SMALL FETUS INTRAUTERINE/

INTRAUTERINE GROWTH RESTRICTION/

FETAL GROWTH RESTRICTION

Dr. Muhammad Ilham Aldika Akbar dr. SpOG SubSp-KFM

Departemen Obstetri Ginekologi
Fakultas Kedokteran Universitas Airlangga – RS Universitas Airlangga
2023
 FGR
MANAGEMENT OF SMALL FETUS/
INTRAUTERINE GROWTH TYPE
RESTRICTION/ FETAL GROWTH
RESTRICTION
DIAGNOSIS

MONITORING

DELIVERY TIMING
Muhammad Ilham Aldika Akbar
INTRODUCTION
• Fetal growth is the result of the maternal availability of nutrients, placental
transfer and fetal growth potential.

• The prevalence of IUGR is estimated 10–15% among pregnant women.

• Presence of IUGR has the higher risk for stillbirth and is 5x greater if it was not
detected antenatally

• 11% of all neonates delivered in developing countries and up to 66% of them in

developed countries have low birth weight.

Muhammad Ilham Aldika Akbar

DEFINITION & CLASSIFICATION OF SMALL FETUS
SMALL FOR INTRAUTERINE GROWTH
DIFFERENTIATE
GESTATIONAL AGE (SGA) RESTRICTION (IUGR)

A small fetus that is not fulfilling its growth

• A constitutionally small but potential because of an underlying pathologic
healthy fetuses at lower risk of condition (ACOG)
Sequential USG
abnormal perinatal outcome.
Fetal growth,
Doppler Waveform
• The term SGA à subgroup of SYMMETRICAL IUGR EARLY ONSET IUGR
(DV) Umbilical
small fetuses à no signs of
Artery (UA), Middle
placental disease and no
Cerebral Artery ASYMMETRICAL
adaptation to an abnormal LATE ONSET IUGR
(MCA), Ductus IUGR
environment, with perinatal
Venosus (DV)
outcomes = normally grown
fetuses
TYPE 1/2/3 IUGR

Muhammad Ilham Aldika Akbar

 SYMMETRICAL VS ASYMMETRICAL IUGR
• A proportional decrease in all measurements, especially in the size of head and
abdomen.
TYPE 1 • Problems during the cellular hyperplasia phase, at the second trimester (early
IUGR)
IUGR • 20–30% of IUGR cases.
• The prognosis is poor compared with asymmetric IUGR regarding perinatal
mortality and morbidity.

• Late onset of changes in growth, in the cellular hypertrophy phase

TYPE 2 • Asymmetry and disharmony, especially in abdominal circumference (AC), while
biparietal diameter (BPD), head circumference (HC) and femur length (FL) are
IUGR normal.
• 70–80% of IUGR cases
• The main etiological factor is placental insufficiency

Type III IUGR includes an association of the previous mechanisms (types I

TYPE 3 IUGR and II).
Muhammad Ilham Aldika Akbar
 EARLY VS LATE ONSET IUGR
EARLY ONSET IUGR
• Abnormality in uteroplacental and
fetal placental circulation à
biophysical profile
• In association with early onset PE
(50%)
• Classic sequence of doppler
deterioration: UA à MCA à DV à
cardiac insufficiency à
Muhammad Ilham Aldika Akbar
32
weeks
LATE ONSET IUGR
• Secondary to placental
insufficiency
• 70% IUGR cases
• Lower incidence of uteroplacental
lesion
• Can have a rapid deterioration
• Cardiovascular adaptation does not extend beyond
the cerebral circulation
• Brain hypoxia susceptible in late
onset fetus à MCA à prediction
of adverse outcomes
EARLY ONSET IUGR PATHOGENESIS LATE ONSET IUGR
Early-onset placental
Placental dysfunction at
dysfunction (vertical gray
term (vertical gray dotted
solid line) will impact at
line) will impact at a time
a time when fetal
when fetal respiratory
nutritional demands
needs (red arrows) rise
(green arrows) rise
exponentially
exponentially

A disproportionate
effect on fetal growth
compared with Compromise fetal
development of fetal wellbeing before fetal
hypoxemia and growth is impaired.
demise

Reprinted from ULTRASOUND IN OBSTETRICS and GYNECOLOGY, Vol 52, B. Thilaganathan, Ultrasound fetal weight estimation at term may do
more harm than good, 5–8, Copyright (2018) Muhammad Ilham Aldika Akbar
Donald School Journal of Ultrasound
Muhammad Ilham AldikainAkbar
Obstetrics and Gynecology, Volume 15 Issue 1 (January–March 2021)
Fetal deterioration in early and late onset IUGR

Muhammad Ilham Aldika Akbar

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 15 Issue 1 (January–March 2021)
 IUGR

Muhammad Ilham Aldika Akbar

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 15 Issue 1 (January–March 2021)
 IUGR COMPLICATIONS
LABOR & EARLY LONG-TERM
PRETERM DELIVERY
INFANCY DEVELOPMENT

Low Apgar scores,

Necrotizing enterocolitis, umbilical cord pH less • Neurological
respiratory distress than 7.0, need for impairment and
syndrome, intubation, seizures and growth delay
bronchopulmonary sepsis, caesarean • “Fetal Origins of
dysplasia, section, convulsions, Adult Disease” –
intraventricular meconium obstruction David Barker
hemorrhage, stillbirth and cerebral palsy
and neonatal death

Muhammad Ilham Aldika Akbar

DIAGNOSIS IUGR

Muhammad Ilham Aldika Akbar

 CLINICAL EVALUATION

Abdominal palpation or measurement of symphysis-fundal height

(SFH) have poor diagnostic rate for IUGR

SFH sensitivity to predict SGA 27-76% and specificity 79-92%

Discrepancy of > 3 weeks between Gestational ages based on

dates and SFH à suspicion of FGR

Muhammad Ilham Aldika Akbar

Uterine Fundal Height
• Serial Measurement using tape

• Draw into Chart development -à less than 10%TILE à suspected growth

restriction
• Between 18 and 30 weeks’ gestation, the uterine fundal height in centimeters
coincides within 2 weeks of gestational age.
• If the measurement is more than 2 to 3 cm from the expected height,
inappropriate fetal growth is suspected
• Sensitivities < 35 %
• Specificity > 90 %
Fundal height chart
TINGGI FUNDUS UTERI
ULTRASOUND
• Exact GA à 1st trimester Crown Rump Length (CRL)
• The AC measurement is the most specific parameter for
detecting IUGR (specificity 89.8% and NPV 90.7%)
• The sensitivity of isolated EFW to predict IUGR is higher
for fetuses with severe growth restriction (EFW <3rd
centile)

Doppler velocimetry should be used for the

diagnosis of IUGR
UtA PI > 95th centile, UA PI > 95th centile, MCA PI > 95th centile,
CPR < 5th centile, CPR<1, AEDV UA, REDV UA, DV PI > 95th centile,
absent or reversed a waved DV

Muhammad Ilham Aldika Akbar

Sonographic Measurements of Fetal Size

• Fetal biometric measurements (Combining head, abdomen, and

femur dimensions)
• No fetal growth on serial USG examination (within 2 weeks)
• Fetal grow under 10% tile growth chart
• FL/AC > 23.5
• Estimated fetal weight < 3rd percentile
• Oligohydramnios
• Abnormal Doppler velocimetry examination
 SGA

IUGR

Muhammad Ilham Aldika Akbar

Muhammad Ilham Aldika Akbar Obstet Gynecol Clin N Am 48 (2021) 371–385
Muhammad Ilham Aldika Akbar Obstet Gynecol Clin N Am 48 (2021) 371–385
Normogram of umbilical artery Doppler indices in singleton pregnancies in south-western Nigerian women:
Umbilical Doppler values in pregnancy
October 2016
Journal of Obstetrics and Gynaecology Research 42(12)

Muhammad Ilham Aldika Akbar

Muhammad Ilham Aldika Akbar
 or RI

Muhammad Ilham Aldika Akbar

 OLIGOHIDRAMNIOS

• Hypoxia and
diminished renal
blood flow
• Ultrasound:
• Subjective
measurement
• One pocket (SDP) <
2 cm
• Amniotic fluid index
(AFI) < 5 cm
DIAGNOSIS CRITERIA OF EARLY AND LATE ONSET IUGR (DELPHI CRITERIA)

Muhammad Ilham Aldika Akbar

Ultrasound Obstet Gynecol 2020; 56: 298–312
 CONSENSUS BASED DEFINITION OF IUGR IN THE NEWBORN

Birthweight < 3rd percentile on population based cohort or customized growth chart
(86%) or at least 3 out of 5 of the following:
• Birthweight < 10th percentile on population based (78%) or customized growth charts (94%)
• HC < 10th percentile (82%)
• Length < 10th percentile (82%)
• Prenatal diagnosis of IUGR (88%)
• Maternal background (Preeclampsia or hypertension et c) (75%)

Reprinted from The Journal of Pediatrics, Vol 196, Irene M. Beune, Frank H. Bloomfield, Wessel Ganzevoort, Nicholas D. Embleton, Paul J. Rozance, Aleid
G. van Wassenaer- Leemhuis, Klaske Wynia, Sanne J. Gordijn, Consensus Based Definition of Growth Restriction in the Newborn, 71–76 e1, Copyright
(2018), with permission from Elsevier.24

Muhammad Ilham Aldika Akbar

Clinical progression and monitoring in early onset IUGR

Muhammad Ilham Aldika Akbar

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 15 Issue 1 (January–March 2021)
Clinical progression and monitoring in late onset IUGR

Muhammad Ilham Aldika Akbar

Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 15 Issue 1 (January–March 2021)
 ROLE DOPPLER VELOCIMETRY IN MONITORING IUGR

UMBILICAL ARTERY (UA) MIDDLE CEREBRAL CEREBRO DUCTUS

ARTERY (MCA) PLACENTAL RATIO VENOSUS (DV)
(CPR)
Improves perinatal outcomes
Useful in tracking Late-IUGR The CPR is more AEDV/ REDV are
independent of UA Doppler sensitive to hypoxia strongly associated
80% cases, AEDV present findings than its individual with perinatal
abnormal UA 1 weeks components mortality
present 2 weeks before acute independently of
before acute Near-term fetuses with isolated
deterioration MCA vasodilation are at risk of CPR <1 or <0.6765 the gestational age
deterioration
adverse outcomes. MoM is used for the
diagnosis of brain
A abnormal UA are associated with sparing.
MCA PI is less sensitive Abnormal DV
risk of neurodevelopment disorders. but more specific. becomes abnormal
Abnormal CPR is associated
with preterm birth, low 48–72 hours before
UADV are used for the surveillance and birthweight centile, adverse the BPP (90% cases)
obstetrical management of early IUGR neonatal outcome and
Muhammad Ilham Aldika Akbar perinatal death
MANAGEMENT OF
EARLY ONSET IUGR

Muhammad
MuhammadIlham Aldika
Ilham Aldika AkbarAkbar
 Ultrasound Obstet Gynecol 2020; 56: 298–312

EARLY ONSET IUGR

PREECLAMPSIA
Placental mediated IUGR
Abnormal transformation
Maternal vascular malperfusion of the spiral arteries
‘Placental Elevated sFlt-1/PlGF
of the placenta Placental villi and Insufficiency’ ratio
multifocal infarction
Elevated UA PI
Delivery represents the only Early changes
therapeutic option in early FGR UA AEDV

UA REDV
Timing of delivery has to be Late changes
balanced against the possible Metabolic Cardiovascular
harm caused by prematurity failure deterioration

Neonatal with early IUGR has a 2 Ductus Venosus (absent Alteration Abnormal Spontaneous repetitive
weeks late survival rate compared or reversed a-wave) of the STV BPP score decelerations on CTG
to normal AGA neonatus

Muhammad Ilham Aldika Akbar, 2023

STILLBIRTH
Muhammad Ilham Aldika Akbar
 MONITORING & THERAPY EARLY ONSET IUGR
The pregnancy should be managed in tertiary- Multidisciplinary counseling by TRUFFLE study: monitor
level fetal medicine and neonatal units neonatology and MFM specialists using DV and cCTG

CTG (NST) Progressive deterioration of UA DV

warrants more intensive monitoring every
Tight Doppler 2 – 3 days when AEDV or REDF UA (+)
monitoring Velocimetry
MCA Doppler is important in
BPP monitoring early IUGR In fetuses with UA AEDV or REDV,
enhanced daily surveillance is
Blood-pressure, and urinary protein/creatinine warranted during steroid
PREECLAMPSIA ratio and renal – hepatic function administration

Recommend corticosteroid prophylaxis to prevent RCOG recommends corticosteroid

CORTICOSTEROID neonatal RDS if the birth is likely to occur < 34 weeks prophylaxis up to 35 + 6 weeks

Many guidelines recommend MGSO4 prophylaxis for

MGSO4 neuroprotection in IUGR fetuses, though the
suggested time varies (<32 weeks)
Muhammad Ilham Aldika Akbar
Muhammad Ilham Aldika Akbar, 2023
Muhammad Ilham Aldika Akbar SPFM: Sound Provoked Fetal Movement
TIMING OF DELIVERY EARLY ONSET IUGR
TRUFFLE Protocol

Elective Cesarean delivery is

recommended in:
Abnormal cCTG STV, DV Doppler
alteration, UA AEDV or REDV,
altered BPP, Maternal indication

Muhammad Ilham Aldika Akbar

Ultrasound Obstet Gynecol 2017; 50: 285–290.
MANAGEMENT OF
LATE ONSET IUGR

Muhammad
MuhammadIlham Aldika
Ilham Aldika AkbarAkbar
 LATE ONSET IUGR
Milder and more aspecific Milder alteration in oxygen Alterations in UA Doppler
placental lesions and nutrient diffusion and DV are rare
Can identify
subtle changes
Late IUGR is still associated with poor perinatal outcome and Use MCA (reduced PI) and CPR between
longer-term educational attainment (cerebroplacental ratio) to monitor placental and
cerebral blood-
flow perfusion
Fetuses near term seem to have reduced tolerance to hypoxemia The biophysical abnormalities

In the presence of UA-PI > 95th Alteration of fetal breathing,

percentile, monitoring 1-2x/weeks
Median interval between low MCA
PI and stillbirth < 5 days
90% stillbirths occurred in 1 week of a
normal BPP score but cerebral
vasodilatation (+)
decreased amniotic fluid volume
and loss of fetal heart rate
reactivity on conventional CTG.
Recommendation for CORTICOSTEROID
prophylaxis is the same as Early onset IUGR
Muhammad Ilham Aldika Akbar Muhammad Ilham Aldika Akbar, 2023
 TIMING OF DELIVERY LATE ONSET IUGR
Indications to termination of pregnancy

36-38 weeks >38 weeks Any Gestational Ages (>32 weeks)

If UA-PI >95th If there is evidence of • Spontaneous repeated persistent unprovoked fetal heart
percentile or AC/EFW cerebral blood-flow rate decelerations
< 3rd percentile redistribution or any • Altered BPP (score ≤4)
other feature of FGR • Maternal indication (e.g. severe pre-eclampsia, HELLP
syndrome) or obstetric emergency requiring delivery
• cCTG STV <3.5ms at 32+0 to 33+6weeks and <4.5ms at
• In the absence of contraindications, ≥34+0weeks
induction of labor is indicated • Absent or reversed UA-EDF
• During labor, continuous fetal heart rate
monitoring is recommended

Muhammad Ilham Aldika Akbar

Muhammad Ilham Aldika Akbar, 2023
 The Disproportionate Intrauterine Growth Intervention Trial at Term (DIGITAT)

Randomly assigned 650 pregnant women over 36 weeks of gestation with suspected IUGR to
induction of labor or expectant monitoring

Equivalent fetal and maternal outcomes for induction and expectant monitoring at IUGR at
term, indicating that both approaches are acceptable

BMJ 2010;341(dec21 1):c7087. DOI: 10.1136/bmj.c7087

Muhammad Ilham Aldika Akbar

ALGORITHM OF IUGR
MANAGEMENT

Muhammad
MuhammadIlham Aldika
Ilham Aldika AkbarAkbar
 The Royal College of Physicians of Ireland

Muhammad Ilham Aldika Akbar

Stage Based Management IUGR (Figueras F, 2013)

Muhammad Ilham Aldika Akbar Fetal Diagn Ther 2014;36:86–98

Stage Based Management IUGR (Figueras F, 2013)

Muhammad Ilham Aldika Akbar Fetal Diagn Ther 2014;36:86–98

 ISUOG Management of IUGR

26 – 32 weeks 32 – 36 weeks 36 – 38 weeks > 38 weeks

Deliver if UA PI >
Deliver if DV Doppler Deliver if any
Deliver if UA AEDV / REDV (+) 95th % or
abnormal AC/EFW < 3rd % sign IUGR (+)

Deliver if: Deliver if:

NST repeated deceleration or BPP < 4 or Maternal indication NST repeated deceleration or
BPP < 4 or UA AEDV/REDV or
maternal indication

Muhammad Ilham Aldika Akbar

Ultrasound Obstet Gynecol 2020; 56: 298–312
THANK YOU
Muhammad Ilham Aldika Akbar