Intra-uterine Growth Restriction Dr ShantalaVadeyar MD, FRCOG, DM Advanced Obstetric Ultrasound (RCOG / RCR) Subspecialist Fetal & Maternal Medicine (RCOG) Consultant Obstetrician, Fetal & Maternal Medicine KokilabenDhirubhaiAmbani Hospital, Mumbai
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
Size v/s Growth • Small for gestational age - <2.5 kg • Preterm gestation and small • Term gestation and small • Healthy but small – Constitutionally small • Pathologically small – IUGR
Causes of IUGR – 1. Maternal • Chronic maternal conditions • Renal disease • Hypertension • Long standing Diabetes • Congenital heart disease • Smoking • Alcohol • Anemia - severe
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
Causes of IUGR – 3. Placental • Placental thrombosis / infarctions • Antiphospholipid syndrome • Chorioamnionitis • Abruptio placentae – usually acute, but sometimes, small recurrent bleeds • Placenta previa
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
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!
Diagnosis • Accurate dating is vital! • < 20 weeks of gestation, preferably < 14 wks • Suspect clinically • Uterus palpates small • Less amniotic fluid • Reduced fetal movements • High risk maternal, placental, uterine or fetal factors
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!
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
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
Umbilical Artery Doppler • Indicates resistance in the feto-placental vascular bed • Angle of insonation should be <60o • From 16 weeks onwards- positive end diastolic flow (EDF) • Reduced EDF, Absent EDF and Reversed EDF represent increasing resistance in the vascular bed
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- HC>AC suggests growth restriction due to placental insufficiency
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)
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
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
What does NOT help… • Duvadilan / Bricanyl • Amnioinfusions • Oxygen therapy • Amninoacid preparations • Bed rest ??
Timing of delivery • >34 weeks – good neonatal outcome • <34 weeks - Betamethasone inj should be given to the mother • Fetal pulmonary maturity • Reduces risk of intra-ventricular haemorrhage • Very preterm gestation - <28 weeks ? • To wait or to deliver…
Preterm labour in IUGR • Often IUGR fetuses / pregnancies tend to go into preterm labour • Nature’s way of resolving the problem • Important to recognise this and avoid prolongation of pregnancy!
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
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
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
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
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
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
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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