Case Study on Intrauterine Growth Restriction

Case Presentation on
Intrauterine Growth
RestrictionModerator
Dr M. K. Majumdar
Asst. Professor, Dept. of Obstetrics and Gynaecology,
Gauhati Medical College & Hospital
Presented by
Students of 8th semester
Roll no. 29, 30, 31, 32, 33, 34, 35

Intrauterine Growth Restriction
(IUGR) or,
Foetal Growth Restriction (FGR)
IUGR is said to be present in those babies whose birth weight is
below the 10th percentile of the average for the gestational age.
Dept.ofObstetrics&Gynaecology,GauhatiMedicalCollege&
Hospital
Dutta D. Fetal Growth Restriction (FGR). In: Konar H, editor. DC Dutta’s Textbook of Obstetrics. 8th ed. New Delhi: Jaypee
Brothers Medical Publishers (P) Ltd; 2015. p. 533.

Salient features of SGA & IUGR
foetuses
IUGR (Intrauterine Growth
Restriction)
SGA (Small for Gestation Age)
30% babies with birthweight <10th
percentile
70% babies with birthweight <10th
percentile
Growth restricted Not growth restricted
Constitutionally and anatomically
abnormal
Constitutionally small but
anatomically normal
↑ Obstetric/neonatal risk No obstetric/neonatal risk
{Variable} Normal ponderal index
{Variable} Normal subcutaneous fat
{Variable} Uneventful neonatal course
Hospital
Dutta D. Fetal Growth Restriction (FGR). In: Konar H, editor. DC Dutta’s Textbook of Obstetrics. 8th ed. New
Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2015. p. 533.

Features of Symmetrical and
Asymmetrical IUGR Foetuses
Symmetrical Asymmetrical
Incidence 20% 80%
Onset Early, during cellular
hyperplasia
Late, during cellular
hypertrophy
Size Uniformly small Head larger than abdomen
Ponderal Index
Birth weight/Crown-heel
length3
Normal Low
HC:AC & FL:AC ratios Normal Elevated
Etiology Genetic disease or infection
(TORCH), involving all organs
including head
Intrinsic to foetus
Chronic placental insufficiency
Extrinsic to foetus
Total cell number Less Normal
Cell size Normal Smaller
Neonatal course Complicated with poor
prognosis
Usually uncomplicated having
good prognosis
Hospital
Dutta D. Fetal Growth Restriction (FGR). In: Konar H, editor. DC Dutta’s Textbook of Obstetrics. 8th ed. New Delhi: Jaypee
Brothers Medical Publishers (P) Ltd; 2015. p. 534.

Etiology
A. MATERNAL
 Constitutional
 Nutrition
 Diseases
 Toxins
B. FETAL
 Non-utilisation of resources by the foetus.
 Due to:
1. Structural anomaly
2. Chromosomal anomaly
3. Infection
4. Multiple pregnancy
C. PLACENTAL
D. UNKNOWN
Hospital

Predictive Factors
1. Presence of high-risk factors (obstetric, medical)
2. Low level of 1st trimester PAPP-1 value
3. Abnormal uterine artery Doppler value (notching) at 20-24
weeks of pregnancy
4. Foetal echogenic bowel based on USG
Hospital

Pathophysiology
• Due to,
 Reduced availability of nutrients, or
 Reduced transfer by placenta to foetus, or
 Reduced utilisation by the fetus.
• ↓ Brain cell size (Asymmetric-SGA) and cell number (Symmetric-
SGA)
• ↓ Liver glycogen
• Oligohydramnios
 Due to ↓ renal and pulmonary contribution
Hospital

Morphology
• Old man look
 Weight deficit: 600g below the minimum in percentile
standard.
 Length unaffected.
 HC relatively larger than body in asymmetric variety
 Dry and wrinkled skin due to less SC fat
 Scaphoid abdomen, thin meconium, stained vernix caseosa
and thin umbilical cord
 Pinna: Cartilaginous ridges
 Plantar creases: Well defined
• Baby is alert, active and having a normal cry. Eyes are open.
• Reflexes: Normal, including Moro-reflex
Hospital

Case Study
Hospital

Patient Particulars
Hospital

Patient Particulars
• Name: Majoni Begum
• Age: 20 years
• Sex: Female
• Religion: Islam
• Educational Status: Class IX
• Occupation: Housewife
• Marital Status: Married
• Husband
 Name: Bubul Ali
 Occupation: Mechanic
 Educational status: Matriculate
• Address: C/o Bubul Ali, Baihata Chariali, Kamrup (Rural), Assam
• Date of admission: 21-02-2017, 3:30 PM
• Date and time of examination: 22-02-2017
• Date of last menstrual period: 25-05-2016
• Estimated date of delivery: 27-02-2017
• Duration of pregnancy: 39 weeks 5 days
Hospital

Chief Complaints
• Cessation of menstruation for 9 months
 For safe hospital confinement
Hospital

History of Present Illness
• Patient came to know that she was pregnant when she missed
her periods for 2 months, after which she did pregnancy kit test
and later got her pregnancy confirmed via the doctor at the
local hospital.
Hospital

Antenatal History
Hospital

First Trimester
• The patient complains of cessation of menstruation. She
complains of increased frequency of micturition by about 7 to 8
times a day in comparison to 4 to 5 times a day normally.
However, it was not associated with any burning sensation or
any pain during voiding.
• The patient gives history of constipation, nausea and vomiting.
There was no history of fever, headache, giddiness, cold, cough,
weakness, abdominal discomfort, discharge or bleeding-par-
vagina.
• She went for her first antenatal check-up in the month of
August. She was given Folic Acid tablets to be consumed daily
which she did. There is no history of consumption of any other
drug, There is no history of exposure to any radiological
investigation but to ultrasonography in the month of August.
• Her sleep and appetite was normal.
Hospital

Second Trimester
• Cessation of menstruation continued and she noticed gradual
enlargement of the abdomen. She perceived the first foetal
movements in the month of October (5th Month). She went for
her next antenatal check-up in the month of October where she
received her 1st dose of Tetanus Toxoid, and the next dose in the
following month.
• She was given Iron and Folic Acid (IFA) Tablets to be consumed
regularly. There is no history of fever, headache, abdominal
discomfort, swelling of legs, blurring of vision, discharge or
bleeding-par-vagina. She did not consume any other drug or
was exposed to any kind of radiological investigation. She
couldn’t specify her weight gain. Her sleep and appetite was
normal, and her bladder and bowel habits were regular.
Hospital

Third Trimester
• Cessation of menstruation continued and so did the gradual
enlargement of abdomen.
• The foetal movements intensified. There was an increased
frequency of micturition which was about 7-8 times per day.
There is no history of fever, headache, abdominal discomfort,
swelling of legs, blurring of vision, discharge or bleeding-par-
vagina. Her sleep and appetite was normal, and her bladder
and bowel habits were regular.
Hospital

Past obstetrics history
Year and
month
Pregnancy
events
Labour
events
Mode of
delivery
Puerperium
period
Baby
26-06-
2012
Duration of
pregnancy:
9 months
Elective
Caesarian
Section
Elective LSCS Uncomplicat
ed
Living
Age: 4 years
7 months
Antenatally
cared:
3ANC
Bezera
Hospital
No history of
blood
transfusion
Birth wt. 2.8
kg
Complication
s:
Absent
Conducted
by:
Gynaecologis
t
Hospital stay:
9 days
Sex: Male
Treatment:
IFA + 2 TT
Breastfed
within 1 hour
Completely
immunised
till date
Hospital
• Patient is G2P1 with 1 living issue (L1)

Menstrual History
• The patient attained menarche at the age of 13. Her cycle was
regular (28 ± 2 days) with a flow for 4-5 days. She used 2-3 pads
per day. There is no history of passage of discharge or clots and
there is no associated pain.
Hospital

Past medical and surgical history
• The patient did not give history of hypertension, asthma,
diabetes mellitus, heart disease, tuberculosis, kidney disease or
any other major illnesses in the past.
• She did not undergo any surgeries in the past.
Hospital

Personal History
• The patient had studied up to IXth standard.
• She is a non-vegetarian and takes three major meals a day
consisting of a rice-based Assamese diet.
• She is a non-smoker, non-alcoholic and does not chew betel nut.
Hospital

Family History
• The patient lives with her husband, child and father-in-law. All
members are enjoying good health.
• There is no history of TB, heart disease, blood dyscrasias,
diabetes, congenital malformation, still birth, recurrent abortion
or twin pregnancy in the family.
Hospital

Socio-economic History
• Patient belongs to lower middle class family with a total income
of ₹6000 per month.
• She lives in a kutcha house with unsanitary latrine.
• She drinks water from tube well without filtering or boiling.
Hospital

Contraceptive History
• She has not used any contraceptives till date.
Hospital

Drug History
• The patient took IFA Tablets during her pregnancy.
• There is no history of use of other drugs during her pregnancy.
Hospital

Immunisation History
• BCG scar is absent.
• She had taken 2 doses of TT in her 4th and 5th month of
pregnancy.
Hospital

Allergy History
• She is not known to be allergic to any inhalant, contactant, or
ingestant.
Hospital

General Examination
Hospital

• Appearance: Patient looks well.
• Decubitus: Left lateral position,
as advised by the doctor.
• Build: Average
• Weight: 53kg
• Height: 155cm
• Nutrition: Fair
• Har and skin: Normal in colour
and texture
• Dehydration: Absent
• Icterus: Absent
• Pallor: Present
• Cyanosis: Absent
• Teeth and gums: Healthy
• Tongue: Moist and smooth
papillae
• Neck vein: Not engorged
• Neck glands: Not palpable
• Clubbing: Absent
• Koilonychia: Absent
• Oedema: Present
Hospital

Vitals
• Respiratory rate: 18/min.
 Regular in rhythm, and thoracic type.
• Blood pressure: 110/70 mm Hg in right upper arm in supine
position.
• Pulse: 84 beats/min.
 Regular in rhythm, normo-volumic, normal arterial wall condition with
normal character.
 No radio-radial and radio-femoral delay found.
 All other peripheral pulses are bilaterally and symmetrically palpable.
• Temperature: 98⁰F
Hospital

Systemic
Examination
Hospital

A. Central Nervous System
• Higher mental functions
 Patient is conscious, alert and cooperative.
 Patient is oriented to time, place and person.
 Her speech is normal and memory is intact.
• Cranial nerves are intact.
• Motor system is normal.
• Reflexes and jerks are normal.
Hospital

B. Respiratory System
• Inspection:
 Shape and size of chest is normal.
 Movement of chest is bilaterally symmetrical.
• Palpation:
 Trachea is in the midline.
 Chest expansion is normal.
 Vocal fremitus is bilaterally symmetrical and normal.
• Percussion:
 Lung field is uniformly resonant in all areas.
• Auscultation:
 Normal vesicular breath sounds are heard and no additional
sounds are heard.
 Vocal resonance is normal on both sides.
Hospital

C. Cardiovascular System
• Inspection:
 Precordium is normal.
 No bulging o visible pulsations are seen.
• Palpation:
 Apex breath is felt in the 5th intercostal space just medial to
the mid-clavicular line.
• Auscultation:
 1st and 2nd heart sounds are heard normally.
 No additional heart sounds are heard.
Hospital

Obstetric
Examination
Hospital

A. Breast Examination
• INSPECTION:
 Size: Uniformly enlarged.
 Skin over breast: Normal
 Nipples: Everted
 Areola: Hyperpigmented
 Montgomery tubercles seen
 No secretions from nipples seen
Hospital

B. Par-abdominal Examination
• INSPECTION:
 Size: Uniformly enlarged
 Shape: Longitudinally ovoid
 Flanks: Not full
 Umbilicus: Everted, in the midline
 Linea nigra seen extending from pubic symphysis to umbilicus
 Stria gravidum seen
 No visible peristalsis or pulsations seen
 No engorged veins seen
 Scar of previous C-section seen
Hospital

Par-abdominal Examination
(Contd.)
• PALPATION:
 No local rise in temperature felt.
 Tenderness: Absent
 Abdominal girth: 87cm/34”
 Symphysiofundal height: 28 cm
 Fundal height corresponds to 34 weeks of gestation
 Foetal movements perceived
 Uterine contractions felt
Hospital

(Contd.)
• Fundal grip:
 Soft, broad, irregular, non-ballotable mass felt, suggestive of foetal
buttocks
• Lateral grip:
 Smooth, curved, resistant surface felt on the right side suggestive of
back of foetus and multiple knob –like structures felt on the left side,
suggestive of foetal limbs.
• First pelvic grip:
 A hard, globular and smooth mass felt, suggestive of foetal head.
 Lie: Longitudinal
 Attitude: Flexion
 Presentation: Vertex
 Engagement: Head is engaged
• Second Pelvic Grip:
 Findings of first pelvic grip are confirmed. Head is flexed and engaged.
Hospital

(Contd.)
• AUSCULTATION:
 Foetal heart sounds heard on right spino-umbilical line
 Foetal heart rate: 132 beats/min
 Regular in rhythm
Hospital

Provisional diagnosis
The patient Majoni Begum, 20 year Muslim female, a married
housewife hailing from Baihata Chariali, Kamrup (R) is a post C/S
multigravida G2P1L1 presenting with a cessation of menstruation for 9
months is provisionally diagnosed to be a case of 39 weeks 5 days of
pregnancy with single live foetus in a longitudinal lie, cephalic
presentation, and not in labour with intrauterine growth restriction.
Hospital

Investigations
Hospital

A. Blood Tests
• ABO Grouping: B+
• Rh Typing: Positive
• Haemoglobin: 9.2 g/dl
• TLC: 11,910/mm3
• DLC
 Neutrophil: 82%
 Lymphocyte: 12.6%
 Monocyte: 4.2%
 Eosinophil: 1.2%
• Platelet: 1.36 lacs/mm3
• Random Blood Sugar: 74 mg/dl
• Serum creatinine: 0.93 mg/dl
• TSH: 0.37 µIU/l
• Hbs Ag: Negative
• HIV: Non reactive
• VDRL: Non reactive
Hospital

B. Urine Examination
• PHYSICAL:
 Quantity: 50 ml
 Colour: Pale yellow
 Sediment: Nil
 Appearance: Clear
 Reaction: Acidic
 Specific gravity: 1.010
• CHEMICAL:
 Albumin: Nil
 Sugar: Nil
 Phosphate: Nil
 Microscopy:
 Pus cells: 1-2 cells/HPF
 Epithelial cells: 1-2/HPF
 RBC: Nil
 Crystals: Nil
 Cast: Nil
Hospital

C. Stool Examination
• No ova or cyst seen.
Hospital

D. Ultrasonography
Parameter Measureme
nt (mm)
GA
BPD 85 34w2d
HC 305 34w0d
AC 301 34w1d
FL 65 33w4d
As on 12-02-2017
Single live foetus with head in the lower
pole with longitudinal lie. Foetal cardiac
pulsations seen normal and heart rate
measures 143 bpm.
• Foetal intracranium, stomach, kidney, spine and
urinary bladder are normal. Foetal limbs, to the extent
visualised appear normal. No evidence of gross
congenital anomalies.
• Foetal movements are normal.
• Four chambered view of heart is normal.
• Placenta has Grade III maturity and is in anterior
upper segment.
• There is no evidence of placenta previa.
• Amniotic fluid adequate.
• No cord seen around neck.
• Cervix normal.
Hospital
GA EDD
Ultrasound 34w0d 26-Mar-17
Menstrual 38w2d 24-Feb-17
Foetal biometry:
Biometry Calculations (LMP=20-May-16)
Impression
1. Single live foetus in cephalic presentation and longitudinal lie with gestational age of
34 weeks corresponding to dates.
2. Approximate foetal weight 2306 g

Final Diagnosis
Our patient, Mrs. Majoni Begum, 20 year old Muslim female, a married
housewife hailing from Baihata Chariali, Kamrup (R), belonging to lower
middle class family, is a post C/S multigravida G2P1L1 with 39 weeks 5 days
of gestation, presenting with a cessation of menstruation for 9 months, is
finally diagnosed to be a case of 39 week 5 days of gestation with a single
live foetus in cephalic presentation and longitudinal lie with gestational age
of 34 weeks corresponding to dates and an approximate foetal weight 2306
g.
Hospital

Case Summary
Hospital

• Mrs Majoni Begum, a 20 year old Muslim female, of G2P1L1
married for last 5 years, coming from a low socioeconomic
status, admitted on 21st February, 2017 for safe hospital
confinement following a cessation of menstruation for 9
months. Her LMP was 25th May, 2016 and EDD is 27th February,
2017 and duration of gestation is 39 week 5 days. Her menstrual
period was regular with an average of 28-30 days duration. She
used to attend antenatal clinic regularly and had taken Iron Folic
acid and TT injection as advised. She had no significant past and
family history.
• On physical examination, her height was 155cm and weight was
53 kg. Her BP was 110/70 mm and pulse was 84 beats/min. No
abnormality was detected during systemic examination.
Hospital

• On obstetric examination, height of fundus corresponds to 34
weeks, longitudinal lie, vertex presentation, head engaged. SFH
is 28 cm (usually less than expected) and abdominal girth is 87
cm. Foetal heart rate 132 bpm and regular, situated on right
spino umbilical line.
• USG report showed a single live foetus in cephalic presentation
and longitudinal lie with gestational age of 34 weeks
corresponding to dates and an approximate foetal weight of
2306 g, which is suggestive of intrauterine growth restriction.
Hospital

Management
Hospital

General
• Bedrest
• Diet
• Maternal hyperoxygenation
• Hyperalimentation
• Maternal Volume Expansion
Hospital

Mode of Delivery
• Since the last delivery was LSCS and there is history of decrease
contraction which was cause of caesarean section, therefore
elective LSCS will be done in this case to prevent any
complication.
• Immediate care of baby after birth is taken care of.
Hospital

Case Study on Intrauterine Growth Restriction

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