Literature review on intrauterine growth restriction and IUGR

1. IUGR
Oligohydramnios

2. Literature Review

3. Intrauterine Growth Restriction
Definition:
 Intrauterine growth restriction (IUGR) occurs when
failure of the fetus to reach growth potential for the
unborn baby is ≤ the 10th centile for his or her age (in
weeks).

4. Small for Gestational Age ( SGA)
• SGA refers to those fetuses whose estimated weight is less than 10th
centile for their gestational age. Most SGA fetuses are healthy.
• SGA and IUGR are not synonymous
• Some SGA – constitutionally small due to normal genetic influence
• IUGR – indicates there is a pathological process operating to restrict
growth rate of a fetus
• Some SGA may not be due to IUGR and can achieve their full growth
potential.
• All IUGR are SGA but not all SGA are IUGR.

5. Classification
5
Symmetrical Asymmetrical
Fetal abdomen is smaller than
the head and the brain which
are of normal size.
Fetal head and body are
proportionately small
-may occur when the fetus
experiences a problem during
early development

7. Aetiology
• IUGR resulting in SGA babies can result from
many factors known and unknown
either acting alone or in conjunction or in
association .
• In a majority of cases (40%) the cause is unknown–
probably due to placental insufficiency

8. Maternal Risk Factors
• Has had a previous baby who suffered from IUGR
• Extremes of age
• Is small in size (Ht & Wt)
• Has poor weight gain and malnutrition during
pregnancy.
• Uses of substances (like tobacco, narcotics, alcohol)
that can also cause abnormal development or birth
defects.
• Has a low total blood volume during early pregnancy

9. • Is pregnant with more than one baby.
• Has a cardio-vascular disease: preeclampsia,
hypertension, cyanotic heart disease, cardiac
disease Gr III & IV, diabetic vascular lesions.
• Chronic kidney disease
• Chronic infection - UTI, Malaria, TB, genital
infections
• Auto immune Disease : antiphospholipid antibody
syndrome, SLE

10. Fetal risk factors
• Exposure to an infection: German measles(rubella),
CMV, herpes simplex, tuberculosis, syphilis, or
toxoplasmosis, TB, Malaria, Parvo virus B19.
• A birth defect : cardiovascular, renal, anencephaly,
limb defect, etc
• A chromosome defect: trisomy-18 (Edwards’
syndrome),21(Down’s syndrome), 16, 13, xo
(turner’s syndrome)
• A chronic lack of oxygen during development
(hypoxia)

11. Placental factors
• Uteroplacental insufficiency resulting from -
• Improper / inadequate trophoblastic invasion and
placenta formation in the first trimester.
• Lateral insertion of placenta.
• Reduced maternal blood flow to the placental bed.
• Foetoplacetal insufficiency due to -
• Vascular anomalies of placenta and cord.
• Decreased placental functioning mass :
• Small placenta, abruptio placenta, placenta
previa & post term pregnancy.

12. Investigation
• Early detection is principle aim
• Early measurement
• Crown-rump length
• Biparietal diameter
• Serial USG biometry in pregnancies at risk of FGR
• Previous history of IUGR or SGA
• Twins pregnancy
• Abnormal uterine artery wave form in Doppler USG
• Sym-fundal height 3cm < expected SFH

13. Diagnosis
• Inadequate growth detected by serial measurement of
Symphysio fundal height
• Ultrasound:
Measure BPD, HC, AC, FL, HC:AC ratio, FL:AC ratio, EFW.
Serial measurements (not less than 2 weeks interval)
• Growth chart-inadequate fetal growth
• Reduced AFI

14. What is oligohydraminos?
• Oligohydraminos is a condition in pregnancy characterized by
a deficiency of amniotic fluid .It is the opposite of
polyhydraminos.
• An AFI(amniotic fluid index) between 8-18cm is considered
normal.
• An AFI < 5-6 cm is considered as oligohydraminos. The exact
number can vary by gestational age.

15. How does oligohydraminos affect
the foetus?
• Birth defects – Problems with the development of the kidneys
or urinary tract which could cause little uterine production ,
leading to low levels of amniotic fluid.
• Placental problems –If the placenta is not providing enough
blood and nutrients to the baby, then the baby may stop
recycling fluid.

17. Why IUGR often associated with
oligohydramnios?
• Amniotic fluid => from placenta , membranes and foetal urine
• Maternal to fetal blood flow decreased => oligohydraminos
• Blood flow to the kidneys -> GFR -> urine output
• It is present in 80-90% of IUGR fetuses

18. Management (IUGR)
• No widely accepted specific treatment for IUGR related to
utero-placental insufficiency
• General measures/ Preventive measures
 Stop smoking, alcohol, drug abuse
 Well nutrition
 Control of DM, Hypertension, thyroid disease
 Infection control
• Aim - To maximize mother health
• To gain as much maturity as possible

19. Maternal bed rest
This is the initial approach for the treatment of IUGR
The benefit of bed rest results in increased blood
flow to the uterus
Fetal Growth Monitoring
(a) Symphysio-fundal height (SFH) chart
(b) Abdominal circumference by Ultrasound
(c) Femur length

20. Fetal well-being
(a) Fetal movement counting
• ‘Count to 10 chart' or ‘Cardiff method’ is done by asking
the mother to record the time at which 10 fetal
movements have been noted.
• Inability to count 10 movements in a 12 hour period is
considered abnormal and associated with increased
likelihood of fetal death.
(b) Intensive fetal surveillance
• Serial USG
• CTG
• Fetal biometry and growth rate
• Doppler USG

21. Doppler investigation
• Fetal blood flow in placental, umbilical, and fetal
vessels may be assessed with modern Doppler blood
flow machine
• Umbilical artery
- If umbilical artery shows presence or increase of
end-diastolic flow (EDF) i.e. placental resistance falls
- If EDF shows absence or reverse, poor placental
function and fetal hypoxia may result.

22. Timing of delivery
• Fetal lungs maturity achieved
• In case of preterm IUGR, decision should be
based on:
- maternal health,
- fetal function tests,
- biochemical test of fetal lung maturity

23. Intra-partum
• Adequate oxygenation
• Continuous fetal monitor with CTG
• Fetal scalp electrode in abnormal CTG
• Cesarean section for deteriorating fetal condition
and/or unfavorable cervix
• Obstetric -Paediatric Team approach to decrease
meconium aspiration

24. Intrapartum monitoring of fetus
 Auscultation of FHR by fetal stethoscope
 Monitoring of liquor color
Normal – clear
Abnormal – meconium stained
 CTG
 Pulse USG using Doppler effect
 Fetal scalp blood sampling
 Fetal scalp electrode

25. Prevention of IUGR in subsequent
pregnancy
• Regular AN care- to prevent and detect at the earliest and
institute effective therapy to cause fetal growth restriction
• To screen for high risk mothers and monitor carefully fetal
wellbeing

26. THANK YOU !!!