INTRAUTERINE FETAL GROWTH RESTRICTION.pdf

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 10
th
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

17. 17INTRAUTERINE 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

24. March 24, 2024 24INTRAUTERINE 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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