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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