Intra-uterine Growth Restriction

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www.totalpregnancycare.com
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Intra-uterine Growth Restriction

• Dr Shantala Vadeyar
• MD, FRCOG, DM
• Advanced Obstetric Ultrasound (RCOG / RCR)
• Subspecialist Fetal Maternal Medicine (RCOG)
• Consultant Obstetrician, Fetal Maternal
  Medicine
• Kokilaben Dhirubhai Ambani Hospital, Mumbai

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Definition

• IUGR is failure to achieve the fetal growth
  potential
• Difference between size and growth
• Size - one measurement
• Growth multiple measurements plotted on a graph
• Growth charts important in fetuses like in
  children

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Size v/s Growth

• Small for gestational age - lt2.5 kg
• Preterm gestation and small
• Term gestation and small
• Healthy but small Constitutionally small
• Pathologically small IUGR

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Causes of IUGR 1. Maternal

• Chronic maternal conditions
• Renal disease
• Hypertension
• Long standing Diabetes
• Congenital heart disease
• Smoking
• Alcohol
• Anemia - severe

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Causes of IUGR 2. Fetal

• Infection TORCH
• Toxoplasma, Rubella, CMV
• Malformation
• Gastroschisis
• Chromosomal abnormalities
• Trisomy 18 (Edward syndrome)
• Multifetal pregnancy
• Chorionicity determination is vital
• MC Twins, Twin twin transfusion syndrome

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Causes of IUGR 3. Placental

• Placental thrombosis / infarctions
• Antiphospholipid syndrome
• Chorioamnionitis
• Abruptio placentae usually acute, but
  sometimes, small recurrent bleeds
• Placenta previa

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Causes of IUGR 4. Uterine

• Poor uterine blood flow
• Poor placental blood flow
• Large fibroids leading to poor placentation
• Uterine anomalies septate or subseptate uterus

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IUGR screening

• Whom to screen?
• Ideally Symphysis Fundal Height 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!

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Diagnosis

• Accurate dating is vital!
• lt 20 weeks of gestation, preferably lt 14 wks
• Suspect clinically
• Uterus palpates small
• Less amniotic fluid
• Reduced fetal movements
• High risk maternal, placental, uterine or fetal
  factors

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Ultrasound diagnosis of IUGR

• Growth
• Measure the fetus biometry
• Head circumference
• Abdominal circumference
• Femur length
• Measure the amniotic fluid- AF index, SDP
• Evaluate the blood flows- Dopplers!

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Uterine Artery Doppler

• Screening test in pregnant women
• High resistance waveform- notching indicates
  poor placentation
• Notches are present in early gestation but
  disappear 24 weeks onwards
• Bilateral notches are significant

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Uterine A Doppler- Normal
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Uterine Artery Doppler

• Notching indicates a high risk pregnancy
• Increased risk of
• Pre-eclampsia
• Growth restriction
• Placental abruption
• Intrauterine fetal death
• Increased monitoring- growth scans, Umbilical
  artery Doppler

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Uterine A Doppler- Notching
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Umbilical Artery Doppler

• Indicates resistance in the feto-placental
  vascular bed
• Angle of insonation should be lt60o
• From 16 weeks onwards- positive end diastolic
  flow (EDF)
• Reduced EDF, Absent EDF and Reversed EDF
  represent increasing resistance in the vascular
  bed

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Umbilical Artery Doppler
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Umbilical A AEDF
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Umbilical A REDF
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Fetal growth

• Serial assessments are important
• Growth trajectory is important, not size!
• Symmetrically small fetus
• Constitutionally small
• Genetic syndromes/ chromosomal abn
• Very early onset IUGR
• Asymmetric- HCgtAC suggests growth restriction due
  to placental insufficiency

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Interpretation of Ultrasound findings in IUGR

• Clinical history
• Previous poor outcome
• Antepartum haemorrhage
• Reduced fetal movements
• Gestation- how accurate? Viability?
• U/S- Growth, Biphysical profile, Umbilical Artery
  and Uterine Dopplers
• CTG (NST)

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Antenatal Surveillance in IUGR

• Watch fetal movements
• Maternal health pre-eclampsia
• Biophysical Profile Score
• Comprises 2 points each for-
• Fetal body movements
• Fetal tone
• Fetal breathing movements
• Amniotic fluid volume
• CTG

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Fetal Middle Cerebral Artery Doppler

• 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)
• Cerebro-placental ratio increases this is
  indicative of IUGR

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MCA Doppler
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MCA Doppler- IUGR
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What does NOT help

• Duvadilan / Bricanyl
• Amnioinfusions
• Oxygen therapy
• Amninoacid preparations
• Bed rest ??

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Timing of delivery

• gt34 weeks good neonatal outcome
• lt34 weeks - Betamethasone inj should be given to
  the mother
• Fetal pulmonary maturity
• Reduces risk of intra-ventricular haemorrhage
• Very preterm gestation - lt28 weeks ?
• To wait or to deliver

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Preterm labour in IUGR

• Often IUGR fetuses / pregnancies tend to go into
  preterm labour
• Natures way of resolving the problem
• Important to recognise this and avoid
  prolongation of pregnancy!

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Mode of delivery

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

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Outcome

• Mild moderate IUGR good
• Severe early onset IUGR some organ systems may
  be compromised
• Gut - Neonatal necrotising enterocolitis
• Kidneys renal failure
• Brain cerebral palsy
• Genetic syndromes / malformations

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IUGR in DC twins

• Dichorionic twins- confirmed by 10-12w scans
• Twin 1
• AC dropped from 10th to 5th centile
• AF 3rd centile
• Absent EDF in one umb artery initially, then both
• Bladder seen, normal biophysical score
• Twin 2
• AC 50th centile, Normal AF, Normal UA Doppler
• Normal sized bladder, heart, biophysical scores

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Management- when to deliver?

• Monitor biophysical profiles and Umbilical Artery
  Dopplers
• Risk of preterm delivery versus compromise
• What is the significance of worsening Umbilical A
  Dopplers?
• Risks of preterm delivery- respiratory distress
  syndrome, necrotising enterocolitis, infection
• Risk to well grown fetus of prematurity
• Intrauterine complications- abruption, worsening
  of maternal PET, IUFD

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Decision to deliver

• Twice weekly Biophysical scores
• Twice daily CTGs, FM monitoring
• 31 weeks Both Umb A in twin 1 showed absent EDF.
  
• Discussion with parents- proceed to LSCS
• Twin 1 was1 kg, twin 2 was 1.8 kg, both males
• NEC in Twin 1 recovered
• Good outcome

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IUGR- Case 2

• 25 year old primigravida
• 34 weeks, presented with severe oedema, raised
  BP, proteinuria
• Diagnosis PET (pre-eclampsia)
• Scan Both AC, HC less than 3rd centile
• Amniotic fluid volume 5th centile
• Biophysical score 6/10

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IUGR- MCA redistribution
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IUGRUmbilical A Doppler AEDF
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IUGR DV- normal
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Profile

• Total Pregnancy Care is an online guide for
  pregnancy, childbirth and motherhood related
  information. Women wanting to conceive, pregnant
  women, expecting parents, and new mothers can use
  this pregnancy portal for a healthy pregnancy,
  fulfilling childbirth and joyful motherhood. With
  pregnancy at its core, this portal covers various
  important aspects and especially addresses those
  matters that the Indian Woman always wanted to
  know but did not know whom to ask.
• This website is compiled by Dr. Shantala, an
  Indian Obstetrician and Gynaecologist. She has
  over 20 years of extensive medical and
  diagnostics experience in areas commonly related
  to the Maternity and Pregnancy fields. She has
  studied and practiced in India as well as in the
  United Kingdom and thus brings about the fusion
  of best practices of the Oriental East and the
  Progressive West.
• A mother of three children, she has complete
  understanding of the emotional, mental and
  physical needs of the New Age Pregnant Woman. Her
  patients appreciate her empathic approach and
  wholeheartedly express their gratitude for her
  generosity and care. Dr.Shantala is presently a
  full time Obstetrics and Gynaecology Consultant
  at the Kokilaben Dhirubhai Ambani Hospital and
  Medical Research Institute, a premier health care
  initiative of the Reliance ADA Group. Dr.Shantala
  has a clear vision to promote a holistic
  pregnancy approach and her mission is to provide
  comprehensive maternity care. This website,
  www.TotalPregnancyCare.com, is her first step
  towards this future.

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Services Offered

• Pre-pregnancy counseling
• Genetic counseling
• Antenatal care, Labour Delivery
• Specialist Ultrasound scans
• Viability scan
• The First trimester scan / Nuchal translucency
  scans
• Detailed anatomy / anomaly scans
• Fetal Echocardiograph
• 3D / 4D scans
• Assessment of the High risk Fetus and Mother
• Amniocentesis
• Chorionic Villous sampling
• Cordocentesis
• Intra-uterine transfusions
• Embryo Reduction / Selective fetocide
• Second opinion scans

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Society Memberships

• British Maternal Fetal Medicine Society
• Fetal Medicine Centre
• Kokilaben Dhirubhai Ambani Hospital Medical
  Research Institute
• Royal College of Obstetricians and
  Gynaecologists
• International Society of Ultrasound in
  Obstetrics and Gynecology

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Contact Us

• Email shantala_at_totalpregnancycare.com
• Mobile [phone]
• KDAH Board line 91 22 30999999

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