+

IUGR (Intrauterine
Growth Restriction)
Putri Mirani
Divisi Fetomaternal
FKUNSRI/RSMH Palembang
+
Introduction
Gestational period extraordinary fetal growth
During 1st trimester, embryo grows approx. 1 mm/day
Fetal length continues in a predictable way, growing
approx. 0.5 cm/week troughout pregnancy
Fetus adds much weight during 3rd trimester, approx.
0.5 lb/week
At term, fetuses are relatively standard in length
(mean 51 cm), with > 95 % infants falling within 10%
of the mean
+
Sonographic Dating &
Assessment Of Fetal Growth
DATING
Accurate dating of pregnancy cornerstone of
obstetrical management of both normal & abnormal
pregnancies
Dating by menstrual history often unreliable
overestimation GA when compared with US
UShas proved better than calculations based on the
menstrual dates
The earlier the US is performed, the more accurate the
assessment of dates
+
Sonographic Dating &
Assessment Of Fetal Growth
FIRST TRIMESTER

Dating by US in the 1st half pregnancy routine part of ANC

Before 6 wks description & measurement of gestational

sac (GS)

GS visible at 4.5 wks, yolk sac (YS) present 95% at 5 wks &
nearly all by 6 wks, fetal heart rate (FHR) is seen beating
86% in 6 wks & always by 7 wks

Max embryos length at 6-10 wks & crown rump length

(CRL) measurement up to 14 wks most accurate at
determining GA
+Sonographic Dating &
Assessment Of Fetal Growth
SECOND & THIRD TRIMESTERS
When CRL > 60 mm, other biometric parameters have
proven useful for dating the pregnancy optimally up to 20
wks
Biometrics parameters include BPD, HC, FL & AC; HL also
frequently obtained during 2nd TM
Transcerebellardiameter in mm provides an accurate
estimation of GA up to 30 mm for 25 wks less accurate
thereafter
Up to 18 wks, best predictive interval is given by HC (7
days SD), BPD, FL & AC are less accurate (8 days SD)
+
Head Measurement
BPD & HC reflect head size reflects brain growth
Can reliably measured from 13 wks when the ossification
of the parietal bones of the skull has occurred
In certain circumstances (ROM, breech presentation,
multiple gestation), shape changes in fetal head
greater error measurement
If suspected the shape of calvarium is other than typical
measure cephalic index
Cephalic index = (BPD : FOD) x 100
Normal cephalic index: 74 - 83
+
Head Measurement

HC is preferable measurement when

there are fetal head shape variations
(dolichocephaly, brachycephaly)
HC = (BPD + OFD) x 1.57
Variability in predicting age from HC
increases progressively throughout
pregnancy peak of approx. 3.8 wks in
late 3rd TM
+
Biparietal Diameter (BPD)
+
Head Circumference (HC)
+Abdominal Circumference (AC)

AC is measure of fetal girth

Itincludes soft tissues of abdominal wall as well as
internal organs, primarily liver
Not influence by bone
Single most sensitive measure of fetal growth
Accurate& consistent measurement of AC important
whenever growth disturbances are suspected
AC linear growth with a mean of 11-12 mm/week
throughout gestation
+
Abdominal Circumference (AC)
+Long Bone Measurement
FL
the most commonly obtained long bone & reproducibly
measured from 13 wks onward
FLmeasured from origin of distal end of the shaft, from
greater trochanter to lateral condyle
Femoral
diaphysis horizontal showing homogenous
echogenicity
Femoral & distal epiphysis not included
Tend to accurately reflect GA
Femur grows 3 mm/wk from 14-27 wga & 1 mm/wk in 3 rd TM
Accuracy from 1 wk (2nd TM) to 3-4 wks at term
+
Femur Length (FL)
+Definition
IUGR

commonly define as a birth weight <

10th percentile at a given gestational
age.
Small for gestational age (SGA)
A population of fetus w/ a weight
below the 10th percentile
wo/ reference to a cause
+Pathophysiology
+
Classification Of IUGR

Type I. Symmetric Type II. Asymmetric

Cause intrinsic & extrinsic: Extrinsic only: placental
genetics, terratogenic, insufficiency
intrauterine infection, severe
nutritional deprivation

20% IUGR 80% IUGR

Onset early in pregnancy Mainly 3rd TM

Frequently microcephalic Weigh > length

Effect on cells Effect on cells

Number reduction Number reduction
Size normal Size subnormal
+
Classification Of IUGR

Type I. Symmetric Type II. Asymmetric

Growth of placenta Subnormal
frequently normal

Fetal anomaly frequent,

multiple Fetal anomaly none

US evaluation US evaluation
BPD: low growth profile BPD: low flattening pattern

pattern AC: small

AC: small HC/AC ratio: remains > 1.0
HC/AC ratio: similar to after 37 weeks
AGA fetus Relative brain sparring

No brain sparring effect effect

+Diagnosis Of
IUGR
+HC/AC Ratio
Used between 15-42 weeks
Normal ratio:
<36 weeks = 1:1
>36 weeks - ratio decreases as the AC increases

This
ratio helps to differentiate between symmetric IUGR,
asymmetric IUGR and a normally proportioned fetus
Symmetric IUGR - ratio is normal
Asymmetric IUGR - ratio increases as the head size is
maintained at the expense of the AC ("Brain-sparing
effect)
+HC/AC Ratio
+
FL/BPD Ratio
Normal ratio = 79 8%
Increased ratio
Microcephaly
Technically
poor measurement of the femur that
erroneously included the distal femoral epiphysis
Decreased ratio
Large head
Skeletal dysplasia (this ratio is a good indicator of fetal
dwarfism) as there is a very low chance that a normal
fetus will have a value that falls outside 4 SD of the
mean
+
FL/AC Ratio
Normal = 22 2% (constant after 24
weeks)
When ratio falls <20% or >24%, the AC
should not be used in the assessment
of gestational age
Growth retardation = >24%
Macrosomia = <20%
+
Amniotic Fluid Volume
Amniotic fluid tends to reflect fetal size
Chronic fetal hypoxemia often produce
oligohydramnios in addition to growth
restriction supports D/ of IUGR
AF can be normal in some cases of IUGR
indicates that fetus is not compromised
Polyhydramnios distinctly unusual in IUGR
unless fetal anomalies are present
+
Umbilical Artery Doppler
+
Umbilical & Uterine Artery
Doppler
+
Middle Cerebral Artery (MCA)
+
MCA Doppler
+
Ductus Venosus Doppler
+Ductus Venosus Doppler
+
Differential Diagnosis

Incorrect pregnancy dating

Normally grown fetus
(physiologically small)
+Management Of IUGR
+
Fetal Intervention
Fetal intervention maximize fetal outcome
Include treating any underlying problems,
behavior modification for the mother
More specific therapy for fetus maternal low
dose aspirin
Antenatal administration to the mother of
high-dose oxygen therapy transiently
improve umbilical arterial pH & oxygen
content
+Treatment Of The Newborn
Because of lack of placenta reserve
more likely to require immediate
resuscitation
Problem that may encounter: neonatal
asphyxia, meconeum aspiration,
hypothermia, polycytemia, hypoglycemia
& other metabolic abnormalities
Examine carefully for any signs of
structural abnormalities
+Long Term Outcome
Depend on underlying cause & on the presence
of additional malformation
Accumulated linking IUGR w/ poor cognitive
function & adverse neurologic outcome in later
childhood
IUGRinfant revealed a significant learning deficit
at age 9-11
IUGRinfants higher rates of impaired gross
motor development, low IQ & speech or reading
disabilities (Gembruch & Gortner, 1998)
Longterm follow up history of IUGR may place
patients at risk of adult-onset hypertension &
cardiovascular complications
+
Genetics & Recurrence
Risk
Many genetics influences that can be
associated w/ IUGR ranging from genetic
abnormalities such as aneuploidy to
constitutional factors such as maternal height &
weight
A previous pregnancy complicated by IUGR
risk factor of developing IUGR in subsequent
pregnancy
Recurent IUGR reflect an underlying maternal
problem
+
Thank You