Introduction and background

• IUGR remains a challenging

problem for both the
obstetrician and pediatrician.
• The ability to diagnose the
disorder and understand its
pathophysiology still outpaces
the ability to prevent its
complications..
Introduction and background
• . Fetal growth restriction is the
second leading cause of perinatal
morbidity and mortality
• . The incidence of intrauterine
growth restriction (IUGR) is
estimated to be approximately 5
percent in the general obstetric
population
PERINATAL IMPLICATIONS
IUGR causes a spectrum of perinatal
complications, including
• fetal deaths, prematurity, neonatal
death, fetal compromise in labor,
neonatal morbidity, induction of labor,
and cesarean delivery.
• Neonates with IUGR who survive the
intrauterine experience are at increased
risk for impaired neurodevelopment, and possibly
type 2 diabetes and hypertension in adult life.
 DEFINITIONS
The term IUGR has changed from
intrauterine growth retardation to the more
current term, intrauterine growth restriction..
•IUGR:- a fetus is unable to grow to its
genetically determined potential size to a
degree that may affect the health of the fetus.
 DEFINITIONS
•SGA :-refer to a fetus that has
failed to achieve a specific
biometric or estimated weight
threshold by a specific gestational
age..
• The commonly used threshold is
the tenth centile for abdominal
circumference and estimated
birthweight
 DEFINITIONS
• 50–70% of fetuses with a birthweight below
tenth centile for gestational age are
constitutionally small, and the lower the
centile for defining SGA, the higher the
likelihood of FGR
• Not all fetuses who are SGA (<10th
percentile) have IUGR, and not all
fetuses who have IUGR are SGA.
• For example, if a couple has had 3 term
4-kg babies and then has a 2.7-kg term
baby, that infant is not SGA but may
have IUGR.
 Symmetric and Asymmetric
IUGR
• . Symmetric growth restriction
implies a fetus whose entire body
is proportionally small.
• Asymmetric growth restriction
implies a fetus who is
undernourished and is directing
most of its energy to maintaining
growth of vital organs, such as
the brain and heart, at the
expense of the liver, muscle and
fat. This type of growth
restriction is usually the result of
placental insufficiency.
 Symmetric and Asymmetric
IUGR
• Investigators have differed on the
importance of this differentiation in
the diagnosis and management
• But recently. The symmetrically
grown infants who were SGA had
outcomes very similar to the infants
who were AGA. E-medicine May 2002
 maternal causes
Possible maternal causes of IUGR :-
• Chronic hypertension
• Pregnancy-associated hypertension
• Cyanotic heart disease
• Class F or higher diabetes
• Hemoglobinopathies
• Autoimmune disease
• Protein-calorie malnutrition
• Smoking
• Substance abuse
• Uterine malformations
• Thrombophilia Severi, 2000
 Fetal causes
• Possible causes of IUGR related to the
placenta and/or umbilical cord :-
• Multiple gestation
• Twin-to-twin transfusion
• Abnormal cord insertion
• Placental abnormality
• Chronic abruption
• Placenta previa
• Cord anomalies
Identifying a cause may not be possible in
as many as 40% of cases
Severi, 2000
 Diagnosis
• Four important issues need to be considered :
1- most measurements require an accurate
estimation of gestation as a prerequisite
2-most tests attempt to diagnose SGA fetuses rather
than growth-restricted fetuses
3-most studies use a one-off measurement (size) to
predict SGA while there is evidence that it is the
trend (growth) that is of more value in predicting
poor fetal outcome
4- no attention is made for important prognostic
factors for SGA, such as maternal height, weight,
ethnicity, parity and fetal gender
 Diagnosis
• It should also be noted that, although an
individual test alone may not be
predictive of SGA or FGR, a composite of
abnormal results such as an
ultrasonically small fetus with reduced
liquor or abnormal uterine artery Doppler
may indicate pathology.
 Diagnosis
. A distinction needs to be made between
biometric tests (tests to measure size) and
biophysical tests (tests to assess fetal
wellbeing
. the diagnosis of SGA would rely on
biometric tests while abnormal biophysical
tests are more indicative of FGR than SGA.
 Diagnosis
1- Abdominal palpation
• Grade C .
Abdominal palpation has
limited diagnostic accuracy to
predict a SGA fetus.

RCOG November 2002

 Diagnosis
2- Fundal height
• Grade B
• Symphyseal fundal height (SFH)
measurement has limited diagnostic
accuracy to predict an SGA neonate.
• Although early studies reported high
sensitivity and specificity , a large study
of 2941 women found the sensitivity and
specificity to be 27% and 88%,
respectively.
• Serial measurements may improve
sensitivity and specificity RCOG November 2002
 Diagnosis
2- Fundal height
• Grade B
• A customised fundal height chart improves
accuracy to predict a SGA fetus.
• A customised SFH chart is adjusted for
physiological variables such as maternal
height, weight, parity and ethnic group.
• Use of such charts was found to result in
improvement in sensitivity .
RCOG November 2002
 Diagnosis
3- Ultrasound biometry
• GradeB
A-Abdominal circumference and estimated fetal
weight to diagnose SGA.
• They are the most accurate diagnostic
measurements to predict SGA.
• In high-risk women, AC at less than the tenth
centile has sensitivities of 72.9–94.5% and
specificities of 50.6–83.8% in the prediction of
fetuses with birthweight at less than the tenth
centile.
RCOG November 2002
 Diagnosis
3- Ultrasound biometry
• Grade B
B-Customised ultrasound charts.
• Customised ultrasound EFW charts that are
adjusted for important independent
physiological variables, such as maternal
weight, maternal height, ethnic group and
parity, have better sensitivities for identifying
SGA fetuses , FGR, have lower false-positive
rates and are predictive of poor perinatal
events.
RCOG November 2002
 Diagnosis
3- Ultrasound biometry
• Grade B
C- Growth velocity in addition to size.
• Serial measurements of AC and EFW (growth
velocities) are superior to single estimates of
AC or EFW in the prediction of FGR and
predicting poor perinatal outcome.
• However, use of fetal growth alone to diagnose
growth restriction (especially when the interval
between the scan is less than two weeks) can
lead to high numbers of false positives.

RCOG November 2002

 Diagnosis
3- Ultrasound biometry
• Ratio measures, such as head to abdominal
circumference (HC/AC) and femoral length to
abdominal circumference (FL/AC) ratios are
poorer than AC or EFW alone in predicting
SGA.
• A systematic review in the Cochrane
Database of Systematic Reviews has shown
that routine ultrasound after 24 weeks in low-
risk pregnancy does not improve perinatal
outcome Cochrane library Evidence
level Ia
 Diagnosis
4- Biophysical tests

• All biophysical tests, including

amniotic fluid volume (AFV),
Doppler, cardiotocography and
biophysical scoring, are poor at
diagnosing a small or growth-
restricted fetus.
RCOG November 2002
 Diagnosis
4- Biophysical tests
• Grade B.
• AFV has minimal value in diagnosing FGR
• Despite the positive association between AFV
and neonatal morphometry, the likelihood ratios
remain low.
• For amniotic fluid index (AFI), a positive test
result has a likelihood ratio (LR) of 2.4 for
predicting skinfold thickness below the tenth
centile
• Serial measurements of AFI have similarly
disappointing results RCOG November 2002
 Diagnosis
4- Biophysical tests
• Grade A.
• Uterine artery Doppler has limited use in
predicting FGR.
• A systematic review with meta-analysis
published in 2000 found that uterine artery
Doppler had limited accuracy in predicting
FGR and perinatal death
• Abnormal uterine artery suggest a maternal
cause for the growth restriction where as
normal uterine artery Doppler studies
suggest that a fetal cause RCOG November 2002
 management
• At this point, the only reasonable goals
in the treatment of IUGR are to deliver
the most mature fetus in the best
condition possible with minimal risk to
the mother. Such a goal requires the
use of antenatal testing in hope of
identifying the fetus with IUGR before it
becomes acidotic.
 1- Assessment for chromosomal
defects
• When a small fetus is diagnosed, assess for
risk of chromosomal defects.
• Up to 19% of fetuses with an AC and EFW less
than the fifth centile may have chromosomal
defects
• The risk is higher when growth restriction is
associated with structural abnormalities, a
normal liquor volume or a normal uterine or
umbilical artery Doppler.
• Therefore, all growth-restricted fetuses need
an ultrasound anatomical survey as a
minimum. It may also be appropriate to offer
karyotyping.
2- Surveillance of the small fetus
(umbilical artery Doppler )
• Grade A
• Use umbilical artery Doppler as the
primary surveillance tool.
• A systematic review with meta-
analysis has provided evidence that
the use of umbilical
artery Doppler to monitor high-risk
fetuses reduces perinatal morbidity
and mortality.
• In addition, there was a significant
reduction in the number of antenatal
admissions and inductionsRCOG
of November
labour2002
 umbilical artery Doppler
• In normal pregnancy, there is a progressive
increase in end-diastolic velocity due to growth and
dilatation of the umbilical circulation. The
resistance index therefore falls.
• A resistance index > 0.72 is outside the normal
limits from 26 weeks gestation onwards.
• In some pregnancies with fetal growth restriction
and/or preeclampsia, there is a reduction in the
diastolic velocity and in severe cases, there is
absent or reversed end diastolic velocity.
2- Surveillance of the small fetus
(umbilical artery Doppler )
• . A study comparing fetal heart-rate
monitoring, biophysical profile and umbilical
artery Doppler found that only umbilical
artery Doppler had value in predicting poor
perinatal outcomes in SGA
• Screening a low-risk or unselected
population by umbilical artery Doppler,, is
not recommended for screening.
2- Surveillance of the small fetus
(umbilical artery Doppler )
• A variety of indices of umbilical arterial
Doppler waveform, such as:-
• resistance index, systolic/diastolic ratio,
pulsatility index and diastolic average
ratio, is used for predicting perinatal
outcome.
• resistance index had the best ability to
predict abnormal outcomes
• When an anomaly scan and umbilical
artery Doppler are normal, the small
fetus is likely to be a ‘normal small fetus
• Evidence suggests that outpatient
management of such fetuses is safe.
RCOG November 2002 Evidence level II
2- Surveillance of the small fetus
(umbilical artery Doppler )
• frequency of monitoring in SGA
fetuses with normal Doppler
need not generally be more than
once every fortnight.

RCOG November 2002 Evidence level II

2- Surveillance of the small fetus
(liquor volume )
• Grade B
• Measure liquor volume using either AFI
or pocket depth as both tests have
similar diagnostic accuracy.
• Abnormal liquor volume has been
variously defined as single cord-free 1-
cm, 2-cm, or an AFI below the fifth
centile for the gestation or . 5 cm.
RCOG November 2002
2- Surveillance of the small fetus
(liquor volume )
• a systematic review with meta-
analysis of 18 studies with over
10 000 patients found an
antepartum AFI of . 5.0 cm was
associated with an increased
risk of an Apgar score of less
than seven at five minutes
RCOG November 2002Evidence level I and III
2- Surveillance of the small fetus
(biophysical profile and cardiotocography )
• Grade A
• The biophysical profile has not been shown
to improve perinatal outcome but sufficient
data do not exist to rule out its value.
• However, there is evidence from
uncontrolled observational studies that
biophysical profile in high-risk women has
good negative predictive value, i.e. fetal
death is rare in women with a normal
biophysical profile
RCOG Nov. 2002 Evidence level Ia
 2- Surveillance of the small fetus
(biophysical profile and cardiotocography )
• the absence of benefit from randomised trials and
since it is a time-consuming test, So it cannot be
recommended for routine monitoring in low risk
pregnancies or for primary surveillance in SGA
• However, when primary surveillance with umbilical
artery Doppler is found to be abnormal, biophysical
profile is likely to be useful given its good negative
predictive value in high-risk populations.
• This recommendation is further supported by evidence
that, in high-risk women, the biophysical profile was
rarely abnormal when Doppler findings were normal.

Evidence level Ib
2- Surveillance of the small fetus
(biophysical profile and cardiotocography )
• Use of cardiotocography (CTG) antepartum
to assess fetal condition is not associated
with better perinatal outcome.
• In fact, a systematic review of randomised
trials showed that there was a trend towards
increased mortality in the group receiving
CTG compared with those who did not.
Computer systems for interpretation of CTG
have better accuracy than clinical experts in
predicting umbilical acidosis and depressed
Apgar scores.
Evidence level Ib
 Timing of delivery
Delivery
• There is wide variation in practice in the timing of
delivery of growth restricted fetuses.

RISK OF stillbirth
k of prematurity
 End diastolic flow is present
(PED)
• Grade C
• When end diastolic flow is present (PED), delay
delivery until at least 37 weeks, provided other
surveillance findings are normal.
• Absent or reversed end diastolic flow is associated
with increased perinatal mortality and morbidity.
The odds ratio for perinatal mortality with absent or
revered end diastolic flow were 4.0 and 10.6,
respectively, compared with when end diastolic flow
was present.
• The incidences of respiratory distress syndrome and
necrotising enterocolitis were not increased with
absent or revered end diastolic volume but there
was an increase in cerebral haemorrhage, anaemia
and hypoglycaemia.
•Evidence level IIa
 End diastolic flow is absent or
reversed
• Grade C
When end diastolic flow is absent or
reversed
• admission, close surveillance and
administration of steroids are required.
• If other surveillance results (biophysical
profile,
venous Doppler) are abnormal, delivery
is indicated.
• If gestation is over 34 weeks, even if
other results are normal, delivery may
be considered.
 If other surveillance results (biophysical profile,
venous Doppler) are normal, and gestation is below34
weeks,
The optimal surveillance strategy in those women is
unclear.
• Options include daily CTG/BPP and/or venous
doppler
deliver when
1. The CTG becomes pathological (decelerations with
reduced variability),
2. The biophysical profile becomes abnormal
3.There is reversal of Doppler velocities in ductus
venosus during atrial contraction
4.or there are umbilical vein pulsations.
Under these circumstances, delivery is likely to be
by caesarean section
 If other surveillance results (biophysical profile,
venous Doppler) are normal, and gestation is below34
weeks,

• The interval between first occurrence of

AED and an abnormal CTG/biophysical
profile has ranged from 1–26 days
depending on Gestational age, the
presence of hypertension and venous
Doppler abnormalities (notably
pulsations in the umbilical vein)
Some forms of
intervention
• . Most prenatal interventions do not show
any significant effects on perinatal outcome.
• . Smoking cessation programmes, can be
effective for a small minority of smokers in
increasing birthweight but there are no data
to suggest that this intervention improves
perinatal outcome.
•.
Some forms of
intervention
• Although a meta-analysis of 13 trials
evaluated the use of aspirin in the
prevention of growth restriction and
found that it reduced the incidence of
FGR, only a few studies have used aspirin
in the treatment of FGR. These trials are
small and have shown conflicting
results. Further trials are needed to
assess the value of aspirin in the
treatment of FGR..
Some forms of
intervention
• A meta-analysis of randomized trials finds
that a daily low dose of aspirin therapy
among high-risk women significantly reduces
the risk of perinatal death and preeclampsia
also a significant reduction in the rate of
spontaneous preterm births and an increase
in birth weights
• . The researchers did not find any evidence of
harm from aspirin therapy in pregnant
women.
• They conclude that, aspirin therapy should be
considered for pregnant women at high risk in
prevention of IUGR.
•ACOG May 31, 2003
 Some forms of intervention
There is not enough evidence to
assess the value of
1. oxygen therapy,
2. nutrient therapy,
3. hospitalisation and bedrest,
4. betamimetics,
5. calcium channel blockers,
6. hormonal therapy
7. and plasma volume expansion
in treating growth restriction.

The Cochrane Library, Issue 3, 20

Some forms of
intervention
• Grade A
•Administer steroids if
gestation is below 36
weeks.
•Antenatal steroids
significantly reduce the
incidence of respiratory
distress syndrome.
RCOG November 2002
Intrpartum management
• Grade C
Deliver in a unit where optimal
neonatal expertise and facilities
are available.
• A skilled resuscitator who is
trained and competent in
resuscitation of the newborn
should be present at delivery.
 Intrpartum management
• Grade C
• Intrapartum monitoring with continuous CTG
is recommended.
• Although a systematic review of randomised
trials found that intrapartum electronic
monitoring did not reduce perinatal mortality,
there are substantial observational data to
suggest that intrapartum CTG in high-risk
populations is likely to be of benefit in
reducing perinatal death.
• Current data are not sufficient to justify a
policy of elective caesarean section of all
small for gestational age babies.
 Key points
1. Fetal growth abnormalities generally
result from either intrinsic fetal, placental,
maternal factors, or exogenous toxins or
infections.
2. FGR is diagnosed by sonographic
examination of the fetus
3. Early determination of gestational age is
of paramount importance.
4. Measuring the abdominal circumference
via U/S is the most useful single parameter
for detecting poor fetal growth.
5. serial U/S measurements are usually
preferred to single measurements
 Key points
6-The goal of surveillance is to accurately detect
the fetus that has or is at risk for acidosis—so
that it can be delivered early.
7- All women with evidence of FGR should be
offered surveillance with umbilical artery
Doppler and biometry as a minimum.
8- Corticosteroids should be offered to all
women who may need delivery between 24 and
36 weeks.
 Key points
9- All women who smoke
should be given full
information regarding
the significance of
smoking in pregnancy
and the postnatal period.
10-Low dose aspirin is
indicated for high risk
patient in prevention of
IUGR.
 Key points
11-Delivery is indicated in following conditions
A-When end diastolic flow is present (PED),
and other surveillance findings are
normal, delay delivery to 37 weeks.
B -When end diastolic flow is absent or
reversed, deliver at 34w regardless of
biophysical tests
C--When end diastolic flow is absent or
reversed and other surveillance results
(biophysical profile, venous Doppler) are
abnormal, delivery is indicated at any time
 Key points
12-Consider conservative
management for women who
have :-
• A-End diastolic flow is
present (PED), before 37
weeks, provided other
surveillance findings are
normal
• B-End diastolic flow is absent
or reversed and other
surveillance results are
normal before 34 w
 Key points
• 13-Where possible, a neonatologist
and A skilled resuscitator should
be present if gestation is extremely
preterm or growth restriction is
severe.
• 14-Intrapartum monitoring with
continuous CTG is recommended