1. INTRAUTERINE GROWTH RESTRICTION

3. DEFINITION
Intra uterine growth restriction is said to be present in those babies whose birth weight is below the tenth percentile of the average for gestational age

4. INCIDENCE
2 -8%

5. TYPES SYMMETRICAL OR TYPE – I
Affected from the very early phase of cellular hyperplasia
Slow rate of growth
A reduction in absolute size
The pathological process is intrinsic to the fetus
All the organs including the head is affected
ASYMMETRICAL OR TYPE – II
Affected in the later months
Phase of cellular hypertrophy is affected
Pathological process is extrinsic to the fetus
Fetal size is reduced

6. ETIOLOGY MATERNAL FACTORS
Constitutional – Small women, racial back ground and genetic
Maternal nutrition before and during pregnancy
Maternal diseases
Decreased blood supply due to high altitude,hemoglobinopathies and cyanotic heart disease
Smocking and tobaco chewing
Ingestion of drugs like etanol,cocaine,hydantoin and coumarin

7. Contd… FETAL FACTORS Congenital infections Congenital malformation
Chromosomal abnormalities
Infections - TORCH
Multiple pregnancy

8. Contd… PLACENTAL FACTORS Abruptio placenta Placental infarction
Small placenta
Post term pregnancy
Placental insufficiency due to maternal vascular diseases
Poor implantation of the placenta
Circumvallate placenta

9. DIAGNOSIS HISTORY Previous medical or obstetric problems
Prior delivery of an IUGR baby
WEIGHT GAIN
Not a reliable indicator
Remains stationary or at times falling
UTERINE FUNDAL HEIGHT
Stationary or may fall
FETAL KICK COUNT
Dimnished fetal movement

10. MANAGEMENT
GENERAL
Adequate bed rest especially in the left lateral position
Balanced diet +300 extra calorie to be taken
Management of associated complicating factors that cause IUGR
Avoidance of smocking and alcohol
Maternal hyperoxygenation for short term prolongation of pregnancy
Low dose aspirin (50mg daily)

11. Contd… ANTEPARTUM EVALUATION Clinical examination USG
Fetal kick counts
Doppler velocimetry
NST
Cord blood for blood gas analysis

12. Contd… TERMINATION OF PREGNANCY
Beyond 37 weeks :Termination of pregnancy should be done
Before 37 weeks :
Uncomplicated mild IUGR
Treatment to improve placental function
Severe degree of IUGR
Attained lung maturity – Terminate pregnancy
Not attained lung maturity – Dexamethasone therapy

13. Methods of termination
LRM followed by oxytocin

14. INTRAPARTUM MANAGEMENT
INTRAPARTUM MONITORING
Continuous electronic fetal heart monitoring and scalp blood sampling
CARE DURING VAGINAL DELIVERY
Delivery in equipped hospital
Intensive intranatal monitoring
Facility for intensive neonatal care
In – Utero transfer of baby to equipped hospital
Precautions as for pre term labour
INDICATIONS FOR LSCS
Fetal distress
Malpresentation
Very low fetal weight
Failed induction
Arrest of progress
Previous cesarean section

15. PHYSICAL FEATURES AT BIRTH
Weight 600 gm below the minimum in percentile standard
Length is unaffected
Head circumference is relatively larger in assymetric variety
Wrinkled skin
Scaphoid abdomen
Thin meconium stained vernix caseosa
Thin umbilical cord
Plantar creases are well developed
The baby is alert ,active with normal cry
Reflexes are normal