1. Macrosomia and Intrauterine Growth
Restriction(IUGR)
DR Manal Behery
Zagazig University,
2013

2. Macrosomia

3. Definition:
 A fetal weight of more than
4.5 kg at term or
 fetal birth weight > 90
percentile for the gestational
age..

4. Causes
Genetic or constitutional:
obese women tend to give
birth to macrosomic babies.
Diabetes and prediabetes.
Post-date (postmaturity).
Multiparity: The first baby is about 100 gm
smaller than the next.
Hydrops foetalis.

5. Macrosomia and diabetes
¼ th of insulin dependent
mothers have Macrosomic
infants
Excess growth happens in 3rd
trimester.
GDM mothers have same
incidence of Macrosomic infants
as other diabetics

6. Risk factors
Excessive maternal weight gain
during pregnancy.
Advanced maternal age.
Male fetus than female.
Previous macrosomic infant.

7. Diagnosis
Clinical palpation: can give a rough
idea.
Ultrasonography: can calculate the fetal
weight

8. Hazards
Prolonged pregnancy
Cephalopelvic disproportion
Obstructed labour.
Shoulder dystocia.
Meconium aspiration syndrome.
Nerve and bone injuries.

9. Management
Proper antenatal care: to prevent macrosomia
and diagnose it before labour commences.
Cesarean section: is the safest for both mother
and fetus.

10. IUGR

11. Definition !
IUGR is defined as a fetus that has an estimated
weight that is less than the 10th percentile for it’s
gestational age
At term, the cutoff birth weight for IUGR is 2,500 g (5 lb, 8 oz)

12. Growth percentiles for fetal weight
versus gestational age

13. Correlation of birth weight percentile to
perinatal morbdity and mortalility

14. Is small for gestational age (SGA) the
same as IUGR?
• IUGR is used synonymously with small for
gestational age (SGA) but implies a pathologic
condition.
 EFW at or below 10th percentile is used to
identify fetuses at risk
 However a certain number of fetuses at or
below the 10th percentile just may be
constitutionally small and not growth
restricted

15. IUGR VS SGA
IUGR: fetus with birth weight <10th
percentile for gestational age due to pathologic
process.
SGA: fetus with birth weight <10th
percentile for gestational age in the absence of
pathologic process

16. 1. Symmetrical growth restriction
 20 % of IUGR Infants
 proportional decrease in all organs
 HC/AC ratio is normal
 Occurs in early pregnancy : Cellular hyperplasia
 Increase risk for long term neurodevelopmental dysfunction
 Due to Intrinsic factor
 Chromosomal abnormalities
 Congenital anomalies
 Intrauterine infection

17. 2.Asymmetrical growth restriction
 80% of IUGR Infants
 Increase HC/AC ratio : decrease in abdominal size
 Brain sparing effects
 Occurs in late pregnancy : cellular hypertrophy
 Risk for perinatal hypoxia, neonatal hypoglycemia
 Good prognosis
 Due to extrinsic factors : Uteroplacental insufficiency
 Maternal vascular disease: hypertension
 Multiple gestations
 Placental disease

18. 3. Combined type
 Asymmetrical symmetrical
 Symmetrical asymmetrical
More morbidities and mortalities
More long term effects

19. Ponderal Index
Ultrasound criteria for diagnosis of fetal malnutrition;
Gestation age independent;
Way of characterizing the relationship of height to
mass for an individual.
PI = 1000 x
Typical values are 20 to 25.
PI is normal in symmetric IUGR.
PI is low in asymmetric IUGR.
Mass (kgs)
Height (cms)

20. Etiology- Overlapping
,,
Fetal
Placental
Maternal

21. Fetal causes
Infection
 CMV, Rubella, Toxoplasma gondii – severe IUGR
 Syphilis, Tuberculosis, Malaria, listeriosis
 Herpes simplex, chicken pox
Chromosomal abnormality
 Trisomy 18,13 –severe IUGR
 Trisomy 21
 Turner syndrome (45,XO), Klinefelter syndrome (47,XXY)
Congenital anomalies
 Congenital Heart diseases
 Anencephaly

22. Case # 1
A baby is delivered
at 36 WGA via
repeat C- section
 BW- 2 kg
 HC- < 10th %tile
 Lt- < 10th %tile
CMV

23. Case #2- What if?
Toxoplasmosis
Rubella

24. Case #3- What if?
Trisomy 18 Turner syndrome

25. Maternal causes
• Maternal malnutrition
• Poor maternal weight gain
• Severe anemia
• Chronic hypoxemia
• Cardiovascular disease
• Drugs and teratogens
• Multiple pregnancy
• Antiphospholipid antibodies syndrome

26. Case #4
Infant is delivered at 38
weeks to mom who
presents with headaches
and epigastric pain
 BW: 2.1 kg
 HC: 50th%tile
 Lt: 30th%tile
Pre-eclampsia/
HELLP

27. Case # 5- What if?
Mom with no
prenatal care
delivers
undiagnosed twins
at EGA 34 weeks
Discordant twins

28. Case # 6- What if?
An infant is
delivered at 42
weeks via c- section
due to NRHTs after
induction
Post dates
- decreased subcutaneous fat
- skin desquamation
- wizened facies
- large AF(diminished membranous
bone formation)
- meconium staining

29. Placental causes
• Placental infarction
• Placental abruption
• Chorioangioma
• Placenta previa , circumvallate placenta
• Marginal or velamentous insertion of umbilical cord

30. Cause
Fetal causes
(intrinsic factors)
Symmetrical IUGR
Maternal causes
Plcental causes
(extrinsic factors)
Asymmetrical IUGR

31. IUGR
Symmetric IUGR Asmmetric IUGR
Small symmetrically. Head is larger than abdomen.
Ponderal index is normal. Ponderal index is low.
Normal head-abdomen ratio. High head-abdomen ratio.
Genetic, infections. Placental vascular insufficiency.
Complicated neonatal course. Benign neonatal course if
complications are treated adequately.

32. Diagnosis
• Clinical assessment
• Ultrasonic measurement
• Doppler velocity

33. History for risk factor
– Teen age
– High altitude
– Socioeconomic factor
– Smoking , Alcohol , Drugs
– Previous IUGR pregnancy history
– previous IUGR in family

34. Signs:
Seldom elicited before 28 weeks of gestation:
Failure of fetus and uterus to grow at the normal rate over
a 4 week period;
Uterine fundal height should be at least 2cm less than
expected for the length of gestation;
Poor maternal weight gain;
Diminished fetal movements.

35. Physical examination
Uterine fundal height
 Uterine fundus  Pubic symphysis
 Simple, Safe, Inexpensive for screening
 Between 18 and 30 weeks,
 the uterine fundal height in centimeters coincides with
weeks of gestation.
 If the measurement is more than 2 to 3 cm from the
expected height or < 1oth percentile from normal curve,
inappropriate fetal growth may be suspected

36. Errors in Fundal Height Estimation:
 Inter-observer variations
 Obese patients
 Transverse lie
 Multiple gestation
 Polyhydramnios / Oligohydramnios
 Uterine fibroids

37. Ultrasonic measurement
Initial U/S at 16 to 20 weeks to establish
gestational age and identify anomalies and
repeated at 32 to 34 weeks to evaluate
fetal growth

38. Ultrasonography Biometry
The measurements most commonly used to measure and
follow fetal growth are:
Biparietal Diameter
Femur Length
Head Circumference
Abdominal Circumference
Ratio :- Head circumference to the abdominal circumference (HC/AC)
.

39. Amniotic Fluid Index
Mild IUGR – Normal amniotic fluid
Severe IUGR – Oligohydramnios (AFI is ≤ 5)
Incidence 40%
On ultrasonography - a pocket of fluid < 1cm is diagnosed
as oligohydramnios.

40. The amniotic fluid index is obtained by summing the
largest cord-free vertical pocket in each of the four
quadrants of an equally divided uterus.

41. Abnormal umbilical artery Doppler velocimetry
A. Normal velocimetry pattern
with an S/D ratio of <30.
B. The diastolic velocity
approaching zero reflects
increased placental vascular
resistance.
C. During diastole, arterial
flow is reversed (negative
S/D ratio), which is an
ominous sign that may
precede fetal demise
– characterized by absent or reversed end-diastolic
flow
– associated with fetal growth restriction

43. An IUGR infant is at risk for
Hypothermia?
Hypoglycemia?
Or
Hypocalcemia?
decreased subcutaneous fat, increased
surface- volume ratio, decreased heat
production
decreased glycogen stores/
glycogenolysis/ gluconeogenesis
increased metabolic rate
deficient catecholamine release
Associated with perinatal stress, asphyxia,
prematurity

44. Management
Prepregnancy: to prevent it by identifying risk factors and
treat as necessary (e.g. improve nutrition intake, stop
smoking or alcohol, ASA in APA syndrome, and Heparin in
thrombophilias)
Antepartum: identify risk factors that can be changed.
Fetal surveillance by ultrasound (BPP) and fetal heart
monitoring (Non-Stress Test). To decide on timing and mode
of delivery.

45. Growth restriction near term
 Prompt delivery
 Recommend delivery at 34 weeks or beyond if
there is clinically significant oligohydramnios

46. Growth restriction remote from term
 No specific treatment
 If diagnosed in prior to 34 weeks, and amnionic
fluid volume and fetal surveillance are normal
 Observation is recommended
screening for
toxoplasmosis,herpes,rubella,CMV and others
 Specific treatment(causes of IUGR) and
supportive care
 If severe IUGR or bad obstetric conditions
 Terminate pregnancy should be considered

47. IUGR- Outcome
Neurodevelopment
 etiology and adverse event dependent
 lower intelligence, learning/ behavioral
disorders, neurologic handicaps
 symmetric, chromosomal disorders, congenital
infections--- poorer outcome
 school performance influenced by social class

48. Case study

49. Case
SW a16 years old G1 P0+0 presented early for prenatal
care
PMH: None
PSH: None
Allergies: None
Medications: Prenatal vitamins
Social Hx: + Tobacco 1ppd x > 5 years, No illicit drug use
• B average in high school and good support system
• Lives in Denver, HIGH ALTITUDE
• Poor nutrition

50. She followed up regularly and had an uncomplicated
1st trimester…..
• At 18 weeks fundal height measured 17 cm
• At 22 weeks fundal height measured 20 cm
• At 24 weeks fundal height measured 21 cm
At this point I am worried about IUGR with this
sluggish growth.
Although we do not use fundal height to diagnose
IUGR, it can be a clue to a developing problem.
•A fundal height that lags by more than 3 cm or is
increasing in disparity with the gestational age
may signal IUGR.
• A lag of 4 cm or more certainly suggests growth
restriction.
• The size of the uterus should be assessed at each
prenatal visit.

51. So now we have increasing concern
over her poor fundal height. What
other risk factors for IUGR does AMY
have?
A) Teen
B) Poor nutrition
C) Poor abdominal girth growth
D) High altitude
E) Smoker
F)All of the above
ANSWER F

52. Maternal weight Gain
Decreased maternal weight gain is a
relatively insensitive sign of IUGR baby…

53. Risk Factors of IUGR
With all these risk factors, poor weight gain,
and an inadequate fundal height…
What would you do to further evaluate for
potential IUGR?
1)Consult OB now
2) Get an ultrasound
3) Do an NST
4) Continue to watch one more week
ANSWER 2

54. The result of 32 wks US
Comments:
a single intrauterine pregnancy. No obvious fetal anatomic
abnormalities were seen. Not all malformations of the above
mentioned organ systems can be detected by ultrasound.
There is an overall growth lag of two weeks, with the head
and abdomen lagging three weeks.
Amniotic fluid is lower limits of normal measuring 8.5 cm . S/D
ratio is slightly elevated. She declined amniocentesis.
Recommend follow up growth in three weeks. This
appointment was scheduled today

55. History of Present Illness
• That was her ultrasound at 24 weeks. You repeat it at 27
weeks: 3 week growth lag and AFI 8.5
• Repeat US at 30 weeks: normal growth since last US – 15
day lag; AFI 10.5
• Repeat US at 32 weeks: EFW 9% AFI 5.9
Is this IUGR? What do you do now?

56. She has an overall 3 week lag and an
EGW 12% at 32 weeks. Is this IUGR?
A) Yes ,any growth lag is IUGR
B)Yes any EFW<l15% is IUGR
C)No ,too early to diagnose IUGR
D) No, IUGR is EGW overall lag 4 weeks
ANSWER C

57. IUGR is usually not detectable before 32-34 weeks
(maximal fetal growth). But it must be suspected
earlier
Signs rarely
occur before 28
weeks of
gestation

58. What is Intrauterine Growth
Restriction (IUGR)?
A fetus with IUGR often has an estimated fetal weight associated
with which of the following?
A) Abdominal circumference is below 5th percentile
B) Abdominal circumference is below the 2.5th percentile
C) Less than the 5th percentile for its gestational age
D) Less than the 10th percentile for its gestational age
ANSWER D

59. What is one of the pathologic
Maternal/Placental causes for
IUGR?
A.Gestational Diabetes
B.Hypertension
C.Obesity
D.Hyperemesis Gravidarum
ANSWER B

60. Which of the following is not a
pathologic FETAL cause for IUGR?
D)CMV infection
C)Congenital heart
disease
B)Cleft lip/palateA)Trisomy 21
ANSWER B

61. Does SW have symmetrical or
asymmetrical IUGR?
A)Asymmetrical
B) Symmetrical
Answer B

62. Comments of the ultrasound at 32 weeks.
It reads:
A complete detailed scan of a single intrauterine pregnancy was
performed. No
obvious fetal anatomic abnormalities were seen. Not all
malformations of the
above mentioned organ systems can be detected by ultrasound.
There is an overall
growth lag of two weeks, with the head and abdomen lagging
three weeks. Amniotic
fluid is lower limits of normal measuring 5.9 cm . S/D ratio is
slightly
elevated.

63. How else can IUGR be diagnosed in addition
to a <10% weight for gestational age?
A) US
B) Inadequate Maternal Weight gain
C) Non-reassuring NST
D) Fundal Height
ANSWER A

64. So SW has had a 32 wk US with
EFW 10% and AFI 6.9.
What is your next step?
A)Repeat US
in
8 weeks
B)No further
US needed
C)Repeat US
in
4 weeks
D)Transfer
to
OB
ANS C

65. Yes! Correct Answer:
Repeat US in 3-4 weeks
Repeat US at 35 weeks:
Comments:
A repeat ultrasound of this single intrauterine pregnancy was performed.
EFW is in the less than 10th percentile in growth.
Amniotic fluid is within normal limits for this gestation.
Umbilical artery dopplers performed and S/D ratio is
normal.
Recommendations include:
1. follow up ultrasound in 1 week for AFI and dopplers
2. follow-up ultrasound in 2 weeks for growth
3. NST testing twice weekly.

66. SW is in your office to review the results. You
explain the results and schedule her for an
ultrasound next week and the week after.
Any other advice for her?
Click for advice
1. Rest as much as possible-
she does not work and is out of school.
2. Perform daily kick counts.
3. She will need weekly visits with biweekly NSTs.
She asks you: “Why so many
ultrasounds?” What do you tell her?

67. You tell her:
“Ultrasound measurement of the fetus is the gold
standard for assessing fetal growth.”
AND
“We need to follow the amount of fluid around the baby as
well. If it is too low, we will need to deliver your baby
early.”
Click here.
Click here next

68. When should we (Family Practice)
Transfer care to the Obstetricians?
 A)Whenever you are unsure or
uncomfortable with the situation
 B)Definite need for C-Section
 C)Worsening fetal status
 D)Severe/worsening Maternal Disease
 E)Unsure of IUGR etiology
 F)All of the above
Answer F

69. Which of the following may we see after
the birth of a baby with IUGR?
A) Decreased oxygen levels
B) Meconium aspiration
C) Hypoglycemia
D) Difficulty maintaining normal body temperature
E) Polycythemia
F) Stillbirth
G) All of the Above
ANSWER G

70. Case Close
• SW remained on the family practice service because she
remained stable and her biweekly BPP and NST were
reassuring.
• In the 36th week, she was found to have
oligohydramnios by US  AFI = 3.2 along with IUGR
EFW < 10%
• Pt was at this time transferred to OB for care.
• She was already known to them because we consulted
them at the first signs of IUGR.
• Amniocentesis was done to ensure fetal lung maturity
and she was induced soon there after.
• Patient vaginally delivered a baby with Down’s
Syndrome
• No other complications at birth

71. Thank you