Fetal growth restriction

FETAL GROWTH
RESTRICTION..
What the evidence says?!
Dr. Kirtan Vyas
M. S. (Ob/Gy)
Assistant Professor,
P.D.U. Medical College, Rajkot

Gujarat Uni. First-Gold medallist
Gujarat Public Service Commission(GPSC) first
Fellow in Gynec Endoscopy(Mumbai)
Fellow in Ultrasonography(FOGSI)
Publications in various International Journals
Presented Scientific Papers and Chaired Sessions at State and
National conferences
Faculty at State and National Conferences
Local Joint Secretary of SOGOG-Gujarat State Org of Ob Gy 2015
 Organizing Secretary for the First Rajkot Obstetrics and Gynec
Society Annual Conference 2015 and Committee Member at State and
National conferences
Organizing secretary for the West Zone Yuva Fogsi 2016, Rajkot
Faculty at FOGSI-JOGI PICSEP Scientific Program 2016 at Rajkot
Presently an Assistant Professor at P.D. U. Medical College, Rajkot
Dr. Kirtan Vyas
M.S.(Ob/Gy)
Dr. Kirtan Vyas # 9825407702

• The major concern in IUGR is not the small
size of the fetus, but the possibility of life
threatening fetal compromise
• Timely identification is difficult but crucial
for proper management and a favorable
neonatal outcome as it is the second leading
cause of perinatal mortality after
prematurity

Baffles the
researchers in the
most controversial
way
Extensively studied, still confusing!!

 To compare and contrast the used
terminology and definitions
 To evaluate screening approaches
 To critically review proposed management
 Surveillance regimens
 Recommendations for timing and mode of delivery
 Risk of Recurrence, preventative strategies
 Postnatal management

DEFINITION
• IUGR: A condition where the fetus fails to
achieve its genetic growth potential and
consequently is at risk of increased perinatal
morbidity & mortality
• SGA: Infant with weight < 10th percentile of
those born at the same gestational age or > 2
SDs below mean for Gestational Age

Easiest way to think about these terms are
• IUGR: is a term used by Obstetrician to
describe a pattern of growth over a period of
time
• SGA: is a term used by Pediatrician to
describe a single point on a growth curve

V/S
• Preterm gestation and small
• Term gestation and small
• Healthy but small – Constitutionally small
• Pathologically small – IUGR

• Thus 2 essential components for
IUGR are
– Birth weight <10th percentile
– Pathologic process that inhibits normal growth potential
(intrinsic) 30 %
• And the 2 essential components for SGA are
– Birth weight <10th percentile
– Absence of pathologic process 70 %

• In 2013, 3 major obstetric colleges in the
UK, Canada, and the USA have published
their clinical recommendations for
pregnancies with FGR
RCOG February
2013
SGA
ACOG May 2013 FGR
SOGC August
2013
IUGR

• All guidelines use a different terminology
• All do agree that an EFW < 10th centile for
gestation should be used to alert clinicians
to small fetal size

INCIDENCE
• 3 - 5% of all pregnancies
• 20 % of still borns are growth restricted
• 1/3 of infants with BW < 2750 gms are growth
restricted and not premature
• Only 20-30% of growth restricted fetuses are
small due to pathological restriction of growth
• Perinatal mortality is 8 - 10 times higher for
these fetuses *Peleg D et al

NORMAL INTRAUTERINE
GROWTH PATTERN
• Stage I (Hyperplasia)
- 4 to 20 weeks
- Rapid mitosis
- Increase of DNA content
• Stage II (Hyperplasia & Hypertrophy)
- 20 to 28 weeks
- Declining mitosis
- Increase in cell size

NORMAL INTRAUTERINE GROWTH
PATTERN
• Stage III ( Hypertrophy)
- 28 to 40 weeks
- Rapid increase in cell size
- Rapid accumulation of fat, muscle and
connective tissue
95% of fetal weight gain occurs during last 20
weeks of gestations

• 15 weeks = 5 grams/day
• May vary by race, gender, multiple gestation

MATERNAL PLACENTAL FETAL
Chronic disease
Cyanotic heart disease
DM (class F or above)
Chronic respiratory disease
Chronic hypertension
Chronic renal disease
General
Malnutrition
Malabsorption syndrome
High attitude
Constitutionally small
mother
Substances abuse
Smoking
Alcohol
Other disorders
Severe anemia
Hemoglobinopathies
Antiphospholipid
antibody syndrome
Recurrent APH
Abnormal
placentation
Abruptio
Infarction
Circumvallate
Placenta
Chorioangioma
Placenta accreta
Placenta previa
Chromosomal
Trisomy 13,
Triploidy 21
Turner syndrome
Structural abnormality
Congenital Heart disease
NTD
Collagen and musculoskeletal.
Fetal infection
CMV
Rubella
Herpes
Toxoplasmosis
Teratogens
Anti-convulsant
Anticoagulant
Alcohol
Narcotic
Multiple gestation (10 times more
common)

RELATIVE FREQUENCY OF
DIFFERENT ETIOLOGIES
• Placental insufficiency -80%
• Tobacco /Smoking -5%
• Fetal Chromosomal -5%
• Fetal Infections -1-2%
Dr. Kirtan Vyas 98254 07702

CLASSIFICATION
• Based on evaluation & USG examination small fetuses are
divided into two categories
Healthy SGA or True IUGR or
Constitutionally small Pathologically growth restricted
TYPE –I TYPE –II
Symmetrical IUGR Asymmetrical IUGR
Intrinsic IUGR Extrinsic IUGR
*Campbell S and Thomas ADr. Kirtan Vyas # 9825407702

FETAL GROWTH - A COMPLEX
PHENOMENON
• Besides these there occurs a delicate
interplay between fetal adaptation to the
maternal metabolism by modulating
placental function
• This means that an adequate maternal
nutritional status does not ensure adequate
supply to the fetus, it requires a normal
placental function also

FGR is a pathologic process associated with
additional features
• abnormal placental morphology
• oligohydramnios or
• abnormal uteroplacental or
fetoplacental doppler

PRIOR H/O IUGR HAS 4FOLD
INCREASE INCIDENCE
• Lagging fundal measurement of 3cms with the
estimated gestational age
• Poor maternal weight gain of <5 kg by 24 wks
or 8 kg by 32 wks (for women with BMI<30)
• EFW <10 percentile
• HC/ AC ratio>1
• AFI ≤ 5
• Grade 3 placenta before 34 wks
• Decrease DFMC

EFFECTS OF IUGR
• The study by Bernstein et al (2000) done on
20,000 neonates born IUGR without major
anomaly described the following RR
Death 2.77
RDS 1.19
IVH 1.13
Intravascular hemorrhage 1.27
NEC 1.27

LONG TERM MORBIDITIES
 Cerebral palsy (Goldenberg RL et al. 1998)
 Hypertension (Hannsens M et al 1996),
 Dyslipidemia (Gogate S. 2001)
 Diabetes Melitus (Mukhopadhyay S et al 2001)
 Breast cancer (LeMarchand L et al 1998)
 Prostate cancer (Ekbom A et al 1996)
 Mental health problems, academic impairment
and poorer general health

IUGR SCREENING
• Whom to screen?
• Ideally Symphysis Fundal Height (SFH) performed
regularly for all pregnancies
• SFH in cms = weeks of gestation
• High risk cases will need ultrasound for growth,
liquor volume, umbilical artery Doppler and
Biophysical Profile
• Umbilical Artery Doppler is the best test!

There are FOUR TESTING MODALITIES
which are helpful
• Daily fetal movement count (DFMC)
• Non-Stress Test (NST)
• Amniotic Fluid Index (AFI)
• Doppler of the Umbilical Artery
• Biophysical Profile (BPP)
Combination of tests are better than an
isolated test

DIAGNOSIS
CLINICAL BIOPHYSICAL BIOCHEMICAL
Ultrasonography MSAFP & hCG in
2nd trimester
Erythropoietin
level in cord blood
is high in IUGR

DIAGNOSIS - CLINICALLY
Maternal weight gain
 Stationary or falling during second half of
pregnancy
Palpation of uterus
 SFH-Normally increases by 1 cm per week
between 14 and 32 wks
- A lag in fundal height of 4 wks s/o moderate
IUGR and over 6 wks s/o severe IUGR
 Abdominal girth – stationary or decreasing
 Liquor volume - less

BIOCHEMICAL MARKERS IN
IUGR
ERYTHROPOIETIN (EPO)
 An elevated HCG and amniotic fluid EPO has been
found which supports the concept of early damage
of placenta sufficient to cause erythroblastic
response (Seppo Heinonen et al 1999)
 High levels of EPO were also found in hypoxic and
growth restricted neonates (Ostlund E at al 2000)
PAPPA
 A positive co-relation of PAPPA with femur length
and abdominal circumference in second trimester
(Leung TY et al 2006)Dr. Kirtan Vyas # 9825407702

SERIAL ULTRASOUND
BIOMETRY AND DOPPLER
STUDIES FORM THE MAINSTAY
OF DIAGNOSIS
• The greater the risk of IUGR based on
clinical findings, the greater is the positive
predictive value of USG
• It must be borne in mind that each
measurement has an error potential of
about 1 week up to 20 weeks gestation, 2
weeks from 20-36 weeks and 3 weeks
thereafter Dr. Kirtan Vyas # 9825407702

USG
Abdominal circumference (AC)
• The most sensitive indicator
• Sensitivity is 95% if it measures below 2.5th
percentile
• HC/AC ratio drops almost linearly from 1.2
to 1.0 between 20-36 weeks normally
• It is elevated in asymmetric IUGR and is
normal in symmetric IUGR
• FL/AC ratio elevated to >2.4 in IUGR

• Remember that we shall not switch to color
doppler directly when patient is referred for
color doppler
• First go for biometry & precisely define
type of growth retardation by plotting the
finding in growth charts, assess fetus for
malformation. Assess Amniotic fluid &
biophysical activity & then switch on the
color doppler

IMPORTANCE OF
COLOUR DOPPLER
THE ACCURACY OF DOPPLER VELOCIMETRY
IN CONJUNCTION WITH 2D ULTRASOUND AND
COLOR FLOW MAPPING IS NOW REGARDED AS
AN INDISPENSABLE COMPONENT OF A
PREGNANCY SONOGRAM

PERSPECTIVE OF COLOUR
DOPPLER
• EXCLUDE FETALANOMALIES
• EVALUATE FETAL SIZE
• QUANTIFY LIQUOR AMNII
• ASSESS PLACENTA, CORD &
CERVIX

Quantitative analysis
Doppler indices

DOPPLER VESSELS TO BE
STUDIED
• MATERNAL SIDE
Uterine artery
• PLACENTAL SIDE
Umbilical artery
• FETAL SIDE
Arterial: MCA, renal and others
Venous: ductus, hepatic, umbilical
Fetal echocardiography

UTERO PLACENTAL
CIRCULATION
Conversion of spiral artery into
utero placental vessel
Brosens et alDr. Kirtan Vyas # 9825407702

UTERINE ARTERY
Normal impedance
to flow the uterine
arteries in 1º
trimester
Normal impedance
to flow the uterine
arteries in early
2ºtrimester
Normal impedance
to flow the uterine
arteries in late 2º
and 3º trimester
UTERO PLACENTAL CIRCULATION
Dr. Kirtan Vyas #
9825407702

UTERINE ARTERY FACTS
• More accurate for screening in high risk-
early onset cases
• At a place, where UtA crosses the EIA
• B/L notch or U/L notch on the side of
placenta is significant
• Best GA is 22-24 weeks
• High negative predictive value

• Progressive rise in the end-diastolic velocity
• Decrease in the pulsatility index
ADVANCING GESTATION
UMBILICALARTERY

UMBILICALARTERY FLOW
• Whether at fetal end,
placental end or in
between – no difference
S/D ratio : 2-3 in 2nd &
3rd trimester
PI : 1.5 – 2.0 in 2nd
trimester1.0 – 1.5 in 3rd
trimester
RI : decreases with gest.
In late 2nd and 3rd it is
around 0.5

UMBILICALARTERY FLOW-
WHAT DOES IT TELL US ??
First sign of hypoxia & growth
retardation

NORMAL UMBILICAL
ARTERY
1º trimester
Absent Diastolic
Flow
early
2ºtrimester
Low Diastolic
Flow
late 2º and 3º
trimester
Resistance further
reduce, more
diastolic flow

UMBILICALARTERY - ABNORMAL
Umbilical arteries
- normal
Umbilical arteries
- high pulsatility index
Umbilical arteries
- Absent end diastolic velocity
- very high pulsatility index.
- pulsation in the umbilical vein
Umbilical arteries
reversal of end diastolic
Dr. Kirtan Vyas #
9825407702

UMBILICALARTERY & CTG
• Umbilical artery 90% more sensitive to
CTG
• Interval between absence of end
diastolic flow & onset of late
deceleration was 3-12 days
Bekedam DJ et al. Early Hum Dev 1990;24:79–89High Resistance

MIDDLE CEREBRALARTERIES
Reflects : cerebral flow
End points : rising PI after a nadir
– More than 1.45 before term
– Fall down to 1
– If less than 1- peak of redistribution

MCA
• 22-28 weeks- no EDF in MCA
• 28w to term- some EDF seen- normal
• Increased EDF ( low PI) suggests ‘brain sparing’
redistribution in IUGR
• Worsening hypoxia- fetal acidemia- paradoxical
rise in resistance (high PI)
• CPR increases – this is indicative of IUGR

MANNING’S BPP
• NST
• FBM
• FM
• FT
• AFI
• Maximum score 10 - Minimum 0
• Oligohydramnios indicates abnormal BPP
regardless of the total score of others

MANAGEMENT
• Depends on the severity of growth restriction
and how early the problem began in pregnancy
• Earlier the onset, more severe is the IUGR and
greater the risk to fetus
• Management is based on the following
o Prevention
o Diagnosis of IUGR
o Antenatal vigilance. Treatment of the cause, if
found to be present.
o Delivery
o Neonatal management

MATERNAL BED REST
• This is the initial approach for the
treatment of IUGR
• Adequate bed rest in left lateral position
results in increased blood flow to the uterus
& placenta

ASPIRIN THERAPY
• The use of aspirin to treat foetus with IUGR is
still controversial
• If aspirin is used, it may be advantageous if
given to patients before 20 weeks of gestation
It is minimal to limited benefit if given at the
time of diagnosis
• (third trimester)

• However it is beneficial in cases with
– history of thrombotic disease
– hypertension
– pre-eclampsia
• The Maternal-Fetal Medicine Network
randomized 3135 women to receive 60mg/d
aspirin or placebo and found no significant
difference in incidence of IUGR

HYPEROXYGENATION
• Fetal oxygenation is crucial for fetal growth
• A positive response to maternal oxygen therapy
found by decreased resistance in placental
circulation is marker of good prognosis and
lack of response is an indication of poor
outcome
(Bilardo et al 1991)

OTHERS….
o Other forms of treatment that have been
studied are maternal hyperalimantation by
aminoacids, nutritional supplementation, zinc
supplementation, fish oil and hormones
o Maternal volume expansion may be helpful in
improving placental perfusion
o Limited studies are available regarding the use
of these modalities in the treatment of IUGR

JUDGE OPTIMUM TIME OF
DELIVERY
Risk of PREMATURITY
Difficult extra uterine
existence
Risk of IUD
hostile intra uterine
environment

MANAGEMENT ACCORDING TO
GESTATIONALAGE
Less than 24 weeks of gestational age
• Antenatal surveillance with Umbilical & Ductus
venous doppler study is reliable
٠ If UmA diastolic flow +nt ٠ If UmA –RDF
٠ DV – Uninterrupted ٠ DV– Interrupted
forward flow forward flow
Fetal Acidosis& Hypoxia
Expectant Management Imminent Fetal Death
Termination

26 to 34 weeks gestational age
• Antenatal surveillance with NST and Umbilical
A, Middle cerebral A, Ductus venous doppler
1. NST-REACTIVE
UmA Doppler-Reassuring Repeat in 1wk
UmA Doppler-Non reassuring
Ductus venous Doppler Reassuring--Repeat 1wk
Non reassuring—Deliver

2. NST-NON REACTIVE
UmA Doppler—follow as above
Or Biophysical profile
≥8 UmA doppler
≤4 Deliver 6 Repeat in 6-24hrs
wait till ≥36wks
Deliver

34 TO 37 WEEKS GESTATIONALAGE
Antenatal surveillance with FHR monitoring by
• NST AND COLOR DOPPLER VELOCIMERY.
1. Both the tests reassuring Repeat in 1 week
Test for lung maturity
Immature Mature
Repeat in 1 wk Deliver
2.Either test non reassuring Deliver

MODE OF DELIVERY
• Labour is a stressful process for the fetus
• Every contraction reduces oxygenation, though
briefly and it recovers
• Prolonged difficult labors should be avoided!
• Continuous fetal monitoring is a MUST!
• Elective LSCS for severe IUGR, abnormal
presentation, oligohydramnios, abnormal CTG/
NST

AMNIOINFUSION
• Amnioinfusion refers to the instillation of fluid
into the amniotic cavity
• This procedure is typically performed during
labor through an intrauterine pressure
catheter introduced transcervically after
rupture of the fetal membranes
• Alternatively, fluid can be infused through a
needle transabdominally, the reverse process of
amniocentesis Dr. Kirtan Vyas # 9825407702

Randomised trial of Amnioinfusion during
labour with meconium stained amniotic fluid
(BJOG Jan 2002)
• Conclusion- Amnioinfusion in an under
resourced labour ward decreases
caesarean section rates and fetal
morbidity

CONCLUSION
• Currently USG measurements are used to confirm small fetal
size, whereas, BPP is used to assess fetal function. Based on BPP
one can consider the safety of continuing pregnancy.
Unequivocal cessation of ultrasound growth would also
constitute fetal grounds for delivery
• Risk of elective delivery after 37 weeks is very small, suspicion
of fetal compromise from any abnormal fetal welfare study may
precipitate decision for undertaking prompt delivery
• LSCS is used increasingly for the compromised fetus because of
high risk of fetal distress in labour
• However, in the Indian setup, facilities for NICU are not
uniformly available. Hence, the decision for time and mode of
delivery needs to be individualized as the management of such a
neonate is a real challenge. If possible, the mother should be
transferred to a center with a well-equipped neonatal care unit
to minimize the risks involved in transfer of the newborn baby

IUGR
• Heads are
disproportionately large
for their trunks and
extremities
• Facial appearance has
been likened to that of a
“wizened old man”
• Long nails
• Scaphoid abdomen

IUGR
“ I AM A FETUS IN THE WOMB
I FEAR IT MAY BECOME MY
TOMB
IF ONLY I COULD GIVE A SHOUT
TO MAKE MY DOCTOR GET ME
OUT!”
UNKNOWN MEDICAL STUDENT
DUBLIN, UK 1982

Fetal growth restriction

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