Intrauterine Growth Restriction

Clinical description

Introduction/ Definition Intrauterine growth restriction (IUGR) presents a complex management problem with increased risk of perinatal morbidity and mortality. IUGR describes a fetus whose estimated fetal weight (EFW) is < 10%-ile for gestational age. Determination of growth by gestational age (GA) requires standardized ultrasound (US) reporting that includes locally relevant nomograms. IUGR represents 30% of all small for gestational age infants. When possible, constitutionally small fetuses should be excluded.

Signs and symptoms

History Ascertain reliability of pregnancy dating; hypertension, vascular disorders, tobacco use, recreational drug use, medications (i.e. anticonvulsants), previous IUGR, previous abruption, placenta praevia in current pregnancy, multiple gestation in current pregnancy ExamComplete examination, including BP, signs of extreme malnutrition, BMI, and stigmata of alcohol, tobacco, and drug use; fundal height (FH) ≥ 3cm smaller than what is expected for GA

Investigations

• US for anatomy: EFW, liquor volume, anomalies
• US for growth every 2-4 wks (frequency depends on precision of measurements)
• Doppler velocimetry of the umbilical artery if available
• Send VDRL
• Screen for thrombophilias if early onset IUGR, early onset severe preeclampsia, thrombosis, or IUFD
• Consider fetal karyotype if structural anomalies, IUGR < 32 wks gestation, IUGR < 3%ile or

polyhydramnios (suggestive of trisomy 18)

Treatment

Because treatment is individualized, review management with the Consultant. The plan depends on the GA, severity of IUGR, maternal condition and fetal condition.

• Mild or moderate IUGR: daily fetal kick counts, weekly antenatal care visits, weekly non-stress test (NST)

or biophysical profile (BPP) if indicated, and serial US, Doppler studies for growth and liquor volume

• Severe IUGR: admit to KCH/QECH, twice weekly NST or BPP
• IUGR < 34 wks gestation: corticosteroids, regular fetal surveillance and deliver at 34 wks gestation
• IUGR > 34 wks gestation: immediate delivery

Mode of delivery

• Vaginal delivery with continuous CTG if fetal surveillance is normal and immediate caesarean delivery is

possible if needed

• Caesarean delivery if antenatal and/or intrapartum fetal surveillance is abnormal
• NB: always alert Neonatal care unit team at delivery