INTRA UTERINE GROWTH RESTRICTION

(IUGR)

Definition
Foetus unable to achieve its potential size
Birth weight below 10th centile (normal is 10-90th centile)
Excludes fetuses that are Small for Gestational Age (SGA)

but are not pathological.

Causes of IUGR
Main Principles:
- Decrease in gas exchange to the fetus
- Decrease in nutrient delivery to the fetus

Maternal

Placental

Foetal

Maternal Causes
Severe malnutrition
Maternal hypoxia: Cyanotic congenital heart

disease, Severe anaemia

Chronic Hypertension
Pregestational diabetes mellitus
Haemoglobinopathies
Autoimmune disease: SLE
Smoking, Alcohol,Substance abuse.
Ulcerative colitis
Protein losing nephropathy

Placental causes
Uteroplacental factors:
Multiple gestations
Placenta previa
Chronic Abruption
Placental infection / infarction
Cord anomalies
Uterine malformations:

Foetal causes
Chromosomal abnormalities - Trisomy18

- Turners syndrome
Intra uterine infection - TORCH
- Syphilis
Congenital malformations: Achondroplasia
Osteogenesis imperfecta
Teratogenic drugs : Methotrexate

Idiopathic: in 40%

Consequences of IUGR
Perinatal problems
- Hematological disorder
- Hypoglycemia
- Hypothermia
- Spontaneous preterm birth
- Seizures in first 24 hours
- Respiratory Distress Syndrome
- Sudden infant death syndrome
- Impaired neurodevelopment

Consequences of IUGR
In adult life - Barkers hypothesis:
Babies born with IUGR are more prone for
- Hypertension,

- Diabetes Mellitus,
- Ischemic Heart Disease

Classification of IUGR
Symmetrical IUGR
Cause

Pathogenesis

Incidence
Head
Circumference
to Abdominal
Circumference
(HC-AC) ratio

Asymmetrical IUGR

Occurs due to an early insult

to fetus, prior to 24 weeks

Occurs often late in pregnancy

after 24 weeks

Growth of both head and the

body is inadequate

Decrease in subcutaneous fat and

abdominal circumference with
relative sparing of head
circumference and femur length

20%

80%

May be normal, but the

absolute growth rate is
reduced

Head is appropriate for the

gestational age & proportionally
larger than the abdomen

Classification of IUGR
Cell size

Ponderal index
Association

Prognosis

Symmetrical IUGR

Asymmetrical IUGR

Associates with normal

cell size

Less effect on total cell

numeric decrease in cell size

Normal

Low

Commonly associated
with intrauterine
infection or congenital
anomalies

Associated with
uteroplacental insufficiency

Poor

Good

Ponderal Index
PI is a measure of leanness of a person calculated
as a relationship between mass and height.
It was first proposed in 1921 as Corpulence Index
by Rohrer.
It is similar to the BMI, however the mass is
normalized with the third power of body height
rather than the second power.

DIAGNOSIS

1) History
Ensure whether accurate dating of the pregnancy
done by 1st trimester scan with CRL measurement.
History of viral infections or exposure to radiation.
History of drug abuse or bleeding in I trimester.
History of decreased fetal movements.
History of poor maternal weight gain.
History of pre-existing medical disorders.
History of previous infant with growth restriction.

2) Clinical examination
Adequate Maternal weight gain
Symphysio Fundal Height (SFH)
Reduced amount of liquor by Umbilical grip
However, the reduced SFH measurements correctly
identified only 25-30% of growth restricted fetus.
The problems related to SFH measurement are poor
inter and intra observer reproducibility.

Estimation of Clinical Fundal Height

36 weeks

Umbilicus 22 weeks

3) Investigations
Foetal Ultrasound biometry
Amniotic fluid index (AFI)
Doppler velocimetry of foetal vessels
Role of umbilical artery doppler
Role of middle cerebral artery (MCA) doppler
Role of venous doppler waveforms

Ultrasound biometry
Measurement of HC/AC ratio FL/AC ratio
The measurements most commonly used are:
Biparietal diameter
Head circumference
Abdominal circumference
Femur length

With normal head and femur measurements,

abdominal circumference less than 2SD is a
reasonable cut-off to consider asymmetry growth
velocity chart plotting abdominal
circumference and estimated fetal weight

Amniotic fluid index (AFI)

Decreased AFI may be an early marker of declining
placental function
If the AFI is <5 at 24 weeks of gestation, the chance
of IUGR is 19%
However if AFI >5, the chance of IUGR is only 9%

Amniotic Fluid Index

Doppler velocimetry of foetal vessels

Doppler flow studies are done in
- Uterine artery,
- Umbilical artery,
- Middle Cerebral Artery (MCA)
The flow of blood through the uterine arteries
dependent upon the strength of the fetal heart
contraction and the health of the placenta.

Role of the umbilical artery doppler

Umbilical artery Doppler is considered abnormal if
diastolic flow is reduced, absent or reversed after
20 weeks of gestation.
In normal pregnancies, umbilical artery (UA)
resistance shows a continuous decline; however,
this may not occur in fetus with uteroplacental
insufficiency.
As the insufficiency progresses, end-diastolic
velocity is lost and finally reversed.

Role of the umbilical artery doppler

UA Doppler measurements may help the clinician
decide whether a small fetus is truly growth
restricted.
When the resistance in the placenta increases further
- Absent diastolic flow becomes
- Reverse diastolic flow in which the
Doppler waveform is observed to be below the baseline

Normal Wave form

Absence of diastolic notch

Resistance Index (RI)

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.
Most common ratios that is used is the Resistance Index (RI)
This is computed by measuring the peak of systole and then
dividing it by the sum of peak systole and diastole.

Resistance Index = Systole / (Systole + Diastole)

Role MCA Doppler

MCA peak systolic pressure (PSV) consistently
showed an increase in blood velocity and
immediately prior to demise, a decrease.
Studies concluded MCA-PSV is a better predictor
of IUGR-associated perinatal mortality than any
other single measurement.

Role of venous Doppler waveforms

Ductus venosus (DV) and Umbilical vein (UV) are
usually looked into for fetal assessment.
It provides information about foetal cardiovascular
and respiratory responses to its intrauterine
environment.
Abnormal readings were reported in fetuses which
were severely compromised.

4) Screenings
No single biometric or Doppler measurement is
accurate to make or to exclude IUGR, so screening
those at-risk fetuses is vital.
USG at 18-20 weeks helps to reconfirm dates and
evaluation of anomalies.
USG at 28-32 weeks helps to assess fetal growth,
amniotic fluid, evidence of asymmetry and brainsparing effect.

MANAGEMENT OF IUGR

Principles
Principles are according to time of pregnancy:
- Prepregnancy

- Antenatal care
- Labor and delivery

Pre pregnancy
Anticipate risk that can be modified before a women becomes
pregnant:
a) Optimizing medical conditions (hypertension prior to
pregnancy)
b) Advice change in lifestyle (smoking)
c) Improving nutritional status and balanced diet
d) Women with Antiphospholipid antibodies associated with
delivery of a prior IUGR infant, low dose aspirin(81mg/day)
in early pregnancy may reduce likelihood of recurrent IUGR
e) Patients with hereditary thrombophilias - Low Molecular
Weight Heparin (LMWH)

Antenatal
Aim is to expedite delivery before the occurrence
of fetal compromise, but at the same time ensure that
lung maturation has achieved.

Antenatal
1) Treatment of underlying contributory conditions:
Treatment of hypertension
Alleviation of hypoxia (Correct anemia, blood transfusion

in sickle cell disease)

Stop smoking and alcohol consumption
Bed rest in lateral position
Working women who becomes fatigue, may take leave
Maternal disease, need of hospitalization
Dietary supplementation for women with low weight gain

Antenatal
2. Perform interval growth scans twice weekly
3. Antepartum fetal surveillance to identify fetal hypoxia/ distress
4. Foetal Kick Count chart - Cardiff Count of 10 - daily
5. Non Stress Test with Cardiotocography(CTG) }
6. Biophysical Profile (BPP) }
7. Amniotic fluid index and }
8. Foetal ultrasound.
} done twice weekly
9. If CTG is non reactive a modified BPP can be done
(NST and AFI)
10. Weekly Doppler flow studies using umbilical arteries

Antenatal
Rule out anomalies in severe symmetrical IUGR
-There is no role for routine amniocentesis / Cordocentesis

to diagnose chromosomal abnormalities in the absence of

USG markers

Timing and Mode of delivery

Based on general consensus when the end diastolic
flow is absent or reversed:
Admission into the hospital
Close surveillance
Administration of steroids Dexamethasone
In the event of abnormal BPP and Venous doppler - delivery

may be considered.
If gestation is over 34 weeks, delivery can be considered

even if other results are normal.

Timing and Mode of delivery

IUGR babies with
Normal wave pattern and weight of >1300 gm should be

delivered at term

IUGR babies with abnormal wave forms and < 1300 gm

would depend upon the gestational age:
If foetal maturity is < 32 weeks - conserve till 32 weeks
If foetal maturity is > 32 weeks - hasten lung maturity by

giving steroids and then deliver

Caesarean section
Advised for Severe intra uterine growth restriction

with expected foetal weight <1500 gm

Intrapartum management
Intrapartum monitoring with continuous CTG
Optimal neonatal expertise and facilities
Skilled Resuscitator:

- blood glucose
- hypothermia
- respiratory distress

Prognosis
Babies who suffer from IUGR are at an increased
risk of
- Hypoglycaemia
- Hypothermia
- Meconium Aspiration Syndrome
- Death