INTRAUTERINE

GROWTH RESTRICTION
TYLER DEFRIECE
SUNY DOWNSTATE M.D. CANDIDATE
MS3 OB/GYN
CASE
Chief Complaint:
Estimated fetal weight in 4th percentile on ultrasound in clinic today
 
History of Present Illness:
This is a 20-year-old G2P0010 female presenting to labor and delivery from clinic for induction of labor due
to estimated fetal weight being in the 4th percentile on ultrasound at 39 weeks and 5 days gestation. She
denies any acute complaints at this time. She denies any vaginal bleeding, leakage of fluid, dysuria,
hematuria, headache, fever, cough, shortness of breath, nausea, vomiting, diarrhea, or chest pain. She
reports feeling fetal movement. She states she has a past medical history of mitral valve prolapse, however
she adds that at previous hospital visits the providers told her they did not find any evidence of this. She
endorses feeling particularly anxious about her first pregnancy. When asked, she states that she feels
sad/guilty/personally responsible for the spontaneous abortion that she had approximately 12 months ago.
She has a personal history of anxiety and depression. Of note, patient was seen in triage three days ago at
which time she was complaining of 6/10 constant pelvic pain accompanied by left-sided crampy back pain.
She was diagnosed with a UTI and discharged to home with Keflex at that time.
INTRAUTERINE GROWTH RESTRICTION

• Diagnosis first suspected when EFW is <10th percentile

• Measured on U/S using HC and diparietal diameter, AC, and FL

• Epidemiology: 350,000 infants per year in the U.S. who are born weighing less
than 2,500 g (5 lb, 8 oz).
• ~33% of these infants have true IUGR, and the remaining 66% are constitutionally small
THREE SCENARIOS TO CONSIDER

• 1: Asymmetrical Growth Restriction

• Body is smaller than the head
• 2: Symmetrical Growth Restriction
• Body and head proportionately growth restricted
• 3: Constitutionally Small Fetus
• Otherwise healthy
FACTORS AFFECTING GROWTH RESTRICTION

• Maternal (Asymmetric); Placental (Asymmetric) and Fetal (Symmetric)

MATERNAL FACTORS
• Poor nutritional intake • Cyanotic heart disease
• Toxic habits • Diabetes mellitus
• Cigarette smoking • Pulmonary insufficiency
• Alcoholism • Hypercoagulable state
• Drug use • Antiphospholipid syndrome
• Cardiovascular disease • Hereditary thrombophilias
• Hypertension
UTEROPLACENTAL INSUFFICIENCY

• Hypertension
• Essential or Gestational
• Obesity
• Associated with leptin resistance
• Chronic renal disease

• One way to try to evaluate the integrity of the placenta, is to monitor data markers such as:
• Fetal growth trajectory
• Doppler velocimetry of the middle cerebral artery and/or umbilical artery
• Amniotic fluid volume
FETAL FACTORS
• 1) Infectious causes
• Toxoplasmosis
• Rubella
• Cytomegalovirus
• Herpes simplex
• Listeriosis
• Malaria in endemic regions
• 2) Multifetal Gestations
• 3) Congenital anomalies
• Trisomy 18 for example
PREGNANCY MANAGEMENT

• The primary goal is to keep the fetus as safe as possible before delivery
• As the placenta ages and becomes less able to transmit nutrients naturally,
the uteroplacental insufficiency (if present) will worsen as well
• Close follow-up required (NST, BPP, Doppler velocimetry)
• Severity of growth restriction determines frequency of follow-up (Exception: Absent or
Reverse DFV)
• It is appropriate to administer corticosteroids during pregnancies if the fetus
is to be delivered preterm
• Medical decision making to be discussed
PREGNANCY MANAGEMENT

• Numerous studies have been done to attempt to optimize growth in IUGR,

with interventions such as:
• Oxygen therapy
• Nutritional supplementation
• Low-dose aspirin
• Bed rest
• Anticoagulation
• Results from these studies have not been supportive of said interventions
OUR PATIENT:
VITAL SIGNS:
HEART RATE: 94 BPM | BLOOD PRESSURE: 97/62 MMHG | TEMPERATURE: 98.1 F | RESPIRATORY RATE: 18
OXYGEN SATURATION: 99% | FETAL HEART RATE: 150’S, MODERATE VARIABILITY, CATEGORY 1 TRACING

Physical Exam: Respiratory: Lungs are clear to auscultation bilaterally. No

General Appearance: Appearing of stated age in no acute
distress
Head: Normocephalic, atraumatic.
Ears: External ears normal.
Eyes: EOM’s grossly intact. Sclera anicteric.
Nose: Nares normal.
Throat: Mucous membranes moist.
Neck: Supple. No meningismus.
wheezing, rales, or ronchi.
Cardiovascular: Regular rate and rhythm. Normal S1, S2.
No murmurs, rubs, or gallops noted by me.
Abdomen: Gravid abdomen consistent with gestational
age, Fundal height=35 cm. No tenderness in any
quadrant, guarding or rebound.
Pelvic: Normal external genitalia, no lesions or discharge.
Cervix: 0.5 cm/60%/-3/mid-position/soft. No blood or
pooling of fluid in the vaginal vault.
Neuro: Alert and oriented x 3. Conversant. Anxiety noted.

Skin: Exposed skin is normal in appearance, warm, and

dry. No rashes or lesions present.
Bishop Score: 6
 LABORATORY AND RADIOLOGY STUDIES

• STI testing: Negative

• GBS Negative
• Blood type: B+
• Ultrasound shows:
• Estimated Fetal Weight: 2707 g / 5lbs 15 oz | 4th percentile
• Amniotic Fluid Index: 17.88
• Biophysical Profile: 8/8
• Absent Diastolic Flow Velocity / Reverse
Diastolic Flow Velocity: Negative
TIMING OF DELIVERY
• The Growth Restriction Intervention Trial (GRIT)
• immediate delivery group had fewer stillbirths, but the babies were more likely to die after
birth—especially if born before 31 weeks gestation.
• The TRUFFLE study
• Found that delaying delivery to wait for late ductus venosus changes resulted in decreased
rates of neurodevelopmental impairment at the age of 2;
• However they did find that the delayed delivery IUGR cohort had a higher rate of stillbirths
• Disproportionate Intrauterine Growth Intervention Trial at Term trial (DIGITAT)
• Found that babies with IUGR whose delivery was delayed until at least 38 weeks gestation
experienced fewer subsequent hospital admissions
• Therefore unless there are other reasons to initiate an induction of labor sooner, it is a
standard of care to attempt to delay to at least 38 weeks as long as close follow-up is an
option
RISK FOR FUTURE STILLBIRTH

• There is an inverse relationship; risk increases for future stillbirth as

gestational age decreases in a small for gestational age birth
• One study noted that this relationship seemed to be a particularly strong
correlation for white women, but the correlation value was weaker for black
women (Salihu, Hamisu M. et al, 2006)
• The study was unable to determine why this was
• Counseling the patient is valuable
HOSPITAL COURSE FOR OUR PATIENT
• This patient, presenting at 39 weeks 5 days, was initially unsure and hesitant about whether she
wanted to have an induction of labor done
• She appeared anxious and spent time discussing the risks, benefits, and options with the attending,
midwife, as well as her mother
• She was given IV hydration, Dilaudid and Phenergan for comfort initially, and later an epidural was
initiated for pain management
• Cervidil was used for cervical ripening and Pitocin was used to initiate and enhance uterine
contractions
• She delivered a baby boy in the right occiput anterior position with APGAR 9 and 9
• Birth weight was actually found to be within normal limits and NOT in range for IUGR!
• This finding could be ascribed to an error on ultrasound

• She was educated on the importance of breastfeeding and was later discharged home with her son
 REFERENCES
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