Intrauterine Growth Restriction (IUGR)

What is intrauterine growth restriction (IUGR)?

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. Another term for IUGR is fetal growth restriction. Newborn babies with IUGR are often described as small for gestational age. A fetus with IUGR often has an estimated fetal weight less than the 10th percentile. This means that the fetus weighs less than 90 percent of all other fetuses of the same gestational age. A fetus with IUGR may be born at term (after 37 weeks of pregnancy) or prematurely (before 37 weeks). Newborn babies with IUGR often appear thin, pale, and have loose, dry skin. The umbilical cord is often thin and dull-looking rather than shiny and fat. Some babies do not have this malnourished appearance but are small all-over.

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. This may occur when the fetus does not receive the necessary nutrients and oxygen needed for growth and development of organs and tissues, or because of infection. Although some babies are small because of genetics (their parents are small), most IUGR is due to other causes. Some factors that may contribute to IUGR include the following:
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Maternal factors: High blood pressure Chronic kidney disease Advanced diabetes Heart or respiratory disease Malnutrition, anemia Infection

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Substance abuse (alcohol, drugs) Cigarette smoking 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 Factors related to the developing baby (fetus): Multiple gestation (for example, twins or triplets) 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) Severe IUGR may result in stillbirth. It may also lead to long-term growth problems in babies and children.

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 lower than expected, an ultrasound is needed to get an estimated fetal size and to diagnose IUGR. 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 assess fetal well-being once IUGR has been diagnosed is Doppler flow, which uses 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 flows through vessels in the both the fetal brain and the umbilical cord 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, but not always.

How is intrauterine growth restriction (IUGR) managed?

Management of IUGR depends on the severity of growth restriction, and how early the problem began in the pregnancy. Generally, the earlier and more severe the growth

restriction, the greater the risks to the fetus. Careful monitoring of a fetus with IUGR and ongoing testing may be needed. Some of the ways to watch for potential problems include the following:

Fetal movement counting. Keeping track of fetal kicks and movements. A change in the number or frequency may mean the fetus is under stress. Nonstress testing. A test that watches the fetal heart rate for increases with fetal movements, a sign of fetal well-being. Biophysical profile. A test that combines the nonstress test with an ultrasound to evaluate fetal well-being. Ultrasound. A diagnostic imaging technique that uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to view internal organs as they function, and to assess blood flow through various vessels. Ultrasounds are used to follow fetal growth. Doppler flow studies. A type of ultrasound that uses sound waves to measure blood flow.

Treatment for IUGR

Although it is not possible to reverse IUGR, some treatments may help slow or minimize the effects. Specific treatments for IUGR will be determined by your doctor based on:

Your pregnancy, overall health, and medical history The extent of the disease Your tolerance for specific medications, procedures, or therapies Expectations for the course of the disease Your opinion or preference 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.

Prevention of intrauterine growth restriction

Intrauterine growth restriction may occur, even when the mother is in good health. However, some factors may increase the risks of IUGR, such as cigarette smoking and poor maternal nutrition. Avoiding harmful lifestyles, eating a healthy diet, and getting prenatal care may help decrease the risks for IUGR. Early detection may also help with IUGR treatment and outcome.

Intra-uterine Growth Retardation/ Small for Gestational Age

What is IUGR?

IUGR stands for intrauterine growth retardation or intrauterine growth restriction. Both describe a fetus (baby before birth) who has grown more slowly and is smaller than s/he should be for the number of weeks of pregnancy. What is SGA? This is a term used after birth to describe a baby whose weight is less than the 10th percent for his/her number of weeks of pregnancy. IUGR and SGA refer to the same process. What causes IUGR/SGA? There are many causes:

In 30-35%, the cause is not known. Some causes arise with the baby. This is most likely true if the baby is abnormal with one or more severe problems in the development of organs. Infection of the fetus weeks to months before birth, called congenital infection. Abnormalities in the blood vessels of the mother and/or placenta or diseases which limit the amount of oxygen and nutrients that get to the baby. These include mothers with:

high blood pressure either before or during pregnancy, including pre-eclampsia severe diabetes severe heart disease severe lung disease sickle cell anemia Very small parents often have small babies Drugs, heavy smoking, moderate to heavy drinking and very poor nutrition Twins, triplets and other multiples What problems do IUGR babies have during birth?

These babies have little reserve of energy and oxygen. They may be more stressed with labor and delivery. If they do not tolerate labor well, a caesarean section (delivery by surgery) may be needed.

They may have their first stool, called meconium, before birth. If stool is taken into the lungs with the first breath, it can cause pneumonia, called meconium aspiration. They may have more trouble with delivery and need more help in breathing in the delivery room.

What problems are common in the nursery?

Low blood sugar - They lack the stored energy reserves such as fat and sugar to help keep their blood sugar normal. High number of red blood cells - Red blood cells carry oxygen. These babies made more blood cells before birth to carry more oxygen. If the red blood cell count is very high, called polycythemia, it may make the blood too thick to easily flow through the smallest blood vessels.

High bilirubin - This is called jaundice. It comes from the normal breakdown of red blood cells. Lung problems - These are most likely if the infant is premature or if the baby has passed stool (meconium) and inhaled it before birth causing pneumonia in the lung. Pneumothorax and pneumomediastinum can also occur.

Primary pulmonary hypertension or persistent fetal circulation - When a baby is in the uterus, most of the blood by-passes the lungs because the mother and placenta control the oxygen and carbon dioxide for the fetus. At delivery the baby must increase the amount of blood flowing to the lungs. If this does not happen normally, the baby has persistence of the fetal circulation.

Keeping warm. They don't have stores of fat and sugar to use to keep themselves warm. Increased risk of infection after birth. If the baby is delivered early, s/he can have all the common problems of preemies. Will my baby catch up in growth? This depends on the severity and cause of the growth problem:

If a baby is low in weight but has a normal length and head size, the baby will usually catch up in growth over the next few months or years. If the baby is small because both parents are small, the child will continue to be small like the parents. If the baby is also short in length and has a small head size, there may be some catch up, but usually growth will remain less than normal and the child will be smaller than expected for the family. Will my baby be normal? This too, depends on the severity and cause of the growth problem:

If a baby is low in weight but has a normal length and head size, the baby usually develops normally. If the baby is small because both parents are small, the child usually develops normally If the baby has small head size and length at birth (<10%) in addition to low weight, there may be problems in development. Minor abnormalities are common. These may appear slowly, be difficult to detect, or may not be obvious until preschool or grade school. They can include:

poor coordination or balance

specific learning disabilities (math or reading) very short attention span behavioral problems difficulty with activities that require coordination of the eyes and hands, for example, catching a ball or copying a simple drawing decreased hearing need for glasses Major problems are less common. Major problems in development include: motor (movement) problems:

tight or stiff muscles slow to crawl, stand, or walk abnormal crawling, toe walking moving one side more than the other frequent arching of the back (not just when angry or at play) slow mental development

does not listen to your voice by age 3-4 months after hospital discharge does not make different sounds by 8-9 months after discharge doesn't seem to understand or say any words by 12-13 months after discharge seizures, also called convulsions blindness deafness Infants at highest risk for major problems are:

Those whose slow growth was due to congenital infection, that is infection present for weeks to months before delivery. Babies whose heads continue to grow too slowly after birth.