1. Intrauterine Growth Restriction Eric H. Dellinger, MD Greenville Hospital System

3. IUGR: Introduction IUGR 2nd leading contributor to PNM rate PNM rate increased 6-10 fold PNM rate 8/1000 background: –120/1000 for all IUGR –60-80/1000 when anomalies excluded

4. IUGR: Introduction 40% of stillbirths have IUGR –53% of preterm stillbirths –26% of term stillbirths Intrapartum asphyxia reported in up to 50% of IUGR fetuses > 60% of IUGR fetuses with FHR tracing abnormalities have hypoxia/acidosis Pardi, NEJM 328:692, 1993

5. When is small, too small? Defining IUGR

6. IUGR: Definition Birth weight < 10th percentile used to define growth restriction at birth Definition carried over to fetuses using ultrasound measurements (+/- 15%) Using 10th percentile, 70% will be constitutionally small (no increase risk) Two SD = less than 3rd percentile AC < 2.5th percentile has 95% sensitivity

7. IUGR: PNM and EFW

8. Background Information

9. Normal Versus Abnormal

10. < 10 th Percentile 70% Normal 30% Abnormal (Constitutional IUGR) (Pathological IUGR)

11. IUGR: Etiology Fetal / Placental Maternal Chromosomal / GeneticHistory of IUGR TwinsHypertension Congenital malformationDiabetes Infectious diseaseMSAFP increase CMVAPS ToxoplasmosisChronic illness RubellaWeight < 90% IBW Placental pathologyHemoglobinopathy PreviaSubstance abuse AbruptionAnemia/Hypoxia Mosaiacism Infarction

12. Past History of IUGR Prior history #1 risk factor for subsequent IUGR 1 prior episode:25% recurrence 2 episodes:Fourfold increase 1/3 population “at risk”: 2/3 IUGR babies 2/3 population “low risk”: 1/3 of the IUGR babies, but most are constitutional

13. IUGR: Diagnosis The Fundal Height Myth: –best from 20-32 weeks: lightening –lag of 4 cm suspicious –Sensitivity of 27%, PPV of 18% Fundal height of limited value –risk factors more predictive

14. IUGR: Fetal Measurements Have you weighed a fetus lately? –EFW derived indirectly “Normal” growth curves difficult to establish PTL strongly associated with IUGR –BW derived charts inaccurate U/S growth curves more accurate over preterm age ranges

15. IUGR: Fetal Growth Patterns When did you last watch a fetus grow?

16. Strategy

17. Normal versus abnormal Symmetric versus asymmetric Fetal causes –Anomalies, arrhythmias, infection Placental problems Amniotic fluid Dopplers Fetal surveillance

18. HC/AC Ratios WeeksRatio 1.0 32-34~ 1.0 >34< 1.0 AsymmetricHC preserved, ratio > 1.0 SymmetricHC, AC both small, ratio ~ 1.0

19. IUGR: HC/AC Ratios Asymmetric Symmetric HC AC HC/AC

20. Asymmetric vs. Symmetric Asymmetric Utereo-placental Symmetric Constitutional Aneuploidy Infection

21. Fetal Causes Aneuploidy Anomalies Arrhythmias Infection

22. Aneuploidy

23. Anomalies

24. Arrhythmias

25. Infection

26. Placental Causes

29. Amniotic Fluid Volume

31. IUGR: Oligohydramnios Initial harbinger of doom –IUGR, preeclampsia –may precede abnormal HC/AC Fluid pocket of BPP: –>2 cm 6% IUGR –1-2 cm20% IUGR –<1 cm39% IUGR –also predicts intrapartum distress