ULTRASOUND EXAMINATION OF IUGR

Jusuf Sulaeman Effendi

Dept. of Obstetrics & Gynecology

dr. Hasan Sadikin Hospital
Bandung
 Introduction
IUGR  problem in perinatology
Incidence : 3-5%
Perinatal morbidity and mortality >>
Growth disturbances and neurology
after birth depend on environment
IUGR : Symmetrical IUGR (type I)

Asymmetrical IUGR (type II)

Asymmetrical IUGR
Symmetrycal IUGR
 Maternal malnutrition, toxic habits

Decrease in intrinsic Uteroplacental insufficiency

fetal growth potensial

Hypertension
Chromosome abnormalities
preeclampsia, etc
inherited syndromes,
fetal infection, etc

Hyperplastic Combined stage Hypertropic

stage (hyperplastic & hypertropic) stage

0 20 28 40 weeks

IUGR IUGR IUGR

type I type III type II

Pathogenesis & classification of IUGR

Risk Factor :
Socio - economic
History of IUGR in the family
Poor obstetric history
Low maternal body weight
Obstetric complication in pregnancy
Medical complication in pregnancy
The purpose of US examination in IUGR

 Growth Disturbances (Fetal morphometry)

 Etiology, degree and prognosis (Functional
assessment)
FETAL MORPHOMETRY

Birth Weight
 Various Equations / variables :
 BPD
 HC
 AC
 FL
 Combination
FUNCTIONAL EVALUATION
1. Hard Sign :
 Amniotic Fluid Volume (AFV)
 Fetal well being
 Doppler velocimetry

 Intrafetal proportions
2. Soft Sign :
 Placentalgrade
 Subcutaneous fat
 Fat and muscle mass
Biometrical parameter principles

 Measurement must be standardized

 Discrimination considers
 Appropriate curves used for population
 Gestational age precisely determined
US examination for Fetal Biometry

Gestational age

False in measurement

Multiple variable

Serial measurement
Fetal weight estimation

 BPD & AC

 HC & AC

 AC, HC & FL
Serial fetal biometry assessment

 Biometry parameters
90%, 50%, 10%
-2 SD + 2SD

 HC / AC ratio
Crown Rump - length

 Sensitive parameter in the early stage

 6-12 weeks
 Error + 5 days in 95% cases
 Abnormal curve chromosomal
anomalies
CRL (mm)

Weeks of gestation

CRL 6-14 weeks

Biparietal diameter
Until 30 weeks linier (3 mm/weeks)
Week 30-38 ( 1,5 mm/week)
Week 38-42 ( 1 mm/week)
After week 42 0
BPD < 5th centile, IUGR in 68% cases
BPD 5-10th centile, 69% newborn was normal
BPD (mm)

Weeks of gestation

BPD & Fetal Age

Head circumference

 More complex in measurement

 Have advantages over BPD

(brachi/dolychocephaly)

 Sensitivity 52%, specificity 80%

Abdominal circumference
 Linier until week 36
 Week 34 is the best time for
differentiating fetuses with IUGR

Length of femur
 Affected in cases of asymmetrical IUGR
(type II)
Length of femur (mm)

Weeks of gestation

FL & Fetal Age

ABDOMINAL CIRCUMFERENCE
NORMAL vs MACROSOMIA
ABDOMINAL CIRCUMFERENCE
NORMAL vs IUGR
 Comparison of several biometric parameters

Predictive value
Sensitivity Specificity (+) (-)

Biparietal diameter 45 74.5 23 81.5

Cephalic circumference 52 80 26 94.3

Abdominal circumference 83 87.7 43 97.8

Femur length 58 81 23.3 95

HC / AC ratio

 HC/AC ratio decreases through out

pregnancy
 > 1.2 at 14-16 weeks
 < 1 after 36 weeks
 Between 0.4 and 1 at term
 Gestation (weeks)

HC / AC ratio
asymmetrical
Symmetrical
Evaluation of fetal function

 Determine the fetal function

 Evaluation of amniotic fluid
 Prediction value 70-100%
 IUGR with olygohydramnion perinatal
death 50 times
 ENVIRONMENT AND
FUNCTIONAL EVALUATION
1. Amniotic Fluid Volume
 Methods : - Subjective
- Objective : - 4-quadrant
- Largest pocket
 Predictive accuracy : 83-100%
 Relative risk : > 50
 Oligohydramnios + IUGR
 Perinatal emergency
 Intervention
 AFV - ASSESSMENT

 Four-quadrant measurement score (< 5 cm)

 Vertical diameter of the largest pocket (< 1 cm)
 Predictive accuracy : 79 - 100%
 Perinatal mortality :  > 50 - fold
 Indication for intervention
 Congenital anomalies
ENVIRONMENT AND FUNCTIONAL
EVALUATION
2. Fetal Well Being
 Accute insult :  Decreased
- Body movements
- Breathing movements
- Fetal tone
- Non reactive NST
 Chronic asphyxia : Oligohydramnios
 Manning et al (1980)
 Vintzileos et al (1987)
 Bpp 8 : 3.4% IUGR
Bpp 4 : 29% IUGR
Bpp 2 : 41 % IUGR
Oligohydramnios
 Postdatism
 IUGR
 Renal diseases
 PROM

Cord compression
Fetal deformation
Hydramnios

 Multiple pregnancy
 Anencephalus
 Gastrointestinal tract disorder
(High obstruction)
 Fetal hydrops
 Biophysical Profile

 Fetal movement, fetal breathing, fetal

tone, amniotic fluid, FHR pattern

 Score < 4 perinatal mortality

 Doppler velocimetry
 Especially in IUGR type II
 Elevation of SD ratio, PI, R I
 The earliest method in detecting IUGR
Growth retardation of fetal organ
Placental maturation
The thickness of subcutaneous fat
Muscle & fat thickness
 Pulse Doppler A.Umbilicales
Abnormality in IUGR

S/D ratio
Loss of end diastolic waveform/reversed
Absent diastolic flow dan
Reversed diastolic flow
Fetal compromized
 Umbilical
artery

Thump
Filter Umbilical
vein

Umbilical artery
A/B ratio = A/B
Resistance index (RI) = A – B
A
Pulsatility index (PI) = A – B
Mean

A schematic wave form

Loss of diastolic wave form in umbilical artery
LOST OF END DIASTOLIC
LOST OF END DIASTOLIC FLOW
Reverse diastolic wave form in umbilical artery
 S/D Ratios
Gest (weeks) Ratio ( % )
10 50 90
16 3.01 4.25 6.07
20 3.16 4.04 5.24
24 2.7 3.50 4.75
28 2.41 3.02 3.97
30 2.43 3.04 3.80
32 2.27 2.73 3.57
34 2.27 2.73 3.57
36 2.27 2.73 3.57
38 2.27 2.73 3.57
40 2.27 2.73 3.57
41 2.27 2.73 3.57
42 2.27 2.73 3.57