Definition of IUGR

The most widely used definition of IUGR is a fetus whose estimated weight is below the 10th percentile for its gestational age and whose abdominal circumference is below the 2.5th percentile. At term, the cutoff birth weight for IUGR is 2,500 g (5 lb, 8 oz.

Maternal factors:
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high blood pressure chronic kidney disease advanced diabetes heart or respiratory disease malnutrition, anemia infection substance abuse (alcohol, drugs) cigarette smoking

Factors involving the uterus and placenta:

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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

Factors related to the developing baby (fetus):

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multiple gestation (twins, triplets, etc.) infection birth defects chromosomal abnormality

Why is intrauterine growth restriction (IUGR) a concern?

IUGR can begin at any time in pregnancy. Early-onset IUGR is often due to chromosomal abnormalities, maternal disease, or severe problems with the placenta. Late-onset growth restriction (after 32 weeks) is usually related to other problems. With IUGR, the growth of the baby's overall body and organs are limited, and tissue and organ cells may not grow as large or as numerous. When there is not enough blood flow through the placenta, the fetus may only receive low amounts of oxygen. This can cause the fetal heart rate to decrease placing the baby at great risk. Babies with IUGR may have problems at birth including:

decreased oxygen levels low Apgar scores (an assessment that helps identify babies with difficulty adapting after delivery)

meconium aspiration (inhalation of the first stools passed in utero), which can lead to difficulty breathing hypoglycemia (low blood sugar) difficulty maintaining normal body temperature polycythemia (too many red blood cells)
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Severe IUGR may result in stillbirth. It may also lead to long-term growth problems in babies and children.

Importance of Accurate Dating Accurate dating in early pregnancy is essential for making the diagnosis of IUGR. The usual qualifier for reliable dating and establishment of an accurate gestational age is a certain date for the last menstrual period in a woman with regular cycles or assessment of gestational age by an ultrasound examination performed no later than the 20th gestational week, when the margin of error is seven to 10 days. Early ultrasound examination, ideally at eight to 13 weeks of gestation, is more accurate for estimating gestational age than ultrasound assessment later in pregnancy. Although ultrasound assessment is used later in pregnancy to estimate fetal weight, ultrasound dating is only accurate to about three weeks when it is performed at term. An error that is commonly made is to change a patient's due date on the basis of a third-trimester ultrasonogram. Doing so can result in failure to recognize IUGR.

Symmetric and Asymmetric IUGR

IUGR is usually classified as symmetric and asymmetric. Symmetric growth restriction implies a fetus whose entire body is proportionally small. Asymmetric growth restriction implies a fetus who is undernourished and is directing most of its energy to maintaining growth of vital organs, such as the brain and heart, at the expense of the liver, muscle and fat. This type of growth restriction is usually the result of placental insufficiency. A fetus with asymmetric IUGR has a normal head dimension but a small abdominal circumference (due to decreased liver size), scrawny limbs (because of decreased muscle mass) and thinned skin (because of decreased fat). If the insult causing asymmetric growth restriction is sustained long enough or is severe enough, the fetus may lose the ability to compensate and will become symmetrically growth-restricted. Arrested head growth is of great concern to the developmental potential of the fetus.1

How is intrauterine growth restriction (IUGR) diagnosed?

During pregnancy, fetal size can be estimated in different ways. The height of the fundus (the top of a mother's uterus) can be measured from the pubic bone. This measurement in centimeters usually corresponds with the number of weeks of pregnancy after the 20th week. If the measurement is low for the number of weeks, the baby may be smaller than expected. Other diagnostic procedures may include the following:

ultrasound Ultrasound (a test using sound waves to create a picture of internal structures) is a more accurate method of estimating fetal size. Measurements can be taken of the fetus' head and abdomen and compared with a growth chart to estimate fetal weight. The fetal abdominal circumference is a helpful indicator of fetal nutrition. Doppler flow Another way to interpret and diagnose IUGR during pregnancy is Doppler flow, which use sound waves to measure blood flow. The sound of moving blood produces wave-forms that reflect the speed and amount of the blood as it moves through a blood vessel. Blood vessels in the fetal brain and the umbilical cord blood flow can be checked with Doppler flow studies. mother's weight gain A mother's weight gain can also indicate a baby's size. Small maternal weight gains in pregnancy may correspond with a small baby.

Management
A patient presents with mild preeclampsia, and her infant demonstrates asymmetric growth restriction. A nonstress test is performed, which reveals normal reactivity. The physician tells the patient to begin bed rest. A 24-hour urine sample for protein demonstrates a level of 0.45 g (slightly elevated). Platelet count and liver function tests reveal normal values. Antenatal steroids are prescribed to promote fetal lung maturity. Daily blood pressure measurements, fetal movement profiles and biweekly nonstress tests remain normal for the next two weeks. At 34 weeks of pregnancy, the patient develops signs and symptoms of severe preeclampsia, and the decision is made to induce labor. The patient delivers a male infant weighing 1,680 g (3 lb, 11 oz), who does well in the intermediate care nursery. The management of IUGR must be individualized for each patient. In addition to managing any maternal illness, a detailed sonogram should be performed to search for fetal anomalies, and karyotyping should be considered to rule out aneuploidy.Symmetric restriction may be due to a fetal chromosomal disorder or infection. This possibility should be discussed with the patient, who may decide to undergo a diagnostic procedure such as amniocentesis. It should be remembered, however, that many infants with evidence of growth restriction are constitutionally small. Serial ultrasound examinations are important to determine the severity and progression of IUGR. A controversy involves the timing of delivery to prevent intrauterine demise because of chronic oxygen deprivation. Preterm delivery is indicated if the growth-restricted fetus demonstrates abnormal fetal function tests, and it is often advisable in the absence of demonstrable fetal growth. The risks of prematurity must be weighed against the complications unique to IUGR. General management measures include treatment of maternal disease, cessation of substance abuse, good nutrition and institution of bed rest. Although not of proven

benefit, bed rest may maximize uterine blood flow. In any case, antenatal testing should be instituted. Options include the nonstress test, the biophysical profile and an oxytocin (Pitocin) challenge test. The biophysical profile involves assessment of fetal well-being with a combination of the nonstress test and four ultrasonographic parameters (amniotic fluid volume, respiratory movements, body movements and muscle tone). The use of Doppler flow velocimetry, usually of the umbilical artery, identifies the growth-restricted fetus at greatest risk for neonatal morbidity and mortality. In controlled trials, Doppler analysis has been associated with improved outcome,although it is considered experimental by the American College of Obstetricians and Gynecologists. Each of these tests has a relatively high falsepositive rate (i.e., 50 percent) in the low-risk patient.

Given the high false-positive rate of nonstress tests, the significance of a nonreactive nonstress test should be further evaluated before any management decision is made. A nonreassuring nonstress test followed by assessment of the biophysical profile has been shown to lead to lower rates of intervention when compared with the oxytocin contraction test, with no impact on perinatal outcome. Combination testing is thought to more accurately predict the status of the fetus. For this reason, close antenatal surveillance is encouraged, with a well-timed delivery. Labor and Delivery Because of the increased risk of intrapartum asphyxia, the fetus should be monitored carefully and continuously during labor. Delivery should be in a hospital capable of dealing with the various neonatal morbidities associated with growth restriction, including asphyxia, meconium aspiration, sepsis, hypoglycemia and malformations. Preterm induction of labor is often required. Amnioinfusion may be of benefit in the presence of a nonreassuring fetal response during labor and a low amniotic fluid index or oligohydramnios. In the face of deteriorating fetal status, a cesarean section should be performed. In subsequent pregnancies, the use of low-dose aspirin may be of benefit in reducing the incidence of IUGR in selected high-risk women. While the results of a recent meta-analysis showed that early aspirin treatment reduced the risk of IUGR, routine use of aspirin in pregnancy is not advocated.
Baby's health

Most IUGR babies progress very well following delivery. They will exhibit 'catch-up' growth to babies born at higher birth weights during their first year of life. If an IUGR baby needs to be admitted to a pediatric special care unit (birth weight 2000-2500g) or a NICU (birth weight <2000g), he/she will undergo tests to see why the baby was born small. In addition, the baby's vision and hearing will be assessed. Most pediatric units, like Mount Sinai Hospital, have a follow up program with a pediatrician that has expertise in infant development. A small proportion of IUGR babies may develop abnormalities of movement of the limbs (cerebral palsy), abnormal vision (retinopathy of prematurity), deafness, or may be slow to attain their developmental milestones. Well-planned resources to

recognize these alterations from normal, together with interventions to assist the child and family, can make a big difference to childhood development and health.

Future pregnancies

IUGR can recur in future pregnancies, but the risk of recurrence depends on: i) the underlying cause; and ii) the mother's health.
Placental insufficiency can be inferred from a review of the ultrasounds, together with the newborn assessment and development. Review of placental pathology can be very helpful to prove the diagnosis. Severe placental insufficiency has a 10% recurrence risk in otherwise healthy women with the same partner. The risk of recurrent IUGR due to placental insufficiency is increased in the following circumstances: o Persistent (chronic) hypertension o Advanced maternal age (>35 years) o Maternal kidney or autoimmune disease o Maternal clotting disorders o Maternal obesity (body mass index [BMI] >30) o Maternal smoking o Certain medications required by the mother long-term Therefore, women who have had an IUGR pregnancy (especially if the infant was born by Cesarean section and <32 weeks or <1500g, or with risk factors listed above), should consider having a pre-pregnancy consultation either with their delivery obstetrician or with a maternal fetal medicine specialist.

he Role of Placental Function Testing in IUGR

Placental function testing is very useful to directly diagnose the placental basis of IUGR. The following may suggest a placental cause of IUGR:
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A false-positive IPS test result. This means that the IPS test was positive for an abnormality (Down Syndrome or spina bifida), but that these abnormalities were not actually present (ruled out by amniocentesis or chorionic villus sampling). As such, the positive test result may indicate abnormal placental functionPresence of maternal risk factors for placental dysfunction (described above) New-onset hypertension Abnormal uterine and umbilical artery Doppler, and/or abnormalities of placental size, shape and texture. .

Image by Leslie Proctor, 2009