JIMMA UNIVERSITY

INSTITUTE OF HEALTH
COLLEGE OF HEALTH SCIENCES
SCHOOL OF MIDWIFERY
3rd year midwifery/2023
Intrauterine growth restriction(IUGR) $
Intrauterine Fetal Death(IUFD)
Intrauterine growth restriction(IUGR)
 Outline of the presentation
• Introduction
• Objectives
• Incidence
• Types of IUGR
• Complication of IUGR
• Diagnosis of IUGR
• Management of IUGR
 Objectives

After completing this session students will be able to:

• Determine the complication of IUGR
• Diagnose IUGR clinically
• Discuses the management of IUGR
 Introduction
• Definition: Intrauterine growth restriction(IUGR) is when a
baby in the womb (a fetus) does not grow as expected.
• The baby is not as big as would be expected for
the stage of the mother's pregnancy(Gestational age)
• Intrauterine growth restriction (IUGR) is a term used to
describe a condition in which the fetus is smaller than
expected for the number of weeks of pregnancy.
 Introduction cont..
• Fetal growth is a dynamic process and appropriate
placental supply of nutrients and oxygen is essential
for fetal growth and development, neonatal health,
and lifelong well-being.
• Conversely, abnormal placental supplies resulting in
abnormal fetal growth, including fetal growth
restriction (FGR) and fetal overgrowth, is associated
with mortality and significant risks to health.
 Introduction
Fetal growth has three consecutive phases:
Phase of cellular hyperplasia
 1st 16 weeks of gestation
 increase in cell number
Phase of concomitant hyperplasia & hypertrophy
 16-32 Wks.
 Increase in cell size & number
Phase of cellular hypertrophy
 >32 wks.
 Rapid increase on cell size
 If during this delicate time of development and weight
gain is disturbed or interrupted, the baby can suffer from
IUGR.
 Relationship between IUGR and SGA
• Two terms are not synonymous.
• Small for gestational age (SGA): is defined as a birth weight
of less than 10th. percentile for gestational age
• Fetal growth restriction (FGR) is a condition in which an
unborn baby (fetus) is smaller than expected for the number of
weeks of pregnancy (gestational age).
• IUGR is failure of normal fetal growth caused by multiple
adverse effects on the fetus.
• SGA cannot be used as a marker for FGR because some infants
with FGR will have a birth weight greater than the 10th percentile.
• All IUGR babies may not be SGA, all SGA may not be small as a
result of growth restriction.
• In FGR, the baby doesn't grow well.

• FGR may affect the overall size of the baby and the growth of
organs, tissues, and cells. This can cause many problems.
• But many newborns who are small may just be small. They may
not have any problems.
• Therefore, this making a distinction between SGA and FGR
 Incidence
 IUGR is observed in 23.8% of the newborn.
 Approximately 30 million babies globally suffered from it
every year.
 Closely,75% of all exposed newborns were occurred in
developing regions.
 IUGR fetus has approximately five to ten-fold increased risk
of dying in the womb.
 Classification of IUGR
Symmetrical growth retardation (chronic):
• Cellular hyperplasia is affected
• All organs decreased proportionally

• It may be intrinsic factors (genetic defects), congenital

infections.
• Extrinsic factors, smoking, poor dietary intake (famine),
or a combination of the two.
• Weight, height, head circumference are proportionately
reduced for gestational age
 Symmetrical growth retardation (chronic):
• Genetically small (symmetrical growth)
• Increased risk of congenital malformation.
• All ultrasound parameters (HC, BPD, AC, FL) are uniformly
smaller than expected.
• Total cell No-less
• Cell size- Normal
• Course- Poor prognosis
 Asymmetrical growth retardation (Acute):
• Fetal weight is reduced out proportion to length and head
circumference.
• Usually caused by extrinsic factors.
• Occurs in the later part of pregnancy >28weeks.
• Usually brain growth is spared, head larger than body but
normal for gestational age.
• Total cell No-normal
• Cell size- smaller
• Good prognosis
• Abdomen scaphoid or sunken, shrinkage of liver and spleen,
depletion of glycogen store and RBC mass respectively.
 Asymmetrical growth retardation (Acute):
• Hypoglycemia
• Decreased subcutaneous fat, loss skin turgor.
• Old appearance
• Vernix caseosa is reduced or absent
• Dry, pale and coarse skin.
 What causes intrauterine growth restriction (IUGR)?

• Intrauterine growth restriction results when a problem or

abnormality prevents cells and tissues from growing or causes
cells to decrease in size and number.
Some factors that may contribute to IUGR include the
following:
• Maternal factors
• Factors involving the uterus and placenta
• Factors related to the developing baby (fetal factors)
 Maternal factors:
 High blood pressure
 Chronic kidney disease
 Advanced diabetes
 Heart or respiratory disease
 Malnutrition and anemia
Pre pregnancy
During pregnancy
 Infection
 Substance abuse (alcohol,
drugs, toxins )
 Cigarette smoking
 Maternal factors cont...
Sociodemographic variables(Race, Extremes of age,
High altitude)
Previous delivery of an FGR neonate
Herself IUGR
 Placental factors involving the uterus and placenta
 Decreased blood flow in the uterus and placenta
 Placental abruption (placenta detaches from the uterus)
 Placenta previa (placenta attaches low in the uterus)
 Infection in the tissues around the fetus

Note: Placental insufficiency is usually the underlying pathology

(decreased nourishment for the fetus, glycogen store reduced).
Consequence hypoglycemia, hypothermia, premature delivery.
•The fetus may only receive low amounts of oxygen.
 Fetal and genetic factors

 Multiple gestation (twins, triplets, etc.)

 Infection
 Birth defects
 Chromosomal abnormality(structural and numerical)
 How Is IUGR Diagnosed?

 During pregnancy, the size of your baby is estimated in

different ways, including:
Clinical evaluation
U/S examination
 Fundal height. Fundal height, measured in centimeters (cm),
is about the same as the number of weeks of pregnancy after
the 20th week.
 If the fundal height is less than expected, it may mean FGR.
 Diagnosis cont.…

Generally, clinical assessment needs:

 Accurate knowledge of GA
 Recognition of risk factors
 Measurement of fundal height
Tape measure
Abdominal palpation
 Diagnosis cont…
Ultrasound: used to determine
 Fetus
 Placenta
 Amniotic fluid

• Fetal ultrasound. Estimating fetal weight with ultrasound is

the best way to find IUGR.
• A diagnosis of IUGR is based on the difference between actual
and expected measurements at a certain gestational age.
 Diagnosis cont.…

• Doppler ultrasound. Provider may also have this special

type of ultrasound to diagnose IUGR.
• Doppler ultrasound checks the blood flow to the placenta and
through the umbilical cord to the baby.
• Decreased blood flow may mean your baby has IUGR.
 Diagnosis cont.…
Ultrasound parameters to diagnose IUGR include:
1. HC/AC ratio: Normally before 32 weeks is greater than one,
at 32-34 weeks is equal to one and after 34 weeks is less than
one.
 In asymmetric IUGR, head remains larger and the ratio is
elevated
 In symmetric IUGR, the ratio is normal
 Using the HC/AC ratio, 85 % of IUGR are diagnosed
 Diagnosis cont.…
2. FL/AC: is 0.22 at all gestational ages from 21weeks to term.

 FL/AC ratio greater than 0.24 is suggestive of IUGR

3. Amniotic fluid volume: reduced amniotic fluid is associated

with IUGR.

Physical features at birth

 Dry & wrinkled skin

 Thin umbilical cord

 Old man’s look
 Normal reflexes including Moro
 Well formed plantar creases
 Complications
There are many complications following IUGR including:
Antepartum
 Stillbirth(40%)
 iatrogenic prematurity
 perinatal stroke
• Intrapartum
 Abnormal fetal status (fetal heart rate tracing)
 Asphyxia(50%)
 Emergency Cesarean section
 Need for active neonatal resuscitation
 Meconium aspiration
 Complications cont..
Neonatal period:
Hypothermia
Hypoglycemia
Hypocalcaemia
Sepsis
Coagulopathy
Hepatocellular dysfunction
Respiratory distress syndrome(RDS)
Necrotizing enterocolitis (NEC)
Intraventricular hemorrhage,ETC
 Complications cont..

Pediatric: increased risk of:

Short stature
Cerebral palsy
Developmental delay
Behavioral and emotional problems
Lower IQ scores
Chronic lung disease
Future cardiovascular disease and hypertension
 Management of IUGR
• Although it is not possible to reverse IUGR, some treatments may
help slow or minimize the effects.

• Majority of deaths occur after 36 weeks, so correct diagnosis &

intervention.
Specific treatments for IUGR will be determined based on:
 Health of pregnancy, overall health and medical history

 The extent of the disease

 Tolerance for specific medications, procedures or therapies

 Expectations for the course of the disease

 Maternal opinion or preference

 Management cont.…
• Treatments may include:
• Nutrition: Some studies have shown that increasing maternal
nutrition may increase gestational weight gain and fetal
growth.
• Bedrest: Bedrest in the hospital or at home may help improve
circulation to the fetus.
• Delivery: If IUGR endangers the health of the fetus, then an
early delivery may be necessary.
 Management cont..

Factors that affect termination of pregnancy include:

 Presence of fetal abnormality/Fetal compromise
 Gestational age
 Degree of growth restriction
 Associated complicating factors
 If GA > 37 weeks, Terminate
 If GA< 37 weeks
 uncomplicated: conservative
 Complicated: if fetal lung maturation confirmed, termination
 Mode of delivery
 Mode of delivery should be based on obstetric indications
alone
 IUGR is not an indication for cesarean delivery.
 However, IUGR fetuses have increased risk of FHT
abnormalities necessitating cesarean delivery.
Thank you
Questions?
Intrauterine Fetal Death(IUFD)
 Outlines of the presentation
• Introduction
• Objectives
• Risk factors of Intrauterine fetal death
• Diagnosis of Intrauterine fetal death
• Management of Intrauterine fetal death
 Objectives
After completing this session students will be able to:
• Determine the risk factors of Intrauterine fetal death
• Diagnosis intrauterine fatal death
• Manage intrauterine fetal death
• Provide care for women and her family with intrauterine fetal
death .
 Introduction
• Definition: World Health Organization definition: Only deaths
occurring in utero in which the fetus or neonate weighs 500
gm or more (WHO).
• Ethiopia: Only deaths occurring in utero in which the fetus or
neonate weighs 1000 gm or more and/ or deaths occurring at
28 weeks of gestation or greater.
• IUFD accounts for approximately half of the perinatal
mortality rate.
 Risk factors to IUFD

Fetal (25 to 40 %)
 Chromosomal anomalies
 Non-chromosomal birth defects
 Nonimmune hydrops
 Infections –virus bacteria and protozoa
 Risk factors to IUFD cont..
• Placental—25 to 35 %
 Prematurely ruptured membranes
 Abruption
 Fetomaternal hemorrhage
 Cord accident
 Placental insufficiency
 Intrapartum asphyxia
 Previa
 Twin-twin transfusion
 Chorioamnionitis
 Risk factors to IUFD cont..
Maternal—5 to 10 %
 Diabetes
 Hypertensive disorders
 Obesity
 Age > 35 years
 Thyroid disease
 Renal disease
 Thrombophilia
 Smoking
 Illicit drugs and alcohol
 Infections and sepsis
 Preterm labor
 Abnormal labor
 Uterine rupture
 Post term pregnancy
 Rh disease
 Drugs
 Trauma
– Unexplained—15 to 35
percent
 Diagnosis of IUFD
• Absent fetal movement
• Pregnancy symptoms absent or diminishing
• White milk expression during pregnancy
• Fundal height-same or decreased.
• Abdominal girth gradually decreased.
• Fetal movements not felt during palpation.
• Absent FHB-pinard stethoscope.
 Diagnosis of IUFD cont..
 Declined serum level of β HCG.

 Urine pregnancy test could be positive or negative.

 Spalding’s sign- the irregular overlapping of the cranial bones

on one another and the rolled up appearance of the fetal trunk.

 Robert’s sign- the appearance of gas bubbles in the thoracic

cavity of the fetus within the heart chambers or great vessels

 Diagnosis of IUFD cont..

• Kehrer’s sign- hyper flexion of the spine.

• Presence of scalp edema
• Amniocentesis dark brown meat water like AF
• Ultrasound diagnosis 100%
 Absent cardiac activity.
 Absent fetal movement.
 Oligohydramnios and collapsed cranial bones.
 Complication of IUFD

• Psychological upset or stress.

• Infection
• During labor-uterine inertia, retained placenta, PPH
• Maternal death
• Blood coagulation disorders (DIC).
 Complication of IUFD cont..
• Each stillbirth may involve unique circumstances and

problems, but it is always a devastating experience for

families and caregivers.

• By defining as clearly as possible the cause of death, the

information obtained from investigating a stillbirth can help to

alleviate the concerns over prenatal events and may have

implications for future pregnancies.

 Prevention of IUFD
• There are no specific prevention measures known.
• IUFDs can’t be totally prevented but the following guidelines
can help to reduce its incidence:
 Preconception care
 Regular ANC
 To screen out at risk mothers.
 Management of IUFD
• Once diagnosis of IUFD is confirmed by ultrasound, she has
the right to be informed soon.(But with cautious counseling)
• Help the couple to grieve appropriately this can minimize
psychological trauma of the devastating loss.
• After these important initial steps, subsequent clinical
management is either

 Expectant/ watchful waiting or

 Active (Termination)
 Expectant Management
 In about 80% the cases, spontaneous expulsion occurs within 2-
3 weeks of death.
 The mother can be to at home with advice of regular follow up
and to come for delivery
 Hypofibrinogenemia 4-5 wks. after IUFD (the risk is minimal
before) ,The risk of DIC is 10% risk (if >5wks).
 Coagulation studies must be started 2 wks. after IUFD
 Delivery should not pass 4 wks. or if fibrinogen < 200mg/ml
 The emotional burden of carrying a dead fetus, however, often
may expedite process of termination at any time after diagnosis.
 Active management(termination)
Indications for active intervention
 Psychological upset of the patient.
 Manifestations of uterine infections.
 Rupture of the membrane.
 Falling fibrinogen level.
 Tendency of prolongation of pregnancy beyond 4 weeks.
 Development of DIC.
 Active management(termination) cont..
• Methods of Termination
Induction of labour
• Medical
 Oxytocin
 Prostaglandin
 Misoprostol
• Surgical
Aminiotomy/ARM contraindicated
Balloon catheterization
Hygroscopic dilators
Membrane striping
 MANAGEMENT OF IUFD CONT..

Surgery
Destructive
Cesarean section Laparatomy
deliveries
• Major degree pp • Intrapartum • IUFD with uterine
• Previous C/s (two deaths rupture.
0r more) • Fully dilated CX
• Transverse lie
• Severely
• Engaged
contracted pelvis presenting part
• Repaired VVF • No sign of
• Failed induction imminent
• Tumor previa uterine rupture
• Invasive cervical ca • Un ruptured UX
 Bereavement Management and the Puerperium
Before discharge the following points need sensitive discussion
Problems with lactation
Resumption of coitus
Fertility and contraception

• Recurrence around 0-8% depending on the cause of IUFD

• Post-partum depression ,Anxiety
Psychotherapy
 Grief and mourning are normal reactions to a loss of a
child.
 The medical team and nursing/midwifery staff should
provide all the support and sympathy to the bereaved
couple.
 Post-partum care
• Post partum clinic after 6 weeks.
• The parents should be encouraged to speak spontaneously
without frequent interruption.
• Clearly some of the discussions should address the cause of
death.
• The results of investigations are reviewed and counseling for
the future pregnancy is made.
Discussion and Planning for The Future pregnancy

• For those that do plan a future pregnancy it is essential to avoid

giving false reassurance.
• Offering bland guarantees concerning future outcomes is a risky
policy which can increase anger if outcome is bad.
• Obstetricians should remember standard pre-pregnancy advice.

• Timing of future pregnancy-no simple answer.

• Parents mental preparedness for pregnancy is the most important

consideration.
 Discussion

• What will be the management in case of multiple

pregnancy(one died, one alive)?
Thank you very much!