1. FETAL GROWTH RESTRICTION
A Panel discussion
with
EXPERTS
Every thing you wanted to
know …..
The experts tell what to do and
when and how to handle F.G.R.

2. MODERATORS
narendra malhotra
neharika malhotra bora
Panelists
Pushpa sethi
Bharti maheshwari
Sangeeta jain
Andaleep agarwal
Anita rajurkar
Gita radhakrishnan
Meenakshi ahuja
Savita tyagi
Rachna agarwal
Sarita sukhija

3. Every fetus has a potential to grow
Failure to achieve growth potential- FGR
Babies can come in different sizes!

4. PHASES OF FETAL GROWTH
First 16 weeks: mostly cellular hyperplasia
16-32 weeks: both hyperplasia and hypertrophy
>32 weeks: mostly hypertrophy
Thus: early growth restriction will affect cell
numbers and have a global (symmetrical)
effect. Later cell size will be affected.

5. Normal Intrauterine Growth
Stage 1 Stage 2 Stage 3
Hyperplasia Hyperplasia/ hypertrophy Hypertrophy
4-20 weeks 20-28 weeks 28-40 weeks
Rapid mitosis Declining mitosis Rapid hypertrophy
Increasing DNA content Increasing cell size Rapid increasing cell size
rapid accumulation of fat,
muscle, connective tissue
Symmetric Mixed- asymmetric Asymmetric

6. • Before we Discuss About IUGR/SGA , it is
important to understand the Fetal Circulation
and how does the Redistribution happen
• Would request one of our Panelists to
elaborate .

7. NORMAL FETAL CIRCULATION

8. FETAL HYPOXIA-ACIDOSIS
AORTIC BODY CHEMORECEPTOR
STIMULATION
REFLEX REDISTRIBUTION OF FETAL
CARDIAC OUTPUT

9. REFLEX REDISTRIBUTION OF FETAL
CARDIAC OUTPUT
INCREASED FLOW
DECREASED FLOW
 KIDNEYS (OLIGURIA)
(OLIGOAMNIOS)
 LUNGS (RDS)
 GUT (NEC)
 LIVER/MUSCLE (IUGR)
BODY FAT/
GLYCOGEN STORES
 BRAIN
 ADRENALS
 HEART

10. Organ-sparing effects
• Heart and brain sparing act
synergistically with venous
and arterial redistribution.
• Both of these organs derive
their blood supply from the
left ventricle.
• Vasodilatation at the organ
level acts synergistically to
increase organ blood flow.

11. F.G.R/I.U.G.R. PROTOCOLS AND
GUIDELINES
DIAGNOSIS AND MANAGEMENT

12. SGA why the concern
• 52% of still births
• Inc perinatal
mortality
• 72% of
unexplained fetal
deaths are SGA
<10th centile
Manning FA. Intrauterine growth retardation. In:
Fetal Medicine: Principles and Practice

13. Impact of Fetal Weight
● 26% of pregnancies in India
● Adverse perinatal outcome
● Abnormal long term neurodevelopmental
outcomes
● Long term cardiovascular dysfunction
● Metabolic Syndrome

14. Q.1 Factors affecting fetal growth
Fetal
MaternalPlacental

15. ● Chromosomal
● Malformations
● Multiple gestations
Fetal Growth Restriction:
Perspective
● Abnormal
invasion
● Chronic abruption
● Velamentous cord
● Circumvallate
placenta
● Chorioangioma
● Genetic/ Constitutional
● Nutrition/ starvation
● Hypoxic
● Vascular
● Renal
● Antiphospholipid
syndrome
● Environment/ drugs
● Infections
Fetal Placental Maternal

16. Factors influencing intrauterine growth
Race (Pygmy=2.64kg Altitude
USA Amerindian=3.6kg)
Gender Multiple gestation
Smoking, alcohol Socioeconomic level
Pathology * Maternal
* Fetal (genetic disorders,
infections)
* Placental

17. DEFINITIONS…
• Gestational age
– Single point estimation
by LMP or Biometry
• Growth
– Multipoint estimation
with continuous
comparison
HOW OLD ARE YOU??
HOW MUCH HAVE YOU
GROWN??

18. Q2 Fetal Growth Restriction:
Definitions

19. A growth restricted fetus is one that fails
to achieve its growth potential (!)
Abdominal Perimeter < 3rd, 5th or 10th centile on standard growth charts
No increase in abdominal perimeter and/or head perimeter on two scans two
weeks apart
Head perimeter to abdominal perimeter ratio > 2 SD
Estimated Fetal Weight < 10th centile on standard
growth charts
Always use a chart that includes HP, AP and FL
Customised or Standard Growth Charts
10th, 50th or 80th Centile
Fetuses that fall from a higher normal to a lower normal centile
FGR vs SGA: FGR is SGA+Abnormal Doppler

20. SGA
• SGA birth is defined as an estimated fetal weight (EFW) or
abdominal circumference (AC) less than the 10th centile and
severe SGA as an EFW or AC less than the 3rd centile.
FGR
• Fetal growth restriction (FGR) is not synonymous with SGA.
Some, but not all, growth restricted fetuses/infants are SGA
while 50–70% of SGA fetuses are constitutionally small, with
fetal growth appropriate for maternal size and ethnicity.The
likelihood of FGR is higher in severe SGA infants.
GROWTH RESTRICTION
• Growth restriction implies a pathological restriction of the
genetic growth potential. As a result, growth restricted
fetuses may manifest evidence of fetal compromise (abnormal
Doppler studies, reduced liquor volume).
LBW
• Low birth weight (LBW) refers to an infant with a birth weight
< 2500 g.

21. Q 3 Fetal Growth Restriction:
Ultrasound Perspective
Steps in
appropriate
evaluation

22. ● Assign fetal age
● Assess fetal size
● Estimate fetal weight
● Exclude Anomalies
● Amniotic fluid assessment
● Color Doppler
● Biophysical profile

23. SO THE GUIDELINE NO.1 IS
● Assign fetal age: Dating scan between
6-13 weeks(understand variability)
● Assess fetal size and weight: Include
HP, AP and FL (serial scans)
● Exclude anomalies & infection, assess
placental structure, assess maternal
medical disease and teratogen
exposure

24. FETAL BIOMETRY
I trimester
Compare USG GA with LMP GA
Assign LMP
EDD
< 1wk
> 1wk
Re assign
EDD
VARIBILITY +/- 5-7 days

27. DATING BEYOND 26 WKS..
• Preferably avoided
• Patient presenting late
• Previous scan- NO reports (common)
Same parameters can still be used but must be
aware if inaccuracies of prediction.
High variability

28. Method – the 8% rule
Determining menstrual age Example
By LMP date – 155 days
By US 20+2wks 142 days
Actual difference
13-days
Expected Margin of error 8%
142 days x 0.08
11.36 days
Actual difference > Expected difference - CHANGE DATES

29. GUIDELINE II
• After fixing the gestational age
“DO NOT CHANGE DATES IN
SUBSEQUENT SCANS”
Don’t use machine generated data
blindly

30. Q 4 DIAGNOSIS OF IUGR

31. • AC < 10th centile (sens. 98.1%)
• EFW – (Sens 85.7%)
• Growth curve gives a “visual effect”

32. IUGR DIAGNOSIS SENSITIVITY
BIRTH wt < 10th
centile
+VE PREDICTIVE
VALUE
AC (<10th
centile)
98.1%
EFW 85.7%
AC <2.5th
centile
36.3%
LOW EFW 50%
AC < 2SD below the mean when head & femur are normal
GUIDELINE III
DIAGNOSIS OF IUGR
ABDOMINAL CIRCUMFERENCE vs EFW

33. Mediscan
DIAGNOSIS OF IUGR
DATING vs GROWTH
DATING
GROWTH

34. GUIDELINE IV
• The growth curve must be plotted for all
fetuses to give a “visual effect” of the
growth..
• Minimum interval 2-3 wks
Growth restricted babies will not be “parallel” to the
normal curve

35. Growth – dates uncorrectedGrowth – dates corrected

36. Q 5 CLASSIFICATION BASED ON
GROWTH CURVE

37. SGA LGA
AGA
Low growth
potential
IUGR
High growth
potential
Macrosomia

38. Q 6. FETAL GROWTH PATTERNS
and CLASSIFICATION

39. • Early onset
– Symmetric
– Asymmetric
• Late onset
– Symmetric
– Asymmetric
 Early insults are
more likely to lead
to symmetric rather
than asymmetric
type of IUGR
 May be
chromosomal or
vascular causes
FETAL GROWTH RESTRICTION

40. Q 7 Identifying etiology is it
necessary?

41. Fetal
MaternalPlacental
KARYOTYPE
INFECTION
SCREENDOPPLER
ANOMALY

42. Q 8 The Supply
Line to the Human
Fetus
How important to
know this ?

43. Cuningham FG, MacDonald PC, Leveno K, Gant NF, Gilstrap LC II Williams Obstetrics 1993
Placentata

44. Q10 Fetal response to hypoxia-
acidosis
The final common pathway
Aortic Body Chemoreceptor stimulation
Reflex redistribution of fetal cardiac output
Increased flow Decreased flow
Brain
Heart
Adrenals
Kidneys (Oliguria)
(Oligoamnios)
Lungs (RDS)
Gut (NEC)
Body stores (FGR)

45. ABNORMAL
CTG
AMNIOTIC FLUID
< 5th %tile
EFW
OLIGOHYDRAMNIOS
Arduini, et al, 1992
BPS
FETAL
DEATH
UMB A PI
GROWTH LAG
REDISTRIBUTION
CEREBRAL BLOOD FLOW
ARED FLOW
Q 14 SEQUENTIAL CHANGES IN TESTS OF
FETAL WELL BEING

46. ABNORMAL
CTG
AMNIOTIC FLUID
< 5th %tile
EFW
OLIGOHYDRAMNIOS
BPS
FETAL
DEATH
>33wks <32wks
UMB A PI
GROWTH LAG
REDISTRIBUTION
CEREBRAL BLOOD FLOW
ARED FLOW
Q 15.THE ACTION POINTS

47. Q 11 what does
DOPPLER tell
us In FGR ?

48. 1To identify etiology of IUGR
– Placental / non placental
2To identify hypoxia & fetal adaptation
3To plan timing of delivery?
4To identify fetuses at risk of perinatal
complications

49. Q 12 Doppler
vessels to be
studied ?

50. • MATERNAL SIDE
Uterine artery
• PLACENTAL SIDE
Umbilical a
• FETAL SIDE
Arterial:mca,fetal a,renal and others
Venous:ductus,hepatic,umbilical
Fetal echocardiography

51. Q 13
Color dopplerUltrasound Evaluation
Can u tell us what these waves are saying
Ut a UA PI MCA PI Ao I

52. Q 14 Monitoring the
fetus- how frequently
and when to admit ?

53. Patterns dictates frequency of testing
Biometry
At least two weeks apart
TCD when gest age is not known
In severe cases twice weekly dopplers
BPP / CTG + AFI weekly / bi weekly /daily
Severe Oligohydramnios dictates delivery
Acute hypoxia / acidemia may happen with normal liqour

54. Q 15 Aim of delivery ?
A live fetus?
Intact survivability?
Risk of intrauterine compromise has to be
weighed against the potential risks from
iatrogenic premature delivery

55. -Perinatal mortality for IUGR infants is 5-20 times greater than for AGA,
mainly due to intrauterine death, perinatal asphyxia, and congenital
anomalies.
-Neurologic morbidity is 5-10 times higher than for AGA infants,
especially for infants with ↓ head circumference at birth. Intellectual and
motor function (excluding those with congenital infections, chromosomal
abnormalities) depends on adverse perinatal events and on the specific
cause of growth restriction. Early identification and treatment of
hypoglycemia and polycythemia improves outcome. Neurologic
abnormalities are usual with genetic and infectious causes of IUGR.
-Retarded growth: With placental causes of IUGR, catch-up growth occurs
after birth, but these patients usually remain smaller than expected.
-Fetal “programming” of cardiovascular disease: Recent studies implicate
IUGR with adult onset of hypertension, coronary heart disease,
hypercholesterolemia, and diabetes. These studies suggest that IUGR has
long term affects on endocrine development and homeostasis.

56. Q 16 When to deliver?

57. • Gestational age at decompensation primary
determinant of perinatal survival
• Neonatal care available dictates gest age of
delivery
• < 32 weeks every day gained is useful
– Every week gained –outcome improved by 40%
– Here venous dopplers help delay delivery
• > 32 – 34 weeks – steroids and delivery once UA A
/R EDV

58. Time to deliver
Factors to decide time to deliver
• Degree of Prematurity
• NICU facility
• Degree of Hypoxia, acidemia, hepatic
metabolic derangement
Challenge to weigh the risks and benefits of
interventions

59. Time to deliver
When you want to deliver?
• ? Mild to moderate Hypoxia
• ? Moderate Hypoxia with early acidemia
• ?? Severe hypoxia with moderate to severe
acidemia & hepatic metabolic derangements
Best time when fetal redistribution
mechanism start failing

60. 24 – 28
weeks
Monitor
Abn doppler /
BPP
Discuss with
family
28 – 32 weeks
monitor
Arrested fetal
growth
A / R EDV UA
Abn. DV
Abn BPP
Steroids
Deliver
Neonatal care
32 – 34 weeks
monitor
Deliver
Arrested growth
Oligo
Abn CTG
A /R EDV

61. Q 17
IS THERE ANY ANTENATAL
TREATMENT ??

62. Antenatal treatments if any
• Iv fluids
• Amino acids
• Oxygen
• Rest
• Drugs
asprin/progesterone/gestin/heparin/complamina
/sildinafil/l arginine/micronutrients
• Monitoring
• Steroids
• Mag sulf

63. Q 19 How to deliver?

64. Mode of delivery depends on
– Parity
– Cervical score
– Degree of growth restriction
• In well compensated babies with reassuring fetal
well being tests and diastolic flow vaginal delivery
• If hypoxemic fetus - avoid trial of labour
– Risk of decompensation in labour very high as reserve is
poor

65. Conclusions
• Fetal growth restirction is a problem
• Risk factors should be assessed
• Proper antenatal care and advice
• Diet and suppliments
• Ultrasound
• Growth charts
• Color doppler
• Intervene timely

66. THANK YOU PANELISTS
THANK YOU ORGANISERS FOR GIVING
US A CHANCE TO MODERATE THIS
PANEL ON FETAL GROWTH RESTRICTION