oxygenation, though briefly and it recovers Prolonged difficult labours should be avoided! Continuous fetal monitoring is a MUST! Elective LSCS for severe IUGR, abnormal presentation, oligohydramnios, abnormal CTG/ NST
Outcome
Mild moderate IUGR good Severe early onset IUGR some organ systems may be compromised Gut - Neonatal necrotising enterocolitis Kidneys renal failure Brain cerebral palsy Genetic syndromes / malformations
IUGR in DC twins
Dichorionic twins- confirmed by 10-12w scans Twin 1
AC : dropped from 10th to 5th centile AF : 3rd centile Absent EDF in one umb artery initially, then both Bladder seen, normal biophysical score
Twin 2
AC: 50th centile, Normal AF, Normal UA Doppler Normal sized bladder, heart, biophysical scores
Management- when to deliver?

Monitor biophysical profiles and Umbilical Artery Dopplers Risk of preterm delivery versus compromise What is the significance of worsening Umbilical A Dopplers? Risks of preterm delivery- respiratory distress syndrome, necrotising enterocolitis, infection Risk to well grown fetus of prematurity Intrauterine complications- abruption, worsening of maternal PET, IUFD
Decision to deliver
Twice weekly Biophysical scores Twice daily CTGs, FM monitoring 31 weeks: Both Umb A in twin 1 showed absent EDF. Discussion with parents- proceed to LSCS Twin 1 was1 kg, twin 2 was 1.8 kg, both males NEC in Twin 1 recovered Good outcome
IUGR- Case 2
25 year old primigravida 34 weeks, presented with severe oedema, raised BP, proteinuria Diagnosis: PET (pre-eclampsia) Scan: Both AC, HC less than 3rd centile Amniotic fluid volume: 5th centile Biophysical score 6/10
IUGR- MCA redistribution
IUGR:Umbilical A Doppler AEDF
IUGR: DV- normal
Profile
Total Pregnancy Care is an online guide for pregnancy, childbirth and motherhood related information. Women wanting to conceive, pregnant women, expecting parents, and new mothers can use this pregnancy portal for a healthy pregnancy, fulfilling childbirth and joyful motherhood. With pregnancy at its core, this portal covers various important aspects and especially addresses those matters that the Indian Woman always wanted to know but did not know whom to ask. This website is compiled by Dr. Shantala, an Indian Obstetrician and Gynaecologist. She has over 20 years of extensive medical and diagnostics experience in areas commonly related to the Maternity and Pregnancy fields. She has studied and practiced in India as well as in the United Kingdom and thus brings about the fusion of best practices of the Oriental East and the Progressive West. A mother of three children, she has complete understanding of the emotional, mental and physical needs of the New Age Pregnant Woman. Her patients appreciate her empathic approach and wholeheartedly express their gratitude for her generosity and care. Dr.Shantala is presently a full time Obstetrics and Gynaecology Consultant at the Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, a premier health care initiative of the Reliance ADA Group. Dr.Shantala has a clear vision to promote a holistic pregnancy approach and her mission is to provide comprehensive maternity care. This website, www.TotalPregnancyCare.com, is her first step towards this future.
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Assessment of the High risk Fetus and Mother Amniocentesis Chorionic Villous sampling Cordocentesis Intra-uterine transfusions Embryo Reduction / Selective fetocide Second opinion scans
Topics covered
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Intra-Uterine Growth Restriction

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www.totalpregnancycare.

Intra-uterine Growth Restriction

Size v/s Growth

Chronic maternal conditions

Causes of IUGR 1. Maternal

Smoking Alcohol Anemia - severe

Causes of IUGR 2. Fetal

Causes of IUGR 3. Placental

Causes of IUGR 4. Uterine

High risk maternal, placental, uterine or fetal factors

Ultrasound diagnosis of IUGR

Uterine Artery Doppler

Uterine Artery Doppler

Increased monitoring- growth scans, Umbilical artery Doppler

Umbilical Artery Doppler

Umbilical Artery Doppler

Asymmetric- HC>AC suggests growth restriction due to placental insufficiency

Interpretation of Ultrasound findings in IUGR

Previous poor outcome Antepartum haemorrhage Reduced fetal movements

Antenatal Surveillance in IUGR

Fetal Middle Cerebral Artery Doppler

MCA Doppler- IUGR

What does NOT help

Preterm labour in IUGR

Management- when to deliver?

IUGR- MCA redistribution

IUGR:Umbilical A Doppler AEDF

IUGR: DV- normal

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