Intrauterine

Growth
Restriction

Jhay Ralph Alaban MD

2nd year Resident
Dept. of Obstetrics and Gynecology
October 25, 2021
Learning Objectives

– To Discuss epidemiology, diagnosis, prevention and

management for pregnant patients with fetal growth
disorders specifically IUGR
Sources

– Fetal growth restriction. ACOG Practice Bulletin No. 227. American

College of Obstetricians and Gynecologists. Obstet Gynecol 2021
– Society for Maternal Society for Fetal Medicine Consult Series #52
Diagnosis and management of fetal growth restriction Society for
Maternal-Fetal Medicine
– Hadlock FP, et al. Estimation of fetal weight with the use of head, body,
and femur measurements--a prospective study. Am J Obstet Gynecol
– Small-for-Gestational-Age Fetus, Investigation and Management
(Green-top Guideline No. 31) Royal College of Obstetricians and
Gynecologists, 2nd Edition February 2013, Minor Revisions January
2014 (Accessed 4/16/21)
General Data

– PR
– 29 Years Old
– Roman Catholic
– DOB: 04/07/1992
– Address: Clarin, Bohol
– Informant: Patient 95% Reliability
Past Medical History

– No Known Comorbidities
– No Food and Drug Allergies
Family History

– No heredofamilial predisposition
Personal and Social
History

– Unemployed for 3 months, Previously a saleslady for an

electronics shop
– Highschool Graduate
– Allegedly no smoking or alcohol intake history
Menstrual and Sexual
History

– Menarche: 11 years old

– Interval: Regular Monthly
– Duration: 3-4 days
– Amount: 3 pads per day
– Symptoms: (-) Dysmenorrhea
– Coitarche: 25
– Sexual Partner: 1
– Contraception: None
– STIs: (-)
Obstetric History

– G1P0
– LMP: 03/18/2021
– PNC: IMAP Tubigon 4 visits
– Medications:
• FeSO4
• Calcium Tablets
History of Present Illness
CC: Labor Pains

– Morning PTA noted labor pains, progress in symptoms

prompted consult
 Review of Systems
GENERAL: SKIN: HEENT: BREAST:
No rashes, urticarial No Ocular Refractive No lumps, pain or
Awake, Alert, Weight
Error, No hearing loss, discomfort, no nipple
Loss of Approximately sneezing, congestion or discharge
4% Prepregnancy wt 49 runny nose description
kg

RESPIRATORY: CARDIO GASTRO GENITO

No cough, No dyspnea VASCULAR: INTESTINAL URINARY:
No chest discomfort No anorexia, nausea, No dysuria, bleeding
vomiting or diarrhea No and incontinence. No
blood in the stool, history of recurrent
abdominal discomfort UTIs, No watery vaginal
not related to labor discharge
pains.
Physical Exam

General Conscious,coherent, not in cardiorespiratory distress

Vital Signs BP: 110/60mmHg Wt- 49kg

HR: 91bpm Ht-152cm
RR: 20cpm BMI : 21.2 kg/m2 (Normal)
T: 36.6 °C
O2sat: 98%

HEENT Anicteric sclerae, pinkish palpebral conjunctivae, (-) Neck

Mass
Chest & Lungs Equal chest expansion, clear breath sounds

Heart Distinct heart sounds, normal rate, regular rhythm, no

murmurs
Physical Exam

Abdomen Gravid, FH 22 cm EFW: 1395g FHT 145 bpm

Leopolds Maneuver
L1: Breech L2: Back at Right L3: Cephalic 4: Unengaged

Contraction
3 in 10 minutes lasting 40 seconds

Speculum Closed Cervix (-) Pooling

Exam:

Internal Exam Closed Cervix

Extremities (-) edema, equally palpable peripheral pulses, CRT<2s

Admitting Impression

G1P0 Pregnancy Uterine 29 6/7 weeks Age

of Gestation, Cephalic in Threatened
Preterm Labor, R/I IUGR
Course in the ER

– Admitted
– Consent Secured
– Vital Signs Monitoring q1h, FHT q15mins
– DAT
– Intake and Output Monitoring every shift
– Venoclysis Started with Plain LR 1L at 30 gtts/min
– Labs: Baseline CTG, RAT, Inflammatory Markers, CBC,
Urinalysis, Chest Radiograph
Course in the ER

– Medications:
1. MgSO4 for Neuroprotection
2. Dexamethasone q12h for four doses
3. Nifedipine 30mg LD then 10mg q4h
Course in the ER

– Pelvic Ultrasound done10/21/2021:

– Pregnancy Uterine 29 weeks and 5 days by fetal biometry, live
singleton in cephalic presentation, adequate amniotic fluid
volume, placenta posterior high lying grade II, female fetus,
estimated fetal weight is appropriate for age of gestation BPP
8/8, Cervical length 2.77cm
 Diagnostics
CBC Day 0 Blood Chem Day 0
Baseline Baseline
WBC 4-10 8.3 TSH 0.35-4.94 0.552
RBC 3.8-5.8 4.48 FT4 0.7-1.4 0.886
Hgb 11.5-16.5 12.10 Na 135-155 134
Hct 37-43 37 K 3.6-5.5 3.7
MCV 76-96 73.7 MCV 76-96 73.7
MCH 27-32 22.5 Crea 44-80 64
MCHC 30-35 32.2 SGOT 0-31 40
RDW-CV 11.5-14.5 16.3 SGPT 0-32 15
Plt 150-450 286
Neu 54-62 68
Lymph 20-40 24
Mono 4-10 5
Eos 1-3 3
Baso 0-1 0
Definition

– Fetal Growth Restriction, FGR is defined as an ultrasound

estimated fetal weight (EFW) of less than the 10th
percentile or abdominal circumference <10% for
gestational age.
Definition

– Small for Gestational Age, is a term used to describe the

size of the baby at birth (neonate) usually characterized by
either:
– Birthweight lower than a predetermined cut-off value
regardless of cause; or
– Birthweight 2 standard deviations (SD) below the mean or 10 th
percentile of a population specific birthweight versus a
gestational age plot
Definition

– Constitutionally Small, is a neonate whose birth weight is

<10th percentile weight for gestational age with a normal
growth trajectory, normal doppler velocimetry of the
umbilical arteries and normal amniotic fluid (AFV)
1. Modest smallness (EFW between 5th and 10th percentile)
2. Progressive growth across gestation
3. Normal Physiology(AFV and Doppler)
4. Appropriate size in terms of maternal characteristics
Definition

– IUGR, is a term used to describe the size of the fetus in-

utero. It refers to a fetus with an EFW <10th percentile on
ultrasound that because of a pathologic process, has failed
to reach a potential growth.
– At least 2 intrauterine growth assessment with diminished
velocity
– Abnormal Doppler findings
Definition

– Early onset IUGR, <32 weeks causes of which include:

– Chromosomal abnormalities
– Maternal diseases
– Severe problems of the placenta
– Late onset IUGR, >32 weeks and may demonstrate normal
doppler studies except for MCA or very mature placentas
(Grannum 3)
Definition

– Symmetric IUGR, occurs early in pregnancy and displays a

proportional decrease in length, weight and head
circumference
– Aneuploidy, congenital infections
– Assymetric IUGR, also known head sparing IUGR, growth
velocity for weight and length are often decreased for a
larger degree than head circumference
– Placental insufficiency in the 3rd trimester
Risk Factors

– Maternal: Extremes of age (<16 and >35), high altitude,

low socioeconomic status, substance abuse, severe
maternal starvation, previous SGA, short maternal stature,
lack of medical care during pregnancy, toxic exposures,
maternal disorders, infection
– Neonatal: Karyotypic abnormalities, congenital anomalies
– Placental: Uteroplacental insufficiency, chronic abruptio,
syncytial knots, multiple gestations
Diagnosis

A. A lag of more than 3 cm between fundal height and

gestational age may identify patients at risk of FGR, who
should then have an ultrasound performed.
Diagnosis

B. Qualitative: Beta-HCG gives a frugal estimate of

gestational age, because as it is done early it can be
detected as early as 8-9 days from ovulation (Williams)
Quantitative: on the other hand gives a rough estimate
of gestational age
Diagnosis
Diagnosis
Diagnosis

– Since fetal weight may vary by as much as +20% in the third

trimester, please err on the side of caution for borderline
cases.
– An additional ultrasound parameter that may suggest the
diagnosis of FGR is oligohydramnios (low amniotic fluid
volume).
– If late care, and unsure if the pregnancy is misdated (less
farther along than dates), if time allows, repeat the growth
ultrasound in 3 weeks to see if the fetus follows the same
curve, suggesting misdating, or flattens out, suggesting FGR.
Antepartum Management

– Fetuses diagnosed as having FGR should have an anatomic

survey performed.
– Fetuses with an EFW <10th percentile or abdominal
circumference <10% should have reflex Doppler studies
done. The clinically relevant Doppler parameters for this
disorder include:
– pulsatility index of the umbilical artery (PI-UMA)
– systolic to diastolic ratio of the umbilical artery (S/D-UMA)
Doppler Study

– UMA: the umbilical artery inserts to the placenta, usually near

the center of its fetal surface, is an indirect measure of the
degree of fetal hypoxia due to placental insufficiency
– MCA: middle cerebral artery, gives an idea on how the fetus
“protects” the brain (brain-sparing reflex) in compensation to
significant hypoxia from uteroplacental insufficiency
– DV: ductus venosus, gives an idea of the presence of cardiac
decompensation, the terminal compensatory event expected
and being monitored. Also, helps in the decision of when to
deliver severely premature IUGR fetuses after steroid
administration
Diagnosis
Diagnosis
Antepartum Management

– Maternal Fetal Medicine consult should be considered

when the diagnosis is made, especially in the setting of
early onset FGR before 32 weeks.
– Manage according to SMFM Algorithm for the diagnosis
and management of fetal growth restriction.
– Surveillance will include Doppler assessment,
cardiotocography, amniotic fluid assessment and nonstress
test/biophysical profile when appropriate.
Antepartum Management
(Adjunct)

– Balanced Energy Protein: protein should be <25% of total

caloric demand in pregnancy based on age of gestation

– Calcium Supplementation: decreases likelihood of

developing preeclampsia in gravid patients with high risk

– Multiple micronutrient supplementation

– Smoking Cessation
Delivery

– The evidence is controversial as to the risks vs benefits of early

delivery in fetuses with growth restriction. Early delivery may
prevent intrauterine fetal demise or future neurodevelopmental
problems. Very early preterm delivery of the growth restricted
fetus is associated with the worst prognosis.
– If delivery is anticipated within 7 days, then administration of
antenatal corticosteroids for fetal lung maturation is indicated in
fetuses diagnosed with growth restriction prior to < 33 6/7
weeks.
– If delivery prior to 32 0/7 is anticipated, then consider
neuroprotection with magnesium sulfate.
Delivery

– Growth restricted fetuses with abnormal Doppler

velocimetry at less than 32 weeks should be discussed with
Maternal Fetal Medicine.
– EFW <3%-ile or abnormal UA Dopplers (S/D or PI >95%ile) at ≤
37 wks
– EFW > 3 - <10%-ile with normal UA Doppler at 38-39 wks
– Continuous electronic fetal monitoring should be instituted
in active labor.
Summary of antenatal
testing and Delivery

For FGR 3rd% - 9th%:

– Fetal heart rate monitoring once per week
– Doppler q 1 – 2 weeks, then if normal, q 2 – 4 weeks
– Fetal growth q 3 – 4 weeks
– Delivery at 38 – 39 weeks
– For FGR < 3rd%:
– Fetal heart rate monitoring once per week
– Doppler q weekly
– Fetal growth every 2 weeks (although we will likely perform growth at 3 – 4
weeks)
– Delivery at 37 weeks or less
THANK YOU