BD7003 DR Ide IUGR

IUGR – Intra Uterine Growth Restriction
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Fetal growth restriction (FGR)
 isdefined as the inability of the fetus to achieve its growth

potential.
 FGR is a complex and multifactorial disorder resulting
from maternal, fetal and placental conditions
 Placentalinsufficiency is the most common cause of FGR
(30–40% of all cases) followed by chromosomal disorders
and congenital malformations (20% of all cases)
Etiology
 Maternal Factors
 Placental Factors
 Fetal Factors
Maternal Factors
 Genetic size
 Demographics
 Age (extremes of reproductive age)
 Race
 Socioeconomic status
 Underweight before pregnancy or malnutrition
 Chronic disease
 Exposure to teratogens (drugs, radiation, etc.)
Maternal Factors (cont.)
Factors that interfere with placental flow and function
  Postmaturity
Heart disease
  Multiple gestation
Renal disease
  Uterine anomalies
Hypertension
  Thrombotic disease
Pulmonary disease
  High altitude environment
Hemoglobinopathies
  Smoking
Collagen-vascular disease
  Cocaine
Diabetes
Placental Factors
 Malformations – vascular
 Chorioangioma
 Infarction
 Abruption
 Previa
 Abnormal trophoblast invasion
Fetal Factors
 Constitutional – genetically small, but genetically normal
 Chromosomal abnormality – only about 5% of SGA babies
 Malformations – CNS, skeletal, gastroschisis
 Congenital infections – CMV, rubella
Classification
 Early-onset (diagnosed < 32 weeks) --> symmetric IUGR

 late-onset (diagnosed ≥ 32 weeks) -->asymmetris IUGR
Characteristics
Characteristics of
of IUGR
IUGR
SYMMETRIC
 EARLY ONSET
 CONSTITUTIONAL OR “NORMAL” SMALL
 DECREASED GROWTH POTENTIAL
 NORMAL PONDERAL INDEX
 BRAIN SYMMETRICAL TO BODY
EXAMPLES
 GENETIC CAUSES, CHROMOSOMAL
 TORCH INFECTIONS
 SYNDROMES
Characteristics of IUGR
Asymmetric
 Late onset
 Environmental
 Growth arrest
 Brain sparing
Examples
 Chronic hypoxia
 Preeclampsia
 Chronic hypertension
 Malnutrition
Diagnosis
 Fetalgrowth restriction (FGR) is diagnosed with a sonographic

estimated fetal weight (EFW) or abdominal circumference (AC)
< 10th percentile for gestational age.
 Smallfor Gestational Age (SGA) should be used to describe a
newborn whose birth-weight is below the 10th percentile.
 Severe growth restriction is defined as EFW below the 3rd
percentile for gestational age or EFW/AC below the 10th
percentile with abnormal umbilical artery Doppler.
COMPLICATION
 Fetus
 Neonates
 Infant and child
 Adult
COMPLICATION - FETUS
 Oligohydramnios,
 non-reassuring fetal heart testing (NRFHR),
 and stillbirth.
COMPLICATION - NEONATE
 Preterm birth and its consequences
 respiratory distress syndrome (RDS),
 intraventricular hemorrhage (IVH),
 necrotizing enterocolitis [NEC]),
 hypoglycemia,
 hyperbilirubinemia,
 hypothermia,
 seizures,
 sepsis,
 neurodevelopmental delay
 and neonatal death.
COMPLICATION - INFANT AND
CHILD
 Impaired gross motor development,
 cerebral palsy,
 lower intelligence quotient,
 mental retardation,
 speech/reading disabilities,
 learning deficits,
 poor academic achievement,
 and suicide.
Growth
Growth Consequences
Consequences of
of IUGR
IUGR
Height at 4 years Weight at 4 years
50 50
40 40
Percent
Percent
30 30
20 20
10 10
<10 10-50 50-90 >90 <10 10-50 50-90 >90

Percent Percent
Term AGA Term SGA Preterm SGA

Growth
Growth Consequences
Consequences of
of IUGR
IUGR
Head Circumference at 4 years
50
40
30
20
10
<10 10-50 50-90 >90

Percent
Term AGA Term SGA Preterm SGA

COMPLICATION - ADULT
 Hypertension,
 coronary artery disease,
 diabetes,
 obesity.
MATERNAL COMPLICATIONS:
• Hypertension in 50% of cases at the time of

diagnosis and 70% at the time of delivery (in
pregnancies complicated by early-onset FGR).
• Increased risk of cesarean delivery.
SURVEILLANCE
• Fundal Height measurement during Antenatal care
• EFW measurement
 Growth ultrasound every 3 to 4 weeks. Three-week (or even two-week) intervals should be
done in particular the setting of severe FGR or with abnormal umbilical artery Doppler.
 Umbilical artery Doppler assessment should be performed initially usually every 1 week to
assess for deterioration.
 If the umbilical artery Doppler remains normal following this initial assessment, a less
frequent interval of umbilical artery Doppler testing (e.g., every 2–4 weeks) can be
considered.
 CTG at least weekly should be performed in pregnancies complicated by FGR.
Frequency should be increased in the presence of A/REDV or other
comorbidities and risk factors.
PREPARATION FOR DELIVERY
 Antenatal corticosteroids:
 if delivery is anticipated before 33 6/7 weeks of gestation
 or for pregnancies between 34 0/7 and 36 6/7 weeks of gestation in women without
contraindications who are at risk of preterm delivery within 7 days and who have
not received a prior course of antenatal corticosteroids.
 Magnesium sulfate for fetal and neonatal neuroprotection is indicated for
women with pregnancies that are less than 32 0/7 weeks of gestation in
whom delivery is likely.
TIMING OF DELIVERY
• 38 0/7 to 39 0/7 weeks of gestation in pregnancies complicated by FGR

with an EFW between the 3rd and the 10th percentile and normal
umbilical artery Doppler.
 37 0/7 weeks of gestation in pregnancies complicated by FGR with an
umbilical artery Doppler waveform with decreased diastolic flow (S/D,
RI or PI above than the 95th percentile) but without A/REDV or in the
setting of severe FGR (EFW less than the 3rd percentile).
TIMING OF DELIVERY
 33 0/7 to 34 0/7 weeks in pregnancies complicated by FGR in the presence

of AEDV.
• 30 0/7 to 32 0/7 weeks in pregnancies complicated by FGR in the presence
of REDV.
• 34 0/7 to 37 6/7 weeks of gestation for FGR associated with
oligohydramnios.
 Irrespective of Doppler findings, and in viable pregnancies with FGR,
delivery is always indicated in the presence of non-reassuring fetal heart
testing, or maternal indications.
MODE OF DELIVERY:
 Cesarean delivery should be considered in pregnancies with

FGR complicated by A/REDV, based on the entire clinical
scenario.
 Induction of labor with mechanical methods appear to have a
lower association with adverse outcomes when compared to
induction with prostaglandins.
MANAGEMENT - PREVENTION
 Accurate Gestational Age Measurement

 First-trimester ultrasound < 13 weeks and 6 days is the most precise method
to determine the EDC.
 Interpregnancy intervals less than 6 months are associated with FGR (OR 1.3;
95% CI 1.1–1.5). In a large retrospective study of 173,205 birth certificates,
infants conceived 18–23 months after a previous live birth had the lowest risks of
adverse perinatal outcomes including SGA at birth
 Smoking cessasion in pregnancy reduced the rate of low birth-weight (RR
0.83, 95% CI 0.73–0.95)
MANAGEMENT - PREVENTION
 Nutrition:
 In high-risk women with nutritional deficiencies, increasing
caloric intake with low-protein supplementation reduces the risk
of FGR by 32%.
 Inthe absence of nutritional deficiency, high protein
supplementation may lead to higher rates of FGR and should be
avoided
 Control of maternal medical disorder
MANAGEMENT - Treatment
 cessation of the substance associated with FGR

 Proper treatment of chronic hypertension, pre-eclampsia,
diabetes, or other medical condition
 low-dose aspirin has been shown to decrease the
incidence of FGR when initiated prior to 16 weeks in
women with a first-trimester abnormal uterine artery
Doppler PI in
Neonatology management
 FGR neonates frequently require assistance with ventilation and feeding,

especially if born preterm.
 FGR neonates < 32 weeks or < 1500 g requires special care, usually in a
tertiary care center.
 Workup of the etiology of FGR should be completed if not already done
prenatally
 Hypoglycemia, polycythemia, and coagulopathies are common, and may
need treatment.
 Involvement of the neonatology team on counseling the patient prior to
delivery on expectations in the intensive care unit may be helpful for
families
Future pregnancy preconception
counseling
 Recurrence risks are dependent upon the etiology, but
when the etiology is uncertain, the rate of recurrence is
increased to as high as 23%.
 In the subsequent pregnancy, screening for FGR with
ultrasound surveillance of fetal growth should be
considered in the third trimester.
THANK YOU
dr.idepustaka.spog
Ide Pustaka Setiawan

BD7003 DR Ide IUGR

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IUGR – Intra Uterine Growth Restriction

Pertumbuhan Janin Terhambat

IDE PUSTAKA SETIAWAN

 isdefined as the inability of the fetus to achieve its growth

 Early-onset (diagnosed < 32 weeks) --> symmetric IUGR

 Fetalgrowth restriction (FGR) is diagnosed with a sonographic

<10 10-50 50-90 >90 <10 10-50 50-90 >90

Term AGA Term SGA Preterm SGA

<10 10-50 50-90 >90

Term AGA Term SGA Preterm SGA

• Hypertension in 50% of cases at the time of

• 38 0/7 to 39 0/7 weeks of gestation in pregnancies complicated by FGR

 33 0/7 to 34 0/7 weeks in pregnancies complicated by FGR in the presence

 Cesarean delivery should be considered in pregnancies with

 Accurate Gestational Age Measurement

 cessation of the substance associated with FGR

 FGR neonates frequently require assistance with ventilation and feeding,

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