INTRAUTRINE GROWTH

RESTRICTION
Dr. H. Nuswil Bernolian,
SpOG(K)

Diagnosis of symptom
Fetal growth failing (arising from
maternal, placental, or fetal origins)
Birth weight lower than expected in
the suitable gestational week (may
be the variable described as below
the 3rd, 5th, or 10th percentile)
A perinatological definition of fetal
IUGR

Dynamic phenomenon
defined the best
A a delay of the growth of the fetus
estimated as a decrease of 25
centiles in the measure of the
abdominal circumference,
according to the standard curve at
the gestational age, and in
subsequent echograhic evaluations
performed at least every 2 weeks.

Classification
Asymmetrical (late onset around 30
weeks of pregnancy) affects
abdominal growth more that the head
circumference.
Symmetrical (early from the beginning
of the second trimester) proportional
lagging of the head circumference,
abdominal circumference, and long
bone growth.

Natural History
The first 16 weeks of pregnancy
cellular hyperplasia
From 16 to 32 weeks of pregnancy,
both cellular hyperplasia and
cellular hypertrophy occur.
The last weeks, cellular
hypertrophy predominates

Risk factors fetal :

Chromosomal abnormalities
(triploidy, trisomy 13 and 18)
Structural malformations
(especially cardiac malformations)
Fetal infections (TORCH, parvovirus
B19, syphilis, listeriosis)

Risk factors placental :

Abnormalities of the placentation
(reduction of number of thin-walled,
distended uteroplacental vessels)
Acute atherosis
Obliteration of small muscular
arteries of the tertiary villi
Confined placental mosaicism
Chorioangioma

Risk factors maternal :

Low socioeconomic status
Chronic maternal under nutrition
Malnutrition (anorexia nervosa,
bulimia)
Cardiovascular diseases (cardiac
failures, hypertension, pre-eclampsia)
Gastroenteric diseases (chronic
enteritis, malabsorption diseases)

Risk factors maternal :

Pulmonary diseases (CF, asthma,
respiratory failure)
Renal diseases
Anemia
Alcohol and drug abuse, smoking
Uterine abnormalities (fibroids,
uterine malformations)

Clinical features :
Clinical examination (symphyseal
fundal distance)
Diagnostic ultrasound (BPD, FL,
AC, EFW) serial measurements
AFI amniotic fluid index
Maturity of the placenta stages
according to Grannum

Doppler examination
Uterine arteries approximately 25% of
women with unilateral persistant notch and
50% of those with bilateral notch at 24
weeks of pgregnancy will have an IUGR
fetus, develop pre-eclampsia, or
experience both (sensitivity 82% and
specificity of 38%)
Umbilical arteries affected fetuses show a
reduced blood flow pattern during diastole

Fetal compromise
Gradually increasing resistance to
blood flow in umbilical arteries
End diastolic component may
disappear or may reverse
Redistribution of blood flow occurs
Brain, heart and adrenal glands are
preferentially perfused
MCA blood flow increases

Brain Sparing
Phenomenon
Cerebroplacental ratio is below 2
SD
Prior to abnormal CTG recordings
about a couple days to 2 weeks
Associated with fetal hypoxia
When resistance in MCA begins to
rise cerebral edema occurs

Utero-placental
insufficiency during
pregnancy
Diagnosis and management

During pregnancy, fetus

depends on the placenta and
umbilical vessels for transport
of oxygen and nutrients from
maternal blood, and for
excretion of carbon dioxide
and products of metabolism

During pregnancy and

labor, fetus may be at risk
of damage or death from
acute or chronic uteroplacental insufficiency.

Acute placental failure may

result from placental
separation by hemorrhage
(abruptio placentae) or it
may come at the end of a
phase of gradually declining
placental efficiency.

Chronic restriction of
maternal blood flow
through the placenta can
have a serious effect upon
fetal growth and
development.

Medical History :
Pregnancy induced hypertension
Maternal diseases (DM; severe anemia;
renal, intestinal, cardiac and lung failures;
malnutrition)
Infections in pregnancy
Multiple pregnancies
Some drugs
Addictions (smoking, alcohol, drug abuse)
Placental pathology (placental infarction,
fetal stem artery thrombosis,
antepartum, hemorrhage)

Tests of placental
function :
Maternal weight
Uterine growth fundal height
Fetal body movements
Fetal growth obtained by ultrasound
Fetal activity biophysical profile, nonstress test (CTG)
Color doppler studies
Placental biochemical tests

Maternal weight
Should normally increase by about 0.5 kg
weekly after the first trimester (provided that
the patient is not dieting or vomiting and has
no other disorder causing malnutrition)
Components of this weight gain include: the
fetus, plcenta, liquid, uterus, breasts and fat
store. Additionally there is the increase in
blood volume and ECF.
These changes depend directly on placental
function, or indirectly by the hormone
production

Uterine growth
Simple measurements of the height of the
fundus of uterus in relation to the
symphysis pubis and umbilicus (eg. in 16th
week of gestation midpoint between pubic
symphysis and the umbilicus; at 24th week
umbilical level)
Fundal height should increase by about 1
cm weekly from the 16th week of
pregnancy, and with an average sized
fetus, should equal the number of weeks of
gestation plus or minus 2cm

Fetal body movements

The most important indication of placental
function is the well being of the fetus
The oldest and simplest method of
evaluation of the fetal well being is kick
count
Mother is asked to note how frequently the
fetus moves in a gives period of time,
perhaps in 30 minutes
Alternatively, she can be asked to note how
long it takes for the fetus to move 10 times

Fetal growth
Dating a pregnancy
Serial measurements obtained with
ultrasound
BPD, AC, HC/AC, FL, EFW
Centers of ossification in long
bones to confirm fetal maturity
Detecting congenital abnormality

Fetal activity
Continuous record of FHR over a period of
30 minutes or more so called NST (non
stress test). It includes recording of changes
in FHR variability (from beat to beat) in
association with fetal movements and
uterine contractions cardiotocography
(CTG)
Biophysical profile a score based on real
time ultrasound observation of fetal
breathing, gross body movements, tone
and amniotic fluid volume

Stress test
In a case of doubtful or suspicious
results of non stress test
Contraction stress test CST
Oxitocin challenge test OCT
Fetal acoustic stimulation test
FAST

Color Doppler examination

Reflection of ultrasound waves from the
wave produced by the pulse of blood moving
along a blood vessel is detected and
compared with the energy output of the
source
This provides a measure of the speed of
passage of the pulse wave and appears as a
typical shape of blood waveform
Seems to be the most useful tool in
prediction of chronic fetal hypoxia

Biochemical markers
of placental function
Evaluation of functional activity of the placenta
by measuring one or more of its hormone or
enzymes products in maternal blood or urine
Excretion of estriol in the maternal urine during
24 hour period gives an indication of placental
function, isolated observations are of little
value, but related observations may show an
obvious trend
Other tests: serum levels of placental lactogen
and of heat stable alkaline phosphatase