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Review Article

Management of Intrauterine Growth Restriction

Liji S. David, Anne George Cherian1, Manisha Madhai Beck
Department of Obstetrics and Gynecology, 1Department of Community Health, Christian Medical College, Vellore, Tamil Nadu, India

Abstract
Intrauterine growth restriction (IUGR) is a condition where the fetus does not attain its biologically determined growth potential due to a
pathological process. The main tools for antenatal surveillance in a growth‑restricted fetus include amniotic fluid volume, Doppler studies, and
biophysical profile. The frequency of surveillance depends on the severity of the growth restriction and the findings on previous ultrasound
studies. The decision to deliver the fetus is dependent on factors such as gestational age, severity of growth restriction, and findings on the
Doppler studies. If there is severe abnormality in the Doppler studies, lower segment cesarean section is recommended as the mode of delivery.
Vaginal delivery may be attempted after induction of labor if Doppler parameters are normal, in a center with adequate facilities for monitoring
facilities and when there are personnel with expertise. This review provides an overview of antenatal monitoring in a pregnancy with IUGR
and decision‑making during the time of delivery.

Key words: Amniotic fluid volume, antenatal surveillance, intrauterine growth restriction

Address for correspondence: Dr Manisha Madhai Beck, Professor and Head, Department of ObGyn, Unit 4, Christian Medical College, Vellore - 632 004,
Tamil Nadu, India. E‑Mail: annegc@cmcvellore.ac.in

Introduction
Intrauterine growth restriction (IUGR) is a condition where the fetus does not attain its biologically determined growth potential
due to a pathological process and is associated with significant morbidity and mortality. The etiology includes maternal and
fetal factors as well as placental or cord abnormalities that lead to a restriction of growth of the fetus in utero. Optimal antenatal
monitoring with ultrasonographic studies and charting of the growth of the fetus can guide the treating physician toward
taking corrective measures and deciding on the time and mode of delivery. The involvement of the mother is an integral part of
surveillance, and simple techniques such as a fetal kick count can help in decision‑making. This review provides an overview
of antenatal monitoring in a pregnancy with IUGR and decision‑making during the time of delivery.

Antenatal Surveillance
The main tools for antenatal surveillance in a growth‑restricted fetus include the following:
1. Amniotic fluid volume assessment
2. Doppler studies
3. Biophysical profile
4. Modified biophysical profile.

Amniotic Fluid Volume Assessment

A quantitative estimate of amniotic fluid volume is an indicator of fetal well‑being and decrease in amniotic fluid associated
with chronic fetal compromise. It is also a part of the biophysical profile. Amniotic fluid volume is assessed by calculating the
four‑quadrant amniotic fluid index (AFI) or by measuring single largest pocket of amniotic fluid.

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DOI:
10.4103/cmi.cmi_78_17 How to cite this article: David LS, Cherian AG, Beck MM. Management
of intrauterine growth restriction. Curr Med Issues 2017;15:271-7.

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David, et al.: Management of intrauterine growth restriction
Amniotic fluid index
The abdomen is divided into four quadrants using, umbilicus as
the reference. AFI is calculated by adding the depths of amniotic
fluid (in cms) in all four quadrants. Each quadrant should be
free of cord loops at the time of measurement. Normal AFI
is 5–25 cm (<5 cm is considered oligohydramnios). RCOG
and ACOG recommend the use of a single deepest vertical
pocket (DVP) to interpret amniotic fluid volume.
Deepest Vertical Pocket
DVP refers to the vertical dimension of the deepest pocket of
amniotic fluid (with a horizontal measure of at least 1 cm) not
containing umbilical cord or fetal extremities and measured at
a right angle to the uterine contour and perpendicular to the
floor. Normal DVP is 2–8 cm.
The use of AFI as the only form of surveillance in small for
gestational age (SGA) fetuses is not advised. It should be used
in conjunction with other surveillance tools.1‑3
Doppler Studies in Intrauterine Growth Restriction
The various Doppler studies used are the following:4
1. Umbilical artery
2. Middle cerebral artery (MCA)
3. Ductus venosus (DV).
The pulsatility index (PI) is the Doppler parameter which
denotes degree of resistance to blood flow through the vessel.
The UmbIlical Artery Doppler
Umbilical artery (UA) Doppler is a primary surveillance
tool in an SGA fetus and helps detect abnormal perfusion
of placental villi. In high‑risk population, its use decreases
perinatal morbidity and mortality. Mortality is decreased by
about 29% when UA is used as a surveillance tool.1
The blood flow in the umbilical artery during diastole is the
parameter of interest in UA. The forward flow is constant
in a normal fetus during diastole [Figure 1a], but in a
growth‑restricted fetus, there is increased resistance to flow
in the umbilical artery leading to a decrease in flow during
diastole [Figure 1b], which corresponds to decreased perfusion
of the placental villi. In severe cases, there is absent and even
a reverse flow (blood flow back to the maternal circulation).
Middle Cerebral Artery Doppler
The MCA Doppler looks at blood flow in the MCA of the fetal
brain. In a normal fetus, there is high resistance flow in the
MCA (in contrast to UA Doppler). IUGR is most commonly
caused by placental insufficiency, in response to which the fetus
adapts its circulation to preserve oxygen and nutrient supply to
the brain (“brain‑sparing”). When there is brain‑sparing, there
is compensatory vasodilation which leads to low resistance and
hence increased flow through the vessel [Figure 2]. This leads
to a decreased MCA‑PI. MCA‑PI less than the 5th centile is a
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surrogate marker of fetal hypoxia. Abnormal MCA Doppler is
associated with adverse perinatal and neurological outcomes.
At term, MCA‑PI <1.2 is considered abnormal.1
Ductus Venosus Dopplers
DV Doppler in the surveillance of preterm SGA fetus has moderate
predictive value for acidemia and adverse perinatal outcome.
Abnormal DV Doppler is used to determine the time of delivery,
especially in preterm IUGRs with abnormal UA Doppler.3
The other modalities of surveillance include nonstress
test  (NST), biophysical profile, and modified biophysical
profile (NST and AFI).
Nonstress test
A reactive NST, with good variability of the heart rate above
the baseline [Figure 3], is indicative of a normal fetus.
A nonreactive NST correlates well with fetal hypoxemia or
academia. It is to be used only in conjunction with other tests.
Biophysical Profile
The biophysical profile includes five components which are
used to evaluate the health of the fetus. These components are
reliable and reproducible tools with a good correlation with
fetal hypoxia if there are abnormal scores.
The five components include:
1. NST
2. Fetal breathing movements
3. Fetal gross body movements
4. Fetal tone
5. Amniotic fluid volume (SVP > 2 cm)
Each component is given score of 2 (normal) or 0 (abnormal), and
the biophysical profile score (BPS) is calculated by adding the
scores [Table 1].5 It must be noted that if there is oligohydramnios,
further evaluation is warranted regardless of the score.
Modified Biophysical Score
A complete BPS is time consuming and takes about 30 min
for each individual, which may not be practical in many
situations. The modified BPS6 which includes only two
components – NST and AFI – may be used as an alternative.
a b
Figure 1: (a) Normal umbilical artery Doppler. (b) Umbilical artery
Doppler waveforms in intrauterine growth restriction showing restricted
flow during diastole.
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David, et al.: Management of intrauterine growth restriction

Abnormal AFI is indicative of chronic hypoxia, and nonreactive
NST is indicative of acute hypoxia.
Surveillance by the Mother
The involvement of the mother is integral to the surveillance
of a fetus with growth restriction. Fetal movement is an
indicator of the integrity of the central nervous system, and
musculoskeletal system of the fetus and the mother must be
taught to monitor the activity of the fetus and to report back
if there are any abnormalities.
Instructions to be Given to Mother
The mother is advised to monitor the fetal movement using the
Cardiff count or the daily fetal movement count (DFMC) chart.
Daily kick count (Cardiff count)
The Cardiff count requires pregnant women to begin a
fetal movement count at a selected time each day, count
ten movements, and record the elapsed time from the first
to the tenth movement. Findings which would indicate
possible danger to the fetus and which should be reported
immediately include less than ten movements in 12 h; no
perception of movement in an 8‑h period; a change in the
usual pattern of fetal movement; or a sudden increase in
violent fetal movements followed by complete cessation
of movement.7
Daily fetal movement count
The daily fetal movement count (DFMC) is a tool that is
inexpensive, uncomplicated, and noninvasive. It is a clinically
effective mean of screening for fetal well‑being after 20 weeks’
gestation. The mother is advised to do a DFMC. For this, she is
asked to lie in left lateral position and focus on fetal movements
for a 2‑h period during the day. If there are ten or more discrete
movements in that 2‑h period or four movements in 1 h, it is
considered normal.
The DFMC chart may also be used to record the number of fetal
movements perceived by the mother for 1 h at a particular time
of the day (e.g., after each meal‑breakfast, lunch, and dinner)
and record it. Serial recordings may be charted according to the
gestational age. Fetal movements are considered satisfactory
if the count is >3 on each occasion.8 This has been shown to
be a useful tool in identifying patients at risk for hypoxia.9

Surveillance and Monitoring by the Physician

Antenatal surveillance by the physician includes clinical
examination and the Doppler studies discussed above. These
will aid in monitoring the growth of the fetus and in deciding
the time and mode of delivery.

Figure 2: Middle cerebral artery Doppler showing normal and abnormal

(high diastolic velocity) waveforms. Figure 3: Reactive nonstress test.

Table 1: Calculation of biophysical profile score

Biophysical score
Component Normal (2 points) Abnormal (0 points)
Fetal breathing movements One or more episodes of fetal breathing lasting at least No episodes of fetal breathing movements lasting at
30 s within 30 min least 30 s during a 30‑min period of observation
Fetal movement 3 or more discrete body or limb movements within <3 body or limb movements in 30 min
30 min
Fetal tone One or more episodes of active extension and flexion Slow extension with no return or slow return to flexion
of a fetal extremity or opening and closing of the hand of a fetal extremity or no fetal movement
within 30 min
Amniotic fluid volume A single deepest vertical pocket of amniotic fluid A single deepest vertical pocket of amniotic fluid
measures>2 centimeters is present measures 2 centimeters or less
NST** Reactive Nonreactive
Interpretation: Score 8 or 10 → normal, Score 6 → equivocal, Score ≤4 → abnormal, **Reactive: Two or more fetal heart rate accelerations that
peak (but do not necessarily remain) at least 15 beats per minute above the baseline and last at least 15 seconds from baseline to baseline during 20 min
of observation, **Nonreactive: Less than two accelerations of fetal heart rate as described above after 40 min of observation. NST: Nonstress test

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David, et al.: Management of intrauterine growth restriction
Frequency of Antenatal Surveillance
The frequency of antenatal surveillance depends on the
severity of the fetal growth restriction (FGR), findings of the
Doppler studies, and the AFI. If there is mild/moderate IUGR,
the recommendation is weekly modified BPS with Doppler
studies and growth scans once in 2 weeks [Figure 4]. In severe
IUGR, frequency of surveillance increases to twice weekly
BPS and Doppler studies with fortnightly growth scans. The
frequency of growth scans is not increased, because this tends
Figure 4: Frequency of surveillance.
Figure 5: Management of intrauterine growth restriction with abnormal umbilical artery Doppler and normal amniotic fluid index.
274
to increase the rate of errors, thus decreasing the sensitivity
and accuracy.
Management Options in Intrauterine Growth
Restriction
For the management of IUGR, the individuals may be
categorized into (1) those with abnormal umbilical artery
Doppler and normal AFI and (2) those with normal Doppler
study and abnormal AFI.
Intrauterine growth restriction with abnormal umbilical
artery Doppler and normal amniotic fluid index
If the UA Doppler is abnormal and the AFI is normal, the
management depends on the gestational age. The three groups
are 28–32 weeks, 32–34 weeks, and 34–37 weeks of gestation,
and in each of these groups, the management depends on
whether the UA Doppler indicates decreased flow or absent/
reversed flow [Figure 5].
28–32 weeks
If there is absent or reversed diastolic flow on UA Doppler,
we would recommend doing a DV Doppler. If the DV
Doppler is normal, the mother must be admitted and initiated
on corticosteroids and monitor with daily NST and Doppler
studies. The baby is delivered when there is an abnormal DV
Doppler study.
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David, et al.: Management of intrauterine growth restriction
If the diastolic flow on UA Doppler is present but decreased,
the mother may be managed on an outpatient basis, with twice
weekly BPS and Doppler studies.
32–34 weeks
If there is absent or reversed diastolic flow on UA
Doppler, we would recommend admitting the mother and
initiating corticosteroids. Further expectant management
is not recommended and the baby is delivered following
administration of steroids.
If the diastolic flow on UA Doppler is present but decreased,
the mother may be managed on an outpatient basis, with
twice weekly modified BPS and Doppler studies along with
fortnightly growth scans. Delivery of the baby is planned at
37 weeks or earlier (1) if there is no growth in the interval
period, (2) if there is an abnormal BPS, or (3) if there is absent
or reversed diastolic flow in UA Doppler at any point.
34–37 weeks
At this gestational age, if there is absent or reversed diastolic
flow on UA Doppler, we would recommend admitting the
mother for delivery of the baby immediately. If the diastolic
flow on UA Doppler is present but decreased, the management
is the same as in the 32–34‑week gestational age group.
Intrauterine growth restriction with normal Doppler study
and abnormal amniotic fluid index
When the AFI is low, the treating obstetrician must rule out
an amniotic fluid leak. If there is no leak and if the gestational
age is >34 weeks, the baby must be delivered as soon as
possible. If the gestational age is <34 weeks, the mother must
be admitted and initiated on corticosteroids and monitored. If
the AFI is persistently low, the baby must be delivered as soon
as possible [Figure 6].
Mode of Delivery
If there is abnormal DV Doppler or if the UA Doppler shows
absent/reversed diastolic flow, lower segment cesarean
section (LSCS) is recommended as the mode of delivery. This
is because with a background of absent or reversed flow the
Figure 6: Management of intrauterine growth restriction with abnormal
amniotic fluid index + normal Doppler nonstress test.
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fetus will not be able to tolerate labor pains. If there is FGR
with either oligohydramnios and normal Doppler studies or
with normal UA Doppler and normal AFI, then vaginal delivery
may be attempted after induction of labor (IOL).3
In case of severe FGR, the mode of delivery is dependent on the
obstetrician’s level of expertise and facilities for monitoring.
Vaginal delivery may be attempted in an appropriate setting
with adequate monitoring facilities [Figure 7].
Where to Deliver?
It is important that a fetus with IUGR be delivered in a facility
with appropriate backup, both obstetric and neonatal. There
must be facility for one‑on‑one monitoring or continuous
cardiotocography.3 There must be facility for doing cesarean
section at any time. There must be an anesthetist available as
well as the necessary theater setup. It is also very important
that facilities are available for appropriate neonatal care as
these babies maybe hypoxic, hypothermic or may go through
various metabolic changes.
When to Refer?
There are instances when one must consider referring patients
with IUGR especially if one is working in a primary or
secondary care facility. Referral is suggested in the following
situations:
• If the fetus has severe growth restriction.
• If there are associated abnormal AFI and Dopplers.
• Early-onset FGR – this also needs further evaluation in
a higher center.
• FGR with associated medical disorders such as diabetes or
hypertension - may also have better outcomes if managed
in a higher level center.
Early‑Onset Intrauterine Growth Restriction
Early FGR is not common, and by definition, it is diagnosed
at or <32 weeks of gestation. It differs from late‑onset
FGR in terms of its clinical manifestations, association
with hypertension, patterns of deterioration, and severity
of placental dysfunction. Common causes for early‑onset
IUGR include uteroplacental insufficiency, chromosomal
abnormalities, and infections.
If there is very early onset of growth restriction, there are
certain investigative procedures that need to be done. Uterine
artery Dopplers help in determining whether the pathology
behind the growth restriction is related to uteroplacental
insufficiency or not. Fetal anatomy screening and karyotyping
will help in detecting chromosomal abnormalities, if any. If the
morphology of the fetus appears to be normal, a karyotyping
can be done. Fetal infections such as cytomegalovirus,
toxoplasmosis, syphilis, and malaria need to be ruled out with
appropriate investigations.
Unfortunately, early‑onset IUGR is usually associated with a
very poor prognosis.
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David, et al.: Management of intrauterine growth restriction
Figure 7: Mode of delivery.
Small for Gestational Age/Constitutionally
Small Fetus
A fetus that is SGA may be constitutionally small and need not be
necessarily growth restricted. One must suspect a constitutionally
small fetus if any of the following factors is present:
• The mother is constitutionally small – a small built mother
is likely to have a constitutionally small fetus
• There are no other antenatal risk factors
• There is adequate interval growth
• The amniotic fluid volume and Dopplers are normal.
A pregnancy with an SGA fetus should manage with close
monitoring which includes fortnightly growth scans and
Doppler studies. Delivery may be planned at 38–39 weeks.
Recent Advances
Role of MCA Dopplers in the management of term
growth‑restricted fetuses
MCA Doppler abnormality is a surrogate marker of fetal
hypoxia and is particularly valuable for the identification
of and prediction of adverse outcomes in late‑onset FGR,
independent of the UA Doppler, which is often normal in these
fetuses. MCA may be abnormal in 20% of those with normal
UA Doppler.2 It helps in identifying these cases and decreases
the chances of a stillbirth.
Unnecessary IOL at 37 weeks must be avoided if MCA Doppler
is normal. RCOG recommends MCA Doppler to time delivery
in term FGR with normal UA Doppler.3,6,10
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Role of cerebroplacental ratio in term growth‑restricted
fetuses
Cerebroplacental ratio (CPR), which is the ratio of
MCA‑PI/UA‑PI, is useful marker for cerebral hypoxia.
A value <1 at term is abnormal. It is associated with an 11‑fold
increase in adverse perinatal outcomes, and 25% of term FGR
can have abnormal CPR.
CPR increases the sensitivity of MCA‑PI and UA‑PI. The CPR may
be abnormal even if the components of the ratio (MCA‑PI/UA‑PI)
are normal and acts an independent predictor of adverse perinatal
outcomes. CPR also helps in deciding time of delivery.1,3,6,10
Role of antenatal steroids in late preterm babies in growth
restriction
The RCOG recommends administration of steroids in
growth‑restricted fetuses between the gestational age of 24
and 35 + 6 weeks if considering early delivery.3
Conclusions
• Fetal growth should be monitored every fortnightly
• Delivery of the child must be done at
• <32 weeks – if there is abnormal DV
• <34  weeks  –  if diastolic flow in UA Doppler is
absent/reversed
• >37 weeks in all cases of FGR
• 38–39 weeks for SGA babies.
• If there is absent/reversed UA or DV Doppler, consider
delivering the baby with elective LSCS
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David, et al.: Management of intrauterine growth restriction

• MCA Dopplers/CPR in should ideally be incorporated in
the management of IUGR
• Early referral can prevent perinatal complications
• Close monitoring during labor with easy access to
operating theater facilities and very good neonatal
intensive care unit backup will help in decreasing the rate
of complications due to IUGR.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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