Updated: 1/28/2020

Intrauterine Growth Restriction

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Snapshot
  • A 35-year-old G3P0 woman at 30 weeks gestation presents to her obstetrician for a routine prenatal visit. She has had an unremarkable pregnancy with normal fetal ultrasounds. She has no medical conditions, but has been smoking throughout pregnancy. She denies the use of alcohol or drugs. Physical exam is significant for a fundal height of 25 cm and a normal fetal heart rate tracing. Ultrasound reveals a fetus with a head circumference consistent with 33 weeks gestation and an abdominal circumference consistent with 23 weeks gestation. Estimated fetal weight is at the 6th percentile for gestational age. 
Introduction
  • Clinical definition
    • Estimated fetal weight below the 10th percentile for a given gestational age
    • Classified as 
      • symmetric intrauterine growth restriction (IUGR)
        • proportional reduction in head, body, and length
      • asymmetric IUGR
        • preservation of head circumference and reduction in trunk and limb length
  • Epidemiology
Epidemiology of Symmetric vs Asymmetric IUGR 

Symmetric
Asymmetric 
Risk factors 
  • Intrinsic factors 
    • genetic abnormalities 
    • congenital infections 
    • congenital heart disease 
  • Extrinsic factors
    • chronic maternal disease (e.g., hypertension, renal failure, diabetes) 
    • pre-eclampsia 
    • smoking 
    • drug use
    • alcohol use
    • teratogenic drugs (e.g., ACE inhibitors, phenytoin, warfarin)

Pathophysiology
  • Caused by a global perturbation of fetal growth due to
    • intrinsic fetal problems
      • trisomy 18
      • renal agenesis
    • infections
      • ToRCHeS
        • rubella infection 
        • toxoplasmosis
  • caused by placental insufficiency
    • secondary to intrinsic placental defects or decreased maternal blood flow to the placenta
    • the fetus now selectively shunts blood flow to the most critical and needed areas (e.g., brain) and away from limbs and abdomen

  • Prognosis
    • increased neonatal mortality 
    • increased risk of pre-term birth 
    • increased risk of disease in adulthood 
      • type II diabetes mellitus
      • obesity
      • cardiovascular disease
      • renal disease 
    • Worse prognosis with early onset and increasing severity of growth restriction
Presentation
  • Physical exam
    • neonatal findings
      • inspection
        • thin, loose, and peeling skin
        • decreased muscle mass
        • decreased subcutaneous fat
        • thin umbilical cord
        • shrunken face
        • larger than expected anterior fontanelle
        • meconium-stained infant
      • motion 
        • decreased or absent fetal movement 
    • maternal findings
      • inspection
        • fundal height discrepancy
Imaging
  •  Ultrasonography
    • indications
      • to confirm the diagnosis in patients with a history and physical exam findings concerning for IUGR
    • findings 
      • decreased fetal weight below 10th percentile of a given gestational age
      • fetal biphysical profile    
        • amniotic fluid volume
        • fetal movement and tone
        • fetal breathing movement
        • heart rate reactivity 
      • doppler velocimetry 
        • reduced or absent doppler flow 
      • measurements of head and abdominal circumference, biparietal diameter, and femur length
Studies
  • Labs
    • screening for congenital infections
    • genetic amniocentesis
    • ultrasonography to detect fetal anomalies
Differential
  • Small for gestational age
    • key distinguishing factor 
      • estimated weight less than the 10th percentile for a given gestational age
  • Incorrect pregnancy dating
    • key distinguishing factor
      • ultrasound measurements for dating 
  • Oligohydramnios
    • key distinguishing factor
      • ultrasound findings demonstrating estimated weight less than the 10th percentile for a given gestational age
Treatment
  • Conservative
    • close fetal monitoring
      • indication
        • in cases of asymmetric IUGR in order to identify fetuses at risk of intrauterine demise and neonatal morbidity in order to determine if pre-term delivery is needed
      • modalities
        • serial ultrasounds
        • umbilical artery Doppler
        • nonstress test and biophysical profile
    • delivery
      • indications
        • in cases of severe IUGR with signs of non-reassuring fetal status 
        • if the fetus is close to term, administer steroids and deliver within 48 hours
      • modalities
        • cessarean delivery
        • vaginal delivery
 Complications
  • Maternal pre-eclampsia
  • Perinatal death
  • Premature delivery
  • Hypoglycemia
  • Polycythemia
  • Impaired cellular immunity
  • Hypocalcemia
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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