Intrauterine growth restriction

1. INTRAUTERINE GROWTH
RESTRICTION DIAGNOSIS AND
MANAGEMENT
PRESENTER: ZEYANA RASSUL
SUPERVISOR: DR.ALI SAID
DATE: 25/03/2024
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2. OUTLINE
• INTRODUCTION
• EPIDEMIOLOGY
• ETIOLOGY
• PATHOPHYSIOLOGY
• CLASSIFICATION
• DIAGNOSIS
• MANAGEMENT
• COMPLICATIONS
• PRACTICE AT MNH
• SUMMARY
• REFERRENCES

3. INTRODUCTION
• Intrauterine growth restriction (IUGR)/ fetal growth restriction(FGR)
is defined as an ultra sonographic estimated fetal weight (EFW) or
abdominal circumference (AC) less than the 10th percentile for a
given gestational age.
• The percentile used is based on the standardized growth charts for
the population.
• The fetus is unable to reach its genetic growth potential influenced
by maternal, fetal, and/or placental factors.

4. INTRODUCTION
• IUGR/FGR and small for gestational age (SGA) have been used
interchangeably yet are not synonymous.
• The American College of Obstetricians and Gynecologists
(ACOG) and the Society for Maternal-Fetal Medicine (SMFM)
recommend the use of IUGR to describe a fetus with a
sonographic EFW below the 10th percentile and SGA to describe
a newborn whose birth weight is below the 10th percentile for
gestational age.

5. INTRODUCTION

6. EPIDEMIOLOGY
• FGR occurs in> 10-15% of all pregnancies worldwide.
• It is the second most prevalent factor causing perinatal morbidity
and mortality.
• Prenatal identification of FGR is associated with lower rates of
stillbirth, highlighting the importance of ultrasound diagnosis and
surveillance

7. ETIOLOGY

8. PATHOPHYSIOLOGY
• Reduced availability of
nutrients in the mother
• Reduced transfer by the
fetus
• Reduced utilization by
the fetus

9. CLASSIFICATION
• Early vs Late (Timing of diagnosis)
• Symmetric vs asymmetric FGR
• Severity of FGR- Severe form of IUGR.

10. CLASSIFICATION CONT.
EARLY FGR LATE FGR
Time of manifestation <32 weeks GA ≥32 weeks GA
Prevalence 30% 70%
Challenge Management (GA at delivery) Detection and diagnosis
Evidence of placental disease High
-70% abnormal umbillical doppler
-60% ass with pre-eclampsia
-severe angiogenic imbalance -
low
-<10% abnormal umbillical doppler
-15% ass with pre-eclampsia
-Mild angiogenic imbalance
Maternal cardiovascular
hemodynamic status
Low cardiac output, high peripheral
vascular resistance.
Less marked cardiovascular findings
Clinical impact High Mortality and morbidity Low mortality & morbidity

11. CLASSIFICATION CONT.
➢ Symmetric FGR (Type I) - weight, length, and head circumference
are all below the 10th percentile.
• Characterized by a similar reduction in all biometric measurements
➢ Asymmetric FGR(Type II) - weight <10 percentile, length, and HC
are preserved. It refers to a reduction in abdominal circumference
(AC) relative to other measures, such as head circumference (HC).
• This classification is however no longer recommended as it does not
provide additional information with regard to etiology, prognosis, and
management (SMFM 2022).

12. CLASSIFICATION CONT.
➢ Severe growth restriction is defined as,
• EFW below the 3rd percentile for gestational age
OR
• EFW/AC below the 10th percentile with abnormal umbilical artery
Doppler.

13. DIAGNOSIS
➢ Serial measurement of Fundal Height
• SFH normally increases by 1cm per week b/w 14 and 32wks
• Lag of 4cm – FGR.
• A lag >6wks is suggestive of severe FGR

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15. DIAGNOSIS CONT.
• Elevated level of MSAFP level in the second trimester are the
markers of abnormal placentation and risks of IUGR
• Abnormal second-trimester analyses such as AFP > 2.0 multiple
of the median (MoM) have also been associated with FGR and
birth weight < 10th percentile

16. DIAGNOSIS CONT.
• Uterine artery doppler- of diastolic notch incomplete invasion of
trophoblasts to uterine arteries.
• Umbilical artery doppler(UA) AEDV/REDV indicates fetal jeopardy
and poor outcome.
• Middle cerebral artery Pulsatility index-brain sparing effect is
observed in FGR, MCA PI reduced.
• Ductus venosus Doppler-Absent or reversed DV a wave is sign
for impending acidemia and fetal demis

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INTRAUTERINE GROWTH RESTRICTION

18. DIAGNOSIS CONT.

19. DIAGNOSIS CONT.

20. DIAGNOSIS CONT.
At birth
• (Old man look)
• Dry and wrinkled skin
• Scaphoid abdomen
• Meconium stained vernix
caseosa
• Thin umbilical cord
At birth

21. DIAGNOSIS CONT.

22. MANAGEMENT
• Fetal movement counting, symptom of preeclampsia, vitals.
• Biophysical profile, NST/cCTG, Amniotic fluid, Doppler
• Fetal growth
• Administer antenatal corticosteroids per standard protocal.

23. MANAGEMENT CONT.
➢ Delivery
• Timing is based on GA, Doppler, NST/cCTG, BPP findings
• IOL, C/S (DV, REDV + If there is indication)
• Magnesium sulfate for fetal neuroprotection – intrapartum.
• Continous fetal heart monitoring

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INTRAUTERINE GROWTH RESTRICTION

25. MANAGEMENT CONT.
➢ Postpartum follow up and counelling for future pregnancy.
• Infant follow up
• Counselling regarding risk of recurrence(23%) and management
of future pregnancies.

26. COMPLICATIONS
➢ Maternal complications
• Complications due to underlying
disease, pre-eclampsia
• Premature labor
• Caesarean delivery.
➢ Fetal complications
• Stillbirth
• Hypoxia
• Acidosis

27. COMPLICATIONS CONT.
➢ Neonatal complications
Hypoglycemia, hypocalcemia, hypoxia and acidosis, hypothermia,
meconium aspiration syndrome, polycythemia, congenital
malformations, sudden infant death syndrome, NEC, and RDS
➢ Long term complications
Lower IQ, learning and behavior problems, major neurologic
handicaps, seizure disorders, cerebral palsy, mental retardation,
hypertension

28. COMPLICATIONS CONT.

29. PRACTICE AT MNH
• EFW in high-risk pregnancy
• UA doppler in case of suspected FGR
• Normal Doppler, monitoring continues unless maternal indication
for delivery
• Abnormal UA Doppler studies esp AEDV, REDV majority (delivery
regardless of GA)
• Mode of delivery-C/S

30. SUMMARY
• There is no gold standard for the diagnosis of FGR
• Identification of FGR is crucial since it has high morbidity and
mortality.
• Early detection and control of underlying maternal conditions
• Severity, and probable cause, should be determined by close
monitoring should be done.
• Birth timing needs to balance the consequences of preterm birth with
the risk of stillbirth in ongoing monitored pregnancies.

31. REFERRENCES
• Williams Obstetrics - 26E – 2014
• Hutchinson's Clinical Methods 23Ed
• Dewhurst's Textbook of Obstetrics and Gynaecology, Eighth Edition-
D. Keith Edmonds
• Fetal growth restriction: Evaluation and management - UpToDate
• Infants with fetal (intrauterine) growth restriction – UpToDate
• ACOG PRACTICE BULLETIN NUMBER 204 FEBRUAURY MAY
2019
• Swanson AM, David AL. Animal models of fetal growth restriction:
considerations for translational medicine. Placenta 2015;36(6):623–
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